Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review

Background

Medication administration errors are frequent and lead to patient harm. Interruptions during medication administration have been implicated as a potential contributory factor.

Objective

To assess evidence of the effectiveness of interventions aimed at reducing interruptions during medication administration on interruption and medication administration error rates.

Methods

In September 2012 we searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Effective Practice and Organisation of Care Group reviews, Google and Google Scholar, and hand searched references of included articles. Intervention studies reporting quantitative data based on direct observations of at least one outcome (interruptions, or medication administration errors) were included.

Results

Ten studies, eight from North America and two from Europe, met the inclusion criteria. Five measured significant changes in interruption rates pre and post interventions. Four found a significant reduction and one an increase. Three studies measured changes in medication administration error rates and showed reductions, but all implemented multiple interventions beyond those targeted at reducing interruptions. No study used a controlled design pre and post. Definitions for key outcome indicators were reported in only four studies. Only one study reported κ scores for inter-rater reliability and none of the multi-ward studies accounted for clustering in their analyses.

Conclusions

There is weak evidence of the effectiveness of interventions to significantly reduce interruption rates and very limited evidence of their effectiveness to reduce medication administration errors. Policy makers should proceed with great caution in implementing such interventions until controlled trials confirm their value. Research is also required to better understand the complex relationship between interruptions and error to support intervention design.

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems

IMPORTANCE

Medication computerised provider order entry (CPOE) has been shown to decrease errors and is being widely adopted. However, CPOE also has potential for introducing or contributing to errors.

OBJECTIVES

The objectives of this study are to (a) analyse medication error reports where CPOE was reported as a 'contributing cause' and (b) develop 'use cases' based on these reports to test vulnerability of current CPOE systems to these errors.

METHODS

A review of medication errors reported to United States Pharmacopeia MEDMARX reporting system was made, and a taxonomy was developed for CPOE-related errors. For each error we evaluated what went wrong and why and identified potential prevention strategies and recurring error scenarios. These scenarios were then used to test vulnerability of leading CPOE systems, asking typical users to enter these erroneous orders to assess the degree to which these problematic orders could be entered.

RESULTS

Between 2003 and 2010, 1.04 million medication errors were reported to MEDMARX, of which 63 040 were reported as CPOE related. A review of 10 060 CPOE-related cases was used to derive 101 codes describing what went wrong, 67 codes describing reasons why errors occurred, 73 codes describing potential prevention strategies and 21 codes describing recurring error scenarios. Ability to enter these erroneous order scenarios was tested on 13 CPOE systems at 16 sites. Overall, 298 (79.5%) of the erroneous orders were able to be entered including 100 (28.0%) being 'easily' placed, another 101 (28.3%) with only minor workarounds and no warnings.

CONCLUSIONS AND RELEVANCE

Medication error reports provide valuable information for understanding CPOE-related errors. Reports were useful for developing taxonomy and identifying recurring errors to which current CPOE systems are vulnerable. Enhanced monitoring, reporting and testing of CPOE systems are important to improve CPOE safety.

Preoperative medication use and postoperative delirium: a systematic review

BACKGROUND

Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use.

METHODS

A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies.

RESULTS

Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result.

CONCLUSIONS

There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention.

TRIAL REGISTRATION

This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).

Clinical pharmacy services in the emergency department

The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal policy statements from several notable organizations, including the American College of Emergency Physicians (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clinical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs, the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes, and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to implementing EM clinical pharmacy programs and limitations are considered.

Impact of admission medication reconciliation performed by clinical pharmacists on medication safety

BACKGROUND

Many activities contribute to reduce drug-related problems. Among them, the medication reconciliation (MR) is used to compare the best possible medication history (BPMH) and the current admission medication order (AMO) to identify and solve unintended medication discrepancies (UMD). This study aims to assess the impact of the implementation of admission MR by clinical pharmacists on UMD.

METHOD

This prospective study was carried out in two units of general medicine and infectious and tropical diseases in a 1844-bed French hospital. A retroactive MR performed in an observational period was compared to a proactive MR realized in an interventional period. We used a logistic regression to identify risk factors of UMD.

