[Reducing drug administration errors using "Do not disturb" tabards and signs]

According to the report published by the Italian Ministry Health on sentinel events collected between 2005-2010, 873 events were reported, of which 4% (about 35) led to mortality, coma or serious functional disorders due to drug administration errors made by nurses. The link between interruptions and patient safety has been emphasized in the USA by the Institute of Medicine as a pivotal variable to improve the quality of nursing care. Airline companies have studied this problem since the 1960s, with a significant reduction of accidents.

This study emphasized that nurses who are never interrupted or distracted, by using 'Do not disturb' tabards and signs, reduce errors during the administration of drugs.

Quasi-experimental study on a convenience sample to explore the cause-effect relationship that reduces errors during drug administration by wearing a 'Do not disturb' tabard and signs. This study was conducted in 8 similar medicine and surgery units within 4 teaching hospitals in Rome. Of these 8 units, 4 were identified for the experimental group and 4 for the control group. Data were collected using the Medication Administration Distraction Observation Sheet tool. Data were analysed using SPSS 10.00 software.

In the four hospitals that participated to the research were filled out 688 observational sheets, 356 (51,7%) for the control group and 332 (48,3%) for the experimental group. 132 were completed in the hospital 1, 143 in the hospital 2, 144 in the hospital 3 e 269 in the hospital 4. Analyzing the four hospitals, it emerged that in the experimental cohort some of the distractions calculated by the mean were lower compared with the control group (distractions by nurses and conversation). Yet, some distractions resulted greater in the experimental group respect to the control group (phone calls, other patients, external noise). At last, it did not emerge a significant difference in the distractions connected to variables such as: physicians, other personnel, visitors, and emergency situations.

Distractions can lead to many errors throughout the drug administration phase. Wearing a high visibility vest while administering drugs proved to be very useful. However, this needs to be supported by effective teamwork, 'do not disturb' signs in all the workplace rooms, and by an education program that should not be limited only to those who administer drugs.