Module 12 Medication Pass No Interruptions

Medication Errors The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as follows: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumer

Causes of Medication Error Multiple factors can contribute to medication errors including nurse’s workload experience level transcription errors, and system deficiencies Distractions and interruptions

Interrupted Workflow In a French study, Tissot and colleagues reported that interrupted workflow during medication administration was a contributing factor to the 6.6% error rate in medication administration.

Interruptions a break in continuity of complete focus on the task of preparing medication verbal or nonverbal cue from another individual prompting the nurse to give a verbal or nonverbal response losing focus on medication preparation and initiating conversation with another person

Strategies to Reduce Errors Computer-based order entry Patient and medication barcode scanning The “Sterile Cockpit Rule” No Interruption Zone (NIZ)

Sterile Cockpit Rule The Federal Aviation Administration in 1981 enacted policies that prohibit nonessential tasks and communications by aircraft personnel during flight operations Distractions and interruptions resulting in omissions or inappropriate actions during flight operations This adherence to the sterile cockpit rule minimizes distractions during critical periods of flight operations and improves airline safety.

No Interruption Zone The NIZ is fashioned after the aviation industry’s “sterile cockpit rule.” Change in nurses’ ability to pass medications more efficiently and think more clearly. No interruptions during med pass Do not allow distractions Avoid personal conversations Avoid phone calls No multitasking

Prevent Phone Distractions Communicate prior to passing medications that you will unable to answer the phone and to take a message Place your phone on vibrate Leave your phone with another nurse Do not multi-task Do not answer the phone while preparing or administering medications

Patient Safety Nurses are primarily responsible for medication safety National initiatives are calling for an increase in medication safety During medication preparation, a No Interruption Zone could decrease interruptions and enhance safety Reference Anthony, K., Wiencek, C., Bauer, C., Daly, B. and Anthony, M. K. (2010). No interruptions please: Impact on a no interruption zone on medication safety. Critical Care Nurse 2010, 30:21-29. doi: 10.4037/ccn2010473 © 2010 American Association of Critical-Care Nurses. Retrieved from: http://ccn.aacnjournals.org/content/30/3/21.full.pdf+html