Mitigating Interruption Effects on High-Risk Procedures

Team
Healthcare Human Factors

Summary

Interruptions have been identified as one of the causal factors in medication administration errors. Healthcare Human Factors conducted research funded by the Canadian Patient Safety Institute to examine the development and implementation of sustainable safety interventions for mitigating the effects of interruptions during medication administration. The purpose of this work was to provide guidance to healthcare managers and executives in improving patient safety.

A direct observation study involving oncology nurses was conducted to determine the prevalence, source, and nature of interruptions at a large cancer hospital in Toronto. Using this background data, high-fidelity scenarios were developed to measure the impact of interruptions on medication safety. Nurses were asked to perform a series of twelve medication administration procedures while being interrupted by various sources. Medication administration error rates were collected and used as a baseline in a second, post-intervention lab study.

Interventions to mitigate the risk of interruptions were designed using a user-centered approach, incorporating nurses’ feedback gathered through focus groups. When the interruption mitigation interventions were introduced in the laboratory setting, improvements were noted in critical errors for all tasks, such as drug verifications, patient identification checks, and intravenous administration of drugs.

IMPACT

Results suggest that addressing interruptions during medication administration is an important strategy for reducing medical errors. For example, the number of nurses who committed pump-programming errors with the use of interventions was significantly decreased (5.3%) compared to nurses who programmed pumps with no such interventions (38.9%).

Funding Agency

Canadian Patient Safety Institute