The impact of “do not disturb” tabards worn by nurses on medicines administration rounds on the safety and quality of patient care.
4th year project, submitted to the University of Manchester in partial fulfillment of the MPharm degree
School of Pharmacy and Pharmaceutical Sciences
Supervisor: Dr. Mary Tully
Medicinal errors are a problem across the UK with the National Patient safety Agency receiving an increased number of error reports each year. Although errors may occur at any stage during the medicines process, those which are of greatest concern to nurses are administration errors; as nurses are often seen responsible for this task. Each error carries the potential of a serious adverse effect and so the NHS is under pressure to improve safety.
Previous research has identified potential factors which may contribute to the error rate; one factor identified is the interruption rate. Literature has found nurses who encounter interruptions during medicines administration have an increased risk of error.
It is due to this that the “do not disturb” tabards were consequently introduced in 2011. The limited research available does suggest tabards reduce administration errors due to fewer interruptions. However, some patient groups have raised concerns regarding tabard use, suggesting they may reduce the quality of patient care, as the patient would feel as though nurses look unapproachable. At a present there are a number of hospitals that use such tabards on a regular basis; nevertheless this number is relatively low. As such, limited degree of research has been carried out to test the impact of the tabards on the quality of patient care. The research presented here aims to identify the impact of the “Do not disturb” tabards on both the safety and quality of patient care.
The research will be conducted through the use of a cluster randomised trial will be used to test this aim, with the use of eight hospitals randomly allocated to either the tabard wearing intervention cluster or the control cluster. In order to measure the impact on safety, the number of administration errors will be recorded via observations. To identify the impact on the quality of patient care, questionnaires will be given to patients discharged from observed wards. The trial period will last 6 months, at the end of this period researchers will analyse data collected and compare the results of the intervention and control cluster.
Patient safety is a major concern within the NHS. Therefore this research aims to evaluate whether the tabards will act as an innovative cost effective idea to improve patient safety outcomes. As a result of this research the use of tabards may be implemented in hospitals across the UK.
I understand the nature of plagiarism and understand that it is a serious academic offence. I confirm that no material in this project has been plagiarised.
This project is made under the sincere guidance of Dr. Mary Tully.
1.1 The role of the nurse
The Royal college of Nursing states “Nursing involves providing care and clinical judgment to help improve, preserve or recover a person’s health, in order to achieve the best quality of life regardless of the person’s condition or disability until death”.(1)
Since 2001 the number of qualified nursing staff employed by the NHS has increased by 16% to over 315, 410. (1) This accounts for over 8% of the total NHS staff and suggests the importance of the role of the nurse. Nurses are usually seen at the forefront of the provision of patient care and regularly carry out tasks such as the administration of medicines, changing beds, feeding patients and administration rounds. (2) Although nurses can be found working throughout different sectors of health, they are required to work alongside other healthcare professionals to ensure positive patient outcomes.
1.2 Medication administration
A fundamental nursing role is the administration of medicines. On average a nurse may carry out this task 4-6 times per day depending on the type of ward and patients present. (3) As this task is often seen as high risk due to the complex nature of certain medicines, the Nursing and Midwifery Council (NMC) has in place strict guidance detailing the step by step process which must be followed.(3) This aims to reduce the number of clinical errors, and also ensure that the quality and care delivered during this process is of a high standard. The simplified version of this process is called “The Five Rights”: Giving the right drug, at the right dose, via the right route, to the right patient at the right time. (3) Nurses are professionally accountable to the Nursing and Midwifery Council for their actions when administrating or assisting self-medication, therefore records of medicines administered or omitted doses must be completed.(3, 4)
1.3 Medication error
A medication error is an incident which occurs at any stage during the prescribing, dispensing, preparation, drug administration and monitoring process. (5) In practice, nurses and healthcare workers are advised to report errors to the National Patient Safety Agency. Since this was set up in 2001, over 4 million medicine errors have been reported. (6) Medication errors are the single most preventable cause of patient harm with approximately 1 in every 250 prescriptions in UK hospitals containing an error. (7)
1.3.1 Medication administration error
Errors made during the administration process are of particular concern to the nursing profession, as a key outcome when measuring the safety and quality of nurse care is the number of administration errors.(1) . Statistics from the National Patient Safety Agency revealed that 59.3% of all medicine errors occur during the administration process. (8) The most common administration error is the omission of medicines, where the drug is not administered to the patient for a number of reasons. Other errors during this stage include: the wrong route, wrong time, wrong dosage form and wrong strength. (9)
In order to gain a better understanding of the nature of administration errors in the UK, a Meta analysis was carried out. A total of nine healthcare databases were searched for the results of observational studies measuring the administration error rate in UK hospitals. The results for non iv administrations revealed an overall medicines administration rate of 5.6% of the total 21533 opportunities for error.(10)The results of this Meta analysis also found that error rates were higher in IV administrations with a 35% error rate out of a total 154 administrations. This is five times greater than the error rate in non IV administrations, and could potentially be due to the complex nature of the medicines involved and the multiple steps required during their preparation. However as errors are voluntary recorded, it is difficult to obtain the true administration error rate in practice, as research has shown that nurses are less likely to report errors due to fears of manager and peer reactions.(11)
Research carried out by Tang et al looked specifically at the nurse error rate through focus groups. Findings revealed that 80% of the 72 female nurses experienced an administration error. The most common places for errors were medical wards and intensive care units due to the complexity of medicines involved.(12) Nurses also believed that they were less likely to report an error due to fear of professional disclosure.
