Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode

Describing Medication Administration and Alert Patterns Experienced by New Graduate Nurses During the First Year of Practice

The aim of this study was to describe medication administration and alert patterns among a cohort of new graduate nurses over the first year of practice. Medical errors related to clinical decision-making, including medication administration errors, may occur more frequently among new graduate nurses. To better understand nursing workflow and documentation workload in today's clinical environment, it is important to understand patterns of medication administration and alert generation during barcode-assisted medication administration. Study objectives were addressed through a descriptive, longitudinal, observational cohort design using secondary data analysis. Set in a large, urban medical center in the United States, the study sample included 132 new graduate nurses who worked on adult, inpatient units and administered medication using barcode-assisted medication administration. Data were collected through electronic health record and administration sources. New graduate nurses in the sample experienced a total of 587 879 alert and medication administration encounters, administering 772 unique medications to 17 388 unique patients. Nurses experienced an average medication workload of 28.09 medications per shift, 3.98% of which were associated with alerts, over their first year of practice. In addition to high volume of medication administration, new graduate nurses administer many different types of medications and are exposed to numerous alerts while using barcode-assisted medication administration.

Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals: A Systematic Review

OBJECTIVES

Intravenous medication delivery is a complex process that poses systemic risks of errors. The objective of our study was to identify systemic defenses that can prevent in-hospital intravenous (IV) medication errors.

METHODS

A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the Grading of Recommendations Assessment, Development and Evaluation system, and the evidence was analyzed using qualitative content analysis.

RESULTS

Forty-six studies from 11 countries were included in the analysis. We identified systemic defenses related to administration (n = 24 studies), prescribing (n = 8), preparation (n = 6), treatment monitoring (n = 2), and dispensing (n = 1). In addition, 5 studies explored defenses related to multiple stages of the drug delivery process. Systemic defenses including features of closed-loop medication management systems appeared in 61% of the studies, with smart pumps being the defense most widely studied (24%). The evidence quality of the included articles was limited, as 83% were graded as low quality, 13% were of moderate quality, and only 4% were of high quality.

CONCLUSIONS

In-hospital IV medication processes are developing toward closed-loop medication management systems. Our study provides health care organizations with preliminary knowledge about systemic defenses that can prevent IV medication errors, but more rigorous evidence is needed. There is a need for further studies to explore combinations of different systemic defenses and their effectiveness in error prevention throughout the drug delivery process.

Dose Verification Errors in Hospitals: Literature Review of the eMAR-based Systems Used by Nurses

BACKGROUND

The effectiveness of the dose verification features of the electronic medication administration record (eMAR) and complementary systems in the hospital setting is not well understood.

PURPOSE

The authors completed a narrative synthesis of literature findings on the effectiveness of eMAR-based systems in the hospital setting.

METHODS

A literature review was carried out across 5 bibliographic databases to evaluate the safety features of current eMAR-based systems in preventing dosing errors and design issues that impede their usability.

RESULTS

While eMAR-based systems are beneficial to reducing order and drug cross-checking errors, safe dose verification features are sporadically available for targeted tasks. Overall, the eMAR had little impact on preventing low to moderate dosing errors. Dosing errors may occur because of error-prone activities that result from system design and work process issues during medication administration.

Medication administration errors: A concept analysis

AIM

To provide an analysis of the concept of medication errors that occur during the nursing task of medication administration.

BACKGROUND

Medication errors occurring during medication administration have an increased risk for an adverse patient outcome. Many terms are associated with medication errors, with limited clarification for a medication administration error at the point of care delivery.

DATA SOURCES

Twenty-seven sources were chosen from database searches of PubMed, CINAHL, EMBASE, and Scopus. Key search terms used to narrow the search consist of the following terminology: ("bedside" OR "point-of-care" OR "nursing care*") AND "medication administration errors" AND ("acute care").

REVIEW METHODS

Rodger's evolutionary method of concept analysis was used to clarify the concept of medication administration error.

RESULTS

The concept analysis identified three attributes of a medication administration error: nurse-provided care, administration, and point of care. Antecedents identified in the analysis are organizational factors and nurse factors. Consequences identified in the analysis are patient, nurse and organizational themes.

CONCLUSION

The continued occurrence of medication administration errors warrants the need for an investigation into existing safety measures. Using this concept analysis may help guide the study of the healthcare environment and determine empirical measures to assess the impact that a medication administration error has.

