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Baehr A, Grohmann M, Guberina M, Schulze K, Lange T, Nestle U, Ernst P. Usability and usefulness of (electronic) patient identification systems-A cross-sectional evaluation in German-speaking radiation oncology departments. Strahlenther Onkol 2024; 200:468-474. [PMID: 37713170 PMCID: PMC11111529 DOI: 10.1007/s00066-023-02148-9] [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: 03/15/2023] [Accepted: 08/13/2023] [Indexed: 09/16/2023]
Abstract
PURPOSE Patient misidentification in radiation oncology (RO) is a significant concern due to the potential harm to patient health and the burden on healthcare systems. Electronic patient identification systems (ePIS) are increasingly being used as an alternative or supplement to organizational systems (oPIS). The objective of this study was to assess the usability and usefulness of ePIS and oPIS in German-speaking countries. METHODS A cross-sectional survey was designed by a group of experts from various professional backgrounds in RO. The survey consisted of 38 questions encompassing quantitative and qualitative data on usability, user experience, and usefulness of PIS. It was available between August and October 2022. RESULTS Of 118 eligible participants, 37% had implemented some kind of ePIS. Overall, 22% of participants who use an oPIS vs. 10% of participants who use an ePIS reported adverse events in terms of patients' misidentification in the past 5 years. Frequent or very frequent drop-outs of electronic systems were reported by 31% of ePIS users. Users of ePIS significantly more often affirmed a positive cost-benefit ratio of ePIS as well as an improvement of workflow, whereas users of oPIS more frequently apprehended a decrease in staffs' attention through ePIS. The response rate was 8%. CONCLUSION The implementation of ePIS can contribute to efficient PI and improved processes. Apprehensions by oPIS users and assessments of ePIS users differ significantly in aspects of the perceived usefulness of ePIS. However, technical problems need to be addressed to ensure the reliability of ePIS. Further research is needed to assess the impact of different PIS on patient safety in RO.
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Affiliation(s)
- Andrea Baehr
- Department of Radiation Oncology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
- Department of Radiation Oncology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Maximilian Grohmann
- Department of Radiation Oncology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Maja Guberina
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Essen, Germany
| | - Katrin Schulze
- Department of Radiation Oncology, Fulda Community Hospital, Fulda, Germany
| | - Tim Lange
- Clinic for Radiotherapy, Hannover, Medical School, Hannover, Germany
| | - Ursula Nestle
- Department of Radiation Oncology, Kliniken Maria Hilf GmbH, Moenchengladbach, Germany
| | - Philipp Ernst
- Department of Radiation Oncology, Kliniken Maria Hilf GmbH, Moenchengladbach, Germany
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Duhalde H, Bjuresäter K, Karlsson I, Bååth C. Missed nursing care in emergency departments: A scoping review. Int Emerg Nurs 2023; 69:101296. [PMID: 37352646 DOI: 10.1016/j.ienj.2023.101296] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/18/2023] [Accepted: 04/17/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Patient safety is a global health priority. Errors of omission, such as missed nursing care in hospitals, are frequent and may lead to adverse events. Emergency departments (ED) are especially vulnerable to patient safety errors, and the significance missed nursing care has in this context is not as well known as in other contexts. AIM The aim of this scoping review was to summarize and disseminate research about missed nursing care in the context of EDs. METHOD A scoping review following the framework suggested by Arksey and O'Malley was used to (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; (5) collate, summarize, and report the results; and (6) consultation. RESULTS In total, 20 themes were derived from the 55 included studies. Missed or delayed assessments or other fundamental care were examples of missed nursing care characteristics. EDs not staffed or dimensioned in relation to the patient load were identified as a cause of missed nursing care in most included studies. Clinical deteriorations and medication errors were described in the included studies in relation to patient safety and quality of care deficiencies. Registered nurses also expressed that missed nursing care was undignified and unsafe. CONCLUSION The findings from this scoping review indicate that patients' fundamental needs are not met in the ED, mainly because of the patient load and how the ED is designed. According to registered nurses, missed nursing care is perceived as undignified and unsafe.
