Strategies implementation to reduce medicine preparation error rate in neonatal intensive care units

Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta-Analysis

INTRODUCTION

Neonates are at greater risk of preventable adverse drug events as compared to children and adults.

OBJECTIVE

This study aimed to estimate and critically appraise the evidence on the prevalence, causes and severity of medication administration errors (MAEs) amongst neonates in Neonatal Intensive Care Units (NICUs).

METHODS

A systematic review and meta-analysis was conducted by searching nine electronic databases and the grey literature for studies, without language and publication date restrictions. The pooled prevalence of MAEs was estimated using a random-effects model. Data on error causation were synthesised using Reason's model of accident causation.

RESULTS

Twenty unique studies were included. Amongst direct observation studies reporting total opportunity for errors as the denominator for MAEs, the pooled prevalence was 59.3% (95% confidence interval [CI] 35.4-81.3, I² = 99.5%). Whereas, the non-direct observation studies reporting medication error reports as the denominator yielded a pooled prevalence of 64.8% (95% CI 46.6-81.1, I² = 98.2%). The common reported causes were error-provoking environments (five studies), while active failures were reported by three studies. Only three studies examined the severity of MAEs, and each utilised a different method of assessment.

CONCLUSIONS

This is the first comprehensive systematic review and meta-analysis estimating the prevalence, causes and severity of MAEs amongst neonates. There is a need to improve the quality and reporting of studies to produce a better estimate of the prevalence of MAEs amongst neonates. Important targets such as wrong administration-technique, wrong drug-preparation and wrong time errors have been identified to guide the implementation of remedial measures.

Intercepting Medication Errors in Pediatric In-patients Using a Prescription Pre-audit Intelligent Decision System: A Single-center Study

OBJECTIVES

Medication errors can happen at any phase of the medication process at health care settings. The objective of this study is to identify the characteristics of severe prescribing errors at a pediatric hospital in the inpatient setting and to provide recommendations to improve medication safety and rational drug use.

METHODS

This descriptive retrospective study was conducted at a tertiary pediatric hospital using data collected from Jan. 1st, 2019 to Dec. 31st, 2020. During this period, the Prescription Pre-audit Intelligent Decision System was implemented. Medication orders with potential severe errors would trigger a Level 7 alert and would be intercepted before it reached the pharmacy. Trained pharmacists maintained the system and facilitated decision making when necessary. For each order intercepted by the system the following patient details were recorded and analyzed: patient age, patient's department, drug classification, dosage forms, route of administration, and the type of error.

RESULTS

A total of 2176 Level 7 medication orders were intercepted. The most common errors were associated with drug dosage, administration route, and dose frequency, accounting for 35.2%, 32.8% and 13.2%, respectively. Of all the intercepted oerrors. 53.6% occurred in infants aged < 1 year. Administration routes involved were mainly intravenous, oral and external use drugs. Most alerts came from the neonatology department and constituted 40.5% of the total alerts, followed by the nephrology department 15.9% and pediatric intensive care unit (PICU) 11.3%. As to dosage forms, injections accounted for 50.4% of alerts, with 21.3% attributable to topical solutions, 9.1% to tablets, and 5.7% to inhalation. Anti-infective agents were the most common therapeutic drugs prescribed with errors.

CONCLUSIONS

The Prescription Pre-audit Intelligent Decision System, with the supervision of trained pharmacists can validate prescriptions, increase prescription accuracy, and improve drug safety for hospitalized children. It is a medical service model worthy of consideration.

Nursing interventions to reduce medication errors in paediatrics and neonates: Systematic review and meta-analysis

BACKGROUND

Medication errors are a great concern to health care organisations as they are costly and pose a significant risk to patients. Children are three times more likely to be affected by medication errors than adults with medication administration error rates reported to be over 70%.

OBJECTIVE

To identify nursing interventions to reduce medication administration errors and perform a meta-analysis.

