Failing to check a patient's identification against his or her medication chart and administering medication at the wrong time were the most common procedural and clinical glitches, respectively, the study reported.
In an accompanying editorial, Kliger described one potential remedy: A "protected hour" during which nurses would focus on medication administration without having to do such things as take phone calls or answer pages.
The idea, Kliger said, is based on the U.S. Federal Aviation Administration's "sterile cockpit" rule. That rule, according to the Aviation Safety Reporting System, prohibits non-essential activities and conversations with the flight crew during taxi, takeoff, landing and all flight operations below 10,000 feet, except when the safe operation of the aircraft is at stake.
Likewise, in nursing, not all interruptions are bad, Westbrook added.
"If you are being given a drug and you do not know what it is for, or you are uncertain about it, you should interrupt and question the nurse," she said.
The Institute for Safe Medication Practices has more on safe medication use.
SOURCES: Johanna I. Westbrook, Ph.D., professor, health informatics, and director, Health Informatics Research and Evaluation Unit, University of Sydney, Australia; Carol Keohane, R.N., program director, Center of Excellence for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston; Linda Flynn, R.N., Ph.D., associate professor, University of Maryland School of Nursing, Baltimore; Julie Kliger, R.N., M.P.A., program director, Integrated Nurse Leadership Program, Center for the Health Professions, University of California, San Francisco; Aviation Safety Reporting System, NASA, Mo
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