Interruptions during therapy preparation, administration and monitoring while caring for the paediatric population: a scoping review

From Firenze University Press Journal: Infermieristica journal

Eustachio Parente, Infermiere

Annalisa Cialdi, Emergency Departement, Careggi University Hospital

Gabriele Frangioni, NOS ErgoMeyer, Meyer Children’s Hospital, Florence

Daniele Ciofi, Hight Nursing Training, Meyer Health Campus, Florence

Khadija El Aoufy, Department of Experimental and Clinical Medicine, University of Florence, Florence

The therapeutic process consists in a series of related interactions that consecutively alter the nature of the relationship between therapist and patients, in paediatrics children and their parents1. In fact, the basic data includes the totality of interactions from the first hello to the final good-bye; thus, we cannot consider only the single act of administration as the whole process. Instead, the therapeutic process as a totality can be broken down in small parts in order to maintain better technical control over the process, and that’s the most challenging part for clinicians and health professionals involved. Nurses are the health professionals who play a pivotal role in the therapeutic process. The time dedicated to the treatment process is very important for the children’s safety; indeed, evaluating the factors that can impact positively or negatively on the process represents an important objective. Additionally, the paediatric context is characterized by its complexity and the presence of various actors, given the presence of the parents. Also, medication administration to infants and children requires complex calculations, individualized dosing and the use of o#-label medications which has limited prescribing information available. The preparation and administration phase are composed by very intimate actions that require a high level of attention; however, unfortunately, they are usually subjected to several interruptions. By interruption, we refer to an event that breaks the continuity of a primary task and causes a switch of the attention from the primary task, as the disrupting new event requires an immediate response; however, while the healthcare professional deal with this event usually continues the preparation of the primary task.

Generally, nurses operate in an unpredictable healthcare environment that is also characterized by involvement of significant cognitive load. Indeed, being interrupted and able to be multitask imposes heavy cognitive loads on individuals, with the result of impairing the attention and leading to errors5. Interruptions and multitasking are considered a source of concern that negatively a#ect the memory of the individual. Healthcare professionals have to memorize several elements at the same time; however, when an interruption occurs there might be an important loss of information previously stored7. In the literature, Westbrook et al., (2010) reported a signi!cant dose-response relationship between interruptions, and procedural failures and clinical errors in medication administration within the hospital settings, with an increase of 12.1% in procedural failures and an increase of 12.7% in clinical errors for drug administration. Their results showed that the more interruptions the nurses received, the greater the number of errors. Furthermore, the severity of errors worsened when the numbers of interruptions increased within a single drug administration process. In particular, the risk of a patient experiencing a major clinical error was doubled in case of four or more interruptions. In 2000, the report “To err is human” of the Institute of Medicine already identified interruptions as a likely contributing factor to medical errors. Thus, reducing interruptions in therapeutic process means reducing both the frequency and severity of errors.

However, medication errors are frequent in the health care environment; for instance, an error is reported every five medication dosages. In addition, the literature highlights that infants and children may have a three times higher risk of medication errors than the adults. Accordingly, as reported in the study of McPhillips et al., (2015)14the authors noticed that the proportion of errors involving children under four years was higher than expected, compared to older children.Interruptions can cause therapy errors resulting from near missing to a real damage, with potential long-term negative effects on the lives of the patient, their relatives and healthcare professionals, also leading to high financial burdens on the healthcare system.Nurses, compared to the other healthcare professionals, are more subject to interruptions during the preparation and monitoring of the therapy. Additionally, an integrative review of the literature investigating interruptions in paediatric nurses’ work and the systems issues related to interruptions in nursing work environments. The literature is generally focused on interruptions that are strictly linked to therapy administration, and medical error administration (MAE). In the study of McGillis et al., (2009) information on sources, types, and causes of interruptions are provided and, interruptions resulted both very common in clinical practice and a main cause of the therapy errors; indeed, during one of the phases of therapy process, interruptions have negative e#ects on the performance and can a#ect the quality of the decision-making process, generating frustration, stress and job dissatisfaction.

Despite some interruptions are unavoidable during the care process and provide healthcare professionals with the necessary information (e.g., monitor alarms that report abnormal vital signs, or a parent who raises doubts about the child’s therapy), it is worth to underline that interruptions of a complex process, such as the therapy, can significantly decrease attention, memory and perception. Most studies focus on errors in the phase of therapy administration; it is interesting to analyse how the interruptions contribute to therapy errors, understand if there is a classi!cation and what are the main containment strategies implemented. Thus, the primary aim of the present scoping review is to search for all the factors associated to interruptions of the therapeutic process (i.e., preparation, administration and, monitoring) for inpatient paediatric population. The secondary aim is to investigate possible implementation strategies to prevent interruptions and, thus, MAE.

The team involved in this scoping review was composed by children’s nurses, an ergonomist, and a research nurse, who discussed the relevance of the research question and agreed on the research strategy and the inclusion criteria.


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The University of Florence is an important and influential centre for research and higher training in Italy