Wide variability of the definitions used for native vertebral osteomyelitis: walking the path for a unified diagnostic framework with a meta-epidemiological approach

BACKGROUND CONTEXT

Native Vertebral Osteomyelitis (NVO) has seen a rise in incidence, yet clinical outcomes remain poor with high relapse rates and significant long-term sequelae. The 2015 IDSA Clinical Practice Guidelines initiated a surge in scholarly activity on NVO, revealing a patchwork of definitions and numerous synonyms used interchangeably for this syndrome.

PURPOSE

To systematically summarize these definitions, evaluate their content, distribution over time, and thematic clustering.

STUDY DESIGN/SETTING

Meta-epidemiological study with a systematic review of definitions.

PATIENTS SAMPLE

An extensive search of multiple databases was conducted, targeting trials and cohort studies dating from 2005 to present, providing a definition for NVO and its synonyms.

OUTCOME MEASURES

Analysis of the diagnostic criteria that composed the definitions and the breaking up of the definitions in the possible combinations of diagnostic criteria.

METHODS

We pursued a thematic synthesis of the published definitions with Boolean logic, yielding single or multiple definitions per included study. Using 8 predefined diagnostic criteria, we standardized definitions, focusing on the minimum necessary combinations used. Definition components were visualized using Sankey diagrams.

RESULTS

The literature search identified 8,460 references, leading to 171 studies reporting on 21,963 patients. Of these, 91.2% were retrospective, 7.6% prospective, and 1.2% RCTs. Most definitions originated from authors, with 29.2% referencing sources. We identified 92 unique combinations of diagnostic criteria across the literature. Thirteen main patterns emerged, with the most common being clinical features with imaging, followed by clinical features combined with imaging and microbiology, and lastly, imaging paired with microbiology.

CONCLUSIONS

Our findings underscore the need for a collaborative effort to develop standardized diagnostic criteria. We advocate for a future Delphi consensus among experts to establish a unified diagnostic framework for NVO, emphasizing the core components of clinical features and MRI while incorporating microbiological and histopathological insights to improve both patient outcomes and research advancements.

How to get over with medication errors underestimation? Improving indices of medication errors with focus on intravenous medications in hematopoietic stem cell transplantation setting; a direct observation study

BACKGROUND

The administration of intravenous (IV) medications is a technically complicated and error-prone process. Especially, in the hematopoietic stem cell transplantation (HSCT) setting where toxic drugs are frequently used and patients are in critical immunocompromised conditions, medication errors (ME) can have catastrophic reactions and devastating outcomes such as death. Studies on ME are challenging due to poor methodological approaches and complicated interpretations. Here, we tried to resolve this problem using reliable methods and by defining new denominators, as a crucial part of an epidemiological approach.

METHODS

This was an observational, cross-sectional study. A total of 525 episodes of IV medication administration were reviewed by a pharmacist using the disguised direct observation method to evaluate the preparation and administration processes of 32 IV medications in three HSCT wards. We reported errors in 3 ratios; 1) Total Opportunities for Error (TOE; the number of errors/sum of all administered doses observed plus omitted medications), 2) Proportional Error Ratio (the number of errors for each drug or situation/total number of detected errors) and, 3) Corrected Total Opportunities for Errors (CTOE; the number of errors/ Sum of Potential Errors (SPE)).

RESULTS

A total of 1,568 errors were observed out of 5,347 total potential errors. TOE was calculated as 2.98 or 298% and CTOE as 29.3%. Most of the errors occurred at the administration step. The most common potential errors were the use of an incorrect volume of the reconstitution solvent during medication preparation and lack of monitoring in the administration stage.

CONCLUSION

Medication errors frequently occur during the preparation and administration of IV medications in the HSCT setting. Using precise detection methods, denominators, and checklists, we identified the most error-prone steps during this process, for which there is an urgent need to implement effective preventive measures. Our findings can help plan targeted preventive measures and investigate their effectiveness, specifically in HSCT settings.

How intervention studies measure the effectiveness of medication safety-related clinical decision support systems in primary and long-term care: a systematic review

BACKGROUND

Medication errors and associated adverse drug events (ADE) are a major cause of morbidity and mortality worldwide. In recent years, the prevention of medication errors has become a high priority in healthcare systems. In order to improve medication safety, computerized Clinical Decision Support Systems (CDSS) are increasingly being integrated into the medication process. Accordingly, a growing number of studies have investigated the medication safety-related effectiveness of CDSS. However, the outcome measures used are heterogeneous, leading to unclear evidence. The primary aim of this study is to summarize and categorize the outcomes used in interventional studies evaluating the effects of CDSS on medication safety in primary and long-term care.

METHODS

We systematically searched PubMed, Embase, CINAHL, and Cochrane Library for interventional studies evaluating the effects of CDSS targeting medication safety and patient-related outcomes. We extracted methodological characteristics, outcomes and empirical findings from the included studies. Outcomes were assigned to three main categories: process-related, harm-related, and cost-related. Risk of bias was assessed using the Evidence Project risk of bias tool.

