1
|
Ryan AN, Robertson KL, Glass BD. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. Int J Clin Pharm 2024; 46:26-39. [PMID: 37688737 PMCID: PMC10830657 DOI: 10.1007/s11096-023-01629-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/17/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Look-alike medications, where ampoules or vials of intravenous medications look similar, may increase the risk of medication errors in the perioperative setting. AIM This scoping review aimed to identify and explore the issues related to look-alike medication incidents in the perioperative setting and the reported risk reduction interventions. METHOD Eight databases were searched including: CINAHL Complete, Embase, OVID Emcare, Pubmed, Scopus, Informit, Cochrane and Prospero and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR). Key search terms included anaesthesia, adverse drug event, drug error or medication error, look alike sound alike, operating theatres and pharmacy. Title and abstracts were screened independently and findings were extracted using validated tools in collaboration and consensus with co-authors. RESULTS A total of 2567 records were identified to 4th July 2022; however only 18 publications met the inclusion criteria. Publication types consisted of case reports, letters to the editor, multimodal quality improvement activities or survey/audits, a controlled simulation study and one randomised clinical trial. Risk reduction intervention themes identified included regulation, procurement, standardisation of storage, labelling, environmental factors, teamwork factors and the safe administration. CONCLUSION This review highlighted challenges with look-alike medications in the perioperative setting and identified interventions for risk reduction. Key interventions did not involve technology-based solutions and further research is required to assess their effectiveness in preventing patient harm.
Collapse
Affiliation(s)
- Alexandra N Ryan
- Pharmacy Department, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD, 4810, Australia.
- College of Medicine and Dentistry, James Cook University, Townsville, Australia.
| | - Kelvin L Robertson
- Pharmacy Department, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD, 4810, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Beverley D Glass
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| |
Collapse
|
2
|
Vaghasiya MR, Poon SK, Gunja N, Penm J. The Impact of an Electronic Medication Management System on Medication Deviations on Admission and Discharge from Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1879. [PMID: 36767245 PMCID: PMC9915082 DOI: 10.3390/ijerph20031879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 06/18/2023]
Abstract
Medication errors at transition of care remain a concerning issue. In recent times, the use of integrated electronic medication management systems (EMMS) has caused a reduction in medication errors, but its effectiveness in reducing medication deviations at transition of care has not been studied in hospital-wide settings in Australia. The aim of this study is to assess medication deviations, such as omissions and mismatches, pre-EMMS and post-EMMS implementation at transition of care across a hospital. In this study, patient records were reviewed retrospectively to identify medication deviations (medication omissions and medication mismatches) at admission and discharge from hospital. A total of 400 patient records were reviewed (200 patients in the pre-EMMS and 200 patients in the post-EMMS group). Out of 400 patients, 112 in the pre-EMMS group and 134 patients in post-EMMS group met the inclusion criteria and were included in the analysis. A total of 105 out of 246 patients (42.7%) had any medication deviations on their medications. In the pre-EMMS group, 59 out of 112 (52.7%) patients had any deviations on their medications compared to 46 out of 134 patients (34.3%) from the post-EMMS group (p = 0.004). The proportion of patients with medication omitted from inpatient orders was 36.6% in the pre-EMMS cohort vs. 22.4% in the post-EMMS cohort (p = 0.014). Additionally, the proportion of patients with mismatches in medications on the inpatient charts compared to their medication history was 4.5% in the pre-EMMS group compared to 0% in the post-EMMS group (p = 0.019). Similarly, the proportion of patients with medications omitted from their discharge summary was 23.2% in the pre-EMMS group vs. 12.7% in the post-EMMS group (p = 0.03). Our study demonstrates a reduction in medication deviations after the implementation of the EMMS in hospital settings.