RESULTS

During both periods, 394 patients were enrolled and 2,725 medications were analyzed in the BPMH. Proactive MR reduced the percentage of patients with at least one UMD compared with retroactive process (respectively 2.1% vs. 45.8%, p<0.001). Patients with at least one UMD during both periods were older compared to patients without UMD (79 vs. 72, p<0.005) and had more medications at admission (7 vs. 6, p<0.0001). UMD occur 38 times more often when there is no clinical pharmacist intervention. Among the 226 UMD detected in both periods, 42% would have required monitoring or intervention to preclude harm, and 10% had potential harm to the patient and 2% were life threatening.

CONCLUSION

Proactive MR performed by clinical pharmacists is an acute process of detection and correction of UMD, but it requires a lot of human resources.

Patient perceptions of proactive medication discontinuation

OBJECTIVE

While many patients prefer fewer medications, decisions about medication discontinuation involve collaboration between patients and providers. We sought to identify patient perspectives on intentional medication discontinuation in order to optimize medication use.

METHODS

We conducted 20 interviews and two focus groups with a convenience sample of patients (22 men, 5 women; mean age 66 years) at two US Veterans Affairs Medical Centers. We queried patients' experiences with and attitudes toward taking multiple medications, preferences about taking fewer medications, and communication with their providers about stopping a medicine. Transcripts were analyzed qualitatively.

RESULTS

Three main themes emerged to create a conceptual model of medication discontinuation from the patient perspective: (1) conflicting views of medication, encompassing the sub-themes of desire for fewer medications, adherence, and specific versus general; (2) importance of patient-provider relationships, encompassing the sub-themes of trust, relying on expertise, shared decision making, and balancing multiple providers; and (3) limited experience with medication discontinuation.

CONCLUSION

Many patients who have a preference to take fewer medicines do not share their beliefs with providers and recall few instances of provider-initiated medication discontinuation.

PRACTICE IMPLICATIONS

Strengthening patient-provider relationships and eliciting patient attitudes about taking fewer medications may enable appropriate discontinuation of unnecessary medications.

Outpatient, combined use of opioid and benzodiazepine medications in the United States, 1993-2014

The combined use of opioid and benzodiazepine medications increases the risk of hazardous effects, such as respiratory depression. Although recent increases in outpatient use of opioid prescriptions have been documented, there are limited data regarding rates and correlates of combined opioid and benzodiazepines among adults in outpatient settings. Our objective was to examine annual trends in outpatient visits including opioids, benzodiazepines, and their combination among adults as well as clinical and demographic correlates. We used data from the 1993–2014 National Ambulatory Medical Care Survey (NAMCS) among non-elderly (i.e., ages 18–64 years) adults to examine the probability of a visit including an opioid, benzodiazepine, or their combination, in addition to clinical and demographic correlates. From 1993 to 2014, benzodiazepines-with-opioids visits increased from 9.8 to 62.5 (OR = 9.23, 95% CI = 5.45–15.65) per 10,000 visits. Highest-represented groups among benzodiazepines-with-opioids visits were older (50–64 years) (49.1%), white (88.8%), commercially insured (58.0%) patients during their first visit (87.6%) to a primary-care physician (41.9%). We identified a significant increase in the outpatient co-prescription of opioids and benzodiazepines, notably among adults aged 50–64 years during primary-care visits. Educational and policy changes to provide alternatives to benzodiazepine-with-opioid co-prescription and limiting opioid prescription to pain specialists may reduce rates of this potentially hazardous combination.

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Current guidelines for prescribing opioids recommend against co-administration with benzodiazepines

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Concurrent use of opioids and benzodiazepines increases the risk of overdose, respiratory depression, and death.

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We examined 22 years of outpatient prescribing patterns of opioids and benzodiazepines using a survey of US physicians.

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Over this period, visits with both opioids and benzodiazepines increased from roughly 9.8 to 62.5 per 10,000 visits.

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These visits were more likely among older (50–64 years), white, privately insured patients with a low-back pain diagnosis.

E-prescribing errors in community pharmacies: exploring consequences and contributing factors

OBJECTIVE

To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors.

METHODS

Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10.