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Affiliation(s)
- Henrik Duhalde
- Department of Health Sciences, Faculty of Health, Science, and Technology, Karlstad University, Karlstad, Sweden.
| | - Kaisa Bjuresäter
- Department of Health Sciences, Faculty of Health, Science, and Technology, Karlstad University, Karlstad, Sweden
| | - Ingela Karlsson
- Department of Health Sciences, Faculty of Health, Science, and Technology, Karlstad University, Karlstad, Sweden
| | - Carina Bååth
- Department of Health Sciences, Faculty of Health, Science, and Technology, Karlstad University, Karlstad, Sweden; Faculty of Health, Welfare and Organisation, Østfold University College, Halden, Norway
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3
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Beirouti M, Kamalinia M, Daneshmandi H, Soltani A, Dehghani P, Fararooei M, Zakerian SA, Zamanian Z. Application of the HEART method to enhance patient safety in the intensive care unit. Work 2022; 72:1087-1097. [DOI: 10.3233/wor-205338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND: The intensive care unit (ICU) is a complex, dynamic, high stress and time-sensitive place. While a variety of rules and regulations provided to reduce medication errors in recent years, many studies have emphasized that medication errors still happen. OBJECTIVE: The purpose of this investigation is to predict, reveal and assess medication errors among surgical intensive care unit (SICU) nurses. METHODS: This study was performed in one of the public hospitals in Shiraz, namely Shahid Faghihi hospital. The human error assessment and reduction technique (HEART) method was adopted to measure and assess medication errors in the ICU. RESULTS: Findings indicate that ICU nurses perform 27 main tasks and 125 sub-tasks. The results also showed that setting and using DC shock task has the highest human error probability value, and assessment of patients by a nutritionist has the lowest human error probability value. CONCLUSION: Medical errors are key challenges in the ICU. Therefore, alternative solutions to mitigate medication errors and enhance patient safety in the ICU are necessary. Although the technique can be used in healthcare; there is a need to localize the coefficients and definitions to achieve more accurate results and take appropriate controls. Employing experienced people and providing conditions that reduce the possibility of errors in nurses, increasing the number of staff, and developing specialized and simulated training were identified as the most important control strategies to reduce errors in nurses.
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Affiliation(s)
- Mohammad Beirouti
- Department of Occupational Health and Safety Engineering, School of Health, Shiraz University of Medical Science, Shiraz, Iran
| | - Mojtaba Kamalinia
- Department of Occupational Health and Safety Engineering, School of Health, Shiraz University of Medical Science, Shiraz, Iran
| | - Hadi Daneshmandi
- Research Center for Health Sciences, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Soltani
- Department of Neurosurgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pooyan Dehghani
- Cardiovascular Research Center, Cardiology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Fararooei
- Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Syed Abolfazl Zakerian
- Department of Occupational Health Engineering, School of Public Health and Institute of Health Research Center, Tehran University of Medical Science, Tehran, Iran
| | - Zahra Zamanian
- Department of Occupational Health and Safety Engineering, School of Health, Shiraz University of Medical Science, Shiraz, Iran
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Arslan S, Fidan Ö, Şanlialp Zeyrek A, Ok D. Intravenous medication errors in the emergency department, knowledge, tendency to make errors and affecting factors: An observational study. Int Emerg Nurs 2022; 63:101190. [PMID: 35809484 DOI: 10.1016/j.ienj.2022.101190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intravenous medication errors are common in hospital settings particularly emergency department. This study aimed to determine intravenous medication preparation and administration errors, contributing factors, tendency towards making errors and knowledge level of emergency department healthcare workers. METHODS A cross-sectional study using a structured, direct observation method was conducted. It was conducted with 23 emergency healthcare workers working in the emergency department of a university hospital in Turkey. Data were collected by questionnaires: Knowledge Test on Intravenous Medication Administration, Intravenous Drug Administration Standard Observation Form, Drug and Transfusion Administration Sub-Dimension scale, Perceived Stress Scale and Pittsburgh Sleep Quality Index. RESULTS It was determined that the knowledge level of the emergency healthcare workers about intravenous medication administration was moderate, and the tendency mistakes regarding drug and transfusion applications was very low. There was no relationship between education level, years of work, years of work in the emergency department, perceived stress level and sleep quality, and the tendency of making mistakes in drug and transfusion applications. CONCLUSION It is important for patient safety to prevent medication errors by determining the factors affecting intravenous medication administration, tendency to make mistakes and knowledge levels, which are frequently used in emergency department.
