We have seen how being distracted while caring for patients can be detrimental to their safety. One issue I noticed during clinicals was nurses being interrupted during medication administration. For example, their phone starts ringing so they answer it and start discussing a different patient while in the middle of caring for someone else. This can be particularly worrisome when they are hanging IVs or administering medications and not fully paying attention to what they are doing. If hanging an IV they could accidentally enter the wrong rate, they could pull the wrong amount of medication or push is too fast. Additionally, from a patient care perspective, it is rude to talk on the phone while caring for someone. They should have the nurses full attention. Interruptions while administering medications can be prevented.
According to one study, having nurses wear a Do not disturb vest greatly decreased the number of distractions and near mistakes for nurses during medication administration (Westbrook et al., 2017). Most nurses said they liked the idea of the vest and that it was very effective, however, they didnt like how bulky and uncomfortable it would get. It would be beneficial to have a transformational leadership style. It would be important to include the nurses in all stages of the PDSA cycle to create a solution that they would follow through with. While nurses classified the Do not disturb vest as very effective, most said they wouldnt continue to wear it (Westfield et al., 2017). Therefore, a transformational leadership style would be beneficial because they would take those comments and create an alternative option that the nurses may be more amenable to.
If a nurse on my unit made a medication error that impacted the patient, it would be really important to investigate what happened and why. Were two medications that look the same with the similar names put in a cubby near each other? Did the pharmacists accidentally place the wrong medication in the wrong drawer? Was the nurse not paying attention with what they were doing? Was the unit short staffed and the nurses were taking care of too many patients and feeling rush? There are so many factors that can contribute to a medication error, so a full investigation of the events leading to the problem should be conducted. Therefore, a transformational leadership approach and root-cause analysis would be important. A root cause analysis is completed after a patient safety event and includes the sequence of events leading up to the event, possible causal factors and root cause, and an action pan that identifies specific strategies to reduce risk (Murray, 2017, pp. 162). While each individual should be held accountable for their error, there are likely to be several near misses due to the same issue. A transformational leader should work with their employees to create a long-term solution.