Impact of Medication Regimen Simplification on Medication Incidents in Residential Aged Care: SIMPLER Randomized Controlled Trial

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we investigated the impact of a structured medication regimen simplification intervention on medication incidents in residential aged care facilities (RACFs) over a 12-month follow-up. A clinical pharmacist applied the validated 5-step Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) for 96 of the 99 participating residents in the four intervention RACFs. The 143 participating residents in the comparison RACFs received usual care. Over 12 months, medication incident rates were 95 and 66 per 100 resident-years in the intervention and comparison groups, respectively (adjusted incident rate ratio (IRR) 1.13; 95% confidence interval (CI) 0.53-2.38). The 12-month pre/post incident rate almost halved among participants in the intervention group (adjusted IRR 0.56; 95%CI 0.38-0.80). A significant reduction in 12-month pre/post incident rate was also observed in the comparison group (adjusted IRR 0.67, 95%CI 0.50-0.90). Medication incidents over 12 months were often minor in severity. Declines in 12-month pre/post incident rates were observed in both study arms; however, rates were not significantly different among residents who received and did not receive a one-off structured medication regimen simplification intervention.

Adoption rates of electronic health records in Turkish Hospitals and the relation with hospital sizes

BACKGROUND

Nation-wide adoption of electronic health records (EHRs) in hospitals has become a Turkish policy priority in recognition of their benefits in maintaining the overall quality of clinical care. The electronic medical record maturity model (EMRAM) is a widely used survey tool developed by the Healthcare Information and Management Systems Society (HIMSS) to measure the rate of adoption of EHR functions in a hospital or a secondary care setting. Turkey completed many standardizations and infrastructural improvement initiatives in the health information technology (IT) domain during the first phase of the Health Transformation Program between 2003 and 2017. Like the United States of America (USA), the Turkish Ministry of Health (MoH) applied a bottom-up approach to adopting EHRs in state hospitals. This study aims to measure adoption rates and levels of EHR use in state hospitals in Turkey and investigate any relationship between adoption and use and hospital size.

METHODS

EMRAM surveys were completed by 600 (68.9%) state hospitals in Turkey between 2014 and 2017. The availability and prevalence of medical information systems and EHR functions and their use were measured. The association between hospital size and the availability/prevalence of EHR functions was also calculated.

RESULTS

We found that 63.1% of all hospitals in Turkey have at least basic EHR functions, and 36% have comprehensive EHR functions, which compares favourably to the results of Korean hospitals in 2017, but unfavorably to the results of US hospitals in 2015 and 2017. Our findings suggest that smaller hospitals are better at adopting certain EHR functions than larger hospitals.

CONCLUSION

Measuring the overall adoption rates of EHR functions is an emerging approach and a beneficial tool for the strategic management of countries. This study is the first one covering all state hospitals in a country using EMRAM. The bottom-up approach to adopting EHR in state hospitals that was successful in the USA has also been found to be successful in Turkey. The results are used by the Turkish MoH to disseminate the nation-wide benefits of EHR functions.

The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review

BACKGROUND

Technology in the form of Automated Dispensing Cabinets (ADCs), Barcode Medication Administration (BCMA), and closed-loop Electronic Medication Management Systems (EMMS) are implemented in hospitals to assist with the supply, use and monitoring of medications. Although there is evidence to suggest that these technologies can reduce errors and improve monitoring of medications in general, little is known about their impact on controlled medications such as opioids.

OBJECTIVES

This review aimed to fill this knowledge gap by synthesising literature to determine the impact of ADCs, BCMA and closed-loop EMMS on clinical work processes, medication safety, and drug diversion associated with controlled medications in the inpatient setting.

METHODS

Eight databases (Medline, Pubmed, Embase, Scopus, Web of Science, PsycINFO, CINAHL, and ScienceDirect) were searched for relevant papers published between January 2000 and May 2019. Qualitative, quantitative, and mixed-methods empirical studies published in English that reported findings on the impact of ADCs, BCMA and/or closed-loop EMMS on controlled medications in the inpatient setting were included.

RESULTS

In total, 16 papers met the inclusion criteria. Eleven studies reported on ADCs, four on BCMA, and only one on closed-loop EMMS. Only four studies focused on controlled medications, with the remainder reporting only incidental findings. Studies reported the elimination of manual end-of-shift counts of controlled medications after ADC implementation but cases of drug diversion were reported despite introducing ADCs. Three quantitative studies reported reductions in medication errors after implementing BCMA, but medications labelled with wrong barcodes and unreadable barcodes led to confusion and administration errors.