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Affiliation(s)
| | - Özlem Fidan
- Pamukkale University: Pamukkale Universitesi, Turkey.
| | | | - Durdu Ok
- Pamukkale University: Pamukkale Universitesi, Turkey
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Khasawneh EA, Gosling CM, Williams BA. Ten-Year Comparison of Medication Complications Rates in Public and Private Hospitals in Victoria, Australia. Hosp Top 2021; 99:37-43. [PMID: 33793391 DOI: 10.1080/00185868.2020.1828011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Medication errors occur as a result of failure in the treatment process at any point in the healthcare system. This is a retrospective study aimed at determining the rates of medication-related errors over a 10-year period in hospitals in Victoria, Australia. From 2009 to 2019, the overall rate for adverse drug events, accidental poisoning and undetermined intent were 86.15, 1.3 and 0.17 per 10,000 hospital separations, respectively. Medication complications occurred more in public hospitals. Adverse drug events account for less than 1% of all hospital separations. Medication errors contributing factors should be investigated in out of hospital environment.
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Affiliation(s)
- Eihab A Khasawneh
- Department of Paramedicine, Monash University, Victoria, Australia.,Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Brett A Williams
- Department of Paramedicine, Monash University, Victoria, Australia
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Crnobrnja L, Metlapalli M, Jiang C, Govinna M, Lim AKH. The Association of Insulin-dextrose Treatment with Hypoglycemia in Patients with Hyperkalemia. Sci Rep 2020; 10:22044. [PMID: 33328554 PMCID: PMC7745028 DOI: 10.1038/s41598-020-79180-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022] Open
Abstract
Treatment of hyperkalemia with intravenous insulin-dextrose is associated with a risk of hypoglycemia. We aimed to determine the factors associated with hypoglycemia (glucose < 3.9 mmol/L, or < 70 mg/dL) and the critical time window with the highest incidence. In a retrospective cohort study in a tertiary hospital network, we included 421 adult patients with a serum potassium ≥ 6.0 mmol/L who received insulin-dextrose treatment. The mean age was 70 years with 62% male predominance. The prevalence of diabetes was 60%, and 70% had chronic kidney disease (eGFR < 60 ml/min/1.73 m2). The incidence of hypoglycemia was 21%. In a multivariable logistic regression model, the factors independently associated with hypoglycemia were: body mass index (per 5 kg/m2, OR 0.85, 95% CI: 0.69–0.99, P = 0.04), eGFR < 60 mL/min/1.73 m2 (OR 2.47, 95% CI: 1.32–4.63, P = 0.005), diabetes (OR 0.57, 95% CI 0.33–0.98, P = 0.043), pre-treatment blood glucose (OR 0.84, 95% CI: 0.77–0.91, P < 0.001), and treatment in the emergency department compared to other locations (OR 2.53, 95% CI: 1.49–4.31, P = 0.001). Hypoglycemia occurred most frequently between 60 and 150 min, with a peak at 90 min. Understanding the factors associated with hypoglycemia and the critical window of risk is essential for the development of preventive strategies.
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Affiliation(s)
- Ljiljana Crnobrnja
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Manogna Metlapalli
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Cathy Jiang
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Mauli Govinna
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Andy K H Lim
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia. .,Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia.