RESULTS

Pharmacy staff detected 75 e-prescription errors during the 45 h observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information.

CONCLUSION

Study findings suggest that a wide range of e-prescribing errors is encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies.

Impact of electronic medication reconciliation interventions on medication discrepancies at hospital transitions: a systematic review and meta-analysis

Background

Medication reconciliation has been identified as an important intervention to minimize the incidence of unintentional medication discrepancies at transitions in care. However, there is a lack of evidence for the impact of information technology on the rate and incidence of medication discrepancies identified during care transitions. This systematic review was thus, aimed to evaluate the impact of electronic medication reconciliation interventions on the occurrence of medication discrepancies at hospital transitions.

Methods

Systematic literature searches were performed in MEDLINE, PubMed, CINHAL, and EMBASE from inception to November, 2015. We included published studies in English that evaluated the effect of information technology on the incidence and rate of medication discrepancies compared with usual care. Cochrane’s tools were used for assessment of the quality of included studies. We performed meta-analyses using random-effects models.

Results

Ten studies met our inclusion criteria; of which only one was a randomized controlled trial. Interventions were carried out at various hospital transitions (admission, 5; discharge, 2 and multiple transitions, 3 studies). Meta-analysis showed a significant reduction of 45 % in the proportion of medications with unintentional discrepancies after the use of electronic medication reconciliation (RR 0.55; 95 % CI 0.51 to 0.58). However, there was no significant reduction in either the proportion of patients with medication discrepancies or the mean number of discrepancies per patient. Drug omissions were the most common types of unintended discrepancies, and with an electronic tool a significant but heterogeneously distributed reduction of omission errors over the total number of medications reconciled have been observed (RR 0.20; 95 % CI 0.06 to 0.66). The clinical impact of unintended discrepancies was evaluated in five studies, and there was no potentially fatal error identified and most errors were minor in severity.

Conclusion

Medication reconciliation supported by an electronic tool was able to minimize the incidence of medications with unintended discrepancy, mainly drug omissions. But, this did not consistently reduce other process outcomes, although there was a lack of rigorous design to conform these results.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0353-9) contains supplementary material, which is available to authorized users.

The association of subjective workload dimensions on quality of care and pharmacist quality of work life

BACKGROUND

Workload has been described both objectively (e.g., number of prescriptions dispensed per pharmacist) as well as subjectively (e.g., pharmacist's perception of busyness). These approaches might be missing important characteristics of pharmacist workload that have not been previously identified and measured.

OBJECTIVES

To measure the association of community pharmacists' workload perceptions at three levels (organization, job, and task) with job satisfaction, burnout, and perceived performance of two tasks in the medication dispensing process.

METHODS

A secondary data analysis was performed using cross-sectional survey data collected from Wisconsin (US) community pharmacists. Organization-related workload was measured as staffing adequacy; job-related workload was measured as general and specific job demands; task-related workload was measured as internal and external mental demands. Pharmacists' perceived task performance was assessed for patient profile review and patient consultation. The survey was administered to a random sample of 500 pharmacists who were asked to opt in if they were a community pharmacist. Descriptive statistics and correlations of study variables were determined. Two structural equation models were estimated to examine relationships between the study variables and perceived task performance.

RESULTS

From the 224 eligible community pharmacists that agreed to participate, 165 (73.7%) usable surveys were completed and returned. Job satisfaction and job-related monitoring demands had direct positive associations with both dispensing tasks. External task demands were negatively related to perceived patient consultation performance. Indirect effects on both tasks were primarily mediated through job satisfaction, which was positively related to staffing adequacy and cognitive job demands and negatively related to volume job demands. External task demands had an additional indirect effect on perceived patient consultation performance, as it was associated with lower levels of job satisfaction and higher levels of burnout.

IMPLICATIONS/CONCLUSIONS

Allowing community pharmacists to concentrate on tasks and limiting interruptions while performing these tasks are important factors in improving quality of patient care and pharmacist work life. The results have implications for strategies to improve patient safety and pharmacist performance.

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting

BACKGROUND

Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood.

OBJECTIVE

The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors.

METHODS

The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment.

RESULTS

Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks.

CONCLUSIONS

Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required.