METHODS

Online databases; British Nursing Index (BNI), Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE and MEDLINE were searched for relevant studies published between January 2000 to 2020. Studies with clear primary or secondary aims focusing on interventions to reduce medication administration errors in paediatrics, children and or neonates were included in the review.

RESULTS

442 studies were screened and18 studies met the inclusion criteria. Seven interventions were identified from included studies; education programmes, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, implementation of smart pumps and improvement strategies. Educational interventional aspects were the most common identified in 13 out of 18 included studies. Meta-analysis demonstrated an associated 64% reduction in medicine administration errors post intervention (pooled OR 0.36 (95% Confidence Interval (CI) 0.21-0.63) P = 0.0003).

CONCLUSION

Medication safety education is an important element of interventions to reduce administration errors. Medication errors are multifaceted that require a bundle interventional approach to address the complexities and dynamics relevant to the local context. It is imperative that causes of errors need to be identified prior to implementation of appropriate interventions.

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.

Intravenous drug use in neonatal intensive care units

OBJECTIVES

Intravenous drug use in neonates is frequent and prone to medication errors. The aim of this study was to describe the intravenous drugs most frequently used in Spanish Neonatal Intensive Care Units (NICU), their preparation and the implementation rate of standardised concentration infusions.

METHODS

We conducted an observational multicentre study based on a survey sent by email to nine Spanish NICUs during January and February 2018. We collected data describing the intravenous drugs frequently used in neonates and their preparation. A descriptive analysis of the medicines reported (and their preparation) was performed, to assess how frequently standard concentrations were used and how medications were prepared in central pharmacies.

RESULTS

Overall, 69 different drugs were reported by participating NICUs. Of these, 33% (n=23) were not approved for use in neonates and 38% (n=26) corresponded to high-alert medications, according to the Institute for Safe Medication Practices. A mean of only 63.5% of intravenous medicines were standardised. The standard-concentration implementation rate was somewhat higher for intermittent (mean 74.1%) than continuous (mean 42.9%) infusions. Notably, infusions were more commonly prepared on wards than in hospital pharmacies.

CONCLUSIONS

Intravenous drug use in NICUs has been identified as a high-risk process, and error-reduction strategies (such as concentration standardisation) have been recommended. Further data are necessary to design the most suitable intervention in our country (Spain), but institutional initiatives are needed to achieve this.

Reducing Cardiac Arrests in the PICU: Initiative to Improve Time to Administration of Prearrest Bolus Epinephrine in Patients With Cardiac Disease

OBJECTIVES

To evaluate the effectiveness of a quality-improvement initiative in reducing cardiac arrests in infants and children in the cardiac ICU.

DESIGN

Prospective observational before-after cohort study.

SETTING

Single pediatric cardiac ICU in the United Kingdom.

PATIENTS

All patients less than 18 years old admitted to the ICU.

INTERVENTION

Initial interdisciplinary training in cardiac arrest prevention followed by clinical practice change whereby patients with high-risk myocardium were identified on daily rounds. High-risk patients had bolus epinephrine preordered and prepared for immediate administration in the event of acute hypotension.

MEASUREMENTS AND MAIN RESULTS

Interrupted time series analysis was used to compare the cardiac arrest rate in the 18 months before and 4.5 years after implementation. Mean monthly cardiac arrest rate was 17.2 per 1,000 patient days before and 7.6 per 1,000 patient days after the initiative (56% decrease). Patient characteristics and ICU interventions were similar in the control and intervention periods. In the time series analysis, monthly cardiac arrest rate in the ICU decreased by 12.4 per 1,000 patient days (95% CI, -1.5 to -23.3; p = 0.03) immediately following the intervention, followed by a nonsignificant downward trend of 0.36 per 1,000 patient days per month (95% CI, -1.3 to 0.6; p = 0.44). Bolus epinephrine was administered during 110 hypotension events in 77 patients (eight administrations per 1,000 ICU days); responder rate was 77%. There were no significant changes in ICU and hospital mortality.

