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Abstract

Introduzione: In Italia i dati pervenuti dall'Osservatorio degli eventi sentinella tra il 2005 e il 2010 hanno descritto 873 eventi di cui il 4%, circa 35 casi, ha provocato morte, coma o gravi alterazioni funzionali per errori di somministrazione, dovuti all'infermiere. La connessione tra le interruzioni e la sicurezza dei pazienti sono state sottolineate negli Usa dall'Institute of Medicine come aspetto chiave per migliorare la sicurezza dell'assistenza infermieristica. Le compagnie aeree studiano il problema gií  dagli anni 60; ciò ha ridotto notevolmente gli incidenti da distrazione.

Obiettivo: L'ipotesi dello studio è stata di dimostrare che gli infermieri che somministrano la terapia, se non vengono interrotti e in presenza di un abbigliamento dedicato ed una cartellonistica di non disturbo, riducono gli errori in fase di somministrazione dei farmaci.

Metodi: Studio quasi sperimentale con campione di convenienza diretto alla scoperta di relazioni causa-effetto che portano alla riduzione di errori in fase di somministrazione dei farmaci, attraverso un abbigliamento dedicato ed una cartellonistica di non disturbo. Lo studio è stato condotto in quattro ospedali di Roma con polo universitario associato. I dati sono stati raccolti con lo strumento (Medication Administration Distraction Observation Sheet).

Risultati: Nei quattro ospedali che hanno partecipato allo studio sono state compilate 688 schede di osservazione delle distrazioni, 356 (51,7%) per il gruppo controllo e 332 (48,3%) per il gruppo sperimentale, di cui 132 nell'ospedale 1, 143 nell'ospedale 2, 144 nel terzo ospedale e 269 nell'ospedale 4. Analizzando i 4 ospedali emerge che nel gruppo sperimentale alcune delle distrazioni medie sono significativamente più basse rispetto al gruppo controllo (distrazioni degli infermieri e conversazioni). Alcune distrazioni risultano, tuttavia, maggiori nel gruppo sperimentale rispetto al gruppo controllo (distrazione telefoniche, altri degenti, rumori). Infine, non emerge una differenza significativa nelle distrazioni dovute alle variabili: medici, altro personale, visite dei parenti/visitatori, prescrizioni ed emergenze.

Conclusioni: Le distrazioni degli infermieri possono causare molti errori durante tutta la fase di somministrazione dei farmaci. L'utilizzo della casacca ad alta visibilití  per la somministrazione dei farmaci si è dimostrato utile. Tuttavia, deve essere supportato da un efficace lavoro in team, da una cartellonistica di non disturbo estesa a tutti gli ambienti di lavoro e da una formazione che non può limitarsi al solo personale che somministra i farmaci.

Parole chiave: errori di somministrazione, interruzioni, distrazioni, casacca di sicurezza, segnaletica di non disturbo.

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

ABSTRACT

Introduction: 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.

Objective: 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.

Methods: 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.

Results: 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.

Conclusions: 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. Keywords: administration errors, interruptions, distractions, safety tabard, not disturb signs.

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Come citare
Mazzitelli, N., Rocco, G., De Andreis, G., Mauro, L., Montevecchi, A., Stievano, A., & Turci, C. (2018). Ridurre gli errori da somministrazione dei farmaci attraverso una casacca segnaletica ed una cartellonistica di non disturbo. PROFESSIONI INFERMIERISTICHE, 71(2). Recuperato da https://profinf.net/pro3/index.php/IN/article/view/499
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