A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting

Potentiality of algorithms and artificial intelligence adoption to improve medication management in primary care: a systematic review

OBJECTIVES

The aim of this study is to investigate the effect of artificial intelligence (AI) and/or algorithms on drug management in primary care settings comparing AI and/or algorithms with standard clinical practice. Second, we evaluated what is the most frequently reported type of medication error and the most used AI machine type.

METHODS

A systematic review of literature was conducted querying PubMed, Cochrane and ISI Web of Science until November 2021. The search strategy and the study selection were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Population, Intervention, Comparator, Outcome framework. Specifically, the Population chosen was general population of all ages (ie, including paediatric patients) in primary care settings (ie, home setting, ambulatory and nursery homes); the Intervention considered was the analysis AI and/or algorithms (ie, intelligent programs or software) application in primary care for reducing medications errors, the Comparator was the general practice and, lastly, the Outcome was the reduction of preventable medication errors (eg, overprescribing, inappropriate medication, drug interaction, risk of injury, dosing errors or in an increase in adherence to therapy). The methodological quality of included studies was appraised adopting the Quality Assessment of Controlled Intervention Studies of the National Institute of Health for randomised controlled trials.

RESULTS

Studies reported in different ways the effective reduction of medication error. Ten out of 14 included studies, corresponding to 71% of articles, reported a reduction of medication errors, supporting the hypothesis that AI is an important tool for patient safety.

CONCLUSION

This study highlights how a proper application of AI in primary care is possible, since it provides an important tool to support the physician with drug management in non-hospital environments.

Prospective risk assessments of patient safety events related to drug shortages in hospitals: Three actor-level perspectives

Background: The increasing number of drug shortages (DSs) worldwide calls for more proactive solutions to prevent the negative impacts of DSs on patient care. Such solutions require in-depth knowledge about potential patient safety risks related to DSs, the processes of recognizing and managing DSs, the contextual setting in which DSs occur, and the actors involved.

Objective: The aim of the study is to use prospective risk assessment to identify patient safety risks in hospitals associated with the management of DSs among actors at national, regional and local level in Denmark.

Methods: Healthcare Failure Mode and Effect Analysis (HFMEA) was employed in composition with elements from the Systematic Human Error Reduction and Prediction Approach (SHERPA) and the Systems-Theoretic Accident Model and Processes (STAMP). Potential risks related to DS management across three actor levels (national, regional and local) in the Danish healthcare system were described. Each actor level consisted of six participants that were identified using a purposive sampling strategy. Processes and sub-processes related to managing critical DSs were outlined and the actors identified, prioritized and rated potential failure modes, causes and consequences related to the processes. Recommendations to mitigate failures were proposed for high risk failures modes.

Results: Overall, a total of 167 failure modes were identified across the three actor levels. At the national level, the process of DS management consisted of 17 sub-processes, from which 71 failure modes were identified. Nine of them were rated as high risk. At regional level, 7 sub-processes and 33 failure modes were identified, of which 9 were rated as high risk. At local level, 14 sub-processes and 63 failure modes were identified, of which 32 were rated as high risk. The high-risk failures were related to a lack of IT support in the medication modules, underestimation of patient safety aspects, and insufficient personnel training and patient information.

Conclusion: Exploring DS management failure modes across actor levels provided an overview of interrelated failures. Potential solutions related to high risk failures were developed to ensure that actors ensure patient safety related to DS in healthcare.

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Healthcare Failure Mode and Effect Analysis (HFMEA) is used to identify patient safety risks in hospitals associated with DS management among actors at national, regional and local level.

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A total of 167 failure modes were identified across three actor levels

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Nine high-risk failures were identified at the national and regional level respectively, and 32 high-risk failures were found at the local level.

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The high-risk failures were related to a lack of IT support in the medication modules, underestimation of patient safety aspects, and insufficient personnel training and patient information.

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Potential solutions related to high-risk failures were developed to ensure patient safety related to DS in healthcare.

Resolving the differences between system development and system operation using STAMP: a road safety case study in a low-income setting

Road safety strategies adopted worldwide have made significant progress in reducing road trauma, but have stagnated more recently. The situation in low- and middle-income countries is even worse with no significant decrease in fatality rates. Safety researchers have argued that adopting sociotechnical systems approach is necessary to make significant advancements and improvements. The aim of this study was to develop a control structure model of the Bangladesh road safety system by identifying the actors and organisations involved across the system. Expert stakeholders were identified and interviewed, and relevant information was gathered in order to generate the Systems Theoretic Accident Model and Process control structure model. Throughout the analysis of this model, differences in the control and feedback mechanisms of the system were identified, and road safety intervention recommendations were made. Future research should also predict potential risks within the system and propose proactive and preventative countermeasures. Practitioner summary: In this article, a Systems Theoretic Accident Model and Process control structure model of the Bangladesh road safety system is developed, and the involved actors are identified. Based on interviews and workshops with expert stakeholders, differences in the controls and feedback mechanisms in the system were identified, and road safety intervention recommendations were made. Abbreviations: BUET: Bangladesh University of Engineering and Technology.

