Evaluation of nurses' errors associated in the preparation and administration of medication in a pediatric intensive care unit

The quality of drugs and drug products - Always guaranteed?

To ensure the efficacy, safety, and quality of drugs, several national and international guidelines and regulatory requirements exist. The most important international regulatory framework for quality is the collection of the guidelines ICH Q1-Q14 (International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use), which form the basis for the development and approval of medicinal products. Additionally, international and national pharmacopoeias and national regulatory authorities like Food and Drug Administration (FDA) and European Directory for the Quality of Medicines and HealthCare (EDQM) have to be considered during the lifecycle of a drug. Further, regular updates and optimization of processes and methods together with periodic audits and inspections of the manufacturing plants help to ensure compliance with the complex regulatory requirements for medicinal products. Although the pharmaceutical world seems to be very well regulated and controlled, several drug recalls per year have to be announced and conducted to remove defect products from the market and protect the patient from any potential health risk. This review article provides an overview of the most common reasons for such recalls presenting several historical and current cases with a detailed discussion of root causes. A specific focus lies on quality issues like drug degradation, impurity and nitrosamine contamination, lack of drug stability, occurrence and transformation of polymorphs, contamination with particulates and foreign matters, amongst others. The role of APIs, excipients and packaging will be discussed as well as the analytical challenges to detect, control and mitigate such quality issues. A final chapter will discuss the current situation and an outlook on emerging topics and future challenges for drug quality.

Opioid-Free Anesthesia: Physico Chemical Stability Studies on Multi-Analyte Mixtures Intended for Use in Clinical Anesthesiology

Objectives: Opioid-free anesthesia is used increasingly often in hospitals around the world. In this type of anesthesia, opioids are replaced by other analgesics, such as ketamine, lidocaine, dexmedetomidine, and magnesium sulfate. Many clinicians prepare these agents as dual, triple, or quadruple admixtures within a single syringe. However, data on the stability of the individual substances within these preparations over time and in different storage conditions is very limited. Here, we aim to investigate various admixture of dexmedetomidine, ketamine, lidocaine, and magnesium sulfate with respect to the stability of the individual agents over time at different storage conditions. Methods: An ultra-high performance liquid chromatography method coupled to mass spectrometric detection was developed and validated to determine the stability of lidocaine, ketamine, and dexmedetomidine. Quantification of magnesium was carried out in parallel by potentiometric titration. Results: Our results demonstrate the stability of dual, triple or quadruple mixtures of selected substances in 0.9% saline under different storage conditions. Under all conditions, analyzed admixtures remain stable for at least 8 weeks. The quadruple mixture of lidocaine, ketamine, dexmedetomidine, and magnesium sulfate was storable for as long as 148 days without a significant loss of analyte. Conclusion: A new chromatographic method was successfully developed to analyze the stability of various pharmacological agents commonly used by clinicians in opioid-free anesthesia. The data we obtained indicate that mixing these agents together in a single syringe is safe and reliable and suggest that hospital pharmacies may prepare these solutions in advance of planned surgeries.

Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions

AIMS

Accurate documentation of medication administration time is imperative for many therapeutic decisions, including dosing of intravenous antimicrobials. The objectives were to determine (1) the discrepancy between actual and documented administration times for antimicrobial infusions and (2) whether day of the week, time of day, nurse-to-patient ratio and drug impacted accuracy of documented administration times.

METHODS

Patient and dosing data were collected (June-August 2019) for 55 in-patients receiving antimicrobial infusions. "Documented" and "actual" administration times (n = 660) extracted from electronic medication management systems and smart infusion pumps, respectively, were compared. Influence of the day (weekday/weekend), time of day (day/evening/night), nurse-to-patient ratio (high 1:1/low 1:5) and drug were examined. Monte Carlo simulation was used to predict the impact on dose adjustments for vancomycin using the observed administration time discrepancies compared to the actual administration time.

RESULTS

The median discrepancy between actual and documented administration times was 16 min (range, 2-293 min), with discrepancies greater than 60 minutes in 7.7% of administrations. Overall, discrepancies (median [range]) were similar on weekends (17 [2-293] min) and weekdays (16 [2-188] min), and for high (16 [2-157] min) and low nurse-to-patient ratio wards (16 [2-293] min). Discrepancies were smallest for night administrations (P < .05), and antimicrobials with shorter half-lives (P < .0001). The observed discrepancies in vancomycin administration time resulted in a different dose recommendation in 58% of cases (30% higher, 28% lower).

CONCLUSIONS

Overall, there were discrepancies between actual and documented antimicrobial infusion administration times. For vancomycin, these discrepancies in administration time were predicted to result in inappropriate dose recommendations.

Stability of prostaglandin E1 solutions stored in polypropylene syringes for continuous intravenous administration to newborns

Objective

We aimed to monitor the physicochemical stability of prostaglandin E₁ (PGE₁) 1.5 and 15 µg/mL in 10% dextrose stored in polypropylene syringes.

Methods

We developed a liquid chromatography-high resolution mass spectrometry (LC-HRMS) method to detect and quantify levels of PGE₁. Method selectivity was performed with a mixture of PGE₁ and its degradation products. Forced degradation tests were performed to determine which degradation products were most likely to form. PGE₁ injection solutions in 10% dextrose were stored in unprotected and shielded-from-light polypropylene syringes in a climatic chamber. Samples were taken immediately after preparation (T₀) and after 24, 48, 72 and 168 hours for analysis. PGE₁ solutions were considered stable if ≥90.0% of the initial concentration was retained.

Results

The LC-HRMS method was validated in the range of 0.086-0.200µg/mL PGE₁ with trueness values between 98.2% and 100.3%, and repeatability and intermediate precision values of <2.2%and <4.7%, respectively. The quantification and detection limits of the method were 0.086 and 0.026µg/mL, respectively. PGE₁ and its degradation products were resolved chromatographically. PGE₁ injection solutions were≥90.0%stable after 48hours in unprotected from light (UPL) syringes. The solutions remained clear without precipitation, colour or pH modification and subvisible particles within the permitted levels. Prostaglandin A₁ was the sole degradation product observed.

Conclusions

A LC-HRMS method to evaluate PGE₁ stability in a 10% dextrose was developed and validated. PGE₁ 1.5 and 15µg/mL in 10% dextrose solution are stable for 48hours when stored at 30ºC in UPL polypropylene syringes.

Physical Compatibility of Intravenous Drugs Commonly Used in Intensive Care Units: An Observational Study and Physical Compatibility Laboratory Tests on Anti-Infective Drugs

Background

The objectives were to perform an observation of the administration of injectable drugs in three ICUs, to identify injectable drugs administered by Y-site infusion or mixed in the same container, to compare with physical compatibility data available in the literature and to test the physical compatibility for missing data.

Methods

An observational study was realised over two weeks and patients receiving more than one injectable drug in the same line simultaneously were included. Physical compatibilities were assessed in pairs by comparing with three databases. For some missing data, three tests were realised for pairs including an anti-infective drug. Visual and subvisual evaluations were performed after the preparation, 1 and a 4-hour storage.

