Among nurses at 2 hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors.
BackgroundIntravenous medication administrations have a high incidence of error but there is limited evidence of associated factors or error severity.ObjectiveTo measure the frequency, type and severity of intravenous administration errors in hospitals and the associations between errors, procedural failures and nurse experience.MethodsProspective observational study of 107 nurses preparing and administering 568 intravenous medications on six wards across two teaching hospitals. Procedural failures (eg, checking patient identification) and clinical intravenous errors (eg, wrong intravenous administration rate) were identified and categorised by severity.ResultsOf 568 intravenous administrations, 69.7% (n=396; 95% CI 65.9 to 73.5) had at least one clinical error and 25.5% (95% CI 21.2 to 29.8) of these were serious. Four error types (wrong intravenous rate, mixture, volume, and drug incompatibility) accounted for 91.7% of errors. Wrong rate was the most frequent and accounted for 95 of 101 serious errors. Error rates and severity decreased with clinical experience. Each year of experience, up to 6 years, reduced the risk of error by 10.9% and serious error by 18.5%. Administration by bolus was associated with a 312% increased risk of error. Patient identification was only checked in 47.9% of administrations but was associated with a 56% reduction in intravenous error risk.ConclusionsIntravenous administrations have a higher risk and severity of error than other medication administrations. A significant proportion of errors suggest skill and knowledge deficiencies, with errors and severity reducing as clinical experience increases. A proportion of errors are also associated with routine violations which are likely to be learnt workplace behaviours. Both areas suggest specific targets for intervention.
Objective: To quantify time doctors in hospital wards spend on specific work tasks, and with health professionals and patients. Design: Observational time and motion study. Setting: 400‐bed teaching hospital in Sydney. Participants: 19 doctors (seven registrars, five residents, seven interns) in four wards were observed between 08:30 and 19:00 for a total of 151 hours between July and December 2006. Main outcome measures: Proportions of time in categories of work; proportions of tasks performed with health professionals and patients; proportions of tasks using specific information tools; rates of multitasking and interruptions. Results: The greatest proportions of doctors’ time were in professional communication (33%; 95% CI, 29%–38%); social activities, such as non‐work communication and meal breaks (17%; 95% CI, 13%–21%), and indirect care, such as planning care (17%; 95% CI, 15%–19%). Multitasking involved 20% of time, and on average, doctors were interrupted every 21 minutes. Most tasks were completed with another doctor (56%; 95% CI, 55%–57%), while 24% (95% CI, 23%–25%) were undertaken alone and 15% (95% CI, 15%–16%) with a patient. Interns spent more time completing documentation and administrative tasks, and less time in direct care than residents and registrars. The time interns spent documenting (22%) was almost double the time they were engaged in direct patient care. Conclusions: Two‐thirds of doctors’ time was consumed by three work categories: professional communication, social activities and indirect care. Doctors on wards are interrupted at considerably lower rates than those in emergency and intensive care units. The results confirm interns’ previously reported dissatisfaction with their level of administrative work and documentation.
Objectives: To evaluate whether introduction of an emergency department (ED) telemedicine system changed patient management and outcome indicators and to investigate clinicians’ perceptions of the impact of the system on care provided and on their work. Design: Before‐and‐after study of use of the Virtual Critical Care Unit (ViCCU), which uses an ultrabroadband connection allowing real‐time audiovisual communication between clinicians at distant sites. Semi‐structured interviews were conducted with medical and nursing staff at the end of the study. Participants and setting: The ViCCU intervention commenced on 1 January 2004. Our study was conducted in the EDs of an 85‐bed district hospital and a 420‐bed metropolitan tertiary hospital. It involved all acutely ill patients requiring urgent care (defined by triage category and grouped into critical care, major trauma and moderate trauma) who were treated during the 12 months before (n = 169) and 18 months after (n = 181) the intervention at the district hospital. Thirty‐one of 33 clinicians (doctors and nurses) participating at the two hospitals took part in interviews at the end of the study. Main outcome measures: Changes in patterns of management (disposition [admission, discharge or transfer], treatment times, number of procedures) and outcomes (rapid acute physiology scores, hours on ventilation or in intensive care, length of stay). Results: Patient disposition remained unaltered for major trauma patients. For critical care patients, admissions fell significantly (54% to 30%), transfers increased (21% to 39%), and more procedures were performed. For moderate trauma patients, discharges increased significantly (45% to 63%), transfers decreased (48% to 25%) and treatment times were longer. No significant changes were found in outcome indicators. Clinicians reported that the ViCCU allowed greater support to remote clinicians. Specialists reported increased workloads and feelings of greater responsibility for patients at the district hospital. Nurses at the district site reported reduced stress, but district doctors reported some loss of autonomy. Conclusions: The ViCCU appears most effective for moderate trauma patients, with associated reductions in admissions and transfers. Large‐scale trials of telemedicine systems that include measurements of both patient care and impact on clinicians’ work are required.
Abstract— The prevalence and severity of fractures of anterior teeth among 12 287 high school students in two areas of northern Sydney was recorded. Overall, six per cent of students had suffered fractures involving dentine or pulp. Twenty‐three per cent of these teeth were non vital. In the less affluent area more fractured teeth remained untreated. Trauma prevalence was twice as high amongst boys as girls; body contact, sports, and bicycles contributed most to this finding.
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