Interruptions during hospital nurses’ medication administration rounds

Medication administration errors are common, costly and the cause of adverse events in clinical practice. Interruptions during medication administration rounds are thought to be a prominent causative factor of these medication errors. In this observational study, data were collected on the number and duration of several different sources of verbal and non-verbal interruptions using unobtrusive structured observations on 32 medication administration rounds. Interruptions occurred very often (6.9 times per nurse each hour), differed in frequency among the medication administration rounds and were from a variety of sources. The most frequent interruptions were caused by nursing colleagues (43%) and non-verbal interruptions from the ward environment (25%), such as noises from pagers, conversations in the vicinity of the nurse, the work of cleaners, or stock management by pharmacy staff. The longest durations of interruptions were from nursing colleagues’ verbal interrup- interruptions. When comparing the medication rounds, more and longer interruptions were observed during the morning rounds than those at noon. A comparison between surgical and non-surgical units showed that interruptions occurred more often and lasted longer in non-surgical units than those in surgical units. But the observed differences were not statistically significant. In conclusion, interruptions during medication administration rounds are frequent and originated from different human and environmental sources. Interventions should target not only interruptions by colleagues, but should also consider ways to reduce self-initiated interruptions and those arising from the immediate ward environment

Best of both worlds: combining evidence with local context to develop a nursing shift handover blueprint

OBJECTIVE: Standardization of the handover process is deemed necessary to ensure continuity and safety of care. However, local context is considered of equal importance to improve the handover process. Our objective was to determine what recommendations on standardized shift handover nurses make, if we combine evidence from the literature with the local context of the nurses. DESIGN: A RAND-modified Delphi consensus process that combines evidence from systematic reviews with expert opinion of local nurses and an evaluation of the consensus process with a survey. SETTING: One academic medical center in the Netherlands. PARTICIPANTS: Twenty nurses from surgical, medical, neurological, psychiatric, cardiology, children's and gynecology departments. RESULTS: Four systematic reviews on nursing handover were included to compose provisional recommendations on how, what, where and the preconditions of shift handover. Nurses reached consensus on a final set of 18 recommendations for a nursing shift handover blueprint: how (1 recommendation), what (12 recommendations), where (3 recommendations) and the preconditions (2 recommendations), which were structured with the mnemonic NURSEPASS. The nurses assessed the method as an effective approach to develop a local blueprint. CONCLUSIONS: Evidence-based consensus is a feasible method to combine evidence from the literature with local context. We anticipate that implementation of the resulting tailored blueprint for nursing shift handover will be facilitated due to the method used. Through evaluation of its effectiveness, we intend to add to the body of evidence on development and implementation of effective nursing handover, which is an essential link for continuity and safety of care

Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients

An accurate handover of clinical information is of great importance to continuity and safety of care. If clinically relevant information is not shared accurately and in a timely manner it may lead to adverse events, delays in treatment and diagnosis, inappropriate treatment and omission of care. During the last decade the call for interventions to improve handovers has increased. These interventions aim to reduce the risk of miscommunication, misunderstanding and the omission of critical information. To determine the effectiveness of interventions designed to improve hospital nursing handover, specifically:to identify which nursing handover style(s) are associated with improved outcomes for patients in the hospital setting and which nursing handover style(s) are associated with improved nursing process outcomes. We searched the following electronic databases for primary studies: Cochrane EPOC Group specialised register (to 19 September 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (to 1 March 2013), MEDLINE (1950 to 1 March 2013) OvidSP, EMBASE (1947 to 1 March 2013) OvidSP, CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1980 to 1 March 2013) EbscoHost and ISI Web of Knowledge (Science Citation Index and Social Sciences Citation Index) (to 9 July 2012). The Database of Abstracts of Reviews (DARE) was searched for related reviews. We screened the reference lists of included studies and relevant reviews. We also searched the WHO International Clinical Trials Registry Platform (ICTRP) http://www.who.int/ictrp/en/ and Current Controlled Trials www.controlled-trials.com/mrct and we conducted a search of grey literature web sites. Randomised controlled trials (RCTs or cluster-RCTs) evaluating any nursing handover style between nurses in a hospital setting with the aim of preventing adverse events or optimising the transfer of accurate essential information required for continuity of care, or both. Two review authors independently assessed trial quality and extracted data. The search identified 2178 citations, 28 of which were considered potentially relevant. After independent review of the full text of these studies, no eligible studies were identified for inclusion in this review due to the absence of studies with a randomised controlled study design. There was no evidence available to support conclusions about the effectiveness of nursing handover styles for ensuring continuity of information in hospitalised patients because we found no studies that fulfilled the methodological criteria for this review. As a consequence, uncertainty about the most effective practice remains. Research efforts should focus on strengthening the evidence abut the effectiveness of nursing handover styles using well designed, rigorous studies. According to current knowledge, the following guiding principles can be applied when redesigning the nursing handover process: face-to-face communication, structured documentation, patient involvement and use of IT technology to support the proces

Quiet please! Drug round tabards: are they effective and accepted? A mixed method study

