Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration Errors

Thomas, Lloyd E.; Donohue-Porter, Patricia; Fishbein, Joanna

doi:10.1097/ncq.0000000000000256

Cited by 63 publications

(86 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Work interruptions are common and frequently cause public problem during the nursing medication administration process [ 9 , 23 , 34 ], usually having a negative consequences on patients' safety and outcome, employees' well-being and performance, and country's resources as a whole [ 19 – 22 , 35 ]. Thus, the main aim of this study was to assess the incidence of work interruption and associated factors in Amhara Regional State.…”

Section: Discussionmentioning

confidence: 99%

Work Interruption Experienced by Nurses during Medication Administration Process and Associated Factors, Northwest Ethiopia

Getnet

Bifftu

2017

Nursing Research and Practice

View full text Add to dashboard Cite

Background During medication administration process, including preparation, administration, and documentation, there is high proportion of work interruption that results in medication administration errors that consequently affect the safety of patients. Thus, the main purpose of this study was to assess the prevalence of work interruption and associated factors during medication administration process. Methods A prospective, observation-based, cross-sectional study was conducted on 278 nurses. Structure observational sheet was utilized to collect data. EPI Info version 3.5.3 and SPSS version 20 software were utilized for data entry and analysis, respectively. Binary and multivariable logistic regression were fitted to identify the associated factors using an odds ratio and 95% CI. Results The incidence of work interruption was found to be 1,152 during medication administration process. Of this, 579 (50.3%) were major/severe work interruptions. Unit of work, day of the week, professional experience, perceived severity of work interruption, source/initiator of interruption, and secondary tasks were factors significantly associated with major work interruptions at p < 0.05. Conclusion In this study, more than half of work interruption was major/severe. Thus, the authors suggest raising the awareness of nurses regarding the severity of work interruptions, with special attention to those who have lower work experience, sources of interruption, and secondary tasks by assigning additional nurses who manage secondary tasks and supportive supervision.

show abstract

Section: Discussionmentioning

confidence: 99%

Work Interruption Experienced by Nurses during Medication Administration Process and Associated Factors, Northwest Ethiopia

Getnet

Bifftu

2017

Nursing Research and Practice

View full text Add to dashboard Cite

show abstract

“…An organizational culture of safety has been acknowledged as important to medication safety. Primary concerns identified by participants in this study, including inconsistent use of the independent‐double check, workload and distractions were identified as factors contributing to medication errors in other studies (Mansour, James, & Edgley, ; Thomas, Donohue‐Porter, & Fishbein, ). Establishing a culture of safety around medication error is complex and requires interdisciplinary approaches (Hawkins, Nickman, & Morse, ).…”

Section: Discussionmentioning

confidence: 68%

“…Working conditions that include interruptions and distractions have been identified as factors contributing to HAM errors (Engles & Ciarkowski, ) and medication errors in general (Blignaut, Coetzee, Klopper, & Ellis, ; Brady, Malone, & Fleming, ; Cabilan et al, ; Johnson et al, ; Keers et al, ; Kosits & Jones, ; Raban & Westbrook, ; Thomas et al, ; Trbovich, Prakash, Stewart, Trip, & Savage, 2). As in our study, others have described the potential of bar‐code scanning to reduce HAM errors but identified frequent nurse workarounds (failure to scan the armband or drug), demonstrating a need to continuously assess and improve processes to support effective use of these technologies (Hawkins et al, ; Miller et al, ).…”

Section: Discussionmentioning

confidence: 99%

Nurses’ perceptions of high‐alert medication administration safety: A qualitative descriptive study

Sessions

Nemeth

Catchpole

et al. 2019

Journal of Advanced Nursing

View full text Add to dashboard Cite

Aims The aim of this study was to determine nurses’ perceptions of supports and barriers to high‐alert medication (HAM) administration safety. Design A qualitative descriptive design was used. Methods Eighteen acute care nurses were interviewed about HAM administration practices. Registered nurses (RNs) working with acutely ill adults in two hospitals participated in one‐on‐one interviews from July–September, 2017. Content analysis was conducted for data analysis. Results Three themes contributed to HAM administration safety: Organizational Culture of Safety, Collaboration, and RN Competence and Engagement. Error factors included distractions, workload and acuity. Work arounds bypassing bar code scanning and independent double check procedures were common. Findings highlighted the importance of intra‐ and interprofessional collaboration, nurse engagement and incorporating the patient in HAM safety. Conclusions Current HAM safety strategies are not consistently used. An organizational culture that supports collaboration, education on safe HAM practices, pragmatic HAM policies and enhanced technology are recommended to prevent HAM errors. Impact Hospitals incorporating these findings could reduce HAM errors. Research on nurse engagement, intra‐ and interprofessional collaboration and inclusion of patients in HAM safety strategies is needed.

show abstract

“…As a result, he failed to fully check Peter's history, hospital medication chart and pre admission medications, increasing the risk of initiating a medication error for Peter (Elliott et al, 2012;Pierce and Fraser, 2009). The impact of frequent interruptions, multitasking and high workloads have been identified as adversely impacting on patient care, including medication errors, increasing the likelihood of a medication error in this scenario (Westbrook et al, 2018;Thomas et al, 2017).…”

Section: Analysis Process-how and Why Did This Medication Error Occur?mentioning

confidence: 99%

To err is human: medication patient safety in aged care, a case study

Gilbert

Kim

2018

QAOA

View full text Add to dashboard Cite

Purpose The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study. Design/methodology/approach In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility. Findings Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013). Originality/value Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

show abstract

Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration Errors

Cited by 63 publications

References 26 publications

Work Interruption Experienced by Nurses during Medication Administration Process and Associated Factors, Northwest Ethiopia

Work Interruption Experienced by Nurses during Medication Administration Process and Associated Factors, Northwest Ethiopia

Nurses’ perceptions of high‐alert medication administration safety: A qualitative descriptive study

To err is human: medication patient safety in aged care, a case study

Contact Info

Product

Resources

About