RESULTS

Thirty-two studies met the inclusion criteria. Almost all studies (n = 31) used process-related outcomes, followed by harm-related outcomes (n = 11). Only three studies used cost-related outcomes. Most studies used outcomes from only one category and no study used outcomes from all three categories. The definition and operationalization of outcomes varied widely between the included studies, even within outcome categories. Overall, evidence on CDSS effectiveness was mixed. A significant intervention effect was demonstrated by nine of fifteen studies with process-related primary outcomes (60%) but only one out of five studies with harm-related primary outcomes (20%). The included studies faced a number of methodological problems that limit the comparability and generalizability of their results.

CONCLUSIONS

Evidence on the effectiveness of CDSS is currently inconclusive due in part to inconsistent outcome definitions and methodological problems in the literature. Additional high-quality studies are therefore needed to provide a comprehensive account of CDSS effectiveness. These studies should follow established methodological guidelines and recommendations and use a comprehensive set of harm-, process- and cost-related outcomes with agreed-upon and consistent definitions.

PROSPERO REGISTRATION

CRD42023464746.

Risks in the analogue and digitally-supported medication process and potential solutions to increase patient safety in the hospital: A mixed methods study

BACKGROUND

In hospital medication errors are common. Our aim was to investigate risks of the analogue and digitally-supported medication process and any potential solutions.

METHODS

A mixed methods study including a structured literature search and online questionnaires based on the Delphi method was conducted. First, all risks were structured into main and sub-risks and second, risks were grouped into risk clusters. Third, healthcare experts assessed risk clusters regarding their likelihood of occurrence their possible impact on patient safety. Experts were also asked to estimate the potential for digital solutions and solutions that strengthen the competence of healthcare professionals.

RESULTS

Overall, 160 main risks and 542 sub-risks were identified. Main risks were grouped into 43 risk clusters. 33 healthcare experts (56% female, 50% with >20 years professional-experience) ranked the likelihood of occurrence and the impact on patient safety in the top 15 risk clusters regarding the process steps: admission (n = 4), prescribing (n = 3), verifying (n = 1), preparing/dispensing (n = 3), administering (n = 1), discharge (n = 1), healthcare professional competence (n = 1), and patient adherence (n = 1). 28 healthcare experts (64% female, 43% with >20 years professional-experience) mostly suggested awareness building and training, strengthened networking, and involvement of pharmacists at point-of-care as likely solutions to strengthen healthcare professional competence. For digital solutions they primarily suggested a digital medication list, digital warning systems, barcode-technology, and digital support in integrated care.

CONCLUSIONS

The medication process holds a multitude of potential risks, in both the analogue and the digital medication process. Different solutions to strengthen healthcare professional competence and in the area of digitalization were identified that could help increase patient safety and minimize possible errors.

Study to evaluate awareness about medication errors and impact of an educational intervention among healthcare personnel in a cancer hospital

INTRODUCTION

Medication errors (MEs) are preventable incidents that can result in harm to patients. Therefore, it is essential for healthcare professionals (HCPs) to be well-informed about MEs. This study aims to assess the awareness levels of HCPs and the impact of educational intervention on their understanding of MEs.

METHODS

Responses to a 17-question structured, self-administered questionnaire assessing the awareness of HCPs regarding fundamental aspects of MEs, ME reporting systems, and their ability to make recommendations for improving the system for handling the MEs were collected both before and after two weeks of educational intervention administration.

RESULTS

Of a total of 114 HCPs who initially participated in the study, six dropped following the intervention. The awareness regarding the Class A questionnaire was good in most physicians (60%), nurses (60%), and pharmacists (57%) before the intervention, which improved postintervention, with physicians (80%), nurses (32%), and pharmacists (78%) demonstrating excellent awareness. The awareness level in the Class B questionnaire was also improved to excellent in most physicians (70%), pharmacists (85%), and nurses (85%) following the intervention, while it was excellent only in 50%, 35%, and 1% of physicians, pharmacists, and nurses, respectively, preintervention. In the Class C questionnaire, most physicians (40%) and nurses (60%) had good awareness, while pharmacists (35%) demonstrated excellent awareness preintervention. Postintervention, most physicians (70%), nurses (77%), and pharmacists (64%) exhibited excellent awareness.

CONCLUSION

Most oncology practice HCPs demonstrate a good to average level of awareness regarding MEs. Clinical pharmacists' educational interventions can significantly enhance awareness among HCPs concerning MEs.

Descriptive analysis on disproportionate medication errors and associated patient characteristics in the Food and Drug Administration's Adverse Event Reporting System

BACKGROUND

Medication errors (MEs) are a major public health concern which can cause harm and financial burden within the healthcare system. Characterizing MEs is crucial to develop strategies to mitigate MEs in the future.

OBJECTIVES

To characterize ME-associated reports, and investigate signals of disproportionate reporting (SDRs) on MEs in the Food and Drug Administration's Adverse Event Reporting System (FAERS).

