1
|
Webster CS. Safety improvement requires data: the case for automation and artificial intelligence during incident reporting. Br J Anaesth 2024; 133:491-493. [PMID: 39127483 DOI: 10.1016/j.bja.2024.06.006] [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: 05/06/2024] [Revised: 06/06/2024] [Accepted: 06/06/2024] [Indexed: 08/12/2024] Open
Abstract
The reporting of incidents has a long association with safety in healthcare and anaesthesia, yet many incident reporting systems substantially under-report critical events. Better understanding the underlying reasons for low levels of critical incident reporting can allow such factors to be addressed systematically to arrive at a better reporting culture. However, new forms of automation in anaesthesia also provide powerful new approaches to be adopted in the future.
Collapse
Affiliation(s)
- Craig S Webster
- Department of Anaesthesiology and Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand.
| |
Collapse
|
2
|
Nunes GDK, Antunes LMS, da Silva RN, da Silva RC. Labelling of intravenous drug delivery devices in critically ill patients: A scoping review. Nurs Crit Care 2024; 29:274-286. [PMID: 37882508 DOI: 10.1111/nicc.12994] [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: 05/08/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Labelling is a strategy that contributes to the correct and faster identification of drugs, minimizing misidentification. There is a gap in knowledge on optimal labelling standards for intravenous (IV) devices applied to the care of critically ill patients. AIM The goal of this article was to map existing knowledge on the labelling of IV drug delivery devices in critically ill patients for the prevention of medication errors. STUDY DESIGN This was a scoping review conducted according to the JBI methodology in the LILACS, MEDLINE, CINAHL, IBECS, Scopus, Embase and Web of Science databases, and on the websites of specialized institutions. Searches were conducted up to December 2022 for scientific articles and grey literature that addressed the labelling of IV devices in intensive care units, emergency departments, and anaesthesia units. The data were collected using a structured form and were later classified, summarized, and aggregated to map the knowledge related to the review question. RESULTS Twenty-one documents were included, which demonstrated variability in label use with IV drug delivery devices. The following features of structure and design stood out: printed format, colour coding, letter size differentiation, and the use of sturdy material. In terms of information, the name of the drug, dose, date and time of preparation, identification of the patient, and who prepared it were found. CONCLUSIONS The identified patterns contributed to the reduction of drug misidentification and the development of timelier drug labelling and administration. RELEVANCE TO CLINICAL PRACTICE The evidence supports the development of standardized labels for the prevention of medication errors.
Collapse
Affiliation(s)
- Geovane de Kassio Nunes
- Federal University of Rio de Janeiro, Anna Nery School of Nursing, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lucas Malta Souza Antunes
- Federal University of Rio de Janeiro, Anna Nery School of Nursing, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rodrigo Nogueira da Silva
- Federal University of Rio de Janeiro, Anna Nery School of Nursing, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rafael Celestino da Silva
- Federal University of Rio de Janeiro, Anna Nery School of Nursing, Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
3
|
Jelacic S, Bowdle A, Nair BG, Nair AA, Edwards M, Boorman DJ. Lessons from aviation safety: pilot monitoring, the sterile flight deck rule, and aviation-style computerised checklists in the operating room. Br J Anaesth 2023; 131:796-801. [PMID: 37879776 DOI: 10.1016/j.bja.2023.08.001] [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: 06/23/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 10/27/2023] Open
Abstract
Commercial aviation practices including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists have direct applicability to anaesthesia care. The pilot monitoring performs specific tasks that complement the pilot flying who is directly controlling the aircraft flight path. The anaesthesia care team, with two providers, can be organised in a manner that is analogous to the two-pilot flight deck. However, solo providers, such as solo pilots, can emulate the pilot monitoring role by reading checklists aloud, and utilise non-anaesthesia providers to fulfil some of the functions of pilot monitoring. The sterile flight deck rule states that flight crew members should not engage in any non-essential or distracting activity during critical phases of flight. The application of the sterile flight deck rule in anaesthesia practice entails deliberately minimising distractions during critical phases of anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. Here we discuss how these commercial aviation practices may be applied in the operating room.