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Impact of changes in community psychiatric service provision on mental health presentations to the emergency department. Ir J Med Sci 2020; 190:1195-1200. [PMID: 33222076 PMCID: PMC7680212 DOI: 10.1007/s11845-020-02442-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/18/2020] [Indexed: 11/18/2022]
Abstract
Background The reconfiguration of many Irish stand-alone psychiatric units has led to many patients in acute mental health need now being assessed in emergency departments (EDs). This has implications for ED resources and raises questions about appropriate assessment location for this group. Aims This report aims to examine the impact of removal of a direct community access point for patients in acute mental health need on ED presentations in a Dublin hospital. Methods We examined data on ED referrals to psychiatry over 5 years: 12 months before the service change, and four subsequent 12-month periods. We compared numbers referred, mode of referral, average ED length of stay, proportion with no physical issue requiring psychiatric assessment only, and numbers who did not wait for psychiatry assessment. Results In the year directly after the service change, referrals to psychiatry from ED increased by 200%, remaining at this level for the subsequent 3 years. Of these, 32.5% were referred by a GP—more than a threefold increase in numbers from the previous year, with both numbers remaining similarly elevated over subsequent years. In the year after the service change, 52.1% of total ED to psychiatry presented solely for mental health reasons—nearly a fourfold increase in cases from the previous year, and remained high. Conclusions Removing a direct community access point for this group resulted in a substantial increase in ED presentations, many of which did not have physical needs. This study has implications for future policy to address the needs of this group, especially in light of the pandemic.
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Valipoor S, Hatami M, Hakimjavadi H, Akçalı E, Swan WA, De Portu G. Data-Driven Design Strategies to Address Crowding and Boarding in an Emergency Department: A Discrete-Event Simulation Study. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2020; 14:161-177. [PMID: 33176477 DOI: 10.1177/1937586720969933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To address prolonged lengths of stay (LOS) in a Level 1 trauma center, we examined the impact of implementing two data-driven strategies with a focus on the physical environment. BACKGROUND Crowding in emergency departments (EDs) is a widely reported problem leading to increased service times and patients leaving without being seen. METHODS Using ED historical data and expert estimates, we created a discrete-event simulation model. We analyzed the likely impact of initiating care and boarding patients in the hallway (hallway care) instead of the exam rooms and adding a dedicated triage space for patients who arrive by emergency medical services (EMS triage) to decrease hallway congestion. The scenarios were compared in terms of LOS, time spent in exam rooms and hallway spaces, service time, blocked time, and utilization rate. RESULTS The hallway care scenario resulted in significantly lower LOS and exam room time only for EMS patients but when implemented along with the EMS triage scenario, a significantly lower LOS and exam room time was observed for all patients (EMS and walk-in). The combination of two simulated scenarios resulted in significant improvements in other flow metrics as well. CONCLUSIONS Our findings discourage boarding of admitted patients in ED exam rooms. If space limitations require that admitted patients be placed in ED hallways, designers and planners should consider enabling hallway spaces with features recommended in this article. Alternative locations for boarding should be prioritized in or out of the ED. Our findings also encourage establishing a triage area dedicated to EMS patients in the ED.
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Affiliation(s)
- Shabboo Valipoor
- Department of Interior Design, College of Design, Construction & Planning, 3463University of Florida, Gainesville, FL, USA
| | - Mohsen Hatami
- M. E. Rinker, Sr. School of Construction Management, College of Design, Construction & Planning, 3463University of Florida, Gainesville, FL, USA
| | - Hesamedin Hakimjavadi
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, 3463University of Florida, Gainesville, FL, USA
| | - Elif Akçalı
- Department of Industrial & Systems Engineering, Herbert Wertheim College of Engineering, 3463University of Florida, Gainesville, FL, USA
| | | | - Giuliano De Portu
- Department of Emergency Medicine, College of Medicine, 3463University of Florida, Gainesville, FL, USA
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9
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Bakhshi F, Mitchell R, Nasrabadi AN, Varaei S, Hajimaghsoudi M. Behavioural changes in medication safety: Consequent to an action research intervention. J Nurs Manag 2020; 29:152-164. [PMID: 32955774 DOI: 10.1111/jonm.13128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 11/28/2022]
Abstract
AIM To explore the extent to which action research assists developing medication safety behaviours among emergency medicine staff. BACKGROUND Health care staff involved in medication therapy are frequently required to implement progressive changes. To permanently improve medication safety, we must consider staff behaviour. This study utilizes action research to engage health care workers and engender behavioural changes. METHOD Two cycles of action research were implemented. Data were collected through pre- and post-medication safety surveys, unstructured interviews and field notes. Staff in the emergency department worked together to progress the study cycles. RESULTS The pre-evaluation phase revealed deficiencies in staff medication safety behaviour. Subsequent to the implementation of safety initiatives, pre- to post-evaluation comparison indicated significant improvement in medication safety behaviours. In response to qualitative reflection phase data in reflection, ward pharmacists were placed in the emergency department and anew policy on responding to medication error was developed. Analysed field notes revealed improved safe patient care, enhanced pharmaceutical knowledge and changes in the emergency department climate. CONCLUSIONS Through action research, this study introduced actions to improve medication safety behaviours in the emergency department. Staff involvement led to changed safety behaviours. IMPLICATION FOR NURSING MANAGEMENT This study advises nurse managers of the benefit of pharmacist-led medication therapy, interprofessional medication safety courses and active communication between front-line staff and managers regarding medication safety.
