"Given the prevalence of other types of errors, an exclusive focus on medication administration errors, often a typical practice, may miss many important and potentially hazardous situations," said Ann E. Rogers, an associate professor in Penn's School of Nursing.
The findings are presented this month in the journal Applied Nursing Research and are derived from a previous study that examined staff nurse fatigue and patient safety.
"Although nurses pride themselves on being able to juggle multiple tasks at once, too many distractions from multiple sources make errors inevitable," Rogers said. "Other reports have shown that a nurse may be interrupted, on average, at least 19 times during a three-hour period by at least 13 different types of sources." Approximately 33 percent of actual medication errors were because of late administration of drugs to patients, which in some cases was due to inadequate numbers of nurses on duty. In one example, a nurse reported a 90-minute delay in giving medications to one patient and a 40-minute delay to another because she could not leave the bedside of a third unstable patient. As hospitalized patients become more ill, with complex care requirements, and the nursing shortage intensifies, such situations may become more common.