Collapse
Affiliation(s)
- Srdjan Jelacic
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Bowdle
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Akira A Nair
- Department of Computer Science, Brown University, Providence, RI, USA
| | - Mark Edwards
- Department of Cardiothoracic and ORL Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | | |
Collapse
|
4
|
Laxton V, Maratos FA, Hewson DW, Baird A, Stupple EJN. Standardised colour-coded compartmentalised syringe trays improve anaesthetic medication visual search and mitigate cognitive load. Br J Anaesth 2023; 130:343-350. [PMID: 36801016 DOI: 10.1016/j.bja.2022.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Anaesthetic procedures are complex and subject to human error. Interventions to alleviate medication errors include organised syringe storage trays, but no standardised methods for drug storage have yet been widely implemented. METHODS We used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. We hypothesised that colour-coded compartmentalised trays would reduce search time and improve error detection for both behavioural and eye-movement responses. We recruited 40 volunteers to identify syringe errors presented in pre-loaded trays for 16 trials in total: 12 error present and four error absent, with eight trials presented for each tray type. RESULTS Errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays (11.1 s vs 13.0 s, respectively; P=0.026). This finding was replicated for correct responses for error-absent trays (13.3 s vs 17.4 s, respectively; P=0.001) and in the verification time of error-absent trays (13.1 s vs 17.2 s, respectively; P=0.001). On error trials, eye-tracking measures revealed more fixations on the drug error for colour-coded compartmentalised trays (5.3 vs 4.3, respectively; P<0.001), whilst more fixations on the drug lists for conventional trays (8.3 vs 7.1, respectively; P=0.010). On error-absent trials, participants spent longer fixating on the conventional trials (7.2 s vs 5.6 s, respectively; P=0.002). CONCLUSIONS Colour-coded compartmentalisation enhanced visual search efficacy of pre-loaded trays. Reduced fixations and fixation times for the loaded tray were shown for colour-coded compartmentalised trays, indicating a reduction in cognitive load. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.
Collapse
Affiliation(s)
- Victoria Laxton
- College of Health, Psychology and Social Care, University of Derby, Derby, UK; TRL, Wokingham, UK
| | - Frances A Maratos
- College of Health, Psychology and Social Care, University of Derby, Derby, UK.
| | - David W Hewson
- Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK; Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Baird
- College of Health, Psychology and Social Care, University of Derby, Derby, UK
| | - Edward J N Stupple
- College of Health, Psychology and Social Care, University of Derby, Derby, UK.
| |
Collapse
|
5
|
Bowdle TA, Jelacic S, Webster CS, Merry AF. Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet. Br J Anaesth 2023; 130:14-16. [PMID: 36333160 DOI: 10.1016/j.bja.2022.09.017] [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: 08/08/2022] [Revised: 09/12/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
An error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.
Collapse
Affiliation(s)
- T Andrew Bowdle
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Srdjan Jelacic
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Craig S Webster
- Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Alan F Merry
- Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| |
Collapse
|
6
|
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
|
7
|
Nunes GDK, Campos JF, da Silva RC. Intravenous therapy device labeling in Intensive Care Units: an integrative review. Rev Bras Enferm 2022; 75:e20220049. [PMID: 36197432 PMCID: PMC9730860 DOI: 10.1590/0034-7167-2022-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/27/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES to synthesize the evidence on intravenous device labeling used to identify medications administered to patients in Intensive Care Units, with a view to preventing medication errors. METHODS an integrative review, in the LILACS, IBECS, Embase, MEDLINE, Scopus, Web of Science and CINAHL databases, from November to December 2021, using descriptors and selection criteria. Data were collected in 11 articles and subsequently classified, summarized and aggregated. RESULTS pre-designed labels, with pre-defined colors and information, help to prevent medication identification errors. There is still a lack of standardization in the practice of labeling syringes, intravenous lines, infusion pumps and saline solution bags. There are errors related to the lack of labeling devices or to their performance with incomplete information. CONCLUSIONS device labeling is a barrier to defending the medication system safety and should be standardized.