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Affiliation(s)
- Fatemeh Bakhshi
- School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.,Macquarie Business School, Macquarie University, Sydney, NSW, Australia
| | - Rebecca Mitchell
- Macquarie Business School, Macquarie University, Sydney, NSW, Australia
| | | | - Shokoh Varaei
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Hajimaghsoudi
- Research Development Center of Shahid Rahnemoon Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Millichamp T, Johnston AN. Interventions to support safe medication administration by emergency department nurses: An integrative review. Int Emerg Nurs 2020; 49:100811. [DOI: 10.1016/j.ienj.2019.100811] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/07/2019] [Accepted: 10/24/2019] [Indexed: 11/26/2022]
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Moon JY, Lee Y, Han JM, Lee MH, Yee J, Song MK, Kim YJ, Gwak HS. Effects of pharmacist interventions on reducing prescribing errors of investigational drugs in oncology clinical trials. J Oncol Pharm Pract 2019; 26:29-35. [DOI: 10.1177/1078155219834723] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
ObjectivesThis study aimed to investigate the effectiveness of pharmacist intervention in reducing and preventing prescribing errors of investigational drugs for cancer patients.Materials and methodsA retrospective study was conducted during two periods: a baseline period from December 2015 to June 2016 and an intervention period from July 2016 to February 2017. The investigational drug service (IDS) pharmacists performed active interventions during the intervention period.ResultsAmong 12,387 investigational drug orders, 395 (6.1%) prescribing errors were detected in 6477 orders at the baseline period, and 278 errors (4.7%) were detected in 5,910 orders at the intervention period. To identify factors that affect prescribing errors, three models were constructed for the multivariate analysis. Among factors affecting prescribing errors, sponsor initiated trial (SIT) was the strongest factor (AOR: 4.16, 95% CI: 3.31–5.23). Pharmacist intervention reduced prescribing errors by at least 25% in all constructed models after adjusting for confounding variables. Prescribing errors were 1.3 times higher when dealing with intravenous medications than when dealing with oral medications. There were 60% fewer prescribing errors in the blinded study than in the open study. SIT and multi-center/multi-nation studies had 4.2 and 2.4 times more frequent prescribing errors than in investigator-initiated trials (IIT) and single-center/single-nation studies, respectively. Fewer errors occurred in phase 2 and trials covering both phase 1 and phase 2 (phase 1/2) than in phase 3 trials.ConclusionsThe IDS pharmacist intervention in cancer clinical trials was associated with significant reductions in prescribing errors and may lead to increased medication safety.
