Pulled Away at the Worst Keystroke

Programming an infusion is a multi-step sequence. An interruption mid-task — a question, an alarm elsewhere, a phone call — can leave a pump half-set, or the clinician returning to the wrong step, believing the task was completed.

In a landmark observational study of 98 nurses and 4,271 medication administrations, each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors; the risk of a major error rose from 2.3% with no interruption to 4.7% with four. (Westbrook et al., Archives of Internal Medicine, 2010.)

1. A clinician begins a multi-step infusion-programming sequence.
2. An interruption — a question, another alarm, a phone call — breaks the task.
3. The pump is left half-set, or the clinician returns to the wrong step.
4. The task is believed complete when it is not.
5. The half-programmed infusion runs, or a step is missed entirely.

Interruptions occurred in 53.1% of medication administrations; each was associated with a 12.7% rise in clinical errors. (Westbrook et al., 2010)

A pump left half-set. Shown through the pump mid-program screen and the abandoned step — never the patient.