The literature suggests that administration errors commonly occur in practice with medicine complexity i.e. intravenous doses increasing the potential risk of error. In order to improve patient safety the cause of these errors must be identified.
1.4 Approaches to administration errors
Although administration errors in practice are common, it is often difficult to identify the root cause of the problem. One approach suggested by Reason, describes errors as the result of active and latent factors. Active factors are those which produce immediate effects and consist of the operator; who in this case is the nurse, as the “faulty” component. A lack of knowledge, non-adherence to protocols and poor calculation skills increases the risk of errors made by nurses. Latent factors such as staffing levels and interruptions are a result of the environment and conditions under which individuals work and it is these factors which over time may trigger the active factors resulting in error. (13)
Administration errors can be linked specifically to a nurse’s professional attributes and competencies.(14, 15) Mc Mullan et al suggest that an error may be caused due to a lack of knowledge regarding the medication such as incorrect formulation, calculation of dose or route of administration. Although basic mathematical skills are essential when calculating drug percentages and dosage forms, this research found that 89% of44 nurses failed a dose calculation test approved by the NMC.(15) The calculations provided were similar to those in practice, suggesting lack of nurse knowledge contributing to error rates. However, a possible explanation of this high fail rate could be the use of calculators, as during these studies they were not used; yet in practice they are used frequently, therefore lacking external validity.
Medicine administration Interruptions
The number of interruptions during the administration process has been identified as a contributory factor to administration errors. (16, 17) When an individual is interrupted it is thought to have a negative impact on memory, as they are required to switch their attention from one task to another. (18) Previous research findings have indicated that nurses who experience a high number of interruptions are more prone to errors.(19, 20) This is especially important during the medicine administration round, which is considered a high risk activity. During this procedure nurses are often stationary at the medication trolley for long periods of time making them more prone to interruptions. (20)
This theory is supported by findings of an 18 month direct observational trial, carried out in 6 hospital wards in 2010. The numbers of clinical errors identified were compared to both observational data and medication charts. An interruption was classed as anything which resulted in the nurse having to deviate from the administration process, such as having to answer a phone call or stopping administration to speak to relatives. From the 4271 medicine administrations, it was found that an interruption occurred in 53.1%, with each interruption associated with a 12.1% increase in clinical error. (16) The researchers therefore concluded these results as significant due to the correlation between number of interruptions and errors. These findings are fully supported from the results of a literature review which analysed 23 studies measuring the nurse interruption rate. An average rate of 6.7 interruptions was recorded per hour. The major cause of interruption was found to be through nurse to nurse communication, whereas a lower proportion of interruptions were caused by system failures e.g. not having the correct medicine on the trolley at the time. The findings from this review also stated there was a strong association between the number of interruptions and the error rate. (21)
Nurse staffing levels
Adequate staff levels are essential in maintaining patient safety.(22-24) The risk of medication errors, falls, infections and overall mortality is thought to increase when appropriate staffing levels are not provided.(22) Currently, there is a shortage of nursing staff in the NHS; an explanation of this could be due to the decreased nursing school capacities, low salaries and an increase in patient expectations. Although the recession has motivated many older nurses to return to fulltime work, the demand for nurses still outweighs the supply. (22, 25)
Research by the Royal college of Nursing suggests that appropriate staffing levels are met when the nurse: patient ratio is at a minimum of 1:5.(25) These figures were based on a questionnaire completed by over 55% of NHS employed nurses who felt care was compromised when the number of patients per nurse increased.(25) Although this is not a true representation of all nurses in the NHS, the results are supported by Aiken et al, who found there was a 7% increase in mortality, for every additional patient per nurse.(22) A more recent study with similar results carried out in England, found that the mortality rate increased by 26% in hospitals who experienced higher nurse: patient ratios (above 1:6). (26)This was also found to decrease the quality of care provided as nurses showed more dissatisfaction and higher levels of burnout.(26, 27)