Collapse
Affiliation(s)
- Milan R. Vaghasiya
- Faculty of Engineering, The University of Sydney, Camperdown, NSW 2006, Australia
- Digital Health Solutions, Western Sydney Local Health District, North Parramatta, NSW 2151, Australia
| | - Simon K. Poon
- Faculty of Engineering, The University of Sydney, Camperdown, NSW 2006, Australia
- Digital Health Solutions, Western Sydney Local Health District, North Parramatta, NSW 2151, Australia
| | - Naren Gunja
- Digital Health Solutions, Western Sydney Local Health District, North Parramatta, NSW 2151, Australia
- Faculty of Medicine & Health, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Jonathan Penm
- Faculty of Medicine & Health, School of Pharmacy, The University of Sydney, Camperdown, NSW 2006, Australia
- Department of Pharmacy, Prince of Wales Hospital, Randwick, NSW 2031, Australia
| |
Collapse
|
3
|
Naseralallah L, Stewart D, Azfar Ali R, Paudyal V. An umbrella review of systematic reviews on contributory factors to medication errors in healthcare settings. Expert Opin Drug Saf 2022; 21:1379-1399. [DOI: 10.1080/14740338.2022.2147921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Lina Naseralallah
- School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Derek Stewart
- Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ruba Azfar Ali
- School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Vibhu Paudyal
- School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| |
Collapse
|
4
|
Stipp MM, Deng H, Kong K, Moore S, Hickman RL, Nanji KC. Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events. Medicine (Baltimore) 2022; 101:e31432. [PMID: 36343025 PMCID: PMC9646678 DOI: 10.1097/md.0000000000031432] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 09/30/2022] [Indexed: 11/09/2022] Open
Abstract
The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study[1] to those identified by self-report via a facilitated incident reporting system at the same 1046-bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.
Collapse
Affiliation(s)
- Melanie M. Stipp
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Mass General Brigham, Wellesley, MA, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Hao Deng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Mass General Brigham, Wellesley, MA, USA
| | - Kathy Kong
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Mass General Brigham, Wellesley, MA, USA
| | - Sonya Moore
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Karen C. Nanji
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Mass General Brigham, Wellesley, MA, USA
| |
Collapse
|
5
|
Chevalier S, Coillot H, Colombat P, Bosselut G, Guilbert L, Fouquereau E. An explanatory model of authentic leadership, flourishing and work-family balance of nurses in French hospitals. Leadersh Health Serv (Bradf Engl) 2021; ahead-of-print. [PMID: 34038041 DOI: 10.1108/lhs-06-2020-0043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE This study aims to investigate the relationship between a positive leadership style [i.e. authentic leadership (AL)] and nurses' psychological health (i.e. nurses' flourishing and satisfaction with work-family balance), including psychological capital (PsyCap) as a mediational variable. DESIGN/METHODOLOGY/APPROACH A cross-sectional study was conducted with a self-report questionnaire including 1,076 nurses from public and private hospitals in France. FINDINGS Structural equation modeling results revealed that AL is related to nurses' flourishing and satisfaction with work-family balance and that PsyCap acted as a partial mediator between this leadership style and positive outcomes. PRACTICAL IMPLICATIONS This research indicated that hospitals can enhance nurses' psychological health not only in their work but also in their lives in general by improving leaders' authentic management style and developing PsyCap (e.g. staffing, training and development). ORIGINALITY/VALUE An original feature of this paper concerns its focus on the mediating role of PsyCap in the relationship between AL and these positive outcomes. Moreover, this study underlined the influence of leadership style on nurses' psychological health beyond occupational health. The research makes a valuable contribution to the existing AL literature by establishing a new explanatory model of AL and nurses' psychological health in the French context. It also highlights the interest in developing this leadership style in health-care settings.