METHODS

FAERS data from 2004 to 2020 was used. ME reports were identified with the narrow Standardised Medical Dictionary for Regulatory Activities® (MedDRA®) Query (SMQ) for MEs. Drug names were converted to the Anatomical Therapeutic Chemical (ATC) classification. SDRs were investigated using the reporting odds ratio (ROR).

RESULTS

In total 488 470 ME reports were identified, mostly (59%) submitted by consumers and mainly (55%) associated with females. Median age at time of ME was 57 years (interquartile range: 37-70 years). Approximately 1 out of 3 reports stated a serious health outcome. The most prevalent reported drug class was "antineoplastic and immunomodulating agents" (25%). The most common ME type was "incorrect dose administered" (9%). Of the 1659 SDRs obtained, adalimumab was the most common drug associated with MEs, noting a ROR of 1.22 (95% confidence interval: 1.21-1.24).

CONCLUSION

This study offers a first of its kind characterization of MEs as reported to FAERS. Reported MEs are frequent and may be associated with serious health outcomes. This FAERS data provides insights on ME prevention and offers possibilities for additional in-depth analyses.

Enhancing Patient Safety: A Cross-Sectional Study to Assess Medical Interns' Attitude and Knowledge About Medication Safety in Saudi Arabia

Introduction and aim Medication errors (MEs) pose a severe threat in the medical field. Since such errors are preventable, it is paramount for all healthcare workers to be educated on the matter. This study aimed to assess medical interns' attitudes and knowledge of medication safety and errors. We also aimed to validate current university programs to educate students about medication safety and errors. Methods A cross-sectional study that utilized a self-administered online questionnaire comprised 31 questions. The questionnaire was distributed via social media networks, such as WhatsApp, Twitter, email, Instagram, and Snapchat among 100 medical, pharmacy, and nursing interns in Saudi Arabia. The study population included both Saudi and non-Saudi interns. Results The majority of participants, comprising 92% (n=92), indicated that they were familiar with the definition of medication errors (ME). Additionally, 85% (n=85) expressed their willingness to report instances of MEs when medications were not prescribed but required. Moreover, 90% (n=90) of the surveyed individuals expressed their willingness to report MEs in situations where patients did not receive medications as prescribed. In cases where patients experienced harm and required treatment due to an ME, 91% (n=91) of respondents committed to reporting such incidents. A total of 52 (52%) respondents stated that they would report MEs regardless of whether they reached/harmed the patient. A good ME knowledge level was observed in 48% of respondents. A higher likelihood of good ME knowledge was significantly associated with safety reporting system (SRS) awareness and reporting MEs regardless of whether they reached/harmed the patient (p<0.05). College, awareness/attitude, or other demographic factors were not significantly related to ME knowledge (p>0.05). Conclusion This study showed that although interns in the healthcare field do have some knowledge about MEs, there is still a significant need to improve their knowledge. This can be achieved through various ways, one of which is by implementing this topic into the university curricula.

Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis

BACKGROUND

Pharmacists have an increasing role as part of the emergency department (ED) team. However, the impact of ED-based pharmacy interventions on the quality use of medicines has not been well characterised.

OBJECTIVE

This systematic review aimed to synthesise evidence from studies examining the impact of interventions provided by pharmacists on the quality use of medicines in adults presenting to ED.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE and CINAHL. Two independent reviewers screened titles/abstracts and reviewed full texts. Studies that compared the impact of interventions provided by pharmacists with usual care in ED and reported medication-related primary outcomes were included. Cochrane Risk of Bias-2 and Newcastle-Ottawa tools were used to assess the risk of bias. Summary estimates were pooled using random-effects meta-analysis, along with sensitivity and sub-group analyses.

RESULTS

Thirty-one studies involving 13 242 participants were included. Pharmacists were predominantly involved in comprehensive medication review, advanced pharmacotherapy assessment, staff and patient education, identification of medication discrepancies and drug-related problems, medication prescribing and co-prescribing, and medication preparation and administration. The activities reduced the number of medication errors by a mean of 0.33 per patient (95% CI -0.42 to -0.23, I²=51%) and the proportion of patients with at least one error by 73% (risk ratio (RR)=0.27, 95% CI 0.19 to 0.40, I²=85.3%). The interventions were also associated with more complete and accurate medication histories, increased appropriateness of prescribed medications by 58% (RR=1.58, 95% CI 1.21 to 2.06, I²=95%) and quicker initiation of time-critical medications.

CONCLUSION

The evidence indicates improved quality use of medicines when pharmacists are included in ED care teams.

PROSPERO REGISTRATION NUMBER

CRD42020165234.

