The use of drug round tabards
The use of drug round tabards is a widespread intervention that is implemented to reduce the number of interruptions and medication administration errors (MAEs) by nurses; however, evidence for their effectiveness is scarce. Purpose: Evaluation of the effect of drug round tabards on the frequency and type of interruptions, MAEs, the linearity between interruptions and MAEs, as well as to explore nurses’ experiences with the tabards. Study Design: A mixed methods before-after study, with three observation periods on three wards of a Dutch university hospital, combined with personal inquiry and a focus group with nurses. Methods: In one pre-implementation period and two post-implementation periods at 2 weeks and 4 months, interruptions and MAEs were observed during drug rounds. Descriptive statistics and univariable linear regression were used to determine the effects of the tabard, combined with personal inquiry and a focus group to ﬁnd out experiences with the tabard. Findings: A total of 313 medication administrations were observed. Signiﬁcant reductions in both interruptions and MAEs were found after implementation of the tabards. In the third period, a decrease of 75% in interruptions and 66% in MAEs was found. Linear regression analysis revealed a model R2 of 10.4%. The implementation topics that emerged can be classiﬁed into three themes: personal considerations, patient perceptions, and considerations regarding tabard effectiveness. The use of drug round tabards
The possible effect of medication errors (MEs) on patient safety raises concerns for healthcare safety boards
worldwide. In reaction to this problem, boards incorporate quality items and safety goals into their programs
that require action by the hospitals (Institute for Safe Medication Practices, 2014; World Health Organization High 5, 2014). Literature indicates that the ME rate may vary from 5% to 25% in all episodes of in-hospital drug administration, but only 19% are reported (Antonow, Smith, & Silver, 2000; Krahenbuhl-Melcher et al., 2007; Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). This could indicate that the actual incidence rates might be higher. Therefore, MEs endanger the safety of patients. MEs occur in every stage of the medication process, with 50% of them associated with medication administration (Krahenbuhl-Melcher et al., 2007). In hospitals, nurses are generally responsible for this stage in the medication process. In general, interruptions or distractions are recognized toreduceefﬁciency andcontributetoerrors(Brixeyetal., 2007). In speciﬁc, interruptions appear to be a prominent causative factor for medication administration errors (MAEs; Biron, Loiselle, & Lavoie-Tremblay, 2009; Freeman, McKee, Lee-Lehner, & Pesenecker, 2012; Trbovich, Prakash, Stewart, Trip, & Savage, 2010; Westbrook et al., 2010). The literature describes several initiatives that inﬂuence nursing medication practice to reduce MAEs (Hodgkinson, Koch, Nay, & Nichols, 2006; Raban & Westbrook, 2013). One of these interventions includes tabards, or vests, with the inscription “do not disturb” or visible signage. The use of drug round tabards is a widespread, inexpensive intervention that is thought to reduce the number of interruptions during drug rounds and MAEs. However, in practice the tabards are unpopular among nurses; they doubt their effectiveness and do not feel comfortable wearing them. Additionally, the evidence on effectiveness of using tabards is limited (Raban & Westbrook, 2013; Scott, Williams, Ingram, & Mackenzie, 2010). When evidence is lacking, the incentive to wear a tabard will be especially weak and one can become reluctant to implement interventions (Glasziou, Ogrinc, & Goodman, 2011; Smeulers, Onderwater, van Zwieten, & Vermeulen, 2014). If the effectiveness of these tabards can be established and barriers and facilitators can be identiﬁed, implementation in clinical practice will be facilitated and endorsed. Therefore, the aim of our study is to evaluate the effect of drug round tabards on (a) the frequency and type of interruptions, (b) the number and type of MAEs, and (c) the magnitude of the relation between interruptions and MAEs during the process of preparation, distribution, and administration of medication in hospital wards. In addition, we explored nurses’ perspectives and experiences with drug round tabards to identify barriers and facilitators for implementation. The use of drug round tabards
Three wards in a Dutch 1,024-bed university hospital contributed to this study: neurology, neurosurgery, and a combined ward with dermatology, ophthalmology, and ENT services. In total, these wards contain 60 beds. Each ward has a closed medication storage and preparation room where medication carts are stored for use during drug rounds. These carts are equipped with drawers and ﬁles containing computer-printed medication prescriptions for each patient. All oral medications are distributed for 24 hr and are checked once by the ward’s night shift. Fluids, intravenous medications, and other medications for injection are prepared and doublechecked during each drug round directly before drug administration. The use of drug round tabards
The participants were all registered nurses. Each had an individual responsibility for distributing medications to their assigned patients.
We performed a mixed method study, using a beforeafter design to collect the number of interruptions and MAEs during drug rounds before the implementation of the tabard in April 2012 (period 1), as well as 2 weeks and 4 months after tabard implementation (i.e., in May and September 2012, respectively periods 2 and 3). An interruption or a distraction was deﬁned as an event initiated by another professional(s) or something else, and when a nurse interrupted him- or herself. In this study, the term interruption was used for distractions as well as for interruptions. MAEs are deﬁned as a breach of one of the seven rights of medication administration: correct patient, drug, dose, time, route, reason, and documentation (Pape, 2003). During period 2, nurses’ perspectives regarding the tabard were collected by documenting spontaneous remarks and asking a single question at the end of the observation: “What is your experience with the drug round tabard?” In period 3, in-depth information on nurses’ perspectives, experiences, and views was collected in a focus group setting to gain insight in barriers and facilitators for implementation of the drug round tabards. The use of drug round tabards
Ethical approval was not considered necessary by the Institutional Review Board of the Academic Medical
Center at the University of Amsterdam. This is in accordance with the Dutch Medical Ethics Law. The use of drug round tabards
Following baseline observation period 1, the intervention was introduced during a 5-day implementation week. All nurses working on the participating wards were instructed to wear the tabards while preparing and administering the medications. Instructions were given by e-mail, posters, and a promotional ﬁlm. Tabards were ﬂuorescent yellow with printed text on the back and small text on the chest, reading “Do not disturb, medication round in progress.” After the implementation week, we refrained from instruction on behavior during the drug rounds to determine the unbiased effect of the tabard. Information on the exact observer’s task, documentation frequency, type of interruptions, and MAEs per observed nurse remained blinded.
Observers All observers (n = 6) were ﬁnal phase baccalaureate nursing students who have followed approximately 2 years of apprenticeship. The observers got instruction on how to score and interpret the items on the observation checklist and also to interfere if they observed MAEs that might be harmful to the patient. Although the students had not graduated yet at the time of the study, we were convinced that they had sufﬁcient knowledge and awareness to assess the severity of clinical situations. The use of drug round tabards
Quantitative data were collected on eight different categories of interruptions that are grouped into either verbal or nonverbal interruptions, based on a previously published observation form (Table 1; Smeulers, Hoekstra, van Dijk, Overkamp, & Vermeulen, 2013). To observe the frequency and type of MAEs, we merged it with the “seven right” items of Pape et al. (2003) that we converted into “seven wrongs”: wrong patient, dose, medication, timing, route, indication, and reporting. In a pilot phase, the observersperformedeight observationsin pairs to validate the checklist. To determine observation agreement on the counting of interruptions and MAEs, the interobserver agreement was calculated using the interclass correlation coefﬁcient (ICC). Of the 14 items, 12 items scored an ICC > .80 (almost perfect agreement) and 2 items (i.e., verbal interruptions caused by patients and nonverbal interruptions caused by the surrounding) scored an ICC between .55 and .60 (moderate agreement; The use of drug round tabards
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