Despite these findings, current research (2012) suggests that working extended hours (more than ten hours), will influence the rate of errors rather than the number of staff present, as then nurses are two and a half times more likely to experience fatigue and burnout, therefore risking patient safety. (27)
1.5 The use of tabards
In 2010 the NHS received over 162,129 written complaints regarding poor patient care, with 21.7% of these directed at the nursing and midwifery profession.(28) Due to this high number of complaints, the NHS is under increasing pressure to develop innovative and cost- effective plans to improve patient care.
The 2011 introduction of the “do not disturb tabards” was set to improve patient safety by reducing the number of interruptions nurses experienced during the administration process, thus reducing medicine administration errors.(17)
1.5.1 Tabard product information
A tabard is a short, loose sleeveless garment worn above clothing. They are available in a variety of colours including red, royal blue and burgundy and have the wording “Do not disturb nurse on drug round” on the front and back. (29) They are available as disposable or non-disposable, which cost approximately 17.5 pence and 41-43 pence respectively per use. (30) Several hospitals including Cardiff and Vale NHS trusts in Wales and The Christie in Manchester have introduced the use of tabards with many more set to follow in the upcoming months.
1.5.2 The impact of tabards on patient safety
Although limited research is available, two studies carried out suggest the use of tabards may result in decreased administration interruptions, which carry the potential risk of administration errors. (17, 31) A one month trial conducted at the Colchester hospital, analysed the number of interruptions, and time taken on the 08:00, 12:00 and 18:00 medication rounds both before and after the introduction of the tabards. It was found that the tabards reduced the number of interruptions by 28%. These positive results provided the basis for a 3 month extended trial, where the rate of interruptions and time taken to complete medicine rounds was again measured. Results found a further 71% reduction in the number of interruptions, and the time taken to administer medication at the 08:00 round was reduced significantly from an average of 108 minutes to 70 minutes. (17) As a result of this research, the hospital has implemented the use of tabards on all medical and elderly wards.
These findings are further supported by the results of a 3 month observational study which explored whether the use of tabards reduced the number of interruptions during administration rounds. Data was collected both pre and post intervention and results found that on average the number of interruptions per medicines round reduced from six to five. There was also a slight decrease in the number of administration errors when compared to the previous year.(31) Although this research may not have been long enough to provide robust evidence, the results do suggest that the use of tabards will reduce the number of interruptions, which in turn may lead to a decrease in error rate.
1.5.3 The impact of tabards on quality of care
Although the tabards were introduced to increase patient safety, reports published suggest they may have a negative effect on the quality of patient care.(32, 33) This concern is related more towards the wording of the tabards, as patients groups such as patient concern believe that the “Do not disturb” makes staff look unapproachable. (32) Although no robust evidence is available to suggest this is the case, the actions taken by East Kent hospital to remove the “Do not disturb” from the tabards implies that the tabards may well have a negative impact on the quality of care. (33)
However, conflicting research suggests that the use of tabards may in fact have a positive effect on care quality. As mentioned in section 2.5.2, tabards have shown to reduce the time taken to administer medication, thus allowing nurses to carry out other tasks and care duties. (17) This will allow nurses to carry out simple tasks such as comforting and talking to patients which has been found to improve the quality of care. (24, 34)
Nevertheless this information is based purely on concerns and reports from individuals and no study has yet looked directly at the impact of tabards on the quality of patient care. Due to this it is not possible to form a cause and effect relationship. What’s more, is the fact that quality is a complex aspect to measure, as it is based on both patient and staff perceptions which will differ in what they believe is good quality.