Prevalence of medication administration errors in hospitalized adults: A systematic review and meta-analysis up to 2017 to explore sources of heterogeneity

Previous estimates to meta-analyze administration error rates were limited by the high statistical heterogeneity, restricting their use. This study aimed to investigate sources of heterogeneity in pooled administration error rates in hospitalized adults. We systematically searched scientific databases up to November 2017 for studies presenting error rates/relevant numerical data in hospitalized adults. We conducted separate meta-analyses for the numerators: One Medication Error (OME) (each dose can be correct or incorrect) and Total Number of Errors (TNE) (more than one error per dose could be counted), using the generic inverse variance with a 95% confidence interval. Heterogeneity was assessed using the I² and Cochran's Q test. We meta-analyzed 33 studies. The global pooled analyses based on the OME and TNE numerators showed very high heterogeneity (I²  = 100%; p < 0.00001). For each meta-analysis, subgroup analyses based on study characteristics (countries, wards, population, routes of administration, error detection methods, and medications) yielded results with consistently elevated heterogeneity. Beyond these characteristics, we stratified the studies according to the mean error prevalence level as the threshold. Based on the OME numerator, we identified two subgroups of low (0.15[0.13-0.17]; I²  = 0%; p = 0.43) and high (0.26[0.24-0.27]; I²  = 38%; p = 0.17) pooled prevalence rates, with controlled heterogeneity. Similarly, for the TNE numerator, we identified two subgroups of low (0.10[0.09-0.10]; I²  = 0%; p = 0.76) and high (0.28[0.27-0.29]; I²  = 0%; p = 0.89) pooled prevalence rates, with controlled heterogeneity. These subgroups differed regarding the denominators used: Total opportunities for errors versus others (doses, observations, administrations). Calculation methods, specifically the denominator, seem a primary factor in explaining heterogeneity in error rates. Standardizing numerators, denominators, and definitions is necessary.

Impact of Partnered Pharmacist Medication Charting (PPMC) on Medication Discrepancies and Errors: A Pragmatic Evaluation of an Emergency Department-Based Process Redesign

Medication errors are more prevalent in settings with acutely ill patients and heavy workloads, such as in an emergency department (ED). A pragmatic, controlled study compared partnered pharmacist medication charting (PPMC) (pharmacist-documented best-possible medication history [BPMH] followed by clinical discussion between a pharmacist and medical officer to co-develop a treatment plan and chart medications) with early BPMH (pharmacist-documented BPMH followed by medical officer-led traditional medication charting) and usual care (traditional medication charting approach without a pharmacist-collected BPMH in ED). Medication discrepancies were undocumented differences between medication charts and medication reconciliation. An expert panel assessed the discrepancies' clinical significance, with 'unintentional' discrepancies deemed 'errors'. Fewer patients in the PPMC group had at least one error (3.5%; 95% confidence interval [CI]: 1.1% to 5.8%) than in the early BPMH (49.4%; 95% CI: 42.5% to 56.3%) and usual care group (61.4%; 95% CI: 56.3% to 66.7%). The number of patients who need to be treated with PPMC to prevent at least one high/extreme error was 4.6 (95% CI: 3.4 to 6.9) and 4.0 (95% CI: 3.1 to 5.3) compared to the early BPMH and usual care group, respectively. PPMC within ED, incorporating interdisciplinary discussion, reduced clinically significant errors compared to early BPMH or usual care.

Medication safety incidents associated with the remote delivery of primary care: a rapid review

OBJECTIVES

The COVID-19 pandemic triggered rapid, fundamental changes, notably increased remote delivery of primary care. While the impact of these changes on medication safety is not yet fully understood, research conducted before the pandemic may provide evidence for possible consequences. To examine the published literature on medication safety incidents associated with the remote delivery of primary care, with a focus on telemedicine and electronic prescribing.

METHODS

A rapid review was conducted according to the Cochrane Rapid Reviews Methods Group guidance. An electronic search was carried out on Embase and Medline (via PubMed) using key search terms 'medication error', 'electronic prescribing', 'telemedicine' and 'primary care'. Identified studies were synthesised narratively; reported medication safety incidents were categorised according to the WHO Conceptual Framework for the International Classification for Patient Safety.

KEY FINDINGS

Fifteen studies were deemed eligible for inclusion. All 15 studies reported medication incidents associated with electronic prescribing; no studies were identified that reported medication safety incidents associated with telemedicine. The most commonly reported medication safety incidents were 'wrong label/instruction' and 'wrong dose/strength/frequency'. The frequency of medication safety incidents ranged from 0.89 to 81.98 incidents per 100 electronic prescriptions analysed.

SUMMARY

This review of medication safety incidents associated with the remote delivery of primary care identified common incident types associated with electronic prescriptions. There was a wide variation in reported frequencies of medication safety incidents associated with electronic prescriptions. Further research is required to determine the impact of the COVID-19 pandemic on medication safety in primary care, particularly the increased use of telemedicine.

An umbrella review of systematic reviews on contributory factors to medication errors in health-care settings

INTRODUCTION

Medication errors are common events that compromise patient safety and are prevalent in all health-care settings. This umbrella review aims to systematically evaluate the evidence on contributory factors to medication errors in health-care settings in terms of the nature of these factors, methodologies and theories used to identify and classify them, and the terminologies and definitions used to describe them.