Analysis of drug-related problems in three departments of a German University hospital

BACKGROUND

During the last decades, pharmaceutical care services have been developed and implemented to optimize drug therapies and ensure medication safety. To investigate the need for pharmaceutical care services, drug-related problems can be measured.

OBJECTIVE

Thus, the aim of this study was to analyse number, type and occurrence of drug-related problems in different clinical departments.

SETTING

A pharmaceutical care service was established on general wards in Urology, Neurology and Gastroenterology at the University Hospital RWTH Aachen, Germany.

METHOD

For each of a total of 306 patients, a pharmacist conducted an extended medication history, performed medication reconciliation, conducted medication safety checks and if drug-related problems were discovered, gave valid recommendations to the attending healthcare team. Drug-related problems were classified using the APS-Doc system. For statistical analyses, SAS(®) 9.1.3, SAS Institute, Cary NC, USA was applied. The project was approved by the local ethics committee.

MAIN OUTCOME MEASURE

Type, occurrence and frequency of DRP in different medical departments.

RESULTS

On average, 2.3 drug-related problems per patient were documented for all three departments. Drug-related problems were found in each category of the APS-Doc system. The most pronounced drug-related problems found were drug-drug interactions (34.6 %). 37 % of the identified drug-related problems occurred before hospital admission, 27 % during transitional care, and 36 % on the ward. Subgroup analysis revealed specific drug-related problem patterns for each clinical department. The number of drug-related problems was found to be associated with the number of drugs and age.

CONCLUSION

Drug-related problems frequently occur in all investigated clinical departments. A holistic pharmaceutical care service could be an option to address this issue. In case of limited resources, individual drug-related problem patterns can be used as a basis for a tailored pharmaceutical care service. As number of drugs and age have been shown to be significant risk factors, it is crucial that the healthcare team including the pharmacist pays special attention to elderly patients and those with polymedication.

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study

Aim

To evaluate the effectiveness of a ‘Do not interrupt’ bundled intervention to reduce non-medication-related interruptions to nurses during medication administration.

Methods

A parallel eight cluster randomised controlled study was conducted in a major teaching hospital in Adelaide, Australia. Four wards were randomised to the intervention which comprised wearing a vest when administering medications; strategies for diverting interruptions; clinician and patient education; and reminders. Control wards were blinded to the intervention. Structured direct observations of medication administration processes were conducted. The primary outcome was non-medication-related interruptions during individual medication dose administrations. The secondary outcomes were total interruption and multitasking rates. A survey of nurses' experiences was administered.

Results

Over 8 weeks and 364.7 hours, 227 nurses were observed administering 4781 medications. At baseline, nurses experienced 57 interruptions/100 administrations, 87.9% were unrelated to the medication task being observed. Intervention wards experienced a significant reduction in non-medication-related interruptions from 50/100 administrations (95% CI 45 to 55) to 34/100 (95% CI 30 to 38). Controlling for clustering, ward type and medication route showed a significant reduction of 15 non-medication-related interruptions/100 administrations compared with control wards. A total of 88 nurses (38.8%) completed the poststudy survey. Intervention ward nurses reported that vests were time consuming, cumbersome and hot. Only 48% indicated that they would support the intervention becoming hospital policy.

Discussion

Nurses experienced a high rate of interruptions. Few were related to the medication task, demonstrating considerable scope to reduce unnecessary interruptions. While the intervention was associated with a statistically significant decline in non-medication-related interruptions, the magnitude of this reduction and its likely impact on error rates should be considered, relative to the effectiveness of alternate interventions, associated costs, likely acceptability and long-term sustainability of such interventions.

Prescriber response to computerized drug alerts for electronic prescriptions among hospitalized patients

BACKGROUND

Clinical decision support systems (CDSS) reduce prescription errors, but their effectiveness is reduced by high alert rates, "alert fatigue", and indiscriminate rejection.

OBJECTIVES

To compare acceptance rates of alerts generated by the SafeRx^® prescription CDSS among different alert types and departments in a tertiary care hospital, identify factors associated with alert acceptance, and determine whether alert overrides were justified.