The use of drug round tabards is a widespread intervention that is implemented to reduce the number of interruptions and medication administration errors (MAEs) by nurses; however, evidence for their effectiveness is scarce. Evaluation of the effect of drug round tabards on the frequency and type of interruptions, MAEs, the linearity between interruptions and MAEs, as well as to explore nurses' experiences with the tabards. A mixed methods before-after study, with three observation periods on three wards of a Dutch university hospital, combined with personal inquiry and a focus group with nurses. In one pre-implementation period and two post-implementation periods at 2 weeks and 4 months, interruptions and MAEs were observed during drug rounds. Descriptive statistics and univariable linear regression were used to determine the effects of the tabard, combined with personal inquiry and a focus group to find out experiences with the tabard. A total of 313 medication administrations were observed. Significant reductions in both interruptions and MAEs were found after implementation of the tabards. In the third period, a decrease of 75% in interruptions and 66% in MAEs was found. Linear regression analysis revealed a model R2 of 10.4%. The implementation topics that emerged can be classified into three themes: personal considerations, patient perceptions, and considerations regarding tabard effectiveness. Our study indicates that this intervention contributes to a reduction in interruptions and MAEs. However, the reduction in MAEs cannot be fully explained by the decrease in interruptions alone; other factors may have also influenced the effect on MAEs. We advocate for further research on complementary interventions that contribute to a further reduction of MAEs. We can conclude that drug round tabards are effective to improve medication safety and are therefore important for the quality of nursing care and the reduction of MAE

Improving handoff communication from hospital to home: the development, implementation and evaluation of a personalized patient discharge letter

To develop, implement and evaluate a personalized patient discharge letter (PPDL) to improve the quality of handoff communication from hospital to home. From the end of 2006-09 we conducted a quality improvement project; consisting of a before-after evaluation design, and a process evaluation. Four general internal medicine wards, in a 1024-bed teaching hospital in Amsterdam, the Netherlands. All consecutive patients of 18 years and older, admitted for at least 48 h. A PPDL, a plain language handoff communication tool provided to the patient at hospital discharge. Verbal and written information provision at discharge, feasibility of integrating the PPDL into daily practice, pass rates of PPDLs provided at discharge. A total of 141 patients participated in the before-after evaluation study. The results from the first phase of quality improvement showed that providing patient with a PPDL increased the number of patients receiving verbal and written information at discharge. Patient satisfaction with the PPDL was 7.3. The level of implementation was low (30%). In the second phase, the level of implementation improved because of incorporating the PPDL into the electronic patient record (EPR) and professional education. An average of 57% of the discharged patients received the PPDL upon discharge. The number of discharge conversations also increased. Patients and professionals rated the PPDL positively. Key success factors for implementation were: education of interns, residents and staff, standardization of the content of the PPDL, integrating the PPDL into the electronic medical record and hospital-wide polic

The trigger tool as a method to measure harmful medication errors in children

OBJECTIVES: The aim of this study was to improve medication safety for children; it is important to quantify the occurrence of preventable medication errors (MEs). A trigger tool may be an effective and time-saving strategy, but its measurement performance is unclear. Therefore, we aimed to estimate the performance of a pediatric medication-focused trigger tool in detecting harmful MEs. METHODS: First, we established a multifaceted method as a reference comparison. Second, we compared the pediatric medication-focused trigger tool with the multifaceted method in a new cohort of patients. All patients admitted in February and March 2013 were screened using the trigger tool and the multifaceted method to obtain full verification. Data collection was performed in separate teams to guarantee blinding of the test results. RESULTS: Review of the clinical records and the voluntary incident reports was most effective in detecting harmful MEs, so this approach was chosen as a reference comparison. In the second part of the study, 369 patients were included. The multifaceted method identified 33 harmful MEs. In contrast, the trigger tool did not identify any harm. When the 2 symptoms pain and nausea/vomiting were added to the trigger tool, 19 harmful MEs were identified. This extended trigger tool resulted in a sensitivity of 21.2 and a positive predictive value of 36.8. CONCLUSIONS: The original pediatric medication-focused trigger tool yielded only false-positive scores and left unsafe situations undiscovered. We conclude that a multifaceted method remains the preferred method to detect harmful MEs. The additional value of the trigger tool stays unclear

Participation of Parents of Hospitalized Children in Medical Rounds: A Qualitative Study on Contributory Factors

Purpose: Factors that promote parents' participation during medical rounds on their hospitalized child have not been fully addressed. The aim of this study was to identify factors that promote the participation of family members during medical rounds. Design and methods: This was a descriptive qualitative study using elements of analysis from the grounded theory method. Semi-structured interviews and non-participant observations were performed from December 2015 until June 2016 and took place on a general academic pediatric ward where the age of children did not exceed 12 months. Results: In total 20 participants were interviewed: 10 pediatric nurses, 4 pediatricians and 6 parents. In addition, five medical rounds were videotaped. Five themes emerged from the analyses of the interviews and videotapes: “conditions”, “structure of medical rounds”, “cast”, “adaptive professionals” and “parents' participation as a process”. Conclusion: Contextual factors, such as the room and seating arrangement, as well as the willingness of healthcare professionals to work together with the parents are important in enabling parents' participation. To promote active participation, professionals have to communicate in layman's terms and information given by parents has to be taken seriously. Support and coaching of parents during the medical rounds and evaluating the rounds are meaningful factors. Practice implications: These findings help healthcare professionals to restructure the traditional medical rounds to enable parents' participation. The identified communication skills and attitudes can enhance the competencies of nurses and doctors as communicators and collaborators. This urge the need for more specific education for professionals to promote parents' participation