AREAS COVERED

Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and Google Scholar were searched from inception to March 2022. The data extraction form was derived from the Joanna Briggs Institute (JBI) Reviewers' Manual, and critical appraisal was conducted using the JBI quality assessment tool. A narrative approach to data synthesis was adopted.

EXPERT OPINION

Twenty-seven systematic reviews were included, most of which focused on a specific health-care setting or clinical area. Decision-making mistakes such as non-consideration of patient risk factors most commonly led to error, followed by organizational and environmental factors (e.g. understaffing and distractions). Only 10 studies had a pre-specified methodology to classify contributory factors, among which the use of theory, specifically Reason's theory was commonly used. None of the reviews evaluated the effectiveness of interventions in preventing errors. The collated contributory factors identified in this umbrella review can inform holistic theory-based intervention development.

Methods of Detecting Medication Administration Point-of-Care Errors in Acute Adult Inpatient Settings: A Scoping Review Protocol

Medication administration is recognized as a risk-prone activity where errors and near misses have multiple opportunities to occur along the route from manufacturing, through transportation, storage, prescription, dispensing, point-of-care administration, and post-administration documentation. While substantial research, education, and tools have been invested in the detection of medication errors on either side of point-of-care administration, less attention has been placed on this finite phase, leaving a gap in the error detection process. This protocol proposes to undertake a scoping review of the literature related to the detection of medication errors at the point-of-care to understand the potential size, nature, and extent of available literature. The aim is to identify research evidence to guide clinical practice and future research at the medication and patient point-of-care intersection. The search strategy will review literature from PubMed, CINAHL, Cochrane Collaboration, Embase, Scopus, PsychInfo, Web of Science, TRIP, TROVE, JBI Systematic Reviews, Health Collection (Informit), Health Source Nursing Academic, Prospero, Google Scholar, and graylit.org dated 1 January 2000–31 December 2021. Two independent reviewers will screen the literature for relevancy to the review objective, and critically appraise the citations for quality, validity, and reliability using the Joanna Briggs scoping review methodology and System for Unified Management, Assessment and Review of Information (SUMARI) tool. The data will be systematically synthesized to identify and compare the medication error administration detection method findings. A descriptive narrative discussion will accompany the findings.

A retrospective analysis of near-miss incidents at a tertiary care teaching hospital in Riyadh, KSA

Objective

This study seeks to establish an error-free reporting system that enhances patient safety and organisational culture. It investigates the prevalence of near-miss incident reporting systems by healthcare professionals in the General Surgery Department.

Methods

This retrospective observational study was conducted at a tertiary care teaching hospital in Riyadh, KSA. A sample of 253 medical records, ranging from January 2018 to December 2020, belonging to secondary patients was obtained using the near-miss Datix reporting and occurrence variance reporting system. The demographic variable data of registered patients were based on their age group (18–80 years), length of stay, date of admission, medication prescribed for more than four days, and whether they underwent surgical interventions. The cases were documented after the occurrence of a near-miss incident using a convenience sampling technique.

Results

In terms of prevalence in the near-miss main categories, medical errors were 248 (98.2%), workplace violations were two (0.80%), and others was one (0.40%). The number of incidence in the subcategories were: prescribing, 227 (89.7%); dispensing, 16 (6.30%) wrong dose/strength, 118 (46.6%), male, 123 (48.6%), and female, 130 (51.4%). The mean age and S.D. of patients was 1.94 ± 0.88 years and the demographic nationality as 1.16 ± 0.37. The one-sample t-test value for the main categories was −235 (p-value < 0.001).

Conclusion

Near-misses are recognised as essential targets for continuous quality improvement tools to mitigate preoperative incidents in hospitals. These findings can benefit the advancement of techniques for improving guidelines related to compliance and effective communication to improve the preoperative safety of patients.

Patients at the centre after a health care incident: A scoping review of hospital strategies targeting communication and nonmaterial restoration

OBJECTIVE

This study aimed to provide an overview of the strategies adopted by hospitals that target effective communication and nonmaterial restoration (i.e., without a financial or material focus) after health care incidents, and to formulate elements in hospital strategies that patients consider essential by analysing how patients have evaluated these strategies.

BACKGROUND

In the aftermath of a health care incident, hospitals are tasked with responding to the patients' material and nonmaterial needs, mainly restoration and communication. Currently, an overview of these strategies is lacking. In particular, a gap exists concerning how patients evaluate these strategies.

SEARCH STRATEGY AND INCLUSION CRITERIA

To identify studies in this scoping review, and following the methodological framework set out by Arksey and O'Malley, seven subject-relevant electronic databases were used (PubMed, Medline, Embase, CINAHL, PsycARTICLES, PsycINFO and Psychology & Behavioral Sciences Collection). Reference lists of included studies were also checked for relevant studies. Studies were included if published in English, after 2000 and as peer-reviewed articles.