Medication-related knowledge, administration practice and adherence among caregivers of chronically ill children in Malaysia

Background

Caregivers’ knowledge, practice and adherence in medication administration who care for children with chronic illness requiring long-term pharmacological treatments are factors associating with children medication safety at home. This study aimed to determine the medication-related knowledge, administration practice and adherence among caregivers of chronically ill children in Malaysia. This cross-sectional study was conducted at the paediatric outpatient clinic of a tertiary public hospital. Caregivers of chronically ill children, who engaged in medication administration at home for at least 3 months, were conveniently recruited. Their medication-related knowledge and administration practice were evaluated based on a checklist, while their adherence to medication administration was assessed using a validated 5-point scale. The associated factors were also explored.

Results

Of the 141 participants, most were mothers (90.8%) and had a full-time job (55.3%). Most of them had adequate medication-related knowledge (71.6%) and an appropriate administration practice (83.0%). The majority of them (83.0%) also rated themselves as adherent to medication administration. The participants with a child above 5 years of age (91.2%) were found to have a better practice than those with younger children (75.3%) in medication administration (p = 0.012). However, those with a child taking two (adjusted OR: 12.53) or three (adjusted OR: 8.29) medications, getting their refills from private health institutions apart from this hospital (adjusted OR = 7.06) and having multiple illnesses (adjusted OR = 21.25) were more likely to be not adherent to medication administration.

Conclusion

Caregivers of chronically ill children in Malaysia generally have sufficient knowledge and an appropriate practice of medication administration at home. Yet, strategies to improve the adherence to medication administration, particularly in those who care for children with complicated health conditions, are warranted.

Medication Without Harm: Developing optimal medication error reporting systems

Medication errors are amongst the most frequently occurring health care related incidents and have the potential to lead to life-threatening harm to patients. An incident reporting system is a traditional approach to improvement of patient safety and entails the retrieval of information from incident reports. This not only provides a better understanding of causes and contributing factors but also enables the collection of data on the severity of incidents, system deficiencies and the role of human factors in safety incidents. Medication error reporting systems are often developed as a part of larger incident reporting systems which deal with other types of incidents. Although a rise in the prevalence of medication errors has led to an increased demand for medication error reporting, little is known about characteristics and limitations of medication error reporting systems. The authors broach the subject of medication error reporting systems and propose a more robust and standardized approach.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness

Aim

Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation.

Design and implementation

We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme.

Results

The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001).

Conclusion

The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Household medication safety practices during the COVID-19 pandemic: a descriptive qualitative study protocol

INTRODUCTION

Those who are staying at home and reducing contact with other people during the COVID-19 pandemic are likely to be at greater risk of medication-related problems than the general population. This study aims to explore household medication practices by and for this population, identify practices that benefit or jeopardise medication safety and develop best practice guidance about household medication safety practices during a pandemic, grounded in individual experiences.

METHODS AND ANALYSIS

This is a descriptive qualitative study using semistructured interviews, by telephone or video call. People who have been advised to 'cocoon'/'shield' and/or are aged 70 years or over and using at least one long-term medication, or their caregivers, will be eligible for inclusion. We will recruit 100 patient/carer participants: 50 from the UK and 50 from Ireland. Recruitment will be supported by our patient and public involvement (PPI) partners, personal networks and social media. Individual participant consent will be sought, and interviews audio/video recorded and/or detailed notes made. A constructivist interpretivist approach to data analysis will involve use of the constant comparative method to organise the data, along with inductive analysis. From this, we will iteratively develop best practice guidance about household medication safety practices during a pandemic from the patient's/carer's perspective.

ETHICS AND DISSEMINATION

This study has Trinity College Dublin, University of Limerick and University College London ethics approvals. We plan to disseminate our findings via presentations at relevant patient/public, professional, academic and scientific meetings, and for publication in peer-reviewed journals. We will create a list of helpful strategies that participants have reported and share this with participants, PPI partners and on social media.

Risk Management in Executive Levels of Healthcare Organizations: Insights from a Scoping Review (2018)

Background

This study attempted to present a framework and appropriate techniques for implementing risk management (RM) in executive levels of healthcare organizations (HCOs) and grasping new future research opportunities in this field.

Methods

A scoping review was conducted of all English language studies, from January 2000 to October 2018 in the main bibliographic databases. Review selection and characterization were performed by two independent reviewers using pretested forms.

Results

Following a keyword search and an assessment of fit for this review, 37 studies were analyzed. Based on the findings and considering the ISO31000 model, a comprehensive yet simple framework of risk management is developed for the executive levels of HCOs. It includes five main phases: establishing the context, risk assessment, risk treatment, monitoring and review, and communication and consultation. A set of tools and techniques were also suggested for use at each phase. Also, the status of risk management in the executive levels of HCOs was determined based on the proposed framework.

