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InterruptionsDuringMedAdministration.pdf
May-June 2016 • Vol. 25/No. 3186
Christine Hughes Cooper, MBA, MSN, RN-BC, is Lead Specialist, Patient Care Informatics, Presence Healthcare, DesPlaines, IL. Ruth Tupper, MS RN, is Research and Education Nurse, Presence Saint Francis Hospital, Evanston, IL. Karyn Holm, PhD, RN FAAN, FAHA, is Professor Emeritus, School of Nursing, DePaul University, Chicago, IL; and Research Consultant, Presence St. Francis Hospital, Evanston, IL.
Interruptions During Medication Administration: A Descriptive Study
I nterruptions are ubiquitous in the complex healthcare work- place (Colligan & Bass, 2012;
Fore, Sculli, Albee, & Neily, 2013; Free man, McKee, Lee-Lehner, & Pesenecker, 2013; Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). In medication administration, nurses have a chance of being interrupted with every medication pass (Smeulers, Hoekstra, van Dijk, Overkamp, & Vermeulen, 2013). Interruptions decrease efficiency by lengthening medication adminis- tration time (McComas, Riingen, & Kim, 2014). Nurses may need to col- lect their thoughts and revisit their original purpose after each interrup- tion during medication administra- tion in the hospital setting (Clark & Flanders, 2012). Nurses must look critically at types of interruptions to determine strategies for addressing them.
Literature Review The following databases were
used: CINAHL Complete, Health - source: Nursing/Academic Edition, Academic Search Complete, and Medline. Search terms included interruptions, medication administra- tion, patient safety, and efficiency. The search was confined to studies published 2009-2016.
Biron, Lavoie-Tremblay, and Loi - selle (2009) studied 102 medication administration rounds using direct observation at a tertiary care univer- sity teaching hospital in Quebec, Canada. They found nurses were interrupted at least once during 53.9% of observations, with an average of 6.3 work interruptions per hour. Nurse colleagues (29.3%)
and system failures (22.8%; includ- ing missing medication or equip- ment) represented the most fre- quent interruptions during medica- tion preparation. Nurses passing the medication (16.9%) and patients (16%) accounted for the most inter- ruptions during medication admin- istration. This study was notewor- thy for pinpointing the actual source of the interruptions and doc- umenting their frequency. How - ever, it did not analyze interrup- tions by time of day or attempt to correlate number of frequencies and time for administration.
Nguyen, Connolly, and Wong (2010) studied 100 medication administration observations during a medication pass timeout at a 600- bed academic teaching hospital in California. Compared to 53.9% interruptions in the study by Biron and colleagues (2009), which had no timeout, 19% of the observations in this study had interruptions. Nguyen and co-authors (2010) also found reducing interruptions result- ed in 100% of medications adminis- tered without errors. This study was
important in demonstrating a time- out intervention could lead to a marked decrease in interruptions. However, the study did not discuss in detail the types of interruptions or note some may be necessary (e.g., colleague question needing immedi- ate response).
Westbrook and co-authors (2010) used an observational technique with a sample of 4,271 medication passes at two major teaching hospi- tals in Sydney, Australia. They found the risk of a major clinical error dur- ing a single drug administration more than doubled, from 2.3% with no interruptions to 4.7% with four interruptions. However, Hopkinson and Jennings (2013) analyzed the earlier study and argued for a more nuanced examination of the rela- tionship between interruptions and medication errors. The study by Westbrook and colleagues (2010) showed a general trend of increased errors with increased interruptions. Interestingly, researchers found clin- ical errors were lower with one or two interruptions than with no interruptions.
Research for PracticeResearch for Practice
Christine Hughes Cooper Ruth Tupper Karyn Holm
Interruptions decrease the efficiency of the medication administra- tion process. In this study, interruptions were found in 63% of the medication passes on four medical-surgical units in a community hospital. However, interruptions do not always lead to negative outcomes.
May-June 2016 • Vol. 25/No. 3 187
Kalisch and Aebersold (2010) observed nurses for 136 hours on seven units at two Midwestern hos- pitals. They found 10 interruptions per hour during all nurse task per- formance, not just during medica- tion administration. Authors actual- ly counted the number of errors per hour (1.5 in the first hospital, 1.89 in the second hospital). They also found significantly more interrup- tions (1 per 4.5 minutes/12 per hour in the first hospital, 1 per 13.3 min- utes/4 per hour in the second hospi-
tal). No significant relationship existed between interruptions and medication errors, but researchers cautioned the complex multitasking environment increased potential for errors. The conclusion interruptions led to increased errors was not sup- ported in this study.
At the time of this study, none of the research to date focused on the time of day of the medication administration. In addition, none of the studies included a statistical analysis of the relationship between
interruptions and time for medica- tion administration. The current study addressed both areas.