MAIN RESULTS AND SYNTHESIS

The search yielded 13,989 hits. The review has a final inclusion of 16 studies. The inclusion led to an analysis of five different hospital strategies: open disclosure processes, communication-and-resolution programmes, complaints procedures, patients-as-partners in learning from health care incidents and subsequent disclosure, and mediation. The analysis showed three main domains that patients considered essential: interpersonal communication, organisation around disclosure and support and desired outcomes.

PATIENT CONTRIBUTION

This scoping review specifically takes the patient perspective in its methodological design and analysis. Studies were included if they contained an evaluation by patients, and the included studies were analysed on the essential elements for patients.

Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review

OBJECTIVES

Delivery of intravenous medications in hospitals is a complex process posing to systemic risks for errors. The aim of this study was to identify systemic causes of in-hospital intravenous medication errors.

METHODS

A systematic review adhering to PRISMA guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the GRADE system and the evidence analyzed using qualitative content analysis.

RESULTS

Eleven studies from six countries were included in the analysis. We identified systemic causes related to prescribing (n = 6 studies), preparation (n = 6), administration (n = 6), dispensing and storage (n = 5), and treatment monitoring (n = 2). Administration, prescribing, and preparation were the process phases most prone to systemic errors. Insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, calculation tasks, failure in double-checking procedures, and confusion between look-alike, sound-alike medications were the leading causes of intravenous medication errors. The number of the included studies was limited, all of them being observational studies and graded as low quality.

CONCLUSIONS

Current intravenous medication systems remain vulnerable, which can result in patient harm. Our findings suggest further focus on medication safety activities related to administration, prescribing, and preparation of intravenous medications. This study provides healthcare organizations with preliminary knowledge about systemic causes of intravenous medication errors, but more rigorous evidence is needed.

Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals: A Systematic Review

OBJECTIVES

Intravenous medication delivery is a complex process that poses systemic risks of errors. The objective of our study was to identify systemic defenses that can prevent in-hospital intravenous (IV) medication errors.

METHODS

A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the Grading of Recommendations Assessment, Development and Evaluation system, and the evidence was analyzed using qualitative content analysis.

RESULTS

Forty-six studies from 11 countries were included in the analysis. We identified systemic defenses related to administration (n = 24 studies), prescribing (n = 8), preparation (n = 6), treatment monitoring (n = 2), and dispensing (n = 1). In addition, 5 studies explored defenses related to multiple stages of the drug delivery process. Systemic defenses including features of closed-loop medication management systems appeared in 61% of the studies, with smart pumps being the defense most widely studied (24%). The evidence quality of the included articles was limited, as 83% were graded as low quality, 13% were of moderate quality, and only 4% were of high quality.

CONCLUSIONS

In-hospital IV medication processes are developing toward closed-loop medication management systems. Our study provides health care organizations with preliminary knowledge about systemic defenses that can prevent IV medication errors, but more rigorous evidence is needed. There is a need for further studies to explore combinations of different systemic defenses and their effectiveness in error prevention throughout the drug delivery process.

What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?

OBJECTIVES

This study investigated severe medication errors (MEs) reported to the National Supervisory Authority for Welfare and Health (Valvira) in Finland and evaluated how the incident documentation applies to learning from errors.

METHODS

This study was a retrospective document analysis consisting of medication-related complaints and authoritative statements investigated by Valvira in 2013 to 2017 (n = 58).

RESULTS

Medication errors caused death or severe harm in 52% (n = 30) of the cases (n = 58). The majority (83%; n = 48) of the incidents concerned patients older than 60 years. Most likely, the errors occurred in prescribing (n = 38; 47%), followed by administration (n = 15; 19%) and monitoring (n = 14; 17%). The error process often included many failures (n = 24; 41%) or more than one health professional (n = 16; 28%). Antithrombotic agents (n = 17; 13%), opioids (n = 10; 8%), and antipsychotics (n = 10; 8%) were the therapeutic groups most commonly involved in the errors. Almost all error cases (91%; n = 53) were assessed as likely or potentially preventable. In 60% (n = 35) of the cases, the organization reported actions taken to improve medication safety after the occurrence of the investigated incident.

CONCLUSIONS

Medication errors reported to the national health care supervisory authority provide a valuable source of risk information and should be used for learning from severe errors at the level of health care systems. High age remains a key risk factor to severe MEs, which may be associated with a wide range of medications including those not typically perceived as high-alert medications or high-risk administration routes. Despite being complex processes, the severe MEs have a great potential to lead to developing systems, processes, resources, and competencies of health care organizations.

Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review

Background

Little is known about the epidemiology of medication errors and medication-related harm following transition from secondary to primary care. This systematic review aims to identify and critically evaluate the available evidence on the prevalence and nature of medication errors and medication-related harm following hospital discharge.

Methods

Studies published between January 1990 and March 2019 were searched across ten electronic databases and the grey literature. No restrictions were applied with publication language or patient population studied. Studies were included if they contained data concerning the rate of medication errors, unintentional medication discrepancies, or adverse drug events. Two authors independently extracted study data.