METHODS

In a retrospective study, we compared acceptance rates of all prescription alerts generated in 2013 in 18 departments of Israel's largest tertiary care center. In a prospective study in 2 internal medicine departments, we collected data on factors potentially associated with alert override, and an expert panel evaluated the justification for each overridden alert. We used multivariate analyses to examine the association between patient and physician-related factors and alert acceptance.

RESULTS

In the retrospective study, of 390,841 prescriptions, 37.1% triggered at least one alert, 5.3% of which were accepted. Acceptance rates ranged from 7.9% for excessive dose alerts to 4.0% for duplicate drug and major drug-drug interactions alerts (p<0.001). In the prospective study, common reasons for alert overriding included "irrelevance to the specific condition" and "medication previously tolerated by the patient". Weekend shifts (incident rate ratio [IRR]=1.50 [95% CI, 1.01-2.22]) and a specific department (IRR=1.87 [1.23-2.87]) were associated with higher alert acceptance, while night shift (IRR=0.47 [0.26-0.85]) was associated with alert override. Most alert overrides (88.6%) were judged justified.

CONCLUSIONS

The vast majority of SafeRx^® alerts are overridden, and overriding is justified in most cases. Minimizing the number of alerts is essential to reduce the likelihood of developing "alert fatigue". Our findings may inform a rational, department-specific approach for alert silencing.

Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study

BACKGROUND

We investigated the benefits of the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT) service versus standard ward-based clinical pharmacy in adult inpatients receiving acute medical care, particularly on prevalence of medication error and quality of prescribing.

METHODS

Uncontrolled before-after study, undertaken in consecutive adult medical inpatients admitted and discharged alive, using at least three medications. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT intervention involved clinical pharmacists being team-based, leading admission and discharge medication reconciliation and undertaking prescription review. Primary outcome measures were prevalence per patient of medication error and potentially severe error. Secondary measures included quality of prescribing using the Medication Appropriateness Index (MAI) in patients aged ≥65 years.

FINDINGS

Some 233 patients (112 PACT, 121 standard) were included. PACT decreased the prevalence of any medication error at discharge (adjusted OR 0.07 (95% CI 0.03 to 0.15)); number needed to treat (NNT) 3 (95% CI 2 to 3) and no PACT patient experienced a potentially severe error (NNT 20, 95% CI 10 to 142). In patients aged ≥65 years (n=108), PACT improved the MAI score from preadmission to discharge (Mann-Whitney U p<0.05; PACT median -1, IQR -3.75 to 0; standard care median +1, IQR -1 to +6).

CONCLUSIONS

PACT, a collaborative model of pharmaceutical care involving medication reconciliation and review, delivered by clinical pharmacists and physicians, at admission, during inpatient care and at discharge was protective against potentially severe medication errors in acute medical patients and improved the quality of prescribing in older patients.

The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study

BACKGROUND

Little is known about interventions to reduce intravenous medication administration errors in hospitals, especially in low- and middle-income countries.

OBJECTIVE

To assess the effect of a clinical pharmacist-led training programme on clinically relevant errors during intravenous medication preparation and administration in a Vietnamese hospital.

METHODS

A controlled before and after study with baseline and follow-up measurements was conducted in an intensive care unit (ICU) and a post-surgical unit (PSU). The intervention comprised lectures, practical ward-based teaching sessions and protocols/guidelines, and was conducted by a clinical pharmacist and a nurse. Data on intravenous medication preparation and administration errors were collected by direct observation 12 h/day for seven consecutive days. Generalised estimating equations (GEE) were used to assess the effect of the intervention on the prevalence of clinically relevant erroneous doses, corrected for confounding factors.

RESULTS

1204 intravenous doses were included, 516 during the baseline period (236 on ICU and 280 on PSU) and 688 during the follow-up period (407 on ICU and 281 on PSU). The prevalence of clinically relevant erroneous doses decreased significantly on the intervention ward (ICU) from 64.0% to 48.9% (p<0.001) but was unchanged on the control ward (PSU) (57.9% vs 64.1%; p=0.132). GEE analysis showed that doses on the intervention ward were 2.60 (1.27-5.31) times less likely to have clinically relevant errors (p=0.013).