CONCLUSIONS

Implementation of the initiative led to a significant, sustained reduction in ICU cardiac arrest rate.

Neonatal Abstinence Syndrome and Preterm Infants: A Look at Current Practice

BACKGROUND/SIGNIFICANCE

Intrauterine opioid drug exposure is associated with an increased risk of preterm birth. Preterm infants may not exhibit the same withdrawal symptoms as term infants diagnosed with neonatal abstinence syndrome (NAS). There are no current standards for how to screen, assess, or treat NAS in preterm infants.

PURPOSE

This study explored the current state of practice for preterm infants born at less than 34 weeks of gestational age exposed to intrauterine opioids.

METHODS

This was a descriptive cross-sectional study of NAS practice in preterm infants born at less than 34 weeks of gestational age in neonatal intensive care units (NICUs) in the United States and Canada. The study was conducted May through September 2018. All respondents cared for preterm infants born at less than 34 weeks of gestational age exposed to intrauterine drugs.

RESULTS

There were 70 respondents representing 67 hospitals in the United States and 1 in Canada. Level III NICUs represented 69% of respondents. Ninety-three percent reported neonatal triggers for further evaluation. Review of maternal history and maternal urine testing was the most consistent practice across NICUs. A modified Finnegan scoring tool was used for both preterm and term infants. Morphine was reported as the most common first-line drug used for treatment.

IMPLICATIONS FOR PRACTICE

Great variability in NAS practice for preterm infants born at less than 34 weeks of gestational age across the multiple NICUs supports the need for a validated preterm infant assessment tool and development of appropriate treatment strategies.

IMPLICATIONS FOR RESEARCH

Future research describing the NAS symptomatology of preterm infants born at less than 34 weeks of gestational age exposed to intrauterine opioids is warranted.

Interventions to Reduce Medication Dispensing, Administration, and Monitoring Errors in Pediatric Professional Healthcare Settings: A Systematic Review

Introduction: Pediatric patients cared for in professional healthcare settings are at high risk of medication errors. Interventions to improve patient safety often focus on prescribing; however, the subsequent stages in the medication use process (dispensing, drug administration, and monitoring) are also error-prone. This systematic review aims to identify and analyze interventions to reduce dispensing, drug administration, and monitoring errors in professional pediatric healthcare settings. Methods: Four databases were searched for experimental studies with separate control and intervention groups, published in English between 2011 and 2019. Interventions were classified for the first time in pediatric medication safety according to the "hierarchy of controls" model, which predicts that interventions at higher levels are more likely to bring about change. Higher-level interventions aim to reduce risks through elimination, substitution, or engineering controls. Examples of these include the introduction of smart pumps instead of standard pumps (a substitution control) and the introduction of mandatory barcode scanning for drug administration (an engineering control). Administrative controls such as guidelines, warning signs, and educational approaches are lower on the hierarchy and therefore predicted by this model to be less likely to be successful. Results: Twenty studies met the inclusion criteria, including 1 study of dispensing errors, 7 studies of drug administration errors, and 12 studies targeting multiple steps of the medication use process. A total of 44 interventions were identified. Eleven of these were considered higher-level controls (four substitution and seven engineering controls). The majority of interventions (n = 33) were considered "administrative controls" indicating a potential reliance on these measures. Studies that implemented higher-level controls were observed to be more likely to reduce errors, confirming that the hierarchy of controls model may be useful in this setting. Heterogeneous study methods, definitions, and outcome measures meant that a meta-analysis was not appropriate. Conclusions: When designing interventions to reduce pediatric dispensing, drug administration, and monitoring errors, the hierarchy of controls model should be considered, with a focus placed on the introduction of higher-level controls, which may be more likely to reduce errors than the administrative controls often seen in practice. Trial Registration Prospero Identifier: CRD42016047127.

