The effectiveness of drug round tabards in reducing incidence of medication errors
Medication errors can be caused by interruptions during drug rounds. This study reports on the impact of drug round tabards on such interruptions
Jude Scott, BSc, RGN, is clinical effectiveness facilitator; David Williams, PhD, MB, BAO, BCh, FRCPE, was clinical lead for patient safety at the time of audit; Jennifer Ingram, Grad Dip Phys, BSc, is risk management adviser - patient safety; Fiona Mackenzie, MA, PGCE, BSc, RGN, OND, was lead nurse for the acute sector at the time of audit; all at Aberdeen Royal Infirmary, NHS Grampian.
Scott J et al (2010) The effectiveness of drug round tabards in reducing incidence of medication errors. Nursing Times; 106: 34, 13-15.
A number of inpatients experience medication errors, which carry potential risks for patients and have cost implications for the NHS. These errors are often a result of interruptions during drug rounds.
Aim This audit study explored whether introducing drug round tabards reduced the number of interruptions during drug rounds and improved patient care and safety.
Method Red tabards, embroidered front and back with “Drug round in progress please do not disturb”, were introduced in three wards. A tick box questionnaire was used to collect information on interruptions during each drug round. NHS Grampian’s Datix incident reporting system was reviewed for medication errors during the audit period and tabards were randomly swabbed to see if any cultures had grown.
Results and discussion The average number of interruptions was reduced significantly from six to five after drug round tabards were introduced and there was a slight reduction in the number of incidents reported over the five week audit period compared with the previous year.
Conclusion Further studies need to be conducted nationwide to provide a better understanding of the effectiveness of drug round tabards. Issues of cost, laundering and infection control need to be further examined.
Keywords Drug round tabard, medication, safety
- This article has been double-blind peer reviewed
- Medication errors often result from interruptions of drug rounds.
- The use of drug round tabards decreases the frequency of interruptions.
- Staff, patients and visitors need to be educated about the use of tabards.
- Nurses would benefit from the introduction of drug administration guidelines.
Recent studies suggest that up to 6.5% of hospital admissions may be related to harm from medicines and around 7% of inpatients may suffer harm from medicines (National Patient Safety Agency, 2007).
The NHS in Scotland places great importance on medication safety but, without evidence for change - specifically on how to reduce the number of medication interruptions - NHS boards have been left to try to resolve this problem unassisted.
In acknowledgement of the need to reduce the number of medication related incidents in Scottish hospitals, the Institute of Healthcare Improvement (2008) published the Medicines Driver Diagram and Change Package as part of the Scottish Patient Safety Programme.
Medication errors are often caused by interruptions during drug rounds and environmental factors, including noise and poor lighting, and the likelihood of an error increases when a dose involves more than one tablet or a calculation is needed before administration (Williams, 2007). The more a nurse is interrupted when conducting a drug round, the greater the number and severity of errors (Westbrook et al, 2010).
After observing 38 drug rounds on a surgical ward, Kreckler et al (2008) calculated that an average of 11% of each drug round was spent dealing with interruptions, confirming their high frequency and potential as a safety hazard. There are no standardised ways to reduce medication interruptions during drug rounds and no guidelines or standards on the use of drug round tabards, so Kreckler et al (2008) suggested that nurses might wear some form of clothing during a drug round to indicate that they should not be interrupted.
This audit study explored the impact of introducing such tabards. In particular, the effects on medication interruptions, staff and patient perspectives, infection control and incident recording were analysed to determine whether introducing tabards:
- Reduced the number of interruptions during drug rounds;
- Improved patient care and safety.
The study also aimed to identify any training or educational needs of staff and patients, and evaluate whether there were any other issues relating to the use of drug tabards that needed to be resolved before their full implementation (for example, cost, infection control and reporting of medication errors through the Datix incident reporting system).
The audit was conducted at Aberdeen Royal Infirmary, the largest hospital within NHS Grampian, between January and March 2008. It is the main acute teaching hospital in Grampian, with approximately 900 beds. It provides a complete range of medical and clinical specialties.