Results

Fifty-four studies were included, most of which were rated as moderate (39/54) or high (7/54) quality. For adult patients, the median rate of medication errors and unintentional medication discrepancies following discharge was 53% [interquartile range 33–60.5] (n = 5 studies) and 50% [interquartile range 39–76] (n = 11), respectively. Five studies reported adverse drug reaction rates with a median of 27% [interquartile range 18–40.5] and seven studies reported adverse drug event rates with a median of 19% [interquartile range 16–24]. For paediatric patients, one study reported a medication error rate of 66.3% and another an adverse drug event rate of 9%. Almost a quarter of studies (13/54, 24%) utilised a follow-up period post-discharge of 1 month (range 2–180 days). Drug classes most commonly implicated with adverse drug events were antibiotics, antidiabetics, analgesics and cardiovascular drugs.

Conclusions

This is the first systematic review to explore the prevalence and nature of medication errors and adverse drug events following hospital discharge. Targets for future work have been identified.

Electronic supplementary material

The online version of this article (10.1007/s40264-020-00918-3) contains supplementary material, which is available to authorized users.

Effectiveness, safety and implementation results of the strategies aimed at the safe prescription of medications in university hospitals in adult patients. Systematic review

Introduction: A broad range of practices aimed at improving the effectives and safety of this process have been documented over the past few years. Objective: to establish the effectiveness, safety and results of the implementation of these strategies in adult patients in university hospitals. Methodology: A review of systematic reviews was conducted, in addition to a database search in the Cochrane Library of Systematic Reviews, Embase, Epistemonikos, LILACS and gray literature. Any strategy aimed at reducing prescription-associated risks was included as intervention. This review followed the protocol registered in the International Prospective Registry of Systematic Reviews (PROSPERO): CRD42020165143. Results: 7,637 studies were identified, upon deleting duplicate references. After excluding records based on titles and abstracts, 111 full texts were assessed for eligibility. Fifteen studies were included in the review. Several interventions grouped into 5 strategies addressed to the prescription process were identified; the use of computerized medical order entry systems (CPOE), whether integrated or not with computerized decision support systems (CDSS), was the most effective approach. Conclusions: The beneficial effects of the interventions intended to the prescription process in terms of efficacy were identified; however, safety and implementation results were not thoroughly assessed. The heterogeneity of the studies and the low quality of the reviews, preclude a meta-analysis.

Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit

BACKGROUND

Minimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists.

OBJECTIVE

We assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team.

METHODS

In this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions).

RESULTS

After the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p < 0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p = 0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p = 0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month.

CONCLUSIONS

The implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.

A Retrospective Study of Pediatric Medication Errors in Saudi Arabia

Background: The peculiarities of medication errors (MEs) among the pediatric population in the Middle East have not been adequately explored. In this study, we describe the MEs reported at the largest tertiary hospital in Saudi Arabia. Methods: This study is a retrospective analysis of MEs reported by health care professionals at a large tertiary hospital in Saudi Arabia between 2015 and 2016. Results: There were a total of 9123 MEs involving 84 different medications. In total, 109 382 drugs were ordered. Thus, 8.3 MEs per 100 prescriptions were reported during the study period. Thirty-nine errors (0.4%) reached the patient, but did not cause any harm. Transcribing errors accounted for more than half of the MEs (n = 4856, 53.2%). Physicians were the least likely to report an ME (n = 159, 1.7%), whereas pharmacists reported more MEs than any other health care professional (n = 4924, 54%). The most common drug causes of MEs were paracetamol, salbutamol, and amoxicillin, which accounted for 21.0%, 16.6%, and 12.4% of MEs, respectively, over the study period. Conclusions: Medication errors are common in pediatric care, especially for drugs such as paracetamol and amoxicillin that are frequently prescribed. Transcription error was common in this study and is more likely to be reported by pharmacists.

Disagreements between emergency patients and physicians regarding chief complaint - Patient factors and prognostic implications

INTRODUCTION

The predictive power of chief complaints reported at presentation to the emergency department (ED) is well known. However, there is a lack of research on the coherence of patient versus physician reported chief complaints. The aim of this study was to determine the rate of disagreement between patients and physicians regarding chief complaint and its significance for the prediction of the outcomes number of resources used during ED work-up, hospitalisation, ICU admission, in-hospital mortality and hospital length of stay.

METHODS

In this secondary analysis of a study conducted over a time course of 9 weeks, consecutive emergency patients and their physicians were independently asked to report the chief complaint upon presentation. The two reports were assessed for pair-wise agreement.

RESULTS

Of 6722 emergency patients (mean age 53.3, 46.8% female), the median number of symptoms reported by patients was two and one reported by physicians. The rate of disagreement on chief complaints was 32.6%. Disagreement was associated with a higher number of resources (β = 0.24; CI, 0.18, 0.31, P <.001) and hospitalisation (OR = 1.31; CI, 1.16, 1.48, P <.001), using multivariable analyses. Patient factors associated with disagreement were age (OR = 1.01; CI, 1.01, 1.01, P <.001), number of patient reported symptoms (OR = 1.27; CI, 1.23, 1.32, P <.001) and male gender (OR = 1.12; 1.01, 1.25, P =.0285).