From the research available it is apparent that medicine errors are a problem throughout the UK. Errors may occur at any point during the medicines process, yet those which are of greatest concern to nurses are those which occur during the administration process.
The complex nature of these errors suggests that they cannot be simplified down to one cause, but more a number of contributing factors. Conflicting research has suggested that low staffing levels and poor nurse education may increase the error rate, yet a common factor found throughout the literature suggests that the interruption rate plays a key role in increasing errors.
Whilst much research has been carried out to identify these factors, little has been done to suggest innovative ways to overcome them.
The introduction of the “Do not disturb” tabards worn by nurses during the administration process, was set to reduce the administration error rate, thereby improving patient safety. Although research carried out by two independent NHS hospitals has confirmed that the tabards do reduce the level of interruptions, concerns have been raised by patient groups over the impact of tabards on the quality of patient care. These concerns suggest that the tabards may in fact reduce care quality by making staff look unapproachable. However these are only concerns and the impact on quality has not yet been studied. What’s more, the literature available measuring the safety of the tabards has lasted no more than 3 months, with small sample sizes, use of single hospitals and lack of study details published questioning the reliability of results.
It is therefore apparent that more robust, reliable research is needed in order to show the impact of the tabards on both the safety and quality of patient care, taking into account a greater nationwide sample size. The research presented will act as the basis for the following investigation.
2. Aims and Objectives
The aim of this study is to determine the impact of the “do not disturb” tabards on both the safety and quality of care when worn by nurses during medicines administration rounds.
The objectives of the following study are:
Observe medicines administrations to identify error rates
Compare error rates from intervention and control groups
Identify possible causes of error
Measure the effect of tabards on drug administration time
Measure the difference in quality of care between a control group and an intervention (tabard wearing) group.
3. Research Design
3.1 Cluster Randomised Controlled trial
The research method chosen to study the impact of tabards on the safety and quality of patient care will be a cluster randomised controlled trial (CRT). The clusters will consist of 8 NHS hospitals located in the North West of England, which will be randomly assigned to either the intervention cluster (tabard wearing), or the control cluster (non tabard wearing). Each cluster will therefore consist of 4 hospitals.
This method was chosen as CRT’s typically focus on the effectiveness of interventions targeted at groups of health professionals rather than individuals. It is due to this, they are often used in therapeutic settings under conditions of actual use. The use of clusters ensures all individuals within the intervention cluster will wear the tabards during medicines administrations. As a result nurses within hospitals will work under the same conditions, therefore increasing the generalisability of results. (35)
3.2 Methodological Justification
Although a cluster randomised trial is considered the most appropriate for this piece of research, other methodological approaches may also be considered.
3.2.1 Randomised controlled trial
Randomised controlled trials are considered to provide the most reliable form of scientific evidence when analysing the effectiveness of an intervention.(35, 36) This method prevents researcher bias, as the research has no control over allocation of hospitals to either cluster therefore methods used can be replicated in order to validate results.
However this particular method is not suitable for this research, as studying both intervention and control groups within the same hospital may lead to contamination of results. Patients may experience confusion and question why some staff wear the tabards and others do not, this may affect their perception of care quality. The results would also lack external validity, as in practice staff within a hospital would adhere to the same guidelines and procedures. (35)
3.2.2 Focus Groups
This method would allow small groups of nurses to share their thoughts on why they believe errors occur and whether the use of tabards has affected the number of errors made by individuals. As this would take place as an open discussion, previously unidentified factors contributing to error rates may be identified allowing researchers to gain a better understanding of the issue.
However as this is a sensitive issue, nurses may not wish to disclose information regarding errors they have made, thus resulting in low contribution rates. This method would not produce any statistical figures, as all data would be based purely on nurses opinions, therefore a definite cause and effect relationship cannot be derived. Instead it may be more appropriate to use nurse focus groups to identify factors which contribute to administration errors.
When used to measure quality of care, a focus group would allow small groups of patients to discuss the care they experienced whilst in hospital. The group moderator present could prompt patient responses and ensure all participants engaged and contributed to the discussion. Unlike a questionnaire, those questions not fully understood by participants could be reworded by the moderator to ensure an appropriate response.