Dunning (2001) suggested that beliefs, attitudes and relationships affect people’s willingness to adopt new behaviours. For this reason, wards were asked to show interest in the audit project rather than being randomly selected. The wards involved included:
- Acute medical (21 beds);
- Specialist cardiology (38 beds);
- Surgical urology (25 beds).
These wards had already noticed a problem and were looking for ways to change their practice.
Letters were sent to all nursing staff, medical staff, pharmacists, physiotherapists, occupational therapists and speech and language therapists, informing them of the audit study. Laminated copies of the letter were made available to patients and visitors on each participating ward.
Red tabards were embroidered front and back with “Drug round in progress. Please do not disturb” and worn by nurses undertaking drug rounds to highlight to staff, patients and visitors that they should not be interrupted (Fig 1).
A tick box questionnaire was used to collect information during each drug round (for example, the number of interruptions and who interrupted the round). Staff were trained and guided by their ward sisters to complete the data collection forms.
The perception of the study as an audit rather than research meant that ethical approval was not needed.
Drug round interruptions were monitored for 14 consecutive days (weeks 1 and 2) in January 2008. Drug round tabards were introduced in week 3 and continued to be used until the end of the audit period. The use of tabards was not audited in week 3 to allow time for staff, patients and visitors to become accustomed to the change.
During weeks 4 and 5 of the audit, interruptions during drug rounds were monitored to determine whether there had been a reduction after the tabards were introduced.
Separate questionnaires were distributed to the following groups to evaluate the impact of the tabards:
- Registered nurses who wore the drug round tabards;
- All other members of staff;
NHS Grampian’s Datix incident reporting system was reviewed for medication errors during the audit period.
Tabards were worn for the duration of the drug round only. The cardiology ward changed them after each drug round, while the acute medical and surgical urology wards changed them at the end of 12 hour shifts. The infection control department randomly swabbed the tabards to check whether any cultures had become established during the course of the audit period.
Data was collected from 602 drug rounds:
- Pre tabards - a total of 369 drug rounds were analysed;
- Post tabards - a total of 233 drug rounds were analysed.
Audit of medication interruptions pre and post tabard use
More forms were completed for the 8am and 10pm drug rounds than at other times. There was no obvious reason for this, but it may have been because these rounds took place at the start of 12 hour shifts, before staff could be sidetracked by competing demands.
|Table 1. Pre and post tabard audit|
|Pre tabard||Post tabard|
|Average number of patients receiving drugs on a drug round||9||9|
|Percentage of drug rounds interrupted||95%||95%|
|Average number of interruptions per drug round (see Fig 3)||6||5|
Table 1 shows that the average number of interruptions reduced significantly from six to five after drug round tabards were introduced (p<0.001) (see Fig 2).The medication interruptions that did occur resulted from patients, lack of drugs (from individual drug lockers), ward nurses, phone calls and medical staff (see Fig 3).
Drug round questionnaire responses
Registered nurses who wore the tabards - 33 (41%) - completed questionnaires. The following results were found:
- Thirty six per cent did not always have access to tabards due to laundry issues;
- Sixty seven per cent wanted to continue to wear the tabards;
- Sixty one per cent liked the colour of the tabards;
- Seventy three per cent thought the tabards were comfortable, although some commented on being too hot and said tabard sizes were an issue;
- When wearing tabards, nursing staff felt supported by nursing colleagues (82%), medical staff (49%) and allied healthcare professionals (45%), although they did not feel supported by patients (49%) and relatives (42%).
Among all other staff, 39 (65%) completed questionnaires. Of those:
- Ninety seven per cent were supportive of tabards;
- Seventy seven per cent thought tabards were effective;
- Ninety per cent said the tabards made them consider who to ask for help.
Of patients, 43 (47%) completed questionnaires. Of those:
- All supported the introduction of tabards;
- Eighty six per cent said the tabards made them consider who to ask for help.
All tabards grew positive general cultures, although this was no different from those cultures that had previously been found on staff uniforms.
Datix incident reporting
There was a slight reduction in incidents reported over the five week time period, compared with the previous year.
The majority of staff and patients supported the introduction of drug round tabards and understood the reasons behind the change in practice.
