Safety in intensive care units no interruptions please: Impact of a no interruption zone on medication

Critical Care Nurse

Volumn 30, Issue 3, 2010, Pages 21-29

  Anthony, Kyle ^a   Wiencek, Clareen ^a,b,c   Bauer, Catherine ^a   Daly, Barbara ^a,b   Anthony, Mary K ^a,d  

^a UNIVERSITY HOSPITALS OF CLEVELAND   (United States)

^b Division of General Internal Medicine   (United States)

^c CASE WESTERN RESERVE UNIVERSITY   (United States)

^d KENT STATE UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; ATTENTION; AVIATION; CASE REPORT; CONSTRUCTION WORK AND ARCHITECTURAL PHENOMENA; DRUG THERAPY; EDUCATION; EPIDEMIOLOGY; EVALUATION; FURNITURE; HEALTH CARE FACILITY; HEALTH CARE QUALITY; HUMAN; INDUSTRY; INTENSIVE CARE UNIT; MALE; MEDICATION ERROR; MIDDLE AGED; NURSE ATTITUDE; NURSING; NURSING EVALUATION RESEARCH; NURSING STAFF; ORGANIZATION AND MANAGEMENT; PILOT STUDY; PSYCHOLOGICAL ASPECT; SAFETY; STATISTICS; SYSTEM ANALYSIS; UNITED STATES; UNIVERSITY HOSPITAL;

ACADEMIC MEDICAL CENTERS; ATTENTION; AVIATION; CAUSALITY; DRUG THERAPY; HEALTH FACILITY ENVIRONMENT; HUMANS; INDUSTRY; INTENSIVE CARE UNITS; INTERIOR DESIGN AND FURNISHINGS; LOCATION DIRECTORIES AND SIGNS; MALE; MEDICATION ERRORS; MIDDLE AGED; NURSE'S ROLE; NURSING EVALUATION RESEARCH; NURSING STAFF, HOSPITAL; OHIO; PILOT PROJECTS; PROGRAM EVALUATION; SAFETY MANAGEMENT; SYSTEMS ANALYSIS;

EID: 77956697132     PISSN: 02795442     EISSN: None     Source Type: Journal    
DOI: 10.4037/ccn2010473     Document Type: Article

References (26)

1. White P, McGillis H. Patient safety outcomes. In: Doran D, ed. Nursing Sensitive Outcomes: State of the Science. Sudbury, MA: Jones and Bartlett; 2002:211-242.
2. Kane-Gill S, Weber R. Principles and practices of medication safety in the ICU. Crit Care Clin. 2006;22:273-290.
3. Rothschild J, Landrigan C, Cronin J, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medication errors in intensive care. Crit Care Med. 2005;33:1694-1697.
4. Valentin, A, Capuzzo, M, Guidet, B, et al. Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) Study. Intensive Care Med. 2006; 32: 1591-1598.
5. Agency for Healthcare Research and Quality. Medication administration safety. In: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008: chap 37. AHRQ publication 08-0043.
6. Federal Aviation Industry. Electronic Code of Regulations, Title 14, sections 121.542 and 135.100. 1981. http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=/ecfrbrowse /Title14/14tab_02.tpl. Accessed November 20, 2009.
7. National Coordinating Council for Medication Error Reporting and Prevention. What is a medication error? www.nccmerp.org /aboutMedErrors.html. Accessed November 20, 2009.
8. Barker K, Flynn E, Pepper G, et al. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162:1897-1903.
9. Joint Commission. Sentinel Event Statistics. 2009. http://www.jointcommission.org/SentinelEvents/Statistics. Accessed November 20, 2009.
10. O'Shea E. Factors contributing to medication errors: a literature review. J Clin Nurs. 1999;8:496-504.
11. Armitage G, Knapman H. Adverse events in drug administration: a literature review. J Nurs Manage. 2003;11:130-140.
12. Roseman C, Booker J. Workload and environmental factors in hospital medication errors. Nurs Res. 1995;44:226-230.
13. Williams A. How to avoid mistakes in medication administration. Nurs Times. 1996; 92:40-41.
14. Potter P, Wolf L, Boxerman S, et al. An analysis of nurses' cognitive work: a new perspective for understanding medical errors. In: Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation. Vol. 1. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ publication 05-0021-1.
15. Manojlovich M, DeCicco B. Healthy work environments, nurse-physician communication, and patients' outcomes. Am J Crit Care. 2007;16:536-543.
16. Tissot E, Cornette C, Demoly P, et al. Medication errors at the administration stage in an intensive care unit. Intensive Care Med. 1999;25:353-359.
17. Potts A, Barr F, Gregory D, et al. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics. 2004;113:59-63.
18. Cummings J, Bush P, Smith D, et al. UHC bar-coding medication administration overview and consensus recommendations. Am J Health Sys Pharm. 2005;62:2626-2630.
19. Leape L, Cullen D, Clapp M, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282:267-270.
20. Pape T. Applying airline safety practices to medication administration. Medsurg Nurs. 2003;12,2:77-93.
21. FSF ALAR Briefing note 2.4: Interruptions/Distractions. Flight Safety Foundation ALAR (Approach-and-Landing Accident Reduction) Tool Kit. Flight Safety Digest. 2000;19:55-58.
22. Agency for Healthcare Research and Quality. Appendix E: Case studies in high reliability applications: medication dispensing machine redesign and executive walkarounds at Sentara Leigh. In: Becoming a High-Reliability Organization: Operation Advice for Hospital Leaders. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ publication 08-0022.
23. Federwisch A. Keep Away: Kaiser South San Francisco RNs don yellow sashes to reduce interruptions and medication errors. 2008. http://include.nurse.com/apps/pbcs.dll/article?AID=/20080714/CA01/107140 073 &template. Accessed November 20, 2009.
24. Agency for Healthcare Research and Quality. Becoming a High-Reliability Organization: Operation Advice for Hospital Leaders. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ publication 08-0022.
25. Beyea SC. High-reliability theory and highly reliable organizations. AORN J. 2005;81: 1319-1322.
26. Institute of Medicine. To Err Is Human: Building a Safer Health System.Washington, DC: The National Academy Press; 2000.