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Affiliation(s)
- Jin Young Moon
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
- Department of Pharmacy, National Cancer Center, Goyang-si, Republic of Korea
| | - Yeonhong Lee
- Department of Pharmacy, National Cancer Center, Goyang-si, Republic of Korea
| | - Ji Min Han
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Mi Hyung Lee
- Department of Pharmacy, National Cancer Center, Goyang-si, Republic of Korea
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, Seoul, Republic of Korea
| | - Jeong Yee
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Mi Kyung Song
- Biometrics Research Branch, Research Institute, National Cancer Center, Goyang-si, Republic of Korea
| | - Young Ju Kim
- Department of Pharmacy, National Cancer Center, Goyang-si, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, Seoul, Republic of Korea
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Myers H, Pugh JD, Twigg DE. Identifying nurse-sensitive indicators for stand-alone high acuity areas: A systematic review. Collegian 2018. [DOI: 10.1016/j.colegn.2017.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Di Simone E, Giannetta N, Auddino F, Cicotto A, Grilli D, Di Muzio M. Medication Errors in the Emergency Department: Knowledge, Attitude, Behavior, and Training Needs of Nurses. Indian J Crit Care Med 2018; 22:346-352. [PMID: 29910545 PMCID: PMC5971644 DOI: 10.4103/ijccm.ijccm_63_18] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aim: The aim was to describe which elements of nurses' knowledge, training needs, behavior, and attitude can prevent Medication errors (Acronym MEs) in the emergency department during all steps of the administration of intravenous (IV) medications. Methods: An anonymous questionnaire made up of 43 items has been drafted and delivered to a sample of 103 nurses of a university hospital in Rome. The study has been supported by specific literature review. Results: Majority of the sample (94%) answered that topics related to the preparation and administration of IV medications were covered during the basic course while 63.2% only during the postbasic course. Only 15.6% of nurses judged excellent their level of knowledge about preparation and administration of IV medications while 89.3% considered that it is important to improve their knowledge; 85.6% said that the teaching about the use of IV medications should be increased during the degree course they attended; 30.3% agreed that specific postgraduate courses on the use of IV drugs should be designed. Moreover, only 22% of the sample believed that the coaching of new recruit nurses is critical to prevent errors. Conclusion: The sample showed appropriate knowledge, positive attitudes, and right behavior related to the preparation and administration of IV medications. The skills that nurses must have in pharmacology are still rising, both due to the safety of drug therapy and to the increasing number of drugs available; the result is that nurses have to update their knowledge regularly.
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Affiliation(s)
- Emanuele Di Simone
- Department of Biomedicine and Prevention - University of Rome Tor Vergata, Italy
| | - Noemi Giannetta
- Department of Biomedicine and Prevention - University of Rome Tor Vergata, Italy
| | | | | | | | - Marco Di Muzio
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
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14
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Blignaut AJ, Coetzee SK, Klopper HC, Ellis SM. Medication administration errors and related deviations from safe practice: an observational study. J Clin Nurs 2017; 26:3610-3623. [PMID: 28102918 DOI: 10.1111/jocn.13732] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2016] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To determine the incidence of medication administration errors, medication administration-related deviations from safe practice as well as factors associated with these errors in medical and surgical units of public hospitals in the Gauteng Province of South Africa. BACKGROUND Several studies have been published on the incidence of medication administration errors, but only a few have studied the incidence of medication administration-related deviations from safe practice. Context-specific research on the incidence of medication administration errors and associated factors (patient acuity, bed occupancy, staffing levels, medication administrators' qualifications, dose calculation skills, level of hospital, unit type, medication administration route and interruptions) within the continent of Africa is lacking. DESIGN A cross-sectional, observational design. METHODS Direct observation was conducted incorporating a previously validated checklist based on basic medication guidelines including the five rights, asepsis and medication documentation. In addition, a knowledge test on dose calculations was performed. Medication administration to 315 patients (1847 medications administered) was observed between February-August 2015 in medical and surgical units from eight public hospitals. Twenty-five medication administrators completed dose calculations. RESULTS In total, 296 medication errors were identified, of which most were wrong-time errors and omissions. Interruptions and patient acuity were significantly associated with wrong-dose and wrong-route errors, respectively. Most medication administration-related deviations from safe practice were related to patient identification or asepsis. Sixteen of 50 dosage calculations were answered incorrectly. Incorrect answers most often occurred in the calculation of parenteral dosages. CONCLUSIONS Medication administration errors, especially wrong-time errors and omissions, are prevalent in public hospitals in the Gauteng Province. Interruptions lower the risk of wrong-dose errors, while patient acuity exacerbates this risk. RELEVANCE TO CLINICAL PRACTICE Factors associated with wrong-time errors and omissions should be addressed. Patient identification and asepsis protocols should be adhered to. Dosage calculation training is indicated.