Although this method has the ability to provide a rich source of qualitative data, due to the nature of the study the responses from patients may be low. Patients recently discharged from hospital may not want to participate, resulting in low participant numbers. Also unlike the use of a questionnaire, patient consent would be required along with data collection methods e.g. video recorder, therefore increasing research costs.
Due to these reasons, the use of a focus group is not suitable for measuring the safety or quality of the tabards.
3.2.3 A before and after study
This non experimental method would involve carrying out the study before the introduction of the tabards, and then during the introduction of the tabards. The findings would be compared and a difference in pre and post intervention results would suggest an impact of tabards on safety. This method would allow comparisons of results within wards.(37)
However this non experimental method has many drawbacks, the lack of control group decreases the ability to find a definite cause and effect relationship, thus reducing the validity of results. Also unlike a cluster controlled trial, there will be no randomisation, which could potentially introduce researcher bias. The fact that the data is collected twice, suggests that the cost of the overall research will increase due to increases in research/resource requirements.
It is due to these reasons, a before and after study is not considered suitable for this research. (37)
4. Hospital recruitment
There are 29 NHS hospitals within the northwest of England; these will be asked to participate in this study. Of those which agree, 8 will be randomly selected to take part. As this is over a quarter of the hospitals, it will ensure a representative sample size. More than this may overcomplicate data collection and analysis. Each hospital will be made aware of the importance of this research and how the findings could affect future practice.
A table of numbers; each representing a hospital, will be used to randomly allocate hospitals to either the intervention cluster or the control cluster. This will be carried out by an independent researcher who has no previous knowledge of hospital error rates in order to prevent bias.
A meeting will be held with hospital and ward managers to reveal which cluster they have been assigned to. This will allow any necessary changes to be made to hospital guidance to ensure all nurses in the intervention group wear tabards during administration. Details regarding the number of research observers and length of the study will be provided beforehand along with safety information sheets. Nurses will therefore be fully aware of the details of the study in advance and will have the opportunity to ask any questions or fears regarding the research.
5. Research Procedures
During the study those in the intervention group will wear the tabards as agreed with hospital managers. The tabards provided will be disposable as they are more cost effective than the reusable tabards.(30) Those in the control cluster will carry out administration under normal working conditions.
Measure of safety
The number of administration errors will be recorded via observations of nurses during ward rounds.
In order to reduce interobserver variability, observers will meet before the study and define a medicines administration error. This will be based upon the National Patient Safety Agency definition:
The wrong dosage form
The wrong route of administration
The wrong time
The wrong form
The wrong strength
Observers will refer to patient medication charts in order to recognise errors. When an error is identified, the drug involved will also be recorded. This will allow researchers during data analysis to categorise errors into mild, moderate or severe depending on the implications the error could have on the patient.
Please see Appendix 2 for more information
During administrations, observers will remain at a distance where they are close enough to observe administration without causing any distress to both patients and nurses.
The records made will remain anonymous and only the time and ward number will be noted. The record card will also have a section to record the number of interruptions. This will identify whether or not the tabards reduce the number of interruptions which result in errors. An interruption will be defined as anything which causes the nurse to deviate from the administration process. The time taken to complete administration rounds will also be recorded, as reducing this potentially allows nurses to carry out other care duties.
If the tabards are effective in improving safety, the number of errors in the intervention group will decrease compared to the control group.
Observations will take place during the week and on weekends at different times each day for approximately 3 hours. The time of day will be randomly assigned using a number generator, where each number will represent a specific 3 hour time period during the day. This will ensure data collected represents all nurses working on the observed wards.
Although all staff nurses in the intervention group will be required to wear the tabards, only the following will be observed during this study:
Fully qualified nursing staff (diploma/degree)
Permanent ward base
Provided written consent
Non nursing staff as they will not be required to wear the tabards
Nurse Managers as it is unusual for them to carry out medicines administration therefore may not reflect true practice
Non permanent staff (bank/agency staff) as it is not feasible to gain written consent.
An advantage of this method is that it allows for data collection in the participants’ natural environment therefore increases the internal validity, also data does not depend on the subjects’ ability to report results, therefore increasing reliability of results.