Patterns of Safety Incidents in a Neonatal Intensive Care Unit

Introduction: Safety incidents preceding manifest adverse events are barely evaluated in neonatal intensive care units (NICUs). This study aimed at identifying frequency and patterns of safety incidents in our NICU. Methods: A 6-month prospective clinical study was performed from May to October 2019 in a German 10-bed level III NICU. A voluntary, anonymous reporting system was introduced, and all neonatal team members were invited to complete paper-based questionnaires following each particular safety incident. Safety incidents were defined as safety-related events that were considered by the reporting team member as a "threat to the patient's well-being" which "should ideally not occur again." Results: In total, 198 safety incidents were analyzed. With 179 patients admitted, the incident/admission ratio was 1.11. Medication errors (n = 94, 47%) and equipment problems (n = 54, 27%) were most commonly reported. Diagnostic errors (n = 19, 10%), communication problems (n = 12, 6%), errors in documentation (n = 9, 5%) and hygiene problems (n = 10, 5%) were less frequent. Most safety incidents were noticed after 4-12 (n = 52, 26%) and 12-24 h (n = 47, 24%), respectively. Actual harm to the patient was reported in 17 cases (9%) but no life-threatening or serious events occurred. Of all safety incidents, 184 (93%) were considered to have been preventable or likely preventable. Suggestions for improvement were made in 132 cases (67%). Most often, implementation of computer-assisted tools and processes were proposed. Conclusion: This study confirms the occurrence of various safety incidents in the NICU. To improve quality of care, a graduated approach tailored to the specific problems appears to be prudent.

Evaluation of the practice of dose-rounding in paediatrics

Objectives

To investigate the rounding of prescribed drug doses for paediatric administration.

Methods

A cross-sectional medication chart review was conducted at a UK paediatric hospital. Proposed administration dose volumes were calculated for prescribed doses using available manufactured liquids measured with oral and intravenous syringes. Resulting percentage deviations in doses administered were calculated.

Results

Of 2031 doses observed, 524 (25.8%) required rounding. The majority of which were for children aged 1–12 months. Twenty-seven rounded doses deviated from the prescribed dose by more than 10%.

Conclusion

This study highlights the impact of dose-rounding in paediatrics and the need for standardisation.

Drug preparation and administration errors during simulated paediatric resuscitations

INTRODUCTION

Very few studies have assessed drug preparation and administration errors during paediatric resuscitation. Current evidence suggests that medication errors in paediatrics are a serious problem. The aim of this study was to evaluate drug preparation and administration errors incurred during the simulated resuscitation of paediatric patients.

METHODS

This was a prospective observational study performed in the emergency department of a tertiary-level hospital. Teams consisting of two emergency doctors were tasked with preparing and delivering medication during simulated emergency scenarios. Preparation processes were video recorded. All phials, syringes and administered volumes were collected and analysed to determine the accuracy of drug preparation and delivery. Deviations from intended volumes were calculated.

MAIN RESULTS

A total of 96 dosages were recorded from 24 participants. Most errors were identified in the withdrawal of drug phase (prior to dilution) (13 of 96 doses had a >20% error), and the administration of medication phase (20 of 96 doses had a >20% error). Overall the median time taken to deliver each drug was 79 s (IQR 59, 100 s). The largest percentage errors were seen when a large syringe was used to withdraw or administer a small volume of medication.

CONCLUSION

The study clearly demonstrated that there were significant errors in the preparation and administration of medication. Training in the preparation and administration of paediatric medications should be available for all emergency nurses and doctors. Correct syringe choice may reduce these errors-smaller syringes should be used for withdrawing or administering smaller volumes.

Quality control and stability of ketamine, remifentanil, and sufentanil syringes in a pediatric operating theater

BACKGROUND

Transforming a drug from its commercial form into a ready-to-use drug is common practice, especially in pediatrics. However, the risk of compounding error is real and data on drug stability in practice are not always available.

AIMS

The aim of this study was to assess, in real conditions, both the error rate and stability of three drugs: ketamine, remifentanil, and sufentanil.