Results

A total of 389 combinations between two injectable drugs was observed for Y-site infusions and 31 mixtures in the same container. According to the literature, 21.1 % associations were physically compatible, 1.8 % as physically compatible potentially, 8.0 % as physically incompatible, 6.4 % have divergent data according to the databases and 62.7 % have no data. Two mixtures were documented. 37 pairs were tested and 70.3 % were physically compatible, 8.1 % were physically incompatible after visual evaluation and 21.6 % after subvisual evaluation.

Conclusions

In the majority of cases, no compatibility data are available in the literature. Laboratory tests give additional information.

Compatibility of Ceftazidime-Avibactam, Ceftolozane-Tazobactam, and Piperacillin-Tazobactam with Vancomycin in Dextrose 5% in Water

Objectives: The compatibility of vancomycin with existing and novel β-lactam/β-lactamase inhibitors at clinically relevant concentrations in 5% dextrose in water has not been fully explored to date. Methods: Vancomycin concentrations tested ranged from 5 to 20 mg/mL. Ceftazidime-avibactam was tested at 8, 20, and 40 mg/mL, ceftolozane-tazobactam at 15 mg/mL, and piperacillin-tazobactam at 28 mg/mL. Compatibility of drug admixtures were tested via both simulated and actual y-site infusion. For the simulated y-site compatibility assessment, 1:1 mixtures of each respective drug were analyzed over 24 hours. Actual y-site infusion followed a 4-hour extended-infusion protocol, with aliquots tested hourly for 4 hours. At all time points, the compatibility of each admixture was determined using 6 different methods: visual, microscopic, Tyndall beam, nephelometric, pH, and microbiologic bioassay assessment. If any admixture failed any one of these 6 assays, it was considered incompatible. Any combination deemed incompatible was filtered through a 0.22 μm filter and reanalyzed to assess impact of particle size. Results: There were no differences in compatibility categorizations between simulated and actual y-site infusion. There were no changes in compatibility over the time course of any experiment. Ceftazidime-avibactam at 8 mg/mL was incompatible with vancomycin at 5 mg/mL. The maximum compatible vancomycin concentrations were 5 mg/mL and 10 mg/mL with 20 and 40 mg/mL of ceftazidime-avibactam, respectively. Ceftolozane-tazobactam 15 mg/mL was compatible with vancomycin concentrations up to 10 mg/mL. The maximum compatible vancomycin concentration with piperacillin-tazobactam 28 mg/mL was 5 mg/mL. None of the β-lactam/β-lactamase inhibitors tested were compatible with 15 or 20 mg/mL of vancomycin. None of the admixtures considered incompatible by other methods displayed any decrease in antimicrobial activity as assessed by bioassay. After filtration, all admixtures originally deemed incompatible maintained their visual turbidity and microscopic particulate matter. Conclusions: Ceftazidime-avibactam prepared at the lowest concentration recommended in the package insert is incompatible with vancomycin. Ceftolozane-tazobactam did not display incompatibility until vancomycin concentrations above 10 mg/mL were tested. Piperacillin-tazobactam at a typical extended-infusion concentration is compatible with vancomycin in D5W. To our knowledge, this is the first study to assess compatibility of antibiotic admixtures via direct measurement of antimicrobial activity. The lack of any decrement in antibacterial activity of any apparently incompatible admixture and maintenance of incompatibility after passage through a 0.22 μm filter may suggest a lack of clinically relevant adverse effects when co-administered. Future compatibility studies should incorporate appropriate methods to accurately assess both efficacy and safety of co-administered drug products.

Particulate Matter in Injectable Drugs: Evaluation of Risks to Patients

One of the fundamental principles guiding the pharmaceutical quality of parenteral products is to prevent injecting contaminants from microbiological, chemical or physical sources. It is just as difficult to ensure the absence of chemical and particulate contaminants in injectable products as it is to weigh up the microbiological risk. The problem of particulate matter is mainly related to the preparing and administrating of injectable drugs rather than through the contamination of marketed products. Particulate contamination also arises

Incidence of Intravenous Medication Errors in a Chinese Hospital

OBJECTIVES

The purpose of this study was to explore intravenous (IV) medication errors in a Chinese hospital. The specific objectives were to 1) explore and measure the frequency of IV medication errors by direct observation and identify clues to their causes in Chinese hospital inpatient wards and 2) identify the clinical importance of the errors and find the potential risks in the preparation and administration processes of IV medications.

METHODS

A prospective study was conducted by using the direct observational method to describe IV medication errors on two general surgery patient wards in a large teaching hospital in Beijing, China. A trained observer accompanied nurses during IV preparation rounds to detect medication errors. The difference in mean error rates between total parenteral nutrition (TPN) and non-TPN medications was tested by using the Mann-Whitney U test.

RESULTS

A final total of 589 ordered IV doses plus 4 unordered IV doses as prepared and administered to the patients was observed from August 3, 2010, to August 13, 2010. The overall error rate detected on the study ward was 12.8%. The most frequent errors by category were wrong dose (5.4%), wrong time (3.7%), omission (2.7%), unordered dose (0.7%), and extra dose (0.3%). Excluding wrong time errors, the error rate was 9.1%. Non-TPN medications had significantly higher error rates than did TPN medications including wrong time errors (P = 0.0162).

CONCLUSIONS

A typical inpatient in a Chinese hospital was subject to about one IV error every day. Pharmacists had a very limited role in ensuring the accuracy of IV medication preparation and administration processes.

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system

Direct observation was used to detect medication errors and Bar Code Medication Administration (BCMA) workarounds on two pediatric units and one neonatal unit at UCSF Benioff Children's Hospital. The study (1) measured the frequency of nursing medication administration-related errors, (2) characterized the types of medication errors, (3) assessed compliance with the institution's six medication administration safety processes, and (4) identified observed workarounds following BCMA implementation. The results of the direct observation were compared to medication administration-related incident reports (IRs) for the same period. The frequency of medication errors was 5% for the three units. Compliance with the process measures was achieved 86% of the time (range 23-100%). Seven medication administration-related IRs were submitted during the same observation period. Three BCMA workarounds were identified; (1) failure to visually confirm patient's identification, (2) failure to compare the medication to the electronic medication administration record at least twice before administration, and (3) charting administration of medication before actual administration. The direct observation methodology identified a low frequency of medication administration errors (MAEs) consistent with post-BCMA implementation. The incident reporting system identified different MAEs than direct observation suggesting that both methods should be used to better characterize the scope of MAEs.

Compatibility of medications during multi-infusion therapy: A controlled in vitro study on a multilumen infusion device

OBJECTIVE

Drug incompatibilities can jeopardize the safety and effectiveness of intravenous drug therapies, especially in the field of anaesthesia and intensive care. Patients receive many drugs simultaneously through limited venous accesses. This study was designed to confirm the impact of a multilumen infusion device on the occurrence of known physical drug incompatibilities.

STUDY DESIGN

In vitro laboratory work.