There were no reported issues with the message on the tabards, although it was acknowledged that a red tabard might create difficulties for some people with colour blindness and that a larger font could be used. It was also noted that the tabards used during the audit did not fit all nurses and that staff became hot when wearing them over their uniforms.
The tabards were considered a specialist garment to launder and this affected availability at times. However, wipeable tabards have recently been marketed, which could solve this problem. Storage hooks would need to be installed for tabards to be kept in the clean drug preparation area.
Although it was acknowledged that there were times when the nurse conducting the drug round had no alternative but to help patients, the majority of staff and patients did consider who they approached during a drug round when the tabards were in use in conjunction with “do not disturb” signs on drug trolleys. This resulted in a statistically significant reduction in interruptions during drug rounds.
The interruptions highlighted by the audit could be reduced by:
- Staff training;
- Educating patients and visitors;
- Filling up drug lockers adequately;
- Asking people to phone back rather than interrupting a drug round.
Interruptions are a contributor to drug incidents and patient risk in general, but it should be noted that other factors also contribute to the problem.
Nurses are at a disadvantage because there is an absence of guidance on how to conduct a drug round effectively. The Nursing and Midwifery Council (2007) simply states that an individual must have an appropriate level of education and training, and be assessed as competent to administer medication. During pre-registration training, students shadow nurses who are administering drugs and run the risk of learning bad habits that have been adopted over the years.
Pape et al (2005) noted that the introduction of medication administration guidance prompted nurses to be more focused during drug rounds, which reduced the number of medication incidents. The increased satisfaction resulting from this empowered nurses to ask patients, visitors, medical staff and other staff members not to disturb them while they were engaged in medication administration.
Brixey et al (2008) suggested that registered nurses need to learn techniques to manage interruptions in a way that has minimal negative impact on staff performance. This would be a positive step in patient safety.
The interruption of drug rounds has considerable implications for patient safety. Pape et al (2005) recognised that preventing interruptions prevents errors and subsequently reduces medication incidents and the cost implications for the NHS.
Data from this audit will be used to determine how effective drug round tabards are at reducing interruptions and, consequently, medication incidents. It should also help NHS Grampian to determine whether to roll the tabards out across the organisation.
However, further studies need to be conducted nationwide to provide a better understanding of the effectiveness of drug round tabards. Issues of cost, laundering and infection control also need to be further examined. Larger studies in the area of medication interruptions would also provide further evidence for NHS Grampian.
At the end of the audit, all three participating wards continued to ask newly qualified nurses or registered nurses who had just been accepted for a nursing post on the ward to use the drug round tabards for 1-3 months, as part of their induction programme.
Although a decision has not yet been made about whether to roll the tabards out across the organisation, individual ward areas have started to buy and implement tabards. In addition, other areas within NHS Grampian are now auditing both medication interruptions and the use of drug round tabards.
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Brixey JJ et al (2008) Interruptions in a level one trauma centre: a case study. International Journal of Medical Informatics; 77: 4, 235-241.
Dunning M (2001) Delivering better healthcare 3. Bandolier Extra. Evidence-based Health Care. Oxford: Bandolier. tinyurl.com/better-healthcare-3
Institute of Healthcare Improvement (2008) Medicines Management Driver Diagram and Change Package. Edinburgh: Institute of Healthcare Improvement.
Kreckler S et al (2008) Interruptions during drug rounds: an observational study. British Journal of Nursing; 17: 21, 1326-1330.
National Patient Safety Agency (2007) Safety in Doses: Improving the Use of Medicines in the NHS. Part 1 - Learning from Medication Incidents. London: NPSA.
Nursing and Midwifery Council (2007) Standards for Medicines Management.London: NMC.
Pape TM et al (2005) Innovative approaches to reducing nurses’ distractions during medication administration. The Journal of Continuing Education in Nursing; 36: 3, 108-116.
Westbrook JI et al (2010) Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine; 170: 8, 683-690.
Williams DJP (2007) Medication errors. The Journal of the Royal College of Physicians of Edinburgh; 37, 343-346.
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