Two Hospitals Collaborate to Reduce Medication Errors Using Human Factors Approaches

Abstract

(41st Biennial Convention) Background/Purpose: Human factors science is an important consideration in preventing medication errors as interruptions continue to be leading causes of medication errors. Teamwork often helps prevent influences of outside forces upon the nurse during medication administration. The purpose of the study was to determine whether specific but different interventions at two hospitals in different cities would reduce medication errors and whether nurses would perceive a decrease in interruptions. Methods: Interventions in Hospital A included: a quiet zone, education, signs, checklist, and nurses carrying red folders containing medication sheets as a sign to not interrupt. Interventions in Hospital B included: a quiet zone, education, signs, checklist, and wearing of a sash as a symbol not to interrupt. Nurses were surveyed using Psychdata via email about number and type of interruptions during medication administration before and after interventions. SPSS 18.0 was used to analyze data. Results: The sample of nurses (n = 236) completing the survey pre and post intervention included: 91% females (n = 215), and 9% males (n = 21) aged 23-67 (µ = 42). Education levels were: LVN (3%; n =7), ADN (35.6%; n = 84), Diploma (7.2%; n = 17), BSN (51.3%; n = 121), MSN or other (3%; n = 7). ANOVA showed significant mean differences based on hospital setting, and that Hospital B reported higher levels of interruptions (p <.001). While there was no change in medication errors with Hospital A, Hospital B reported a 49% decrease compared to the previous five months. Both hospitals demonstrated mean decreases in many interruption categories. Conclusion: Our research demonstrates that specific interventions reduce medication errors and interruptions for nurses. The most affected categories of interruptions will be described. The need for further research to improve safe medication administration using human factors approaches as a global initiative will be emphasized.