METHODS

Two infusion devices were studied: a standard single-lumen set and a multilumen infusion access device (Edelvaiss Multiline-8, Doran International). Up to six drugs were infused simultaneously: three acidic solutions of midazolam, amiodarone and dobutamine, and three alkaline solutions of furosemide, pantoprazole and amoxicillin/clavulanate. Saline, Ringer' solution and 5% dextrose were used as hydration vehicles with an infusion rate initially set at 100 mL/h and with stepwise decreases of 10 mL/h until precipitation. Two methods were used to highlight physical drug compatibility according to the European Pharmacopoeia: visual inspection of the extension set and an obscured-light sub-visible particle count test of infusions. The lowest infusion rate value for vehicle infusion to satisfy the two tests in all trials is reported for each infusion device.

RESULTS

The standard set did not satisfy the test in 82% of the assessed drug combinations. The Edelvaiss Multiline-8 was able to prevent the occurrence of drug incompatibilities in 49% of the drug combinations tested. This device is therefore advantageous, especially when simultaneously infusing two or four incompatible drugs.

CONCLUSIONS

Infusion device characteristics have an impact on physical drug incompatibilities. Our results confirm that the Edelvaiss Multiline-8 device prevents physical drug incompatibilities under specified conditions.

Incidence of intravenous drug incompatibilities in intensive care units

AIMS

Drug incompatibilities are relatively common in inpatients and this may result in increased morbidity/mortality as well as add to costs. The aim of this 12 month study was to identify real incidences of drug incompatibilities in intravenous lines in critically ill patients in two intensive care units (ICUs).

METHODS

A prospective cross sectional study of 82 patients in 2 ICUs, one medical and one surgical in a 1500-bed university hospital. One monitor carried out observations during busy hours with frequent drug administration. Patients included in both ICUs were those receiving at least two different intravenous drugs.

RESULTS

6.82% and 2.16% of drug pairs were found to be incompatible in the two ICUs respectively. Among the most frequent incompatible drugs found were insulin, ranitidine and furosemide.

CONCLUSIONS

The study showed that a significant number of drug incompatibilities occur in both medical and surgical ICUs. It follows that the incidence of incompatibilities could be diminished by adhering to a few simple rules for medication administration, following by recommendations for multiple lumen catheter use. Future prospective studies should demonstrate the effect of applying these policies in practice.

A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care

AIMS AND OBJECTIVES

To prevent medication errors in drug handling in a paediatric ward.

BACKGROUND

One in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce.

DESIGN

A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling.

METHODS

After approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors.

RESULTS

The number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct 'volume of solvent for IV drugs' from 49-25%.

CONCLUSION

Paediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes.

RELEVANCE TO CLINICAL PRACTICE

Worldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings.

Paediatric nurses' adherence to the double-checking process during medication administration in a children's hospital: an observational study

AIM

To evaluate how closely double-checking policies are followed by nurses in paediatric areas and also to identify the types, frequency and rates of medication administration errors that occur despite the double-checking process.

BACKGROUND

Double-checking by two nurses is an intervention used in many UK hospitals to prevent or reduce medication administration errors. There is, however, insufficient evidence to either support or refute the practice of double-checking in terms of medication error risk reduction.

DESIGN

Prospective observational study.

METHODS

This was a prospective observational study of paediatric nurses' adherence to the double-checking process for medication administration from April-July 2012.

RESULTS

Drug dose administration events (n = 2000) were observed. Independent drug dose calculation, rate of administering intravenous bolus drugs and labelling of flush syringes were the steps with lowest adherence rates. Drug dose calculation was only double-checked independently in 591 (30%) drug administrations. There was a statistically significant difference in nurses' adherence rate to the double-checking steps between weekdays and weekends in nine of the 15 evaluated steps. Medication administration errors (n = 191) or deviations from policy were observed, at a rate of 9·6% of drug administrations. These included 64 drug doses, which were left for parents to administer without nurse observation.

CONCLUSION

There was variation between paediatric nurses' adherence to double-checking steps during medication administration. The most frequent type of administration errors or deviation from policy involved the medicine being given to the parents to administer to the child when the nurse was not present.

Drug administration errors in hospital inpatients: a systematic review

CONTEXT

Drug administration in the hospital setting is the last barrier before a possible error reaches the patient.

OBJECTIVES

We aimed to analyze the prevalence and nature of administration error rate detected by the observation method.

DATA SOURCES

Embase, MEDLINE, Cochrane Library from 1966 to December 2011 and reference lists of included studies.

STUDY SELECTION

Observational studies, cross-sectional studies, before-and-after studies, and randomized controlled trials that measured the rate of administration errors in inpatients were included.

DATA EXTRACTION

Two reviewers (senior pharmacists) independently identified studies for inclusion. One reviewer extracted the data; the second reviewer checked the data. The main outcome was the error rate calculated as being the number of errors without wrong time errors divided by the Total Opportunity for Errors (TOE, sum of the total number of doses ordered plus the unordered doses given), and multiplied by 100. For studies that reported it, clinical impact was reclassified into four categories from fatal to minor or no impact. Due to a large heterogeneity, results were expressed as median values (interquartile range, IQR), according to their study design.

RESULTS

Among 2088 studies, a total of 52 reported TOE. Most of the studies were cross-sectional studies (N=46). The median error rate without wrong time errors for the cross-sectional studies using TOE was 10.5% [IQR: 7.3%-21.7%]. No fatal error was observed and most errors were classified as minor in the 18 studies in which clinical impact was analyzed. We did not find any evidence of publication bias.

CONCLUSIONS

Administration errors are frequent among inpatients. The median error rate without wrong time errors for the cross-sectional studies using TOE was about 10%. A standardization of administration error rate using the same denominator (TOE), numerator and types of errors is essential for further publications.

Prevalence and Nature of Medication Administration Errors in Health Care Settings: A Systematic Review of Direct Observational Evidence

OBJECTIVE:

To systematically review empirical evidence on the prevalence and nature of medication administration errors (MAEs) in health care settings.

DATA SOURCES:

Ten electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, Scopus, Applied Social Sciences Index and Abstracts, PsycINFO, Cochrane Reviews and Trials, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, and Health Management Information Consortium) were searched (1985-May 2012).

STUDY SELECTION AND DATA EXTRACTION:

English-language publications reporting MAE data using the direct observation method were included, providing an error rate could be determined. Reference lists of all included articles were screened for additional studies.

DATA SYNTHESIS:

In all, 91 unique studies were included. The median error rate (interquartile range) was 19.6% (8.6–28.3%) of total opportunities for error including wrong-time errors and 8.0% (5.1–10.9%) without timing errors, when each dose could be considered only correct or incorrect. The median rate of error when more than 1 error could be counted per dose was 25.6% (20.8–41.7%) and 20.7% (9.7–30.3%), excluding wrong-time errors. A higher median MAE rate was observed for the intravenous route (53.3% excluding timing errors (IQR 26.6–57.9%)) compared to when all administration routes were studied (20.1%; 9.0–24.6%), where each dose could accumulate more than one error. Studies consistently reported wrong time, omission, and wrong dosage among the 3 most common MAE subtypes. Common medication groups associated with MAEs were those affecting nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antiinfectives. Medication administration error rates varied greatly as a product of differing medication error definitions, data collection methods, and settings of included studies. Although MAEs remained a common occurrence in health care settings throughout the time covered by this review, potential targets for intervention to minimize MAEs were identified.

CONCLUSIONS:

Future research should attend to the wide methodological inconsistencies between studies to gain a greater measure of comparability to help guide any forthcoming interventions.