CONCLUSIONS

The pharmacist-led training programme was effective, but the error rate remained relatively high. Further quality improvement strategies are needed, including changes to the working environment and promotion of a safety culture.

An education intervention to improve nursing students' understanding of medication safety

Medication safety is a significant issue. Whilst medication administration is a routine task, it is a complex nursing activity. It is recognised in the literature that medication related adverse events are most often related to systems failures associated with the complex process of medication administration. This paper examines student's perceived effectiveness of an educational intervention, designed to demonstrate the complex and multidisciplinary factors of systems related failures in medication administration. The intervention was underpinned by adult and experiential learning concepts and used a problem-based learning approach. A series of short digital recordings were developed along with discussion points to illustrate multidisciplinary interactions involved in medication administration. A small sample of second and third year undergraduate nursing students (n = 28) evaluated the effectiveness of the educational resource. Our findings suggest that such resources are effective in demonstrating the complexity of medication related error and were authentic to practice. An educational intervention using problem based learning afforded nursing students the opportunity to engage with the systems factors that contribute to medication errors. Interventions that highlight these factors may play an important role in raising awareness of these issues and encourage students to carry this knowledge into clinical practice.

Classification of medication incidents associated with information technology

INTRODUCTION

Information technology (IT) plays a pivotal role in improving patient safety, but can also cause new problems for patient safety. This study analyzed the nature and consequences of a large sample of IT-related medication incidents, as reported by healthcare professionals in community pharmacies and hospitals.

METHODS

The medication incidents submitted to the Dutch central medication incidents registration (CMR) reporting system were analyzed from the perspective of the healthcare professional with the Magrabi classification. During classification new terms were added, if necessary.

MAIN MEASURES

The principal source of the IT-related problem, nature of error. Additional measures: consequences of incidents, IT systems, phases of the medication process.

RESULTS

From March 2010 to February 2011 the CMR received 4161 incidents: 1643 (39.5%) from community pharmacies and 2518 (60.5%) from hospitals. Eventually one of six incidents (16.1%, n=668) were related to IT; in community pharmacies more incidents (21.5%, n=351) were related to IT than in hospitals (12.6%, n=317). In community pharmacies 41.0% (n=150) of the incidents were about choosing the wrong medicine. Most of the erroneous exchanges were associated with confusion of medicine names and poor design of screens. In hospitals 55.3% (n=187) of incidents concerned human-machine interaction-related input during the use of computerized prescriber order entry. These use problems were also a major problem in pharmacy information systems outside the hospital.

CONCLUSIONS

A large sample of incidents shows that many of the incidents are related to IT, both in community pharmacies and hospitals. The interaction between human and machine plays a pivotal role in IT incidents in both settings.

A multi-disciplinary approach to medication safety and the implication for nursing education and practice

BACKGROUND

Medication management is a complex multi-stage and multi-disciplinary process, involving doctors, pharmacists, nurses and patients. Errors can occur at any stage from prescribing, dispensing and administering, to recording and reporting. There are a number of safety mechanisms built into the medication management system and it is recognised that nurses are the final stage of defence. However, medication error still remains a major challenge to patient safety globally.

OBJECTIVES

This paper aims to illustrate two main aspects of medication safety practices that have been elicited from an action research study in a Scottish Health Board and three local Higher Education Institutions: firstly current medication safety practices in two clinical settings; and secondly pre and post-registration nursing education and teaching on medication safety.

METHOD

This paper is based on Phase One and Two of an Action Research project. An ethnography-style observational method, influenced by an Appreciative Inquiry (AI) approach was adapted to study the everyday medication management systems and practices of two hospital wards. This was supplemented by seven in-depth interviews with nursing staff, numerous informal discussions with healthcare professionals, two focus-groups, one peer-interview and two in-depth individual interviews with final year nursing students from three Higher Education Institutions in Scotland.

RESULT

This paper highlights the current positive practical efforts in medication safety practices in the chosen clinical areas. Nursing staff do employ the traditional 'five right' principles - right patient, right medication, right dose, right route and right time - for safe administration. Nursing students are taught these principles in their pre-registration nursing education. However, there are some other challenges remaining: these include the establishment of a complete medication history (reconciliation) when patients come to hospital, the provision of an in-depth training in pharmacological knowledge to junior nursing staff and pre-registration nursing students.

