Abstract
Despite the safety-critical nature of healthcare, it is an interrupt-laden domain. Patient safety organizations have long called for a reduction in interruptions to healthcare workers, in an effort to reduce the likelihood of preventable medical error occurring during patient care. The goal of this research was to examine the impact that interruptions have on nurses’ task performance during medication administration, specifically intravenous (IV) push delivery, and the development of appropriately designed interventions to mitigate the potential harmful effects of interruptions on patient safety. IV push administration errors have been found to be common, and occur when doses are administered faster or slower than recommended. Direct observations found that nurses were interrupted every time they administered an IV push, sometimes more than once. Furthermore, the percentage of nurses who made errors when performing IV pushes during simulated scenarios was significantly higher when interrupted than in the uninterrupted condition. Data collected through focus groups qualitatively described perceptions and preferences that led to the design of a successful and appropriate intervention to solve this important patient safety problem.
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