Medication errors in the Middle East countries: a systematic review of the literature

Background

Medication errors are a significant global concern and can cause serious medical consequences for patients. Little is known about medication errors in Middle Eastern countries. The objectives of this systematic review were to review studies of the incidence and types of medication errors in Middle Eastern countries and to identify the main contributory factors involved.

Methods

A systematic review of the literature related to medication errors in Middle Eastern countries was conducted in October 2011 using the following databases: Embase, Medline, Pubmed, the British Nursing Index and the Cumulative Index to Nursing & Allied Health Literature. The search strategy included all ages and languages. Inclusion criteria were that the studies assessed or discussed the incidence of medication errors and contributory factors to medication errors during the medication treatment process in adults or in children.

Results

Forty-five studies from 10 of the 15 Middle Eastern countries met the inclusion criteria. Nine (20 %) studies focused on medication errors in paediatric patients. Twenty-one focused on prescribing errors, 11 measured administration errors, 12 were interventional studies and one assessed transcribing errors. Dispensing and documentation errors were inadequately evaluated. Error rates varied from 7.1 % to 90.5 % for prescribing and from 9.4 % to 80 % for administration. The most common types of prescribing errors reported were incorrect dose (with an incidence rate from 0.15 % to 34.8 % of prescriptions), wrong frequency and wrong strength. Computerised physician rder entry and clinical pharmacist input were the main interventions evaluated. Poor knowledge of medicines was identified as a contributory factor for errors by both doctors (prescribers) and nurses (when administering drugs). Most studies did not assess the clinical severity of the medication errors.

Conclusion

Studies related to medication errors in the Middle Eastern countries were relatively few in number and of poor quality. Educational programmes on drug therapy for doctors and nurses are urgently needed.

Terms used in patient safety related to medication: a literature review

PURPOSE

There is a lack of homogeneity in the terminology used in the context of patient safety related to medication. The aim of this review was to identify the terms and definitions used in patient safety related to medication within the scientific literature.

METHODS

Original and review articles that were indexed between 1998 and 2008 in MEDLINE and EMBASE and contained terms used in patient safety related to medication were included. Terms and definitions were extracted and categorised according to whether its definition referred to the process of medication use, or to the clinical outcome of medication use, or both.

RESULTS

Of 2564 articles, 147 were included. Sixty terms used in patient safety related to medication with 189 different definitions were identified. Among terms that referred only to the process of medication use (n = 23), medication error provided the greatest number of definitions (n = 29). Among terms that referred only to the clinical outcome of medication use (n = 31), adverse drug event provided the greatest number of definitions (n = 15). Finally, among terms that referred both to the process of use and to the clinical outcome of medication use (n = 13), drug-related problem provided the greatest number of definitions (n = 7).

CONCLUSIONS

A multitude of terms and definitions are used in patient safety related to medication. This heterogeneity makes it difficult to compare the results among studies and to appreciate the true magnitude of the problem. Classifying and unifying the terminology is necessary to advance in patient safety strategies.

Medication administration errors in an intensive care unit in Ethiopia

BACKGROUND

Medication administration errors in patient care have been shown to be frequent and serious. Such errors are particularly prevalent in highly technical specialties such as the intensive care unit (ICU). In Ethiopia, the prevalence of medication administration errors in the ICU is not studied.

OBJECTIVE

To assess medication administration errors in the intensive care unit of Jimma University Specialized Hospital (JUSH), Southwest Ethiopia.

METHODS

Prospective observation based cross-sectional study was conducted in the ICU of JUSH from February 7 to March 24, 2011. All medication interventions administered by the nurses to all patients admitted to the ICU during the study period were included in the study. Data were collected by directly observing drug administration by the nurses supplemented with review of medication charts. Data was edited, coded and entered in to SPSS for windows version 16.0. Descriptive statistics was used to measure the magnitude and type of the problem under study.

RESULTS

Prevalence of medication administration errors in the ICU of JUSH was 621 (51.8%). Common administration errors were attributed to wrong timing (30.3%), omission due to unavailability (29.0%) and missed doses (18.3%) among others. Errors associated with antibiotics took the lion's share in medication administration errors (36.7%).

CONCLUSION

Medication errors at the administration phase were highly prevalent in the ICU of Jimma University Specialized Hospital. Supervision to the nurses administering medications by more experienced ICU nurses or other relevant professionals in regular intervals is helpful in ensuring that medication errors don't occur as frequently as observed in this study.

Developing a drug library for smart pumps in a pediatric intensive care unit

BACKGROUND

The most serious medication errors occur during intravenous administration. The potential consequences are more serious the more critical and younger the patient. Smart pumps can help to prevent infusion-related programming errors, thanks to associated dose-limiting software known as "drug library". Drug libraries alert the user if pre-determined high dosage limits are exceeded or if entry is below pre-determined low dosage limits.

OBJECTIVE

To describe the process for developing a specific drug library for a pediatric intensive care unit (PICU) and the key factors for preventing programming errors.

METHODS AND MATERIALS

The study was performed by a multidisciplinary team consisting of a clinical pharmacist, a PICU pediatrician, and the chief nurse of the unit. The process of developing the drug library lasted seven months. A literature review was carried out to determine standard concentrations and accurate limits for intravenous administration of high-risk drugs. Alaris(®) syringe pumps and Guardrails(®) CQI v4.1 Event Reporter software were used.

RESULTS

Several manufacturers offer smart pump technology. Users should be aware of differences in features, such as definition of parameters and associations between them, definition of safety limits, organization of the drug library, and data use. Our infusion pump technology covered 108 drugs. Compliance with the drug library was 85% and nurses' acceptance of the drug library was high as 94% would recommend implementation of this technology in other units. After nine months of implementation, several potentially harmful infusion-related programming errors were intercepted.

CONCLUSIONS

Drug libraries are specifically designed for a particular hospital unit, and may condition the success in implementing this technology. Implementation of smart pumps proved effective in intercepting infusion-related programming errors after nine months of implementation in a PICU.

Medication errors reported in a pediatric intensive care unit for oncologic patients

BACKGROUND

Considering all sources of errors that may occur during healthcare, medication errors are the most common and also the most frequent cause of adverse events.

OBJECTIVE

The objective of the study was to describe the medication errors reported in a pediatric intensive care unit for oncologic patients.

METHODS

This is a descriptive and exploratory study. The errors were reported by the professionals involved in the medication system in a medication error report form developed for the study.

RESULTS

The sample consisted of 110 medication errors reported on 71 forms. The omission error was the most common error type reported (22.7%), followed by administration error (18.2%). No harm to patients was reported in 83.1% of the notifications.

CONCLUSION

The analysis of the110 medication errors provides evidence of the context of their occurrence and the need to implement measures that can prevent or intercept these errors.

IMPLICATIONS FOR PRACTICE

In an institution without adverse events report and a formal system to patient safety analysis, the implementation of a local nonpunitive approach to medication errors notification represented an important tool to patient safety promotion.