Collapse
|
8
|
Raghavan KC, Burlison JD, Sanders II EM, Rossi MG. Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm. Pediatr Qual Saf 2022; 7:e596. [PMID: 38584960 PMCID: PMC10997222 DOI: 10.1097/pq9.0000000000000596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/12/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Significant adverse drug events (ADEs) due to anesthesia infusion pump programming errors were reported at our institution. We incorporated independent two-provider infusion pump programming verification, an evidence-supported intervention, into our anesthesia medication infusion process with a goal of reducing associated ADEs to zero in 2 years. Methods Using the model for improvement, we developed key drivers and interventions and utilized plan-do-study-act (PDSA) cycles. Drivers included education and training, verification process, visual aids, information technology, and safety culture. Interventions included anesthesia provider training, information dissemination, independent two-provider verification process of smart pump programming, verification documentation capability, verification compliance tracking, and visual aids. Our outcome measures were relevant ADEs and near-miss events. Process and balancing measures were the percentage of smart pump programs with independent second verification and delayed case starts due to second provider verification, respectively. Results During the project period, only one related grade E ADE occurred, and the root cause was not conducting an independent pump programming verification. Thirteen grade B near-miss events were prevented due to independent second verification. Second verification adherence reached 85% and was sustained, and no delayed case starts occurred. Conclusions With structured quality improvement methods, the process of independent two-provider verification of infusion pump programming during anesthesia can be successfully implemented, and errors in a high-volume setting reduced without negatively affecting case start times. The cultural and organizational factors we report may aid other institutions in gaining project buy-in and sustainment.
Collapse
Affiliation(s)
- Kavitha C. Raghavan
- From the Division of Anesthesiology, St Jude Children’s Research Hospital, Memphis, Tenn
| | - Jonathan D. Burlison
- Office of Quality and Patient Safety, St. Jude Children’s Research Hospital, Memphis, Tenn
| | - Edward M. Sanders II
- From the Division of Anesthesiology, St Jude Children’s Research Hospital, Memphis, Tenn
| | - Michael G. Rossi
- From the Division of Anesthesiology, St Jude Children’s Research Hospital, Memphis, Tenn
| |
Collapse
|
9
|
Webster CS. Existing Knowledge of Medication Error Must Be Better Translated Into Improved Patient Safety. Front Med (Lausanne) 2022; 9:870587. [PMID: 35655855 PMCID: PMC9152084 DOI: 10.3389/fmed.2022.870587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Craig S Webster
- Department of Anaesthesiology and Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand
| |
Collapse
|
10
|
Hailu S. Assessment of the Practice of Storage, Labeling and Usage of Anesthetic Medications in the Operation Theatres of Selected Southern Ethiopian Hospitals: A Multicenter Descriptive Cross-Sectional Study. OPEN ACCESS SURGERY 2022. [DOI: 10.2147/oas.s366258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
11
|
Derese M, Agegnehu W. Challenges of Medical Error Reporting in Mizan-Tepi University Teaching Hospital: A Qualitative Exploratory Study. Drug Healthc Patient Saf 2022; 14:51-59. [PMID: 35502287 PMCID: PMC9056101 DOI: 10.2147/dhps.s347738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Medical error is defined as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result”. It is a serious public health problem that can pose a threat to patient safety and if managed it can be an opportunity to an organizational learning. This study aimed to assess the challenges of error reporting. Methods Explorative qualitative cross-sectional study was conducted. The study was conducted among healthcare providers in Mizan-Tepi University Teaching Hospital. The study participants were selected purposely based on the patient contact hour and had served in this hospital for long period of time. Twenty-one in-depth interviews were undertaken. From each wards, three in-depth interviews were held. Case team leaders and other healthcare providers were identified and interviewed. The data were analyzed thematically. Results Twenty-one healthcare providers were recruited for this study. Majority of the participants, 12 (57.1%) were nurses and midwives and as to marital status, 18 (85.7%) were married. Challenges for reporting medical errors were identified as perceived lack of confidentiality of the medical errors, perceived punitive measures, lack of good reporting system, perceived fear of losing acceptance, lack of learning culture from errors, information asymmetry, mass-media publication of medical errors, avoidance of conflict and attitude of health professionals. Conclusion There were system and individual related challenges for reporting of medical errors. Healthcare managers should enhance medical error reporting for organizational learning by addressing these system and individual factors.