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Affiliation(s)
- Alwiena J Blignaut
- School of Nursing Science, North-West University (Potchefstroom Campus), Potchefstroom, South Africa
| | - Siedine K Coetzee
- School of Nursing Science, North-West University (Potchefstroom Campus), Potchefstroom, South Africa
| | - Hester C Klopper
- INSINQ Research Unit, North-West University (Potchefstroom Campus), Potchefstroom, South Africa
| | - Suria M Ellis
- Statistical Consultation Service, North-West University (Potchefstroom Campus), Potchefstroom, South Africa
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15
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Laha B, Hazra A. Medication error report: Intrathecal administration of labetalol during obstetric anesthesia. Indian J Pharmacol 2016; 47:456-8. [PMID: 26288484 PMCID: PMC4527074 DOI: 10.4103/0253-7613.161278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 06/03/2015] [Accepted: 06/07/2015] [Indexed: 11/23/2022] Open
Abstract
Labetalol, a combined alfa and beta-adrenergic receptor antagonist, is used as an antihypertensive drug. We report a case of an acute rise in blood pressure and lower limb pain due to the inadvertent intrathecal administration of labetalol, mistaking it for bupivacaine, during obstetric anesthesia. The situation was rescued by converting to general anesthesia. The cesarean delivery was uneventful, and mother as well as newborn child showed no ill-effect. This particular medication error was attributable to a failure on the part of the doctors administering the injection to read and cross-check medication labels and the practice of keeping multiple injections together. In the absence of an organized medication error reporting system and action on that basis, such events may recur in future.
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Affiliation(s)
- Baisakhi Laha
- Department of Anesthesiology, Midnapore Medical College and Hospital, Midnapur, West Bengal, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
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16
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Dollinger C, Schwiertz V, Sarfati L, Gourc-Berthod C, Guédat MG, Alloux C, Vantard N, Gauthier N, He S, Kiouris E, Caffin AG, Bernard D, Ranchon F, Rioufol C. SIMulation of Medication Error induced by Clinical Trial drug labeling: the SIMME-CT study. Int J Qual Health Care 2016; 28:311-5. [PMID: 26976831 DOI: 10.1093/intqhc/mzw025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the impact of investigational drug labels on the risk of medication error in drug dispensing. DESIGN A simulation-based learning program focusing on investigational drug dispensing was conducted. SETTING The study was undertaken in an Investigational Drugs Dispensing Unit of a University Hospital of Lyon, France. PARTICIPANTS Sixty-three pharmacy workers (pharmacists, residents, technicians or students) were enrolled. INTERVENTION Ten risk factors were selected concerning label information or the risk of confusion with another clinical trial. Each risk factor was scored independently out of 5: the higher the score, the greater the risk of error. From 400 labels analyzed, two groups were selected for the dispensing simulation: 27 labels with high risk (score ≥3) and 27 with low risk (score ≤2). Each question in the learning program was displayed as a simulated clinical trial prescription. MAIN OUTCOME MEASURE Medication error was defined as at least one erroneous answer (i.e. error in drug dispensing). For each question, response times were collected. RESULTS High-risk investigational drug labels correlated with medication error and slower response time. Error rates were significantly 5.5-fold higher for high-risk series. Error frequency was not significantly affected by occupational category or experience in clinical trials. CONCLUSIONS SIMME-CT is the first simulation-based learning tool to focus on investigational drug labels as a risk factor for medication error. SIMME-CT was also used as a training tool for staff involved in clinical research, to develop medication error risk awareness and to validate competence in continuing medical education.
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Affiliation(s)
- Cecile Dollinger
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Vérane Schwiertz
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Laura Sarfati
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France Université Lyon 1, EMR UCBL/HCL 3738, Lyon, France
| | - Chloé Gourc-Berthod
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Marie-Gabrielle Guédat
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Céline Alloux
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Nicolas Vantard
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Noémie Gauthier
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Sophie He
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Elena Kiouris
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Anne-Gaelle Caffin
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Delphine Bernard
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Florence Ranchon
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France Université Lyon 1, EMR UCBL/HCL 3738, Lyon, France
| | - Catherine Rioufol
- Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France Université Lyon 1, EMR UCBL/HCL 3738, Lyon, France
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