Smart pump alerts: all that glitters is not gold

INTRODUCTION

The implementation of smart pump technology can reduce the incidence of errors in the administration of intravenous drugs. This approach involves developing drug libraries for specific units and setting hard and soft limits for each drug. If a programming error occurs and these limits are exceeded, an alarm sounds and the infusion can be blocked. A detailed analysis of these alarms is essential in order not to bias the results in favor of a positive impact of this technology.

PURPOSE

To evaluate the results of the first analysis of the use of smart infusion pumps and to assess the significance and practical implications of the alarms sounded.

METHODS

The study was performed by a multidisciplinary team that consisted of a clinical pharmacist, a pediatrician from the pediatric intensive care unit (PICU), and the chief nurse of the unit. A library of 108 drugs was developed over a 7-month period and introduced into 40 syringe pumps and 12 volumetric pumps (Alaris(®) with Plus software) before being applied in 6 of the 11 beds in the PICU. After four month's use, data were analyzed using the Guardrails(®) CQI v4.1 Event Reporter program.

RESULTS

Following the first four months of implementation, compliance with the drug library was 87%. By analyzing the alerts triggered, we were able to detect problems such as the need to increase user training, readjust limits that did not correspond to clinical practice, correct errors in the editing of the drug library and including a training profile.

CONCLUSION

It is difficult to obtain accurate data on the true impact of this technology in the early stages of its implementation. This preliminary analysis allowed us to identify improvement measures to distinguish, in future evaluations, the alarms triggered by a real programming error from those caused by incorrect use.

Frequency of pediatric medication administration errors and contributing factors

This study examined the frequency of pediatric medication administration errors and contributing factors. This research used the undisguised observation method and Critical Incident Technique. Errors and contributing factors were classified through the Organizational Accident Model. Errors were made in 36.5% of the 2344 doses that were observed. The most frequent errors were those associated with administration at the wrong time. According to the results of this study, errors arise from problems within the system.

The impact of type of manual medication cart filling method on the frequency of medication administration errors: a prospective before and after study

BACKGROUND

The medication cart can be filled using an automated system or a manual method and when using a manual method the medication can be arranged either by round time or by medication name. For the manual methods, it is hypothesized that the latter method would result in a lower frequency of medication administration errors because nurses are forced to read the medication labels, but evidence for this hypothesis is lacking.

OBJECTIVES

The aim of this study was to compare the frequency of medication administration errors of two different manual medication cart filling methods, namely arranging medication by round time or by medication name.

DESIGN

A prospective, observational study with a before-after design.

PARTICIPANTS AND SETTINGS

Eighty-six patients who stayed on an orthopaedic ward in one university medical centre in the Netherlands were included.

METHODS

Disguised observation was used to detect medication administration errors. The medication cart filling method in usual care was to fill the cart with medication arranged by round time. The intervention was the implementation of the second medication cart filling method, where the medication cart was filled by arranging medicines by their names. The primary outcome was the frequency of medication administrations with one or more error(s) after the intervention compared with before the intervention. The secondary outcome was the frequency of subtypes of medication administration errors.

RESULTS

After the intervention 170 of 740 (23.0%) medication administrations with one or more medication administration error(s) were observed compared to 114 of 589 (19.4%) before the intervention (odds ratio 1.24 [95% confidence interval 0.95-1.62]). The distribution of subtypes of medication administration errors before and after the intervention was statistically significantly different (p<0.001). Analysis of subtypes revealed more omissions and wrong time errors after the intervention than before the intervention. Unauthorized medication errors were detected more frequently before the intervention than after the intervention.

CONCLUSION

The frequency of medication administration errors with the medication cart filling method where the medication is arranged by name was not statistically significantly different compared to the medication cart filling method where the medication is arranged by round time.

A purging procedure for pantoprazole and 4-lumen catheters to prevent IV drug incompatibilities

OBJECTIVE OF THE STUDY

The purpose of this prospective intervention study was to assess the number of patients with Y-site incompatibilities before and after implementation of quality improvement measures to prevent incompatibilities consisting of a focused instruction for pantoprazole as a drug frequently involved in incompatible drug pairs and of a recommendation to use 4-lumen instead of 3-lumen catheters to increase the number of available central infusion lines.

SETTING

Cardiovascular intensive care unit where several standard operating procedures (SOPs) dealing with compatibility were already in place.

METHOD

In a prospective intervention study, patients' IV medication was assessed for potential incompatibilities using a database containing compatibility information on approximately 60,000 drug pairs. In a first period, routine administration was monitored in 53 consecutive patients (control group). Then, quality improvement measures were implemented recommending a purging procedure before and after bolus administration of pantoprazole as a drug frequently causing incompatibilities in this setting. Additionally, the use of 4-lumen instead of 3-lumen catheters was suggested whenever considered useful by the responsible physicians. The monitoring was repeated during a second period in another 58 patients consecutively admitted to the same unit (intervention group).

MAIN OUTCOME MEASURE

Overall number of patients with at least one incompatible drug pair and number of patients receiving incompatible pantoprazole combinations.

RESULTS

The number of patients receiving incompatible pantoprazole combinations decreased from 15 of the 15 patients receiving pantoprazole (100.0%) in controls to 9/16 (56.2%) in the intervention group (P < 0.01). The overall number of patients with incompatibilities was not influenced by the intervention with 36/58 (62.1%) compared to controls with 38/53 (71.7%, P = 0.28). The fraction of central lines contributed by four lumen central catheters was larger due to the intervention (80/168 lines, 47.6%) compared to controls (16/184, 8.7%, P < 0.001). Only sporadically there were incompatible combinations of drugs governed by the already existing SOPs.

CONCLUSION

In an intensive care setting with good SOP adherence, purging before and after administration decreased the respective incompatibility rate whereas the use of 4-lumen instead of 3- lumen catheters had not the expected benefit on separating drug pairs.

Evaluation of tools to prevent drug incompatibilities in paediatric and neonatal intensive care units

OBJECTIVE

Intravenous drug administration in neonatal (NICU) and paediatric intensive care units (PICU) is critical because of poor venous access, polymedication, fluid restriction and low infusion rate. Risk is further increased by inadequate information on the physicochemical compatibility of drugs. Eight decision-supporting tools were hence evaluated to improve the detection of drug incompatibilities in paediatric wards.

SETTING

NICU and PICU, University hospital.

METHOD

Eight tools (Thériaque 2007, Stabilis 3, Perfysi 2 databases; KIK 3.0 software; Neofax 2007 handbook; King 2008 Guide, CHUV 9.0, pH 2007 cross-tables) were assessed by two pharmacists using 40 drug pairs (20 incompatible; 20 compatible) frequently prescribed in PICUs and NICUs. Trissel's 14th Ed. handbook served as the gold standard. Four criteria were evaluated (each with a maximum of 250 points): accuracy (sensitivity, specificity, positive and negative predictive values), completeness (number of drug pairs documented), comprehensiveness (presence of 16 different items), and applicability (by combining the time needed by 7 pharmacists to classify 5 drug pairs, plus an evaluation of their design, usefulness, reliability and ergonomics, using visual analogy scales). The percentage of non-compliant answers (NCA) was calculated for both the performing pharmacists and the tools.

MAIN OUTCOME MEASURE

Global score of drug incompatibilities (accuracy + completeness + comprehensiveness + applicability).