METHODS

A new rapid and easy-to-use high-performance liquid chromatography method with a diode array detector has been developed and validated to quantify these drugs and detect their degradation products. Over a 1-month period, 151 syringes were collected in the postanesthesia care unit. Seventy-three were stock solution syringes containing a 10-fold dilution of commercial drugs and 78 were serial dilution syringes made from successive dilutions of stock solutions. A comparison between real and expected concentrations as well as the detection of possible degradation products was carried out on these samples.

RESULTS

All stock solution syringes had good chemical stability throughout the working day. A 4-µg/mL remifentanil serial dilution syringe, however, had to be discarded as a degradation peak was detected. Overall, 15.3% (95% CI, 9.5-21.1%) of syringes had a drug concentration outside the ±10% acceptability range, that is, 11.0% (95% CI, 3.7-18.2%) and 19.5% (95% CI, 10.6%-28.4%) of stock and diluted syringes respectively, with drug amounts ranging from -25.3% to 22.0%. The highest error rates were observed with sufentanil syringes: 20% and 28% for stock solution and serial dilution, respectively.

CONCLUSION

The study shows that stock solution syringes prepared in advance are chemically stable throughout the day, unlike certain serial dilution syringes, indicating that the latter should be prepared just before administration to ensure chemical stability. Our results show that the error rate for serial dilution syringes is twice that of stock solution. Different safety measures are under discussion and have to be further studied.

Interventions to reduce medication errors in neonatal care: a systematic review

Background

Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors.

Methods

A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and reference-list checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting.

Results

A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50-70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors.

Conclusion

While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice.

Intravenous medicine preparation technique training programme for nurses in clinical areas

Objective

The key objective of this study was to highlight the weak points in the medicine use process.

Method

We collected 15 videos from eight neonatal intensive care units where staff nurses showed how medicine preparation was performed. Recorded medicines were: vancomycin (6), gentamicin (5), caffeine citrate (2) and phenobarbital (2).

Results

We did not review any video without errors. In 8/15 (53.3%) videos, the same syringe was used to measure the medicine and the diluent. In 8/15 (53.3%) videos, the syringes used were not the correct size for the volume being measured. In 4/15 (26.6%) videos, the volume measured into the syringes was not checked after it was measured from vials or ampoules. In just one vancomycin preparation could the reconstitution process be described as a correct process; in the other five videos, mixing after diluent addition to the vancomycin vial was almost non-existent (less than 10 s). Mixing after the medicine and diluent were in the same syringe was also non-existent in all of the videos.

Conclusions

Hospitals should provide training programmes outlining the correct preparation technique.

Standard concentration infusions in paediatric intensive care: the clinical approach

The use of standard concentrations of intravenous infusions has been advocated by international organisations to increase intravenous medication safety in paediatric and neonatal critical care. However, there is no guidance on how to identify and implement these infusions leading to great interunit variability.

OBJECTIVE

To identify the most appropriate clinical concentrations required by our paediatric intensive care unit (PICU) population with regard to accuracy of delivery and overall fluid allowance.

METHODS

Firstly a matrix was used to balance the concentration, dose and infusion volume (weight range 1.5-50 kg). Results were further refined considering: patient fluid allowance based on fluid volume targets, infusion pump accuracy and challenging each infusion against clinical scenarios requiring administration of multiple drug infusions found in PICU. Consideration was given to the standard concentrations routinely used in adults, in order to assess whether alignment with paediatrics was possible for some of the concentrations proposed. Finally a risk assessment of the infusions was conducted using the NPSA 20 tool.

KEY FINDINGS

Twenty-five drugs identified as the most commonly used intravenous infusions in the unit. For the majority of the medicines, three weight bands of standard concentrations were necessary to cover the children's weight ranges and kept within predefined fluid requirements and accuracy of delivery.

CONCLUSIONS

This work shows a patient focused systematic approach for defining and evaluating standardised concentrations in intensive care children.