Purpose The purpose of this study was to
determine the number and type of interruptions, and identify their effect on the time needed for med- ication administration. The study also analyzed the number and type of interruptions by time of day. Finally, the study was to include a statistical analysis of the relation- ship between interruptions and amount of time needed for medica- tion administration.
Methodology
Design This study employed direct
observation of medication adminis- tration. Direct observation can pro- duce valid, reliable results (Feleke, Mulatu, & Yesmaw, 2015; McLeod, Barber, & Franklin, 2015).
Sample Setting The study site was a 271-bed
acute care Magnet® hospital. Nurses cared for an average of six patients. Medical-surgical units were targeted because of concerns about their effi- ciency of medication passes.
Sample Size Medication administration was
observed for 30 patients on two telemetry (40%, n=12), one medical (36.6%, n=11), and one combined medical-surgical-oncology unit (23.3%, n=7). In addition, 52.6% (n=20) were distributed at 9:00 a.m.; 3.3% (n=1) at 1:00 p.m.; 13.3% (n=4) at 5:00 or 6:00 p.m.; 13.3% (n=4) at 9:00 p.m.; and 3.3% (n=1) at 1:00 a.m. Times and distribution of observations were consistent with the percentage of medications administered in a 24-hour period.
Data Collection The study was presented to the
Institutional Review Board (IRB) at Presence Saint Francis Hospital (Evanston, IL) with the checklist for
Purpose
The purpose of this study was to quantify medication administration interruptions on four medical-surgical units and examine their effect on efficiency in the medication administration process.
Background
Interruptions decrease the efficiency of the medication process workflow. Research on the relationship between interruptions and medication errors is not conclusive. Therefore, nurses examining the role of interrup- tions in safety, as opposed to efficiency, need to be mindful of this dis- tinction.
Method
Researchers used direct observation of nurses obtaining, passing, and documenting the administration of patient medications on four medical- surgical units (two telemetry units, one medical-surgical unit, and one combined medical-surgical/oncology unit) in a 271-bed Magnet® com- munity hospital in suburban Chicago.
Findings
Interruptions occurred in 63% of the medication passes (n=30). The mean number of interruptions per medication pass was 1.50 (SD=1.61, CI 0.8975-2.1025). The median number of minutes from obtaining the med- ication to documentation was 7 minutes, increasing to 10.5 minutes with one to two interruptions, and to 16 minutes with three to five interrup- tions. A positive correlation between interruptions and medication pass time was found; thus, the more times the nurse was interrupted, the longer the time required for the medication pass (Spearman’s rho=0.404, p=0.05; n=30).
Conclusions
In this study, interruptions during medication passes resulted in an increased amount of time to pass medications, decreasing efficiency. An action plan was developed that focused on increased preparation before beginning medication rounds along with reduction of unnecessary inter- ruptions during medication rounds. Necessary interruptions, such as calls from physicians, critical lab results, and calls from families, still were per- mitted. This separation of necessary from unnecessary interruptions was based on research that questions the view all interruptions have negative consequences.
Interruptions During Medication Administration: A Descriptive Study
May-June 2016 • Vol. 25/No. 3188
data collection. The IRB approved the study; members determined no need existed for nursing consent because there was no deviation from normal practice, data on nurs- ing identity were not collected, and the standard of care for medication administration did not change. No patient information was collected.
A tool developed by the California Nursing Outcomes Coalition (Raban & Westbrook, 2013) was used for this study, with the following indicators: �• Comparison of medication to the medication administration record (MAR) before administration
�• Lack of distraction or interrup- tion during medication adminis- tration
�• Nurse checking of two forms of patient identification
�• Explanation of medication to the patient
•� Charting of medication on the MAR immediately after adminis- tration The representative workflow mo -
deled after the California Nurs ing Outcomes Coalition tool was re - viewed with a nursing administra- tor and several senior clinical nurses from the study site, chosen because they knew the medication work- flow on the study units. The check- list based on this model was evalu- ated for validity by nurse staff and the Director of Nursing.
Data collectors were educated con- cerning the workflow and purpose of the study. Each point on the tool was identified. Minor changes to the tool included the addition of times at every point. The checklist (see Table 1) was evaluated for reliability by having data collectors observe identi- cal medication passes and complete the tool. Inter-rater reliability was 100% with 10 observations.
Nurses administering medica- tions at identified times on the des- ignated units were chosen for obser- vation. Nurses starting their med- ication pass when the data collector arrived were chosen for observa- tion. Nurses were observed assess- ing laboratory results, vital signs, and patient physical symptoms; obtaining and preparing the med- ication; comparing the medication to the electronically generated
TA B LE 1 .
