Do Not Disturb

This is one of the least expensive and easiest-to-implement ideas for minimizing medications errors: a simple “Do Not Disturb” sign.

A recent study conducted jointly by Oregon Health Sciences University, Rutgers Center for State Health Policy, University of Washington Bothell, and Northern Illinois University found that medications being given at the wrong time was the most common type of medication error encountered in their study of medication management in 15 assisted living communities in four states.

The investigators observed the administration over 4800 medications during their study. Here is the breakdown of types of errors they observed:

  • Wrong time – 71.3%
  • Omitted dose – 12.2%
  • Wrong dose – 11.3%
  • Extra dose – 3.7%
  • Unauthorized drug – 1.4%
  • Wrong drug – 0.2%

While the overall impression of the co-investigators was that very few errors post potential for harm, they did note that assisted living medication aides are forced to assist with medications for a high volume of medications in a compressed time frame. We have all seen this when a med aide is attempting to pass all of the morning medications during a short two-hour window at breakfast.

One of the simple but effective strategies they came across to limit errors was a sign hanging in the window of the med room at one of the assisted living communities being observed that said “Please Do Not Disturb…I am busy with your medications.” The sign served as a simple but direct way to notify other staff members and even residents and visitors that the med aide was busy and needed to stay focused on their medication pass.

Of course there must be additional staff on hand to handle resident emergencies or other concerns, but otherwise this simple approach can allow the med aide to work uninterrupted; allowing him/her to complete the medication pass more efficiently and with fewer errors.

In next week’s blog we will look at strategies to avoid having so many medications being administered at the same time of day…

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