Collapse
Affiliation(s)
| | | | | | - Grégoire Bosselut
- EuroMov Digital Health in Motion, University of Montpellier, IMT Mines Ales, France
| | - Laure Guilbert
- Epsylon 4556, University of Montpellier, Montpellier, France
| | | |
Collapse
|
6
|
Mrayyan MT, Al-Atiyyat N, Al-Rawashdeh S, Sawalha M, Awwad M. Comparing rates and causes of, and views on reporting of medication errors among nurses working in different-sized hospitals. Nurs Forum 2021; 56:560-570. [PMID: 33884638 DOI: 10.1111/nuf.12581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medication errors are detrimental to patient safety and the quality of hospital services. PURPOSE The purpose of the study was to compare registered nurses working in the small-, medium-, and large-sized Jordanian hospitals' responses in terms of reported rate and cause of medication errors and their views on medication error reporting. METHODS This was a cross-sectional comparative design, with a total sample of 229 nurses working in different-sized hospitals. RESULTS The rates of reported medication errors were significantly different across hospitals representing 53.5% in small-sized, 41.8% in medium-sized, and 32.8% in large-sized hospitals. No significant differences between hospitals regarding the nurses' reported causes of medication errors. Nurses' views were significantly different in all aspects of their reporting except in their failure to report (drug) error. CONCLUSIONS The hospital's size may associate with nurses' reporting rate and nurses' views on reporting such errors. There is an urgent need for more diligent systematic efforts to prevent, detect, and report medication errors. Collaboration with other health team members, including information technology members, will enhance the outcomes associated with medication administration. The findings of this study warranted further investigations.
Collapse
Affiliation(s)
- Majd T Mrayyan
- Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Nijmeh Al-Atiyyat
- Department of Adult Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Sami Al-Rawashdeh
- Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Murad Sawalha
- Department of Maternal, Child, and Family Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | | |
Collapse
|
7
|
|
8
|
Abstract
The older population is expected to nearly double across the globe by 2050, and the baby boom cohort is expected to represent at least 20% of the US population by 2030. Geriatric patients will increasingly utilize the health-care system, and therefore surgical and perioperative care must be tailored to this sensitive group given the increased risk for perioperative complications. The literature was reviewed to highlight fundamental components of the preoperative evaluation as well as cardiac, pulmonary, and renal complications. Frailty is a multidimensional process that can lead to the physiologic effects of aging and estimates the risk of perioperative morbidity and mortality better than chronologic age alone. Health-care providers should assess a geriatric patient's cognitive status, decision-making capacity, frailty, advance care planning, medications, and anesthetic approach in a multidisciplinary fashion to ensure optimal care. The risks of postoperative cardiac, pulmonary, and renal complications should be evaluated and optimized preoperatively to reduce the potential for adverse outcomes.
Collapse
Affiliation(s)
- Aditya P Devalapalli
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deanne T Kashiwagi
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
9
|
Drug safety management in the operation room of referral hospital: cross-sectional study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
10
|
The Mediating Role of Burnout in the Relationship between Perceived Patient-safe, Friendly Working Environment and Perceived Unsafe Performance in an Obstetric Unit. Adv Health Care Manag 2019; 18. [PMID: 32077647 DOI: 10.1108/s1474-823120190000018005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Medical errors in obstetric departments are commonly reported and may involve both mother and neonate. The complexity of obstetric care, the interactions between various disciplines, and the inherent limitations of human performance make it critically important for these departments to provide patient-safe and friendly working environments that are open to learning and participative safety. Obstetric care involves stressful work, and health care professionals are prone to develop burnout, this being associated with unsafe practices and lower probability for reporting safety concerns. This study aims to test the mediating role of burnout in the relationship of patient-safe and friendly working environment with unsafe performance. The full population of professionals working in an obstetrics department in Malta was invited to participate in a cross-sectional study, with 73.6% (n = 184) of its members responding. The research tool was adapted from the Sexton et al.'s Safety Attitudes Questionnaire - Labor and Delivery version and surveyed participants on their working environment, burnout, and perceived unsafe performance. Analysis was done using Structural Equation Modeling. Results supported the relationship between the lack of a perceived patient-safe and friendly working environment and unsafe performance that is mediated by burnout. Creating a working environment that ensures patient safety practices, that allows communication, and is open to learning may protect employees from burnout. In so doing, they are more likely to perceive that they are practicing safely. This study contributes to patient safety literature by relating working environment, burnout, and perceived unsafe practice with the intention of raising awareness of health managers' roles in ensuring optimal clinical working environment for health care employees.
