Interruptions to Intensive Care Nurses and Clinical Errors and Procedural Failures: A Controlled Study of Causal Connection

Santomauro, Chiara; Powell, Madeleine; Davis, Chelsea S.; Liu, David; Aitken, Leanne M.; Sanderson, Penelope

doi:10.1097/pts.0000000000000528

Cited by 20 publications

(26 citation statements)

References 39 publications

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“…Increased patient acuity has been linked to an increased medication administration error rate 30,31 . Additionally, nurses in these settings experience more interruptions than on general wards, 32 which are also associated with an increased medication administration error rate 20,33 . Future work examining the effect of an increased nurse‐to‐patient ratio should control for confounders, including patient acuity and nurse interruptions.…”

Section: Discussionmentioning

confidence: 99%

Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions

Roydhouse

Carland

Debono

et al. 2021

Brit J Clinical Pharma

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Aims: Accurate documentation of medication administration time is imperative for many therapeutic decisions, including dosing of intravenous antimicrobials. The objectives were to determine (1) the discrepancy between actual and documented administration times for antimicrobial infusions and (2) whether day of the week, time of day, nurse-to-patient ratio and drug impacted accuracy of documented administration times.Methods: Patient and dosing data were collected (June-August 2019) for 55 inpatients receiving antimicrobial infusions. "Documented" and "actual" administration times (n = 660) extracted from electronic medication management systems and smart infusion pumps, respectively, were compared. Influence of the day (weekday/weekend), time of day (day/evening/night), nurse-to-patient ratio (high 1:1/low 1:5) and drug were examined. Monte Carlo simulation was used to predict the impact on dose adjustments for vancomycin using the observed administration time discrepancies compared to the actual administration time. Results:The median discrepancy between actual and documented administration times was 16 min (range, 2-293 min), with discrepancies greater than 60 minutes in 7.7% of administrations. Overall, discrepancies (median [range]) were similar on weekends (17 [2-293] min) and weekdays (16 [2-188] min), and for high (16 [2-157] min) and low nurse-to-patient ratio wards (16 [2-293] min). Discrepancies were smallest for night administrations (P < .05), and antimicrobials with shorter half-lives (P < .0001). The observed discrepancies in vancomycin administration time resulted in a different dose recommendation in 58% of cases (30% higher, 28% lower).Conclusions: Overall, there were discrepancies between actual and documented antimicrobial infusion administration times. For vancomycin, these discrepancies in administration time were predicted to result in inappropriate dose recommendations.

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Section: Discussionmentioning

confidence: 99%

Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions

Roydhouse

Carland

Debono

et al. 2021

Brit J Clinical Pharma

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“…Even fewer studies satisfy the further criterion of prospective experimental control via manipulation. However, even in the Santomauro et al (2018) study, causality is not as clear as it might seem. The errors they observed were not necessarily contingent upon and contiguous with interruptions in a manner that satisfies the Bradford Hill criteria of specificity of association or temporality.…”

Section: Epidemiology Metanarrativementioning

confidence: 76%

“…In contrast, Santomauro et al (2018) ran a larger between-subjects simulation study and found that ICU nurses receiving four interruptions per medication scenario made twice as many clinical errors and 20% more procedural failures than nurses receiving one interruption. As a dose-response relationship, this satisfies the Bradford Hill criterion of biological gradient, but more strongly than Westbrook et al (2010) due to the prospectively controlled nature of the trial.…”

Section: Epidemiology Metanarrativementioning

confidence: 98%

Interruptions in Health Care: Assessing Their Connection With Error and Patient Harm

2019

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Objective: We address the problem of how researchers investigate the actual or potential causal connection between interruptions and medical errors, and whether interventions might reduce the potential for harm. Background: It is widely assumed that interruptions lead to errors and patient harm. However, many reviewers and authors have commented that there is not strong evidence for a causal connection. Method: We introduce a framework of criteria for assessing how strongly evidence implies causality: the so-called Bradford Hill criteria. We then examine four key “metanarratives” of research into interruptions in health care—applied cognitive psychology, epidemiology, quality improvement, and cognitive systems engineering—and assess how each tradition has addressed the causal connection between interruptions and error. Results: Outcomes of applying the Bradford Hill criteria are that the applied cognitive psychology and epidemiology metanarratives address the causal connection relatively directly, whereas the quality improvement metanarrative merely assumes causality, and the cognitive systems engineering metanarrative either implicitly or explicitly questions the feasibility of finding a direct causal connection with harm. Conclusion: The Bradford Hill criteria are useful for evaluating the existing literature on the relationship between interruptions in health care, clinical errors, and the potential for patient harm. In the future, more attention is needed to the issue of why interruptions usually do not lead to harm, and the implications for how we approach patient safety.

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“…Given the positive outcome, the data could be explored further to help explain the relationship. An interesting finding from the eventual health care study, though not reported in Santomauro et al (2018), was that errors appeared to be distributed fairly evenly across the scenarios and did not seem to be contingent upon, or contiguous with, specific interruptions. If this is upheld, it may suggest that at some level, interruptions create a generalized disposition to make more errors.…”

Section: Notementioning

confidence: 87%

“…The health care simulation study is described in more detail in Santomauro et al (2018), so it will be only summarized here. Based on the sample size calculations produced from Pilot 2, 70 ICU nurses from a major metropolitan tertiary hospital were allocated to either a condition with one interruption per scenario ( n = 35 nurses experiencing three interruptions overall) or four interruptions per scenario ( n = 35 nurses experiencing 12 interruptions overall).…”

Section: Case Studymentioning

confidence: 99%

From bartending interruptions to medication delivery interruptions: Managing the risks of a high-fidelity simulation study with pilot research.

Santomauro

Sanderson

2020

Journal of Experimental Psychology: Applied

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In this paper we describe the risks of complex applied research, especially in work domains where professional practitioners are scarce. For such research, careful preparation and piloting is needed, especially when estimating sample size is required for a full study. However, such pilot work may reduce the potential sample size for the full study. We describe how the these issues have been addressed in applied psychology contexts. We then present a case study illustrating how we determined sample size for a study investigating the impact of workplace interruptions on errors that intensive care unit nurses might make during medication preparation and administration. The pilot work was performed in a functionally related domain to nursing-bartending-and bartender participants filled cocktail orders. Pilot 1 investigated performance with 0 interruptions and applied a model from a field observation to estimate probable effect sizes and sample sizes with 1 or 4 interruptions per medication scenario. Pilot 2 collected empirical data on the effect of 1 or 4 interruptions per cocktail scenario on cocktail errors and estimated sample size for the medication study, which was subsequently successfully run. The applied community could benefit from further discussions about these issues and the means for addressing them. Public Significance StatementApplied experimental psychologists increasingly perform studies in complex work environments that can be hard to access. Careful piloting to determine feasibility and target sample size is valuable, but piloting might require only approximating the target work environment. This paper describes how a pilot study testing the impact of interruptions on bartending work was used to prepare for a major simulation study of the impact of interruptions to intensive care unit nurses preparing medications.

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Interruptions to Intensive Care Nurses and Clinical Errors and Procedural Failures: A Controlled Study of Causal Connection

Cited by 20 publications

References 39 publications

Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions

Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions

Interruptions in Health Care: Assessing Their Connection With Error and Patient Harm

From bartending interruptions to medication delivery interruptions: Managing the risks of a high-fidelity simulation study with pilot research.

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