CONCLUSIONS

More quality, targeted research is needed to provide evidence on the benefits and also risks of implementing technology to safeguard against inappropriate use of controlled medications in the inpatient setting. Processes need to be in place to supplement technological capabilities, and resources should be made available for post-implementation evaluations and interventions.

Alert Types and Frequencies During Bar Code-Assisted Medication Administration: A Systematic Review

BACKGROUND

Existing literature explores the effectiveness of bar code-assisted medication administration (BCMA) on the reduction of medication administration error as well as on nurse workarounds during BCMA. However, there is no review that comprehensively explores types and frequencies of alerts generated by nurses during BCMA.

PURPOSE

The purpose was to describe alert generation type and frequency during BCMA.

METHODS

A systematic review of the literature using PRISMA guidelines was conducted using CINAHL, PubMed, EMBASE, and Ovid Medline databases.

RESULTS

After screening for inclusion and exclusion criteria, a total of 8 articles were identified and included in the review. Alert types included patient mismatch, wrong medication, and wrong dose, though other alert types were also reported. The frequency of alert generation varied across studies, from 0.18% to 42%, and not all alerts were clinically meaningful.

CONCLUSIONS

This systematic review synthesized literature related to alert type and frequency during BCMA. However, further studies are needed to better describe alert generation patterns as well as factors that influence alert generation.

Implementation and Evaluation of a RFID Smart Cabinet to Improve Traceability and the Efficient Consumption of High Cost Medical Supplies in a Large Hospital

The efficiency of a smart cabinet with RFID technology to improve the information about inventory management for cardiothoracic surgery as well as for time savings, was assessed in a large reference hospital. In a 6-month study, the implemented operational RFID process (StocKey® Smart Cabinet) consisted of: i) product reception, registration and labelling in the general warehouse; ii) product storage in the cabinet and registered as inputs by radiofrequency; iii) products registered as outputs as required for surgery; iv) product assignment to a patient in the operating room; and v) return of products not used to the cabinet. Stock-outs, stock mismatches, urgent restocking, assignment of high-value medical products to patients, and time allocated by the supervisory staff to the stock management, were assessed on a monthly basis. 0% stock-outs and 0% stock mismatches using RFID were observed during the study. Monthly percentages of products requiring urgent restocking ranged from 0% to 13.3%. No incorrect assignments to patients of surgery products or prostheses were detected. The percentage of correct assignments increased from 36.1%–86.1% to 100% in the first 4–5 months. The total average time allocated by the supervisory staff to the whole logistic chain was reduced by 58% (995 min with the traditional manual system vs. 428 min with RFID). The RFID system showed the ability to monitor both the traceability and consumption per patient of high-value surgery products as well as contributed to significant time savings.

Development and application of a closed-loop medication administration system in University of Hongkong-Shenzhen Hospital

Objective

This study aimed to develop and apply a closed-loop medication administration system in a hospital in order to reduce medication administration errors (MAEs).

Methods

The study was implemented in four pilot general wards. We used a before-and-after design to collect oral medication administration times before and after the implementation of the closed-loop medication administration system, evaluated MAE alert logs after the intervention, and conducted a survey of the nurses’ satisfaction with the system in the pilot wards.

Results

(a) Nursing time of oral medication administration: before the adoption of the closed-loop medication administration system, the average nursing time was 31.56 ± 10.88 minutes (n = 78); after the adoption of the system, the time was 18.74 ± 5.60 minutes (n = 54). Independent sample t-tests showed a significant difference between two groups (t = 8.85, P <0.00). (b) Degree of nurses’ satisfaction with the closed-loop medication administration system: 60.00% (n = 42) of nurses considered the system to be helpful for their work and nearly half of the nurses (47.14%, n = 33) believed that the system could facilitate clinical work and reduce workload; 51.43% (n = 36) believed that the system could reduce checking time and enhance work efficiency; 82.86% (n = 58) believed that the system was helpful in improving checking accuracy to reduce MAEs and ensure patient safety. More than 60% of the nurses considered the system to be a method that could help to track MAEs to improve nursing quality. (c) The MAE alert logs during observation period: it revealed only 27 alerts from the repeated scans of 3,428 instances of medication administration.

Conclusions

The nurses were satisfied with the closed-loop medication administration system because it improved their work efficiency and reduced their workload. The current investigation was limited by time; therefore, further research is needed to more closely examine the relationship between the system and MAEs.

Comparative Cost-Effectiveness Analysis of Three Different Automated Medication Systems Implemented in a Danish Hospital Setting

INTRODUCTION

Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice.

METHODS

The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period.

RESULTS

With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation.

CONCLUSION

The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.