RESULTS

Thériaque obtained the best global score (840/1000 points), followed by pH (807), CHUV (803), Perfysi (776), Neofax (678), King Guide (642), Stabilis (584) and KIK (523), respectively. The highest scores were reached by Thériaque for accuracy (234/250); Thériaque and pH for completeness (200/250); Thériaque and Perfysi for comprehensiveness (218/250); and pH for applicability (298/250). The range of pharmacists' NCAs was between 9% (4/45 NCAs) and 33% (15/45), whereas that for drug pairs was between 10% (6/63) and 30% (19/63). The range of NCAs for tools was between 6% (2/35, pH) and 49% (18/35, Perfysi).

CONCLUSIONS

Thériaque proved outstanding as a drug-incompatibility tool. However, all resources showed some shortcomings. The large ranges of pharmacists' NCAs shows that such an assessment is subject to different interpretations. Standard operating procedures for drug-incompatibility assessment should be implemented in drug-information centres. Tools with low NCA percentage, such as the pH or CHUV tables, may be useful for nurses in ICUs.

Drug administration errors in paediatric wards: a direct observation approach

Paediatric patients are more vulnerable to drug administration errors due to a lack of appropriate drug dosages and strengths for use in this group of patients. Therefore, the aim of the present study was to determine the extent and types of drug administration errors in two paediatric wards and to identify measures to reduce such errors. A researcher was stationed in two paediatric wards of a teaching hospital to observe all drugs administered to paediatric inpatients in each of the ward, for 1 day in a week over ten consecutive weeks. All data were recorded in a data collection form and then compared with the actual drugs and dosages prescribed for the patients. Of the 857 drug administrations observed, 100 doses had errors, and this gave an error rate of 11.7% [95% confidence interval (CI) 9.5-13.9%]. If wrong time administration errors were excluded, the error rate reduced to 7.8% (95% CI 6.0-9.6%). The most common types of drug administration errors were incorrect time of administration (28.8%), followed by incorrect drug preparation (26%), omission errors (16.3%) and incorrect dose (11.5%). None of the errors observed were considered as potentially life threatening, although 40.4% could possibly cause patient harm. Drug administration errors are as common in paediatric wards in Malaysia as in other countries. Double-checking should be conducted, as this could reduce drug administration errors by about 20%, but collaborative efforts between all healthcare professionals are essential.

The pathophysiology of medication errors: how and where they arise

1. Errors arise when an action is intended but not performed; errors that arise from poor planning or inadequate knowledge are characterized as mistakes; those that arise from imperfect execution of well-formulated plans are called slips when an erroneous act is committed and lapses when a correct act is omitted. 2. Some tasks are intrinsically prone to error. Examples are tasks that are unfamiliar to the operator or performed under pressure. Tasks that require the calculation of a dosage or dilution are especially susceptible to error. 3. The tasks of prescribing, preparation, and administration of medicines are complex, and are carried out within a complex system; errors can occur at each of many steps and the error rate for the overall process is therefore high. 4. The error rate increases when health-care professionals are inexperienced, inattentive, rushed, distracted, fatigued, or depressed; orthopaedic surgeons and nurses may be more likely than other health-care professionals to make medication errors. 5. Medication error rates in hospital are higher in paediatric departments and intensive care units than elsewhere. 6. Rates of medication errors may be higher in very young or very old patients. 7. Intravenous antibiotics are the drugs most commonly involved in medication errors in hospital; antiplatelet agents, diuretics, and non-steroidal anti-inflammatory drugs are most likely to account for 'preventable admissions'. 8. Computers effectively reduce the rates of easily counted errors. It is not clear whether they can save lives lost through rare but dangerous errors in the medication process.

Prevention of intravenous drug incompatibilities in an intensive care unit

PURPOSE

The frequency of drug administration errors and incompatibilities between intravenous drugs before and after an intervention in an intensive care unit (ICU) is discussed.

METHODS

Critically ill adult patients with intoxications, multiorgan failure, and serious infections were included in a retrospective analysis and in a prospective two-period, one-sequence study. In the retrospective analysis, the most frequent brands of i.v. medications used in the ICU of a gastroenterologic department in a teaching hospital were identified. All possible combinations and resulting incompatibilities were defined. Based on the results, a standard operating procedure (SOP) was established to prevent frequent and well-documented incompatibilities among i.v. medications. In the prospective study, trained pharmacy students assessed incompatible coinfusions before and after SOP implementation.

RESULTS

In the retrospective analysis of 100 patients, 3617 brands of drug pairs were potentially given concurrently through one i.v. line and 7.2% of the drug pairs were incompatible. Antibiotics, such as piperacillin-tazobactam and imipenem-cilastatin, were the most frequent incompatible drug pairs. The newly developed SOP mandated that administration of these drugs be separated from all other drugs and suggested the use of an idle i.v. line for infusion whenever possible. In the prospective study of 50 patients, the frequency of incompatible drug pairs was reduced by the time of intervention from 5.8% to 2.4%. Incompatible drug pairs that were governed by the new SOP were reduced from 1.9% to 0.5%.

CONCLUSION

Administration of incompatible i.v. drugs in critically ill patients was frequent but significantly reduced by procedural interventions with SOPs.

Standardization of infusion solutions to reduce the risk of incompatibility

PURPOSE

Although critically ill patients usually have various central intravenous (i.v.) lines, numerous drugs have to be infused simultaneously through the same lines. This can result in potentially harmful in-line incompatibility that can cause decreased drug effectiveness or increased microparticle load. To minimize the risk of these medication errors at an anesthesia intensive care unit (ICU), the preparation and administration of continuously infused drugs were standardized and the practicability in daily clinical routine was evaluated.

SUMMARY

The concentration and diluent of continuously administered i.v. drugs were standardized. The drugs were grouped according to pH, medical indication, and chemical structure. The ICU staff decided to use multilumen central venous catheters, and each group of drugs was assigned to one lumen. Only drugs that belonged to the same group were infused simultaneously through the same lumen; therefore, intragroup incompatibilities had to be excluded before establishing the new drug administration plan at the ICU. The visual compatibility of 115 clinically reasonable intragroup drug mixtures was investigated. All drug combinations were compatible for six hours except mixtures containing thiopental, which was reassigned to a single-line use. In the following year, the practicability of this drug administration plan was evaluated. No deviations were found in the compliance of the staff prescribing and preparing only standardized concentrations and diluents. Further research to investigate the chemical compatibility of the drugs in these multiple mixtures will follow.

CONCLUSION

A project intended to avoid incompatibility among i.v. drugs infused in the intensive care setting included steps to standardize solutions and determine which could be given together.

A secondary care nursing perspective on medication administration safety

AIM

This paper is a report of a study to explore how nurses in a secondary care environment understand medication administration safety and the factors that contribute to, or undermine, safe practice during this process.

BACKGROUND

Medication safety is an important issue in which acute care nurses are actively involved on a daily basis. International research highlights that, despite attempts to maintain patient safety during this process, many errors are made.

METHOD

Data were collected in 2005 using three focus groups of nurses that formed part of a larger study examining organizational safety and medication administration from a nursing perspective. A narrative approach was employed to analyse the transcripts.