D at a C ol le ct io n To ol
Da te :
Ti m e
RN re vie ws m ed ica tio ns o n M AR
ye s
no RN o bt ain s m
ed ica tio n
m ed d ra we r
Py xis
re frig er at or
be ds ide
RN co m pa re s m
ed ica tio n to M AR
ye s
no Su pp lie s o bt ain ed
ye s
su pp lie s r eq ue ste d
RN ta ke s m
ed ica tio n to p at ien t
m ed ca rt
tra y
po ck et
RN a ss es se s p at ien t b ef or e ad m ini str at ion
ye s
no 2n d RN a ss es se s d os e
ye s
no NA
RN id en tifi es p at ien t
ch ec ks n am e ba nd
as ks n am e
as ks d at e of b irth
ot he r
RN re vie ws m ed ica tio ns w ith p at ien t
ye s
no RN a dm ini ste rs m ed ica tio n
ye s
no
M ed ica tio n ro ut e
IV IV PB
to pic al
or al
ot he r
Fr eq ue nc y
sta t
PR N
ro ut ine
sin gle d os e
RN re co rd s a dm ini str at ion o n M AR
ye s
no RN ch ar ts in sy ste m
blo od su ga r
vit als
re as on m ed ica tio n no t g ive n
In te rru pt ion s t o RN
ph on e
ph ys ici an
pa tie nt fa m ily
an ot he r p at ien t
an ot he r R N/ sta ff
Pa tie nt re sp on se re co rd ed
ye s
no Nu rs ing u nit
Research for Practice
May-June 2016 • Vol. 25/No. 3 189
MAR; administering the medica- tion; and documenting the admin- istration manually. All parts of the observations were timed.
Results
Frequency of Interruptions No interruptions occurred in
37% (n=11) of the 30 medication passes. One or two interruptions occurred in 33% (n=10) of the pass- es; three to five interruptions occurred in 30% (n=9). Mean inter- ruptions per medication pass were 1.50 (SD=1.61).
Correlation of Number of Interruptions with Time to Administer Medications
The medication pass was timed from when the medication was obtained until it was documented on the MAR. Routine medication passes could include multiple med- ications. Mean time from medica- tion retrieval to documentation was 15.5 minutes, with one observation of medication pass taking 70 min- utes (SD=15.1, n=24). This calcula- tion did not include the entire 30- pass sample size because data on documentation were not available for six medication passes. Median time from retrieval to documenta- tion was 11 minutes. See Figure 1 for median times from obtaining the medication to documentation; median times were used because of the effect of outliers on a small sam- ple. A statistically significant correla- tion between the number of inter- ruptions and the time from obtain- ing the medication to documenta- tion (Spearman’s rho=0.404, p=0.05, n=24), as well as a statistically signif- icant correlation for the time from obtaining medication to administra- tion (Spearman’s rho=0.404, p=0.05, n=30), were found. The sample size was smaller for the former group because data on documentation were not available for six medica- tion passes.
Interruptions by Shift and Unit Type
Interruptions were more frequent during the day shift than the eve -
ning shift (see Figure 2). Day shift interruptions were from telephone calls, other staff, physicians, families, and other procedures. Evening-night shift interruptions were from other staff and telephone calls. Nurses on the day shift also were interrupted by interprofessional staff seeking information or performing patient care. Telemetry units had fewer instances of more than two interrup- tions than either medical-surgical units or medical-surgical oncology units (see Figure 3).
Interruptions to Retrieve Supplies
Nurses retrieved supplies not on the cart during 43% of the observa- tions (n=30). When supplies were obtained, the mean time from obtaining the medication to med- ication administration increased from 5.7 (SD=5.6) to 10.6 minutes (SD=5.4); median time increased from 4 to 11 minutes. Nurse plan- ning influenced the need to inter- rupt the medication pass to obtain supplies. Some nurses stocked their carts before beginning their medica- tion passes; others continually returned during passes to the nurs- es’ station for supplies (e.g., water, applesauce, syringes).
Interruptions to Perform Additional Assessment and Interventions
All nurses spent time reviewing each medication with the electronic printout of the MAR. Nurses also monitored orders for new medica- tions that should be included in the current pass. Some situations called for additional assessment to hold medications or request changes in an order if patients experienced adverse effects or nurses learned of potential contraindications.
Discussion of Findings Interruptions were widespread
during medication passes on four medical-surgical units in a commu- nity hospital, similar to findings of Smeulers and colleagues (2013) and Verweij, Smeulers, Maaskant, and Vermeulen (2014). Sources of inter- ruptions included talking directly with physicians, family members, or other staff; taking telephone calls from staff, family, or nursing homes; obtaining supplies; obtain- ing patients’ assessment informa- tion; stopping to fulfill patient requests; and seeking clarification of orders. By comparison, recent studies found primary sources of interruptions to be other nurses (Hall et al., 2010; McLeod et al.,
FIGURE 1. Median Minutes from Obtaining the Medication to Documentation
by Number of Interruptions
M in ut es
Interruptions
20 18 16 14 12 10 8 6 4 2 0
0 n=7
1-2 n=10
3-5 n=7
7
10.5
16
Interruptions During Medication Administration: A Descriptive Study
May-June 2016 • Vol. 25/No. 3190
2015) and the patients themselves (McLeod et al., 2015). Other inter- ruption sources identified by researchers included transport per- sonnel and alarms (Federwisch, Ramos, & Adams, 2014).
