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      Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study

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          Abstract

          Aim

          To evaluate the effectiveness of a ‘Do not interrupt’ bundled intervention to reduce non-medication-related interruptions to nurses during medication administration.

          Methods

          A parallel eight cluster randomised controlled study was conducted in a major teaching hospital in Adelaide, Australia. Four wards were randomised to the intervention which comprised wearing a vest when administering medications; strategies for diverting interruptions; clinician and patient education; and reminders. Control wards were blinded to the intervention. Structured direct observations of medication administration processes were conducted. The primary outcome was non-medication-related interruptions during individual medication dose administrations. The secondary outcomes were total interruption and multitasking rates. A survey of nurses' experiences was administered.

          Results

          Over 8 weeks and 364.7 hours, 227 nurses were observed administering 4781 medications. At baseline, nurses experienced 57 interruptions/100 administrations, 87.9% were unrelated to the medication task being observed. Intervention wards experienced a significant reduction in non-medication-related interruptions from 50/100 administrations (95% CI 45 to 55) to 34/100 (95% CI 30 to 38). Controlling for clustering, ward type and medication route showed a significant reduction of 15 non-medication-related interruptions/100 administrations compared with control wards. A total of 88 nurses (38.8%) completed the poststudy survey. Intervention ward nurses reported that vests were time consuming, cumbersome and hot. Only 48% indicated that they would support the intervention becoming hospital policy.

          Discussion

          Nurses experienced a high rate of interruptions. Few were related to the medication task, demonstrating considerable scope to reduce unnecessary interruptions. While the intervention was associated with a statistically significant decline in non-medication-related interruptions, the magnitude of this reduction and its likely impact on error rates should be considered, relative to the effectiveness of alternate interventions, associated costs, likely acceptability and long-term sustainability of such interventions.

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          Most cited references 33

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          Association of interruptions with an increased risk and severity of medication administration errors.

          Interruptions have been implicated as a cause of clinical errors, yet, to our knowledge, no empirical studies of this relationship exist. We tested the hypothesis that interruptions during medication administration increase errors. We performed an observational study of nurses preparing and administering medications in 6 wards at 2 major teaching hospitals in Sydney, Australia. Procedural failures and interruptions were recorded during direct observation. Clinical errors were identified by comparing observational data with patients' medication charts. A volunteer sample of 98 nurses (representing a participation rate of 82%) were observed preparing and administering 4271 medications to 720 patients over 505 hours from September 2006 through March 2008. Associations between procedural failures (10 indicators; eg, aseptic technique) and clinical errors (12 indicators; eg, wrong dose) and interruptions, and between interruptions and potential severity of failures and errors, were the main outcome measures. Each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors. The association between interruptions and clinical errors was independent of hospital and nurse characteristics. Interruptions occurred in 53.1% of administrations (95% confidence interval [CI], 51.6%-54.6%). Of total drug administrations, 74.4% (n = 3177) had at least 1 procedural failure (95% CI, 73.1%-75.7%). Administrations with no interruptions (n = 2005) had a procedural failure rate of 69.6% (n = 1395; 95% CI, 67.6%-71.6%), which increased to 84.6% (n = 148; 95% CI, 79.2%-89.9%) with 3 interruptions. Overall, 25.0% (n = 1067; 95% CI, 23.7%-26.3%) of administrations had at least 1 clinical error. Those with no interruptions had a rate of 25.3% (n = 507; 95% CI, 23.4%-27.2%), whereas those with 3 interruptions had a rate of 38.9% (n = 68; 95% CI, 31.6%-46.1%). Nurse experience provided no protection against making a clinical error and was associated with higher procedural failure rates. Error severity increased with interruption frequency. Without interruption, the estimated risk of a major error was 2.3%; with 4 interruptions this risk doubled to 4.7% (95% CI, 2.9%-7.4%; P < .001). Among nurses at 2 hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors.
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            Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic).

             T. McGinn (2004)
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              A meta-analysis of the effects of cell phones on driver performance.

              The empirical basis for legislation to limit cell phones while driving is addressed. A comprehensive meta-analysis of the effects of cell phones on driving performance was performed. A total of 33 studies collected through 2007 that met inclusion criteria yielded 94 effect size estimates, with a total sample size of approximately 2000 participants. The dependent variables of reaction time, lateral vehicle control, headway and speed and the moderating variables of research setting (i.e., laboratory, simulator, on-road), conversation target (passenger, cell phone) and conversation type (cognitive task, naturalistic) were coded. Reaction time (RT) to events and stimuli while talking produced the largest performance decrements. Handheld and hands-free phones produced similar RT decrements. Overall, a mean increase in RT of .25s was found to all types of phone-related tasks. Observed performance decrements probably underestimate the true behavior of drivers with mobile phones in their own vehicles. In addition, drivers using either phone type do not appreciably compensate by giving greater headway or reducing speed. Tests for moderator effects on RT and speed found no statistically significant effect size differences across laboratory, driving simulation and on-road research settings. The implications of the results for legislation and future research are considered.
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                Author and article information

                Journal
                BMJ Qual Saf
                BMJ Qual Saf
                qhc
                bmjqs
                BMJ Quality & Safety
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-5415
                2044-5423
                September 2017
                23 February 2017
                : 26
                : 9
                : 734-742
                Affiliations
                [1 ] Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University , Sydney, New South Wales, Australia
                [2 ] Australian Institute of Health Innovation, Macquarie University , Sydney, New South Wales, Australia
                [3 ] Nursing Research Institute, St. Vincent's & Mater Health Sydney and Australian Catholic University , Darlinghurst, New South Wales, Australia
                [4 ] Faculty of Pharmacy, Sydney, New South Wales, Australia
                Author notes
                Correspondence to Professor Johanna Westbrook, Macquarie University, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Sydney, NSW 2109, Australia; Johanna.westbrook@ 123456mq.edu.au
                Article
                bmjqs-2016-006123
                10.1136/bmjqs-2016-006123
                5574391
                28232390
                1cff1913-de83-4b59-a3c3-9d8fbecfce53
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                Product
                Funding
                Funded by: National Health and Medical Research Council, http://dx.doi.org/10.13039/501100000925;
                Award ID: Program grant APP1054146
                Categories
                1506
                1507
                Original Research
                Custom metadata
                unlocked
                editors-choice

                Public health

                medication safety, nurses, randomised controlled trial, interruptions, cluster trials

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