Collapse
|
11
|
Wei H, Corbett RW, Rose MA, Wei TL. Parents' and healthcare professionals' perceptions of the quality of care: A PITSTOP model of caring. Nurs Forum 2019; 54:661-668. [PMID: 31583716 DOI: 10.1111/nuf.12391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Quality of care is measured by various indicators. Besides objective quantifications, it is necessary to understand the meaning of quality of care from the perspectives of patients, families, and healthcare professionals. OBJECTIVES This study aimed to understand parents' and healthcare professionals' perceptions of the quality of care. METHODS This was a secondary data analysis of two qualitative studies examining parents' and healthcare professionals' perceptions of caring in 2014 and 2018, respectively. Both studies took place in a children's hospital in the United States. There were 40 participants, 13 parents of children undergoing heart surgery and 27 healthcare professionals. The current study focused on parents' and healthcare professionals' viewpoints about the quality of care. RESULTS Seven themes emerged: patient-centered care, interprofessional collaboration, team communication, safety and security, trusting relationships, optimal outcomes, and positive patient experiences. The acronym PITSTOP was developed to enable healthcare professionals to recall the elements deemed as important to the quality of care by parents and professionals. CONCLUSIONS This study brought up a novice opinion that healthcare should be like a "pitstop," not just a "repair shop." Healthcare encounters may be brief but invaluable in helping patients and families succeed in their health promotion.
Collapse
Affiliation(s)
- Holly Wei
- Department of Advanced Nursing Practice and Education, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Robin Webb Corbett
- Department of Advanced Nursing Practice and Education, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Mary Ann Rose
- Department of Advanced Nursing Practice and Education, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Trent L Wei
- Department of Internal Medicine, Duke University Hospital, Durham, North Carolina
| |
Collapse
|
12
|
Sarasin DS, Brady JW, Stevens RL. Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 1. Anesth Prog 2019; 66:162-172. [PMID: 31545675 PMCID: PMC6759645 DOI: 10.2344/anpr-66-03-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/26/2019] [Indexed: 11/11/2022] Open
Abstract
For decades, the dental profession has provided anesthesia services in office-based, ambulatory settings to alleviate pain and anxiety, ranging from local anesthesia to general anesthesia. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a substantial lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article will illuminate the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medicine has implemented to manage such problems, and introduce a method for addressing these issues with the dental anesthesia medication safety paradigm.
Collapse
Affiliation(s)
- Daniel S. Sarasin
- Private Practice, Oral and Maxillofacial Surgery, Cedar Rapids, Iowa
| | - Jason W. Brady
- Private Practice, Dental Anesthesiology, Phoenix, Arizona
- Attending Faculty, Dental Anesthesiology, New York University Langone Health, New York City, New York
| | - Roy L. Stevens
- Private Practice, Special Care Dentistry of Oklahoma, Oklahoma City, Oklahoma
| |
Collapse
|
13
|
Jones JH, Treiber LA. Nurses' rights of medication administration: Including authority with accountability and responsibility. Nurs Forum 2018; 53:299-303. [PMID: 29687447 DOI: 10.1111/nuf.12252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Medication errors continue to occur too frequently in the United States. Although the five rights of medication administration have expanded to include several others, evidence that the number of errors has decreased is missing. This study suggests that medication rights for nurses as they administer medications are needed. The historical marginalization of the voice of nurses has been perpetuated with detrimental impacts to nurses and patients. In recent years, a focus on the creation of a just culture, with a balance of accountability and responsibility, has sought to bring a fairer and safer construct to the healthcare environment. This paper proposes that in order for a truly just culture to exist, the balance must also include nurses' authority. Only when a triumvirate of responsibility, accountability, and authority exists can an environment that supports reduced medication errors flourish. Through identification and implementation of Nurses Rights of Medication Administration, nurses' authority to control the administration process is both formalized and legitimized. Further study is needed to identify these rights and how to fully implement them.
Collapse
Affiliation(s)
- Jackie H Jones
- WellStar School of Nursing, Kennesaw State University, Kennesaw, GA
| | - Linda A Treiber
- Department of Sociology and Criminal Justice, Kennesaw State University, Kennesaw, GA
| |
Collapse
|