CONCLUSION

This paper argues that the 'five rights' principle during medication administration is not enough for holistic medication safety and explains two reasons why there is a need for strengthened multi-disciplinary team-work to achieve greater patient safety. To accomplish this, nurses need to have sufficient knowledge of pharmacology and medication safety issues. These findings have important educational implications and point to the requirement for the incorporation of medication management and pharmacology in to the teaching curriculum for nursing students. There is also a call for continuing professional development opportunities for nurses working in clinical settings.

Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture

BACKGROUND

Experts in patient safety stress the importance of a shared culture of safety. Lack of consensus may be detrimental to patient safety. This study examines differences in patient safety culture perceptions among providers, management and staff in a large national survey of safety culture in ambulatory practices in the USA.

METHODS

The US Agency for Healthcare Research and Quality Medical Office Survey on Patient Safety Culture (SOPS) assesses perceptions about patient safety issues and event reporting in medical offices (ie, ambulatory practices). Using the 2014 data, we analysed responses from medical offices with at least five respondents. We calculated differences in perceptions of patient safety culture across six job positions (physicians, management, nurse practitioners (NPs)/physician assistants (PAs), nurses, clinical support staff and administrative/clerical staff) for 10 survey composites, the average of the 10 composites and an overall patient safety rating using multivariate hierarchical linear regressions.

RESULTS

We analysed data from 828 medical offices with responses from 15 523 providers and staff, with an average 20 completed surveys per medical office (range: 5-367) and an average medical office response rate of 65% (range: 3%-100%). Management had significantly more positive patient safety culture perceptions on nine of 10 composite scores compared with all other job positions, including physicians. The composite that showed the largest difference was Communication Openness; Management (85% positive) was 22% points more positive than other clinical and support staff and administrative/clerical staff. Physicians were significantly more positive than PAs/NPs, nursing staff, other clinical and support staff and administrative/clerical staff on four composites: Communication About Error, Communication Openness, Staff Training and Teamwork, ranging from 3% to 20% points more positive.

CONCLUSIONS

These findings suggest that managers need to pay attention to the training needs of office staff, since this was an area with one of the greatest gaps in perceptions. In addition, both office managers and physicians need to encourage more open communication. As medical offices innovate to improve value, efficiency and patient-centred care, it is important that they continue to foster shared perceptions about what organisational members need, understanding that those perceptions may differ systematically by job position.

Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project

Background

Prescribing errors occur in up to 15% of UK inpatient medication orders. However, junior doctors report insufficient feedback on errors. A barrier preventing feedback is that individual prescribers often cannot be clearly identified on prescribing documentation.

Aim

To reduce prescribing errors in a UK hospital by improving feedback on prescribing errors.

Interventions

We developed three linked interventions using plan–do–study–act cycles: (1) name stamps for junior doctors who were encouraged to stamp or write their name clearly when prescribing; (2) principles of effective feedback to support pharmacists to provide feedback to doctors on individual prescribing errors and (3) fortnightly prescribing advice emails that addressed a common and/or serious error.

Implementation and evaluation

Interventions were introduced at one hospital site in August 2013 with a second acting as control. Process measures included the percentage of inpatient medication orders for which junior doctors stated their name. Outcome measures were junior doctors' and pharmacists' perceptions of current feedback provision (evaluated using quantitative pre-questionnaires and post-questionnaires and qualitative focus groups) and the prevalence of erroneous medication orders written by junior doctors between August and December 2013.

Results

The percentage of medication orders for which junior doctors stated their name increased from about 10% to 50%. Questionnaire responses revealed a significant improvement in pharmacists' perceptions but no significant change for doctors. Focus group findings suggested increased doctor engagement with safe prescribing. Interrupted time series analysis showed no difference in weekly prescribing error rates between baseline and intervention periods, compared with the control site.

Conclusion

Findings suggest improved experiences around feedback. However, attempts to produce a measurable reduction in prescribing errors are likely to need a multifaceted approach of which feedback should form part.

