Disruptions cause medication disruptions.

(Tittle:) Avoidable Interruption During Drug Administration in an Intensive Rehabilitation Ward: Improvement Project.

(Authors:) Sara Buchini and Rosanna Quattrin.

(Source:) Journal of Nursing Management 20, 326-334.

Many medical errors cause irreversible and tragically avoidable human death and suffering. This study, which is based on data collected from observations of Italian hospitals, is trying to find ways to stop medication error. Medication error is when a patient is given the wrong medicine or is given overdose. These medication errors cause thousands of death each year in Italy. All medication errors are avoidable and are caused by ineffectual book keeping, unsatisfactory management, and poor training of medical staff. This study focuses on nurses who are primarily responsible for giving patients their medication.

The disruption that leads to the medication error happens during the preparation and administration of the drug.  Preparation of a drug has many steps that can be disrupted by a miss calculation, bad organization, or a random event (like patient falling and needing help). This can lead to a patient receiving an overdose or the wrong medicine.

A nurse administrating medicine can be distracted by a disruption; this can lead to the nurse to not log the medicine administration. If the nurse does not log the session then another nurse will give the patient the medicine again, this can cause an overdose. Nurses are disrupted between 2.8 and 14 time an hour. All these disruptions can lead to medication error.

Medication error can be avoided if hospitals make improvements. These include better methods of keeping medication records, having more nurses to spread out work load, and giving nurses better training.