Collapse
Affiliation(s)
- Msganaw Derese
- Department of Nursing, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Wubetu Agegnehu
- Department of Public Health, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| |
Collapse
|
12
|
Neo HJ, Sim MA, Ti LK, Ang SBL. Evaluation of the Efficiency and Safety of a Safe Label System: A Prospective Simulation Study. J Patient Saf 2022; 18:e568-e572. [PMID: 35188941 DOI: 10.1097/pts.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Our study aims to investigate the safety and efficiency of the Codonics Safe Label System (SLS) in a prospective simulation study. METHODS Three sets of simulated experiments involving 82 anesthetists were carried out on patient simulator mannequins. The primary outcome assessed through the simulated experiments was the effectiveness of the SLS in avoiding vial swap errors. Secondary outcomes analyzed included the efficacy of the SLS in preventing syringe swap and the difference in time taken to prepare standardized drugs as compared with conventional methods. RESULTS The SLS was associated with a significant reduction in all 4 stages of vial swap error. The incidence of wrong ampoule breakage was significantly lower in the SLS group compared with the conventional group (12.1% versus 38.5%, P = 0.007). The number of staff who drew the wrong ampoule was similarly lower in the SLS group compared with the conventional group (4.9% versus 33.3%, P = 0.001). The proportions of staff who eventually wrongly labeled the loaded syringe were 0% in the SLS group and 17.9% in the conventional group (P = 0.005).Drug preparation time was longer for the SLS group than for the conventional group (239.6 ± 45.9 versus 160.3 ± 46.5 seconds, P < 0.001).There was no significant difference in the incidence of syringe swap with the use of the SLS. CONCLUSIONS The use of the SLS is effective in reducing vial swap error, but not syringe swap errors, and is associated with increased time taken for anesthetic drug preparation.
Collapse
Affiliation(s)
- Hong Jye Neo
- From the Department of Anaesthesia, National University Hospital
| | - Ming Ann Sim
- From the Department of Anaesthesia, National University Hospital
| | | | | |
Collapse
|
13
|
Williams J, Malden S, Heeney C, Bouamrane M, Holder M, Perera U, Bates DW, Sheikh A. Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review. J Patient Saf 2022; 18:e547-e562. [PMID: 35188939 PMCID: PMC8855945 DOI: 10.1097/pts.0000000000000867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Considerable international investment in hospital electronic prescribing (ePrescribing) systems has been made, but despite this, it is proving difficult for most organizations to realize safety, quality, and efficiency gains in prescribing. The objective of this work was to develop policy-relevant insights into the optimization of hospital ePrescribing systems to maximize the benefits and minimize the risks of these expensive digital health infrastructures. METHODS We undertook a systematic scoping review of the literature by searching MEDLINE, Embase, and CINAHL databases. We searched for primary studies reporting on ePrescribing optimization strategies and independently screened and abstracted data until saturation was achieved. Findings were theoretically and thematically synthesized taking a medicine life-cycle perspective, incorporating consultative phases with domain experts. RESULTS We identified 23,609 potentially eligible studies from which 1367 satisfied our inclusion criteria. Thematic synthesis was conducted on a data set of 76 studies, of which 48 were based in the United States. Key approaches to optimization included the following: stakeholder engagement, system or process redesign, technological innovations, and education and training packages. Single-component interventions (n = 26) described technological optimization strategies focusing on a single, specific step in the prescribing process. Multicomponent interventions (n = 50) used a combination of optimization strategies, typically targeting multiple steps in the medicines management process. DISCUSSION We identified numerous optimization strategies for enhancing the performance of ePrescribing systems. Key considerations for ePrescribing optimization include meaningful stakeholder engagement to reconceptualize the service delivery model and implementing technological innovations with supporting training packages to simultaneously impact on different facets of the medicines management process.