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement

OBJECTIVES

To evaluate how often and why providers overrode drug allergy alerts in both the inpatient and outpatient settings.

DESIGN

A cross-sectional observational study of drug allergy alerts generated over a 3-year period between 1 January 2009 and 31 December 2011.

SETTING

A 793-bed tertiary care teaching affiliate of Harvard Medical School and 36 primary care practices.

PARTICIPANTS

Drug allergy alerts were displayed for a total of 29 420 patients across both settings.

MAIN OUTCOME MEASURES

Proportion of drug allergy alerts displayed and overridden, proportion of appropriate overrides, proportion of overrides in each medication class, different reasons for overriding and types of reactions overridden.

RESULTS

A total of 158 023 drug allergy alerts were displayed, 131 615 (83%) in the inpatient setting and 26 408 (17%) in the outpatient setting; 128 157 (81%) of which were overridden. A random sample of inpatient (n=200, 0.19%) and outpatient (n=50, 0.25%) alert overrides were screened for appropriateness, with >96% considered appropriate. Alerts for some drug classes, such as 'non-antibiotic sulfonamides', were overridden for >81% of prescriptions in both settings. The most common override reason was patient has taken previously without allergic reaction. In the inpatient setting alone, 70.9% of alerts that warned against the risk of anaphylaxis were overridden.

CONCLUSIONS

The information contained in patients' drug allergy lists needs to be regularly updated. Most of the drug allergy alerts were overridden, with the majority of alert overrides in the subsample considered appropriate. Some of the rules for these alerts should be carefully reviewed and modified, or removed. Further research is needed to understand providers' overriding of alerts that warned against the risk of 'anaphylaxis', which are more concerning with respect to patient safety.

Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years

BACKGROUND

Despite the widespread implementation of Tall Man lettering, little evidence exists regarding whether this technique has reduced drug errors due to look-alike sound-alike (LA-SA) drug names. This study evaluated rates of potential LA-SA drug errors in the drug management process through to the point of dispensing before and after implementation of Tall Man lettering in 2007.

METHODS

We used detailed pharmacy data for paediatric inpatients (<21 years old) from 42 children's hospitals in 2004-2012. After prespecifying a set of 8 potential LA-SA drug error patterns we searched within each hospitalisation for the occurrence of one of these patterns for a total of 12 LA-SA drug pairs deemed highly relevant to paediatric inpatients. To assess for potential change of error rates before and after Tall Man lettering implementation, we performed segmented regression analyses for each of 11 LA-SA drug pairs (because 1 pair had no detected potential errors) and for the overall total errors of all 11 LA-SA drug pairs.

RESULTS

Among 1 676 700 hospitalisations, no statistically significant change was detected for either the intercept or the slope of LA-SA error rate for each of the 11 drug pairs or for the combined error rate. In a sensitivity analysis of the moving average of the potential error rate over the entire study period, no downward trend in potential LA-SA drug error rates was evident over any time period 2004 onwards.

CONCLUSIONS

Implementation of Tall Man lettering in 2007 was not associated with a reduction in the potential LA-SA error rate. Whether Tall Man lettering is effective in clinical practice warrants further study.

"Natural" is not synonymous with "Safe": Toxicity of natural products alone and in combination with pharmaceutical agents

During the 25 years since the US Congress passed the Dietary Supplement Health and Education Act (DSHEA), the law that transformed the US Food and Drug Administration's (FDA's) authority to regulate dietary supplements, the dietary supplement market has grown exponentially. Retail sales of herbal products, a subcategory of dietary supplements, have increased 83% from 2008 to 2018 ($4.8 to $8.8 billion USD). Although consumers often equate "natural" with "safe", it is well recognized by scientists that constituents in these natural products (NPs) can result in toxicity. Additionally, when NPs are co-consumed with pharmaceutical agents, the precipitant NP can alter drug disposition and drug delivery, thereby enhancing or reducing the therapeutic effect of the object drug(s). With the widespread use of NPs, these effects can be underappreciated. We present a summary of a symposium presented at the Annual Meeting of the Society of Toxicology 2019 (12 March 2019) that discussed potential toxicities of NPs alone and in combination with drugs.