The type of interruption should be analyzed carefully because inter- ruptions may cause a negative or positive patient outcome (Hopkin - son & Jennings, 2013). Beneficial interruptions include being in - formed of laboratory results that would contraindicate giving a med- ication or dose or being provided information of a patient’s earlier symptom (e.g., diarrhea) that could warrant withholding the medica- tion. In fact, communication dur- ing a medication pass may be the only time for critical conversations between physicians and nurses. Positive interruptions also may come from machines (e.g., cardiac monitors, intravenous pumps) noti- fying the nurse of updated patient information that would warrant a delay in medication administration (Jennings, Sandelowski, & Mark, 2011). Eliminating these interrup- tions could lead to negative patient outcomes (Freeman et al., 2013).
Clinical nurses, managers, and directors reviewed and prioritized distractions experienced during medication administration to elimi- nate interruptions that could have a negative effect on patient out- comes. An action plan was devel- oped that included screening of telephone calls during prime med- ication administration times. Calls were categorized as follows: �• Emergent calls continued to go directly to the nurse (e.g., physi- cian, critical laboratory results, patient-family calls).
�• Calls patient care technicians and unit secretaries could address were routed to them (e.g., trans- portation).
�• Other calls were delayed for the nurse to return later (e.g., nursing home follow up, personal calls). To minimize unnecessary inter-
ruptions, nurses received patient reports from transferring units, ensured medications were available, and collected necessary assessment parameters (vital signs and pertinent
FIGURE 2. Medication Pass Interruptions by Shift
Pe rc en
ta ge
100
90
80
70
60
50
40
30
20
10
0
Interruptions 0 1-2 2+
Days n=22
Evenings n=7
Nights n=1
FIGURE 3. Percentage of Medication Passes Interrupted by Unit Type
Pe rc en
ta ge
50
45
40
35
30
25
20
15
10
5
0
Interruptions 0 1-2 2+
Telemetry n=12
Medical n=11
Medical-Surgical, Oncology n=7
42
36
28.5
50
18
28.5
8
46 43
Research for Practice
May-June 2016 • Vol. 25/No. 3 191
laboratory values) before beginning the routine medication pass.
Nursing Implications Medication administration is a
complex process for medical-surgi- cal nurses caring for an average of six patients each. During the task, nurses also analyze adverse medica- tion effects, assess patients’ under- standing of the medication and its side effects, and meet knowledge deficits in preparation for safe administration by the patient when discharged.
The following additional recom- mendations may help minimize unnecessary interruptions: �• Nurses should stock carts with supplies before beginning medica- tion rounds.
�• Consideration should be made for the availability of nursing assistants during the 9:00 a.m. medication pass. In this study, because this medication pass coincided with morning care, nurses often were required to assume tasks nursing assistants otherwise would manage.
�• Messages to nurses during med- ication administration can be in the form of less obtrusive texting rather than telephone calls (Tomietto, Sartor, Mazzocoli, & Palese, 2012).
�• Nurses should know the schedule of patients leaving the unit for physical therapy, x-ray, or proce- dures to give them their medica- tions first. These events thus would not become an interrup- tion.
Limitations Nurses were aware they were
being observed. The direct observa- tion technique has been criticized for altering the behavior of the observed subject. However, the effect can be negligible if observers are experienced, objective, unobtrusive, and nonjudgmental (Westbrook et al., 2010). The small sample size was another limitation. A larger number of observed nurses could have con- tributed to more robust findings.
Recommendations for Future Research
More research is needed to deter- mine if recommended changes to reduce interruptions will lead to increased efficiency and reduced medication errors. More research also is needed on the relationship between interruptions during med- ication administration and patient outcomes. Such research could ana- lyze the type of interruption and determine if it impeded or facilitat- ed the nurse’s role in providing patient care.
Conclusion Nurses must be flexible and avail-
able to meet ever-changing patient conditions (Federwisch et al., 2014). Communicating with physicians, reporting critical laboratory values, receiving important messages from family members, or learning about substantial patient concerns from other nursing staff may be necessary despite their occurrence during medication administration. How - ever, interruptions should be delayed if they are not essential to current medication administration or patient outcome.
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Interruptions During Medication Administration: A Descriptive Study
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