Collapse
Affiliation(s)
- Jac Williams
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephen Malden
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Catherine Heeney
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Matt Bouamrane
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Mike Holder
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Uditha Perera
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Aziz Sheikh
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
14
|
Nunes GDK, Campos JF, Silva RCD. Rotulagem de dispositivos de terapia intravenosa em Unidades de Terapia Intensiva: revisão integrativa. Rev Bras Enferm 2022. [DOI: 10.1590/0034-7167-2022-0049pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RESUMO Objetivos: sintetizar as evidências sobre a rotulagem de dispositivos intravenosos utilizada para a identificação de medicamentos administrados nos pacientes em Unidades de Terapia Intensiva, com vistas à prevenção dos erros de medicação. Métodos: revisão integrativa, nas bases de dados LILACS, IBECS, Embase, MEDLINE, Scopus, Web of Science e CINAHL, no período de novembro-dezembro de 2021, com uso de descritores e emprego de critérios de seleção. Os dados foram coletados em 11 artigos e, posteriormente, classificados, sumarizados e agregados. Resultados: rótulos pré-desenhados, com cores e informações pré-definidas contribuem para prevenir os erros de identificação dos medicamentos. Persiste a falta de padronização da prática de rotulagem em seringas, linhas intravenosas, bomba infusoras e bolsas de soro. Há erros relacionados à ausência de rotulagem dos dispositivos ou à sua realização com informações incompletas. Conclusões: a rotulagem dos dispositivos é uma barreira para a defesa da segurança do sistema de medicação, devendo ser padronizada.
Collapse
|
15
|
Kim JY, Moore MR, Culwick MD, Hannam JA, Webster CS, Merry AF. Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS. Anaesth Intensive Care 2021; 50:204-219. [PMID: 34871511 DOI: 10.1177/0310057x211027578] [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] [Indexed: 11/16/2022]
Abstract
Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.
Collapse
Affiliation(s)
- Jee Young Kim
- Department of Anaesthesia and Perioperative Medicine, 58991Auckland City Hospital, Auckland City Hospital, Auckland, New Zealand
| | - Matthew R Moore
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Martin D Culwick
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jacqueline A Hannam
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Craig S Webster
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Alan F Merry
- Department of Anaesthesia and Perioperative Medicine, 58991Auckland City Hospital, Auckland City Hospital, Auckland, New Zealand.,Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| |
Collapse
|
16
|
Ciapponi A, Fernandez Nievas SE, Seijo M, Rodríguez MB, Vietto V, García-Perdomo HA, Virgilio S, Fajreldines AV, Tost J, Rose CJ, Garcia-Elorrio E. Reducing medication errors for adults in hospital settings. Cochrane Database Syst Rev 2021; 11:CD009985. [PMID: 34822165 PMCID: PMC8614640 DOI: 10.1002/14651858.cd009985.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death. OBJECTIVES To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments. DATA COLLECTION AND ANALYSIS We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible. MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131). Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724). Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311). Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88). Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775). AUTHORS' CONCLUSIONS Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.
Collapse
Affiliation(s)
- Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
| | - Simon E Fernandez Nievas
- Quality and Patient Safety, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Mariana Seijo
- Quality of Health Care and Patient Safety, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - María Belén Rodríguez
- Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy (IECS), Ciudad Autónoma de Buenos Aires, Argentina
| | - Valeria Vietto
- Family and Community Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Sacha Virgilio
- Instituto de Efectividad Clínica y Sanitaria (IECS), Ciudad Autónoma de Buenos Aires, Argentina
| | - Ana V Fajreldines
- Quality and Patient Safety, Austral University Hospital, Buenos Aires, Argentina
| | - Josep Tost
- Urgencias � Calidad y Seguridad de pacientes, Consorcio Sanitario de Terrassa, Barcelona, Spain
| | | | - Ezequiel Garcia-Elorrio
- Quality and Safety in Health Care, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| |
Collapse
|
17
|
Webster CS. The evolution of methods to estimate the rate of medication error in anaesthesia. Br J Anaesth 2021; 127:346-349. [PMID: 34238549 DOI: 10.1016/j.bja.2021.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Craig S Webster
- Department of Anaesthesiology, and Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand.