Conclusion

The framework can be used as a training tool to guide in effective risk assessment as well as a tool to assess non-clinical risks of healthcare organizations. Managers of healthcare organizations who seek to ensure high quality should use a range of risk management methods and tools in their organizations, based on their need, and not assume that each tool is comprehensive.

Critical failures in the use of home ventilation medical equipment

Home ventilation involves the use of medical devices at patient's home by personnel who are not healthcare practitioners. This implies new potential risks not fully addressed by current standards and guidelines. A methodological approach to investigate potential failures and define improvement actions to address the dangerous potential situations in HV is required.

A multidisciplinary team performed an extended version of Failure Mode, Effect and Criticality Analysis (FMECA) to analyse the home ventilation service provided by the Local Healthcare Unit of Naples (ASL NA1) that assisted 60 homebound ventilator dependent patients. The failures were identified in three risk areas: device, electrical system & fire hazard, and indoor air quality. The corrective actions were formulated with two extra steps: identification of critical failures with a threshold applied to the risk priority number and analysis of causes by means of contributory factors (Organization, Technology, Information, and Structure) based on Reason's theory of failures.

22 of 86 potential failures were identified as critical. Specific corrective actions were addressed and proposed through contributory factors to improve the overall quality of home ventilation service.

The use of this systemic approach oriented the improvements to reduce the harms caused by vulnerabilities in high-risk care service as life support home ventilation.

Patient Involvement in Evaluation of Safety in Oral Antineoplastic Treatment: A Failure Mode and Effects Analysis in Patients and Health Care Professionals

OBJECTIVES

To identify risks associated with delivery of treatment with oral antineoplastic agents in an outpatient setting and to evaluate additional value and feasibility of engaging patients in a proactive risk analysis.

METHODS

We conducted 2 separate but parallel failure mode and effects analyses (FMEAs) among patients and health care professionals (HCPs) at a clinical oncology department in Denmark. Comparative analyses were performed using the FMEA process maps and risk priority numbers (RPNs) as main outcome measures. The FMEAs were augmented by semistructured interviews with HCPs and patients on acceptability and feasibility of FMEAs analyzed using systematic text condensation.

RESULTS

Patients and HCPs found failures in information regarding treatment (cause, aim, and plan) to be of high risk. Also, HCPs found failures in checking for potential interactions to be of high risk. HCPs focused on the in-hospitals procedures, whereas patients identified risks related to both the hospital and the home setting. Both HCPs and patients found participation in the FMEA process meaningful but found the use of RPNs difficult.

CONCLUSIONS

Patient engagement in proactive risk analysis using FMEA is acceptable, meaningful, and feasible, with patients providing a different perspective on the risks associated with oral antineoplastic treatment compared with HCPs.

Medication Safety at Home: A Qualitative Study on Caregivers of Chronically Ill Children in Malaysia

Introduction: Medication errors are more likely to occur in chronically ill children, who are highly dependent on caregivers for medication administration. This study aimed to explore the issues related to medication safety among pediatric outpatients in Malaysia from the caregivers' perspective. Methods: This was a qualitative study conducted between May and June 2018 at a pediatric clinic of a regional referral hospital. Caregivers of children who (1) were under 6 years of age and (2) had hypothyroidism, epilepsy, thalassemia, asthma, or other chronic diseases were recruited via purposive sampling. Each selected disease was represented by at least 3 caregivers, who were identified from the medical records of their children. Face-to-face interviews were conducted with each of them, facilitated by a semi-structured interview guide. All the interviews were audio-recorded, transcribed verbatim, and analyzed using the thematic analysis approach. Results: A total of 15 mothers with a median age of 34 years were interviewed. Three themes emerged from the interviews: (I) actual experiences with medication errors, (II) underlying risk factors for medication errors, and (III) recommendations to improve medication safety. Several cases of administration errors, including missed doses and self-decided dose adjustment, were detected. Furthermore, the caregivers were found to have inadequate understanding of the medications in general. Conclusions: While children were shown to be consistently exposed to medication errors at home in Malaysia, the recommendations of the caregivers, including the use of written instructions and a diary, could be effective strategies to improve the out-of-hospital medication safety in children.

Managing the patient safety risks of bottom-up health information technology innovations: Recommendations for healthcare providers

Health information technology (IT) offers exciting opportunities for providing novel services to patients, and for improving the quality and safety of care. Many healthcare professionals are already improving services through the development of numerous bottom-up local health IT innovations. Such innovations from the ground up are to be welcomed, but healthcare providers are struggling to develop processes for managing the risks that come with the introduction of health IT into clinical processes. I argue that too often the main strategy appears to be one of organisational ignorance. This puts patients at risk, and it threatens the successful adoption of health IT. I recommend that healthcare providers focus on strengthening their processes for organisational learning, promoting proactive risk management strategies, and making risk management decisions transparent and explicit.