FINDINGS

Participants had good understandings of organizational culture in relation to medication safety and recognized the importance of effective multi-disciplinary teams in maintaining a safe environment for patients. Despite this, they acknowledged that not all systems work well, and offered a variety of ways to improve current medication practices.

CONCLUSION

These findings highlight the meaningful contribution nurses can make to patient safety and emphasize the importance of including the nursing voice in any quality improvement initiatives. Researchers must seek nurses' opinions on safe medication practice in order that medication safety can be improved. Local contexts may influence medication safety in ways that only nurses can identify. When addressing the issue of medication safety, it is important to focus nursing research on both the macro and the micro contexts.

Interventions to reduce dosing errors in children: a systematic review of the literature

Children are a particularly challenging group of patients when trying to ensure the safe use of medicines. The increased need for calculations, dilutions and manipulations of paediatric medicines, together with a need to dose on an individual patient basis using age, gestational age, weight and surface area, means that they are more prone to medication errors at each stage of the medicines management process. It is already known that dose calculation errors are the most common type of medication error in neonatal and paediatric patients. Interventions to reduce the risk of dose calculation errors are therefore urgently needed. A systematic literature review was conducted to identify published articles reporting interventions; 28 studies were found to be relevant. The main interventions found were computerised physician order entry (CPOE) and computer-aided prescribing. Most CPOE and computer-aided prescribing studies showed some degree of reduction in medication errors, with some claiming no errors occurring after implementation of the intervention. However, one study showed a significant increase in mortality after the implementation of CPOE. Further research is needed to investigate outcomes such as mortality and economics. Unit dose dispensing systems and educational/risk management programmes were also shown to reduce medication errors in children. Although it is suggested that 'smart' intravenous pumps can potentially reduce infusion errors in children, there is insufficient information to draw a conclusion because of a lack of research. Most interventions identified were US based, and since medicine management processes are currently different in different countries, there is a need to interpret the information carefully when considering implementing interventions elsewhere.

Incidence and nature of medication errors in neonatal intensive care with strategies to improve safety: a review of the current literature

Neonates are highly vulnerable to medication errors because of their extensive exposure to medications in the neonatal intensive care unit (NICU), the general lack of evidence on pharmacotherapeutic interventions in neonates and the lack of neonate-specific formulations. We searched PubMed and EMBASE to identify relevant original studies published in the English language. Eleven studies were identified on the frequency of medication errors in the NICU. The highest rate was 5.5 medication errors per 100 prescriptions; however, medication error rates varied widely between studies, partly due to differences in the definition of an error and the rigor of the method used to identify medication errors. Furthermore, studies were difficult to compare because medication error rates were calculated differently. Most studies did not assess the potential clinical impact of the errors. The majority of studies identified dose errors as the most common type of error. Computerised physician order entry and interventions by clinical pharmacists (e.g. the participation of pharmacists in ward rounds and review of patients' prescriptions prior to dispensing) were the most common interventions suggested to improve medication safety in the NICU. However, only very limited data were available on evaluation of the effects of such interventions in NICUs. More research is needed to determine the frequency and types of medication errors in NICUs and to develop evidence-based interventions to improve medication safety in the NICU setting. Some of these research efforts need to be directed to the establishment of clear definitions of medication errors and agreement on the methods that should be used to measure medication error rates and their potential clinical impact.

[Medication administration errors in a pediatric intensive care unit]

The administration act, as each step of the drugs circuit, can lead to an adverse drug event potentially harmful for the patient. The aim of this study was to highlight the adverse drug events outcoming at the administration stage and to suggest improvement elements. Errors were identified in a retrospective manner. We compared the written prescriptions ("Prescription forms") with the administration registration ("Administration forms"). The differences observed between these two paper media were classified according to the errors types defined by the American Society of Hospital Pharmacists and by the American Society of Consultant Pharmacists. This study settled in the pediatric intensive care unit of a teaching hospital. We checked 1035 administrations lines: 180 errors (17,4%) were detected, including 63 omissions, 44 infusion rate errors, 42 administrations without prescription, 20 administration time errors, 7 dose errors, 2 drug form errors, 2 errors of other types, but no route of administration error. This method choice is debatable because without direct observation we could only compare what was noted to be administrated and not what was really administrated. We did not try to identify neither the causes nor the consequences of these errors on the patients. Following this study, several improvements have been set up: a new "Prescription form" (expecting the computerized prescription order entry) and reconstitution and dilution protocols for the most prescribed drugs.

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit

OBJECTIVE

To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated.

DESIGN

Prospective, direct observation study.

SETTING

A 16-bed pediatric medical/surgical ICU at a tertiary care academic medical center.

PATIENTS

One enrolled nurse caring for at least one pediatric ICU patient age <18 yrs was randomly chosen during each observation period.

INTERVENTIONS

Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort.

MEASUREMENTS AND MAIN RESULTS

Medication errors and potential and actual ADEs were identified throughout the entire medication use process. The 26 12-hr observation periods included 357 reviewed written orders and 263 observed doses. The study observers identified 58 incidents, which were subsequently classified by the evaluators according to clinical importance, severity, and preventability. Fifty-two of these incidents were considered medication errors; six incidents were determined to be nonpreventable ADEs. Of the 52 medication errors, 42 (81%) were considered clinically important. Potential ADEs comprised 35 (83%) of these important medication errors; the other seven (17%) were classified as actual, preventable ADEs. Overall, the actual and potential ADE rate occurred at 3.6 events and 9.8 events per 100 orders, respectively.

CONCLUSIONS

Our medication error rate was similar to that of previous pediatric ICU studies that used the direct observation method for reporting but higher than the rates in previous studies using other detection techniques such as voluntary incident reporting. Periodic direct observation and other ongoing data collection methods such as voluntary incident reporting have the potential to be complementary approaches to medication error and ADE detection.

Systematic review of medication errors in pediatric patients

OBJECTIVE

To systematically locate and review studies that have investigated the incidence of medication errors (MEs) in pediatric inpatients and identify common errors.

METHODS

A systematic search of studies related to MEs in children was performed using the following databases: MEDLINE (1951-April 2006), EMBASE (1966-April 2006), Pharm-line (1978-April 2006), International Pharmaceutical Abstracts (1970-April 2006), Cumulative Index to Nursing and Allied Health Literature (1982-April 2006), and British Nursing Index (1994-April 2006). Studies of the incidence and nature of MEs in pediatrics were included. The title, abstract, or full article was reviewed for relevance; any study not related to MEs in children was excluded.

RESULTS

Three methods were used to detect MEs in the studies reviewed: spontaneous reporting (n = 10), medication order or chart review (n = 14), or observation (n = 8). There was great variation in the definitions of ME used and the error rates reported. The most common type of ME was dosing error, often involving 10 times the actual dose required. Antibiotics and sedatives were the most common classes of drugs associated with MEs; these are probably among the most common drugs prescribed.

CONCLUSIONS

Interpretation of the literature was hindered by variation in definitions employed by different researchers, varying research methods and setting, and a lack of theory-based research. Overall, it would appear that our initial concern about MEs in pediatrics has been validated; however, we do not know the actual size of the problem. Further work to determine the incidence and causes of MEs in pediatrics is urgently needed, as well as evaluation of the best interventions to reduce them.

