Medication Safety: Do Not Disturb

Lights, buzzers, people talking, asking questions, discussing the weekend’s sports events or an impending change in weather!

Multiple sensory stimuli can impact your medication administration rounds and interruptions are commonplace. A task which requires critical thinking and precision can be fraught with unexpected and unwanted interruptions, which could lead to a medication error.

How can this process and other aspects of medication dispersal become more accurate? What would need to be in place to reduce medication errors in any facility? What factors impact nurses interception of errors?

Nurses, statisticians and pharmacists at Rutgers College of Nursing and the New Jersey Collaborating Center for Nursing decided to seek answers to these questions. Among other things, they learned one of the biggest issues during medication administration is interruptions.

They also discovered a supportive nursing practice environment contributes to fewer medication errors. So in other words, if your boss and your organization have your back, your patients benefit!


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Doing the Research

The path to answers began when Linda Flynn – lead author of “Nurses’ Practice Environments, Error Interception Practices and Inpatient Medication Errors” – read a passing comment in a research article saying nurses intercept about 80 percent of medication errors before they reach the patient.

“That was all the article said, but I wanted to know more about why this happens,” said Flynn, PhD, RN, FAAN, who is now professor at the University of Colorado, Denver, College of Nursing. “Little is known about organizational factors that help nurses’ to catch medication errors before the drug is administered,”

Partnering with Geri L. Dickson, PhD, RN; Minge Xie, PhD; and Dong-Churl Suh, PhD, all at Rutgers at the time, they created a study to learn what elements of the nurse practice environment impact catching errors. They used the definition of errors in prescribing, transcribing, dispensing and administration as any preventable event that may lead to inappropriate medication or patient harm.

The issue is worth investigating for patient safety alone. Annually, more than 7,000 inpatient deaths are attributed to medication errors – an average of one per day in any U.S. hospital. Since errors also result in longer lengths of stay, they add about $4 million per hospital to annual patient care costs.

Asking Questions


While the problem is nationwide, for their research Flynn, et al. concentrated on hospitals in New Jersey. In 82 med/surg units in 14 acute care hospitals in the Garden State they queried 686 staff nurses.

“We knew through past research that certain characteristics of the nursing practice environment are an important organizational determinant of quality nursing care and patient outcomes,” Flynn told ADVANCE. “However, there was little research investigating the impact of the practice environment on nurses’ error interception practices.”

That environment is described in their article, published June [2012 Pam: gave year in case article doesn’t run until January.] in the Journal of Nursing Scholarship (44(2), 180-186), as a core set of institutional traits, including:

• “opportunities for nurses to participate in organizational decisions;

• competent and supportive front-line nurse managers;

• collaborative nurse-physician relationships;

• strong foundations for quality care, including staff development and continuous quality improvement activities, and

• adequate resources.”

Flynn explained more than one study was conducted. “In the first, we conducted qualitative interviews with about 50 nurses who discussed barriers and facilitators to catching errors. Interruptions were mentioned often.”

Consequently some hospitals did their own observation studies in 2008, Flynn said, “watching nurses give medications and noting the number of times they were interrupted. They just stood in a corner with a clipboard and watched. They were amazed!”


That amazement persisted even after the data was analyzed, proving nurses’ skill at intercepting errors.

“Four practices that fostered intercepting errors were revealed in the data,” Flynn said.

“First, a thorough knowledge of the patient helped. They could look at the order and ask ‘is this right.’ Nurses talked about using their critical thinking skills to ask before giving the medication: ‘Why is this patient getting this? Is this appropriate or has something changed?’ Second, they independently compared their administration record against the patient chart at the beginning of the shift. Often they realized this medication should have been discontinued and hadn’t been.”

Flynn said the third practice involved nurses being “assertive and requesting a physician rewrite an erroneous order, since most of the facilities in the study didn’t have full implementation of CPOE. Administration support allowed this third practice to flourish.

Lastly, they talked about the patient and family being the last line of defense in preventing errors. Making sure the family and patient understood what medications they were getting and why, empowered them to ask questions should anything be different.”

The issue of interruptions during med passes was the most obvious problem and one facilities immediately began to address.

Using the Takeaway Message

At least two New Jersey hospitals involved in the study are implementing further measures to reduce errors or are doing further research.

Jayne Craig, PhD, RN, nurse researcher at CentraState Healthcare System, Freehold, NJ, said they received a grant from the Cardinal Foundation to study issues impacting interruptions. They expect their findings to be published in 2013.

Meridian Health’s Jersey Shore University Medical Center, Neptune, NJ, experimented with a system their chief nursing executive observed in a Singapore hospital. “We wanted to address interruptions as soon as possible,” said Mary Ann Donohue, PhD, RN, APN, NEA-BC, vice president and CNE at Jersey Shore University Medical Center.

“When I was in Singapore to prepare a hospital for Magnet certification, I saw that nurses distributing medications were wearing vests that said something like ‘do not disturb, I’m giving medications’. Our nurses weren’t keen on the vests but they were interested in creating a do-not-disturb zone.”


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Amanda Hessels, MSN, MPH, RN, CIC, CPHQ, quality excellence coordinator, Patient Care Services at Jersey Shore, said “one size doesn’t fit all when it comes to solutions. It’s important to tailor the intervention to your practice environment and setting.”

“Our nurses didn’t like the vest concept,” Hessels explained. “They felt they didn’t deliver the right message about nursing and would not work in our setting.”

Hessels said the Medication Safety Committee, of which she is an ad hoc member, decided to decrease the stimuli during medication passes. “We brought in medication carts and initiated some ‘no pass’ zones and hourly rounding to limit interruptions.”

These hospitals are approaching the problem as if it were a systems problem. Flynn advocates that.

“Reason’s [James Reason’s ‘Systems Approach to Organizational Errors’] developed the Swiss cheese model of error,” she said. “If there is a hole in the system it goes all the way through to the patient. It’s not so much the individual’s thoughts but system factors that predispose the error. That is what we found in our research.”

Gail O. Guterl is a frequent contributor to ADVANCE.

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