Interruptions and distractions were the main reasons given for drug errors, in a study at one acute hospital trust.
These were mentioned 14 times as contributing to drug errors in a three month pilot study of an enhanced reporting scheme carried out at Bradford Teaching Hospitals Foundation Trust. Heavy workload and labelling errors were both mentioned 10 times in the 49 reports included in the study.
Although the numbers are too small to be statistically significant, research by Gerry Armitage, a senior research fellow at Bradford Institute for Health Research, confirms interruptions is a factor that needs to be dealt with.
“We live in a time pressured environment and interruptions and distractions are contributing,” he told a healthcare events conference on improving patient safety on wards in Manchester last week.
The Bradford Hospitals’ reporting scheme is being further tested in a multicentred pilot study, and the full findings are likely to be published at the end of the year.
The work is part of a project funded by the Department of Health that explores factors connected with drug errors and the reporting of them carried out between 2004 and 2007. It included a systematic review of literature on the topic (unpublished), a retrospective analysis of 991 drug error reports (Clinical Governance 2007;12:102-14), and 40 in depth interviews with doctors, nurses, and pharmacists (unpublished).
Fifteen doctors, 15 nurses, and 10 pharmacists were interviewed. Interruptions, work pressures, and the double checking of medicines were perceived as common contributory factors across all disciplines of respondents, Gerry Armitage said.
One nurse told him: “When an incident’s happened, you look at the factors leading up to it. I think interruptions, nine times out of ten, is there…you just can’t concentrate on doing your medicines and nothing else.”
Another said: “Managers are…the first who’ll sit down and say, ‘Right, we have to tackle these drug errors. Let’s put tabards [short sleeveless tunics] on [when you are dispensing medicines] to stop you being interrupted,’ but they are the first ones who are on the phone saying, ‘Actually, no, can I speak to her now.’”
Tabards might be a reasonable idea, commented Mr Armitage, but there were deeper issues around ways of working. “It is not just business interruptions that interfere with medicine administration, it is social interruptions as well. This inability to say ‘No, not now’ is indicative of a cultural problem.”
Evidence also suggests resourceful and adaptable staff who “normalise” interruptions are hiding away organisational weaknesses, he added.
“We need to almost systematise our interruptions, which is approach advocated by some in the aviation industry. People should interrupt at the right time and the interruption process should enhance the persuasiveness of what we are saying.”
Possible solutions include using a red flag system in environments where medicines are prepared, increasing staff knowledge of how errors occur, and changing staff attitudes so that they sometimes refuse to be interrupted. To do this there has to be improved reporting with cues for learning, especially at the point of reporting, said Mr Armitage. Feedback and praise for reporting errors was also crucial to reinforce its importance because staff said they saw little result or response from making the effort to report.
Suzette Woodward, conference chairwoman and director of the strategy unit for the National Patient Safety Agency, agreed. “Interruptions need addressing. They are indicative of a wider problem with the culture,” she said.
Improving Patient Safety on the Wards www.healthcare-events.co.uk