Principles and practices of medication safety in the ICU

Medication errors are a significant public health problem in United States hospitals. Patients in the ICU are at particular risk for medication errors because of the characteristics of an ICU and the nature of its patients. This article reviews the principles of medication safety and applies these principles to the ICU, and suggests safe practices to improve medication safety in the ICU.

Conseqüências dos erros de medicação em unidades de terapia intensiva e semi-intensiva

O estudo objetivou caracterizar erros de medicação e avaliar conseqüências na gravidade dos pacientes e carga de trabalho de enfermagem em duas Unidades de Terapia Intensiva (UTI) e duas Semi-Intensiva (USI) de duas instituições hospitalares do município de São Paulo. A amostra foi constituída por 50 pacientes e os dados obtidos por meio do registro de ocorrências e prontuários, retrospectivamente. A gravidade e carga de trabalho de enfermagem foram avaliadas antes e após o erro. Do total de 52 erros, 12 (23,08%) ocorreram por omissão de dose, 11 (21,15%) e 9 (17,31%) por medicamento e dose erradas, respectivamente. Não houve mudança na gravidade dos pacientes (p=0,316), porém houve aumento na carga de trabalho de enfermagem (p=0,009). Quanto ao grupo de medicamentos envolvidos, potencialmente perigosos e não potencialmente perigosos, não houve diferenças estatisticamente significantes na gravidade (p=0,456) e na carga de trabalho de enfermagem (p=0,264), após o erro de medicação.

Medication errors and adverse drug events in an intensive care unit: Direct observation approach for detection

OBJECTIVE

To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence.

DESIGN

Prospective, direct observation study.

SETTING

Tertiary care academic medical center.

PATIENTS

Patients in a medical/surgical intensive care unit.

INTERVENTIONS

Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort.

MEASUREMENTS AND MAIN RESULTS

The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%).

CONCLUSIONS

Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.

[Medication errors resulting from drug preparation and administration]

BACKGROUND

The risks associated with drug use are not confined to adverse reactions. Failures can occur in the process of drug prescribing, dispensing and administration. Such preventable events are termed 'medication errors'. Errors in preparation and administration, the last step in the medication process, constitute a good indicator of the quality of the medication process, and are irredeemable.

METHODS

A protocol for measuring errors in the preparation and administration of medication has been developed and used in an internal medicine department at the University Hospital of Dijon.

RESULTS

This protocol has enabled several different rates of medication errors to be determined depending on the calculation approach used: 15.1% with respect to interventions by nurses, 41% relating to the total number of opportunities for error, and 8.8% with respect to a methodological problem analysed in the study. The potential clinical significance, incidence and causes of errors during the medication process were also analysed.

DISCUSSION AND CONCLUSION

Medical errors are not detected in our health system and are thus not preventable. Their consequences are incompatible with a well organised treatment process. The rate of medication errors is therefore a good indicator of the quality of the medication system in a hospital that is following the current steps for risk reduction and accreditation.

Drug administration errors and their determinants in pediatric in-patients

OBJECTIVE

. To quantify the type and frequency of drug administration errors to pediatric in-patients and to identify associated factors.

DESIGN

Prospective direct-observation study of drug administration errors from April 2002 to March 2003.

SETTING

Four clinical units in a pediatric teaching hospital.

STUDY PARTICIPANTS

Twelve observers accompanied nurses giving medications and witnessed the preparation and administration of all drugs to all patients on all weekday mornings.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Discrepancies between physicians' orders and actual drug administration.

RESULTS

During the 1719 observed administrations to 336 patients by 485 nurses, 538 administration errors were detected, involving timing (36%), route (19%), dosage (15%), unordered drug (10%), or form (8% form). These errors occurred for 467 (27%) of the 1719 administrations. Intravenous drugs (OR = 0.28; CI = 0.16-0.49; versus miscellaneous) were associated with fewer errors. Error rates were higher for cardiovascular (OR = 3.38; CI = 1.24-9.27; versus miscellaneous) and central nervous system drugs (OR = 2.65; CI = 1.06-6.59; versus miscellaneous); unspecified dispensing system (OR = 2.06; CI = 1.29-3.29; versus store in the unit); non-intravenous non-oral administration (OR = 4.44; CI = 1.81-10.88; versus oral administration); preparation by the pharmacy (OR = 1.66; CI = 1.10-2.51); and administration by a hospital pool nurse, temporary staffing agency nurse, or nurse intern (OR = 1.67; CI = 1.04-2.68; versus registered full-time nurse). Each additional management procedure in the patient increased the risk of error (OR = 1.22; CI = 1.01-1.48).

CONCLUSIONS

The risk factors identified in our study should prove useful for designing preventive strategies, thereby improving the quality of care.

Medication errors in anaesthesia and critical care

There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers. However, study of medication error is hampered by difficulty with definitions, research methods and study populations. Few doctors are as involved in the process of prescribing, selecting, preparing and giving drugs as anaesthetists, whether their practice is based in the operating theatre, critical care or pain management. Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. New technology, theories of human error and lessons learnt from the nuclear, petrochemical and aviation industries are being used to tackle the problem.

Dishing the drugs: a qualitative study to explore paediatric nurses' attitudes and practice related to medication administration

AIMS

The objectives of this study were to identify nurses' attitudes toward medication policies and the perceived factors that influence nurses' adherence to the medication policy or their ability to follow policy in the clinical environment of a tertiary paediatric hospital.

METHODS

Using a focus group methodology, data were collated from a group of 32 nurses working in eight clinical areas of a tertiary paediatric hospital. Each discussion was transcribed and the data were subjected to a qualitatively based content analysis.

RESULTS/FINDINGS

Four main categories emerged from the data including accessibility of information, time constraints, practice issues and professional conflict.

CONCLUSIONS

Medication administration is a complex area of paediatric nursing practice. In an innovative attempt to assist in understanding nursing medication practice, this research has directly obtained nurses' perceptions of the factors that may influence their adherence to medication policy in the clinical environment. These results will inform future risk management strategies related to nursing medication practice.

Incidence and nature of dosing errors in paediatric medications: a systematic review

In paediatric medicine, drug doses are usually calculated individually based on the patient's age, weight and clinical condition. Therefore, there are increased opportunities for, and a relatively high risk of, dosing errors in this setting. Consequently, a systematic literature review using several databases was conducted to investigate the incidence and nature of dosing errors in children; 16 studies were found to be relevant. Eleven of the 16 studies found that dosing errors are the most common type of medication error, three of the remaining studies found it to be the second most common type. This review of published research on medication errors therefore suggests that dosing errors are probably the most common type of error in the paediatric population. In addition, there was a great variation in the error rates reported; this is likely to be due to the differences in the medication error definitions and methodologies employed. For example, the dosing error rate determined using spontaneous reporting ranges from 0.03 per 100 admissions in the UK to 2 per 100 admissions in the US. Extrapolating this, if the under-reporting rate is about 1 in 100, then the true incidence would be around 50,000 paediatric dosing errors per year in England. The information available shows that dosing errors are not uncommon and that 10-fold overdoses caused by calculation errors have led to serious consequences. There is an urgent need to develop methods to reduce medication errors in children and dosing errors should be the first priority.