Medication Administration and the Myth of Multitasking

I love my new Chevy Colorado pickup truck. But one day, as I put some items in the back jumper seats, and proceeded to my destination, upon parking and turning off the engine, a surprising alert message appeared on the dashboard along with a chime that said, “Rear Seat Reminder Look in Rear Seat.” What’s that safety feature all about? According to Kelly Blue Book, “In recent years, the growing number of children and pets left unattended in cars prompted automakers to add rear occupant alert systems in vehicles.” Kelly further states, “According to National Highway Traffic Safety Administration (NHTSA), a child dies in a hot car about every nine days. The National Safety Council reports that over the past 25 years, more than 950 children have died of heatstroke because they were left unattended in a hot car.”

The beginning point of this post follows: the vast majority of these cases are not due to overt neglect, but because people forget that their infants or sleeping toddlers are in the back seat: “According to research from the National Highway Traffic Safety Administration (NHTSA), around 52% of hot car deaths involving children happen because someone forgets a child is in the car, meaning a significant portion of caregivers experience this lapse in memory; one study even found that nearly 1 in 4 parents with children under 3 have lost awareness of their child being present in the car at some point during a drive.”

How can this happen? First, infants or toddlers resting in a car seat are often sleeping and not making noise, and are out of sight because they are in the back seat of the vehicle. And, while the caregiver is driving, they are more than likely thinking about other things, or an overdue project at work. If the first stop is daycare, and the caregiver is focused on work or some other destination that is the subject of focus, the caregiver may go directly to the second destination of focus and forget that the child is in the backseat.

Proud fathers or mothers that scoff at such a notion and don’t see it happening to them because their mind is as sharp as a tack, nevertheless, probably experience Doorway Effect Syndrome.

The doorway effect or location updating effect is a replicable psychological phenomenon characterized by short-term memory loss when passing through a doorway or moving from one location to another. People tend to forget items of recent significance immediately after crossing a boundary and often forget what we were thinking about or planning on doing upon entering a different room. Research suggests that this phenomenon occurs both at literal boundaries (e.g., moving from one room to another via a door) and metaphorical boundaries (e.g., imagining traversing a doorway, or even when moving from one desktop window to another on a computer).

Memory is organized around specific events or episodes, such as attending a lecture or having a family meal, rather than being a continuous stream interrupted by sleep. This organization is called episodic memory, which involves receiving and storing information about events that are temporarily dated, along with their time and place relationships.

Numerous psychological studies have indicated that the external context, including the location where events occur, plays a significant role in how memories are separated. This context helps establish distinctions between different remembered events. Memories of events that happen in the environment we’re currently in are easier to access compared to those from different places.  As a result, when we experience spatial changes and move to a different location, it can act as a boundary marker that separates and categorizes our continuous flow of memories into distinct segments.

Recently, I saw a humorous video on Tic Toc. A lady is leaving the house and unplugged her iron. She gets into her car, and starts it, but can’t remember if she unplugged the iron. She returned to the ironing board, confirms that she unplugged the iron, and returns to her car and starts it. But, once again, she questions herself in regard to unplugging the iron. She thinks she did, but once again, wants to be absolutely positive. Frustrated, she returns to the ironing board and takes a selfie with herself holding the plug in the air. However, again, once entering her car, she has doubts. She finally resolves the issue by taking the iron with her.

As nurses, we all wish we had a dollar for every time we left a med cart and questioned ourselves as to whether or not we remembered to lock the cart. I wonder how many nurses will admit they poured water into a medicine cup during a busy shift? This is because automatic memory confuses memories during the doorway effect and stress compounds this phenomenon.

Contextual memory and memory that works with the automatic nervous system can be easily conflated. Please note the primary point: the human mind is most reliable when it is focused on one thing at a time; in fact, the human mind is built to primarily focus on one subject at a time. We can’t confirm in our minds that we positively unplugged the iron because while we were doing it, we were also thinking about many other things including why we are leaving the house. It is obvious that in any school, multiple subjects are not taught in the same room and at the same time.

With this in mind, facts about memory are set against an annoying fad that is in vogue; i.e., showing how smart and capable you are by multitasking. This annoying fad is particularly prevalent in nursing. In our day, talking with someone while writing an email is no longer considered rude. Nurses that focus on one task at a time are deemed, “inefficient.” However, the vast majority of current neurological studies have concluded that multitasking is grossly inefficient and decreases IQ performance (Dr. Travis Bradberry. Why Smart People Don’t Multitask. LinkedIn, June 13, 2022).

And regarding medication administration, it’s dangerous.

The US Food and Drug Administration (FDA) receives more than 100,000 reports of medication errors each year. Here are some other statistics about medication errors in the United States: 

• Number of patients affected: More than 7 million patients in the US are affected by medication errors each year.
• Number of deaths: 7,000 to 9,000 Americans die from medical errors each year.
• Number of injuries: Approximately 530,000 injury incidents occur yearly in outpatient clinics due to medication errors.
• Percentage of hospital patients affected: 10% of the patients in every hospital will be part of a medication error.
• Percentage of Americans who have experienced a medical error: 41% of Americans report being involved in a medical error personally or secondhand.

Medication errors occur because how the mind works is not taken into consideration. Medication administration should have a fixed process that becomes habitual. The process needs to circumvent the doorway effect and distractions. Here are some suggestions that focus mostly on long-term care.

• Only administer to one resident at a time. NEVER administer to more than one resident at a time to save steps.
• The resident that you are administering to needs to be on the E-mar from the begging of the administration until the end of the administration when you confirm that the medications have been given. This focuses your mind on one resident from beginning to end.
• Use mind cautions. This is your own unique way of having a dashboard warning light in your mind when distractions occur during the med pass. If you are distracted during the process of administrating meds to a resident, discontinue the process altogether and start over after the distraction is dealt with. DO NOT multitask.
• Remember that pre-setting greatly enhances the doorway effect.
• When pulling meds, confirm the 5 rights: right resident, right drug, right dose, right route, right time and indicate that the drug has been pulled. The 6th right is, right documentation. NEVER sign off drugs before or after administration.
• Keep your process the same every time. Make the process habitual. Make prevention automatic.
• In long-term care, older people trend to development like characteristics and mannerisms. If you have a tendency to get two particular residents confused, insert cautions into your procedure.
• Always write the residents full name on the medicine cup with the room number. Compare the cup with the mar when you leave the med cart, compare the cup with the room nomenclature when entering the room, and look at the cup one more time before you administer to the resident. This is perhaps the most effective element of the med- pass that prevents error. It supplies a chain of evidence, or chain of custody, legally speaking, from the mar to the resident regardless of what else is going on.
• Nursing school teaches us that the subconscious memory is real. We all wonder how we passed some tests. Usually, when we are not confident about a selection on a test, it is the wrong choice. If you are administering a med to a resident, and something doesn’t feel right, LISTEN TO YOU GUT!!!! And, this feeling, that is, that something isn’t right, is usually due to not following your process, particularly, using the med cup for chain of evidence.
• Remember, if you pre-set, the chain of evidence between the mar and the cup is absent. You have no evidence that the right name is on the right cup with the right meds because you aren’t double checking with the mar, that process is skipped.

Paul M. Dohse, LPN, ADN, MA-C, STNA, CDP