| |
Collapse
|
18
|
Maximous R, Wong J, Chung F, Abrishami A. Interventions to reduce medication errors in anesthesia: a systematic review. Can J Anaesth 2021; 68:880-893. [PMID: 33709263 DOI: 10.1007/s12630-021-01959-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/03/2021] [Accepted: 02/18/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The objective of this study was to provide a synthesis of the interventions designed to reduce medication errors in anesthetized patients. METHODS We electronically searched major databases using index and free-text keywords related to anesthesia and medication errors. We included cohort studies exploring interventions to reduce anesthetic medication errors in both adult and pediatric patients. The risk of bias for each study was assessed using the Newcastle-Ottawa Scale. RESULTS One thousand five-hundred and fifty-eight titles or abstracts were screened, and 56 full-text studies were assessed for eligibility; eight studies were included in the final analysis. Case reports and retrospective studies were excluded. The quality of most studies (n = 6) was graded as "low". There were three categories of interventions: I) multimodal interventions (6 studies, n = 900,170 medication administrations) showed a reduction in rates of errors of 21-35% per administration and 37-41% per anesthetic; II) improved labels (1 study, n = 55,426 medication administrations) resulted in a 37% reduction in rates of errors per anesthetic; and III) the effect of education was assessed in one study and showed no effect. CONCLUSION Multimodal interventions and improved labelling reduce medication errors in anesthetized patients.
Collapse
Affiliation(s)
- Ramez Maximous
- Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Symth Road #2044, Ottawa, ON, K1H 8M5, Canada.
| | - Jean Wong
- Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada
| | - Frances Chung
- Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada
| | - Amir Abrishami
- Niagara Health, St. Catharines, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Cairns Family Health and Bioscience, Niagara Regional Campus, St. Catharines, ON, Canada
| |
Collapse
|
19
|
Sustainable quality and safety improvement in healthcare: further lessons from the aviation industry. Br J Anaesth 2020; 125:425-429. [DOI: 10.1016/j.bja.2020.06.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/01/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022] Open
|
20
|
Understanding the limitations of incident reporting in medication errors. Br J Anaesth 2020; 125:e343-e344. [PMID: 32536441 DOI: 10.1016/j.bja.2020.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/04/2020] [Accepted: 05/10/2020] [Indexed: 11/23/2022] Open
|
21
|
Gonzalez LS, Chaney MA, Wahr JA, Rebello E. What's in That Syringe? J Cardiothorac Vasc Anesth 2020; 34:2524-2531. [PMID: 32507463 DOI: 10.1053/j.jvca.2020.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/04/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Laura S Gonzalez
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| | - Joyce A Wahr
- Department of Anesthesiology,University of Minnesota, Minneapolis, MN
| | - Elizabeth Rebello
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
22
|
Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system. Br J Anaesth 2020; 124:197-205. [DOI: 10.1016/j.bja.2019.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 09/28/2019] [Accepted: 10/06/2019] [Indexed: 11/20/2022] Open
|
23
|
Aiming to avoid inadvertent wrong administration of medications: should drug ampoules and packaging be standardised? Br J Anaesth 2019; 122:e81-e82. [PMID: 30961916 DOI: 10.1016/j.bja.2019.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 02/26/2019] [Accepted: 03/06/2019] [Indexed: 11/22/2022] Open
|
24
|
Webster CS. Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies. Br J Anaesth 2019; 122:723-725. [PMID: 30954239 DOI: 10.1016/j.bja.2019.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/16/2019] [Accepted: 02/22/2019] [Indexed: 12/31/2022] Open
Affiliation(s)
- Craig S Webster
- Department of Anaesthesiology and Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand.
| |
Collapse
|
25
|
Bowdle A, Jelacic S, Nair B, Jense R, Webster C, Merry A. Why we scan the barcodes of anaesthetic medications. Br J Anaesth 2019; 122:e24-e26. [DOI: 10.1016/j.bja.2018.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022] Open
|
26
|
Feedback and constraints: rethinking medication safety countermeasures. Br J Anaesth 2018; 121:1188-1190. [PMID: 30442240 DOI: 10.1016/j.bja.2018.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 11/24/2022] Open
|