CONCLUSION

Disagreement on chief complaint between patient and physician may be an early marker for a complex work-up, requiring more resources and hospitalisations. The relevance of this finding is the newly identified signal of chief complaint replacement. It is easy to identify and should generate attention, as it affects a certain phenotype (older male patients with higher numbers of complaints).

Medication Errors in Surgery: A Classification Taxonomy and a Pilot Study in Postcall Residents

INTRODUCTION

The post-call state in postgraduate medical trainees is associated with impaired decision-making and increased medical errors. An association between post-call state and medication prescription errors for surgery residents is yet to be established. Our objective was to determine whether post-call state is associated with increased proportion of medication prescription errors committed by surgery residents in an academic hospital without a computerized physician order entry (CPOE) system.

METHODS

This prospective observational study was conducted at a tertiary academic hospital between June 28 and August 31, 2017. It compared the proportion of medication prescription errors committed by surgery residents in their post-call (PC) and no-call (NC) states. A novel taxonomy was developed to classify medication prescription errors.

RESULTS

Sixteen of twenty-one eligible residents (76%) participated in this study. Self-reported hours of sleep per night was significantly higher in the NC group compared to the PC group (6(4-8) vs 2(0-4) hours, P < 0.01). PC residents committed a significantly higher proportion of medication prescription errors versus NC residents (9.2% vs 3.2%; p=0.04). Decision-making and prescription-writing errors comprised 33% and 67% of errors, respectively.

CONCLUSIONS

The post-call state in surgery residents is associated with a significantly higher proportion of medication prescription errors in a hospital without a CPOE system. Decision-making and prescription-writing errors could potentially be addressed by additional educational interventions.

Intervention study for the reduction of medication errors in elderly trauma patients

OBJECTIVE

To analyse the impact of a set of measures designed by a working group to reduce medication errors (MEs) during the care transition of elderly trauma patients. The secondary objectives were to classify MEs and determine their location.

METHODS

A 43-month pre-post prospective intervention study in a university hospital. A working group was set up in the Trauma Service. A pharmacist analysed the pharmacotherapeutic processes of all patients admitted to the Trauma Service in different healthcare locations from Monday to Friday. To detect MEs, the pharmacist reviewed this process at the following points: reconciliation, prescription, validation, dispensing, and administration records. Errors were classified according to the Ruiz Jarabo classification. Subsequently, the working group designed a set of measures that were implemented with the incorporation into the Acute Care Team and the intervention of a pharmacist. Data on MEs were again collected in a post-implementation phase.

RESULTS

There was a statistically significant reduction in MEs between phases. A total of 132 (31.3%) patients experienced MEs during the pre-implementation phase and 75 (16.2%) during the post-implementation phase. Among the measures implemented, the incorporation of the pharmacist to the team, as well as training sessions and design of medication protocols. During the pre-implementation and post-implementation phases, the ME rates were respectively as follows: reconciliation 31.6% (172) vs 14.8% (91); prescription 7.7% (79) vs 1.9% (23); dispensing 1% (10) vs 0.3% (3); administration record 0.4% (4) vs 0.0% (0); and validation 0.3% (3) vs 0.1% (1). There were significant reductions in reconciliation, prescription, and dispensing errors. The majority of the MEs occurred in the Trauma Service.

CONCLUSIONS

The implementation of specific measures by a Multidisciplinary Safety Group reduced MEs in the care transition of elderly trauma patients, particularly those MEs that occurred during reconciliation. The greatest reduction in MEs occurred in the Trauma Service.

Dispensing errors in Lebanese community pharmacies: incidence, types, underlying causes, and associated factors

OBJECTIVES

To assess the incidence, types, the causes of as well as the factors associated with dispensing errors in community pharmacies in Lebanon.

METHODS

An observational cross-sectional study was conducted in 286 pharmacies located all over Lebanon. Data were collected by senior pharmacy students during their experiential learning placement. Collected data included information on the types of dispensing errors, the underlying causes of errors, handling approaches, and used strategies for dispensing error prevention. Data were analyzed using multiple logistic regression to determine factors that were associated with dispensing errors.

RESULTS

In the twelve thousand eight hundred sixty dispensed medications, there were 376 dispensing errors, yielding an error rate of 2.92%. Of these errors, 67.1% (252) corresponded to dispensing near-miss errors. The most common types of dispensing errors were giving incomplete/incorrect use instructions (40.9% (154)), followed by the omission of warning(s) (23.6% (89)). Work overloads/time pressures, illegible handwriting, distractions/interruptions, and similar drug naming/packaging were reported as the underlying causes in 55% (206), 23.13% (87), 15.15 % (57), and 7% (26) of the errors respectively. Besides, high prescription turnover volume, having one pharmacist working at a time, and extended working hours, were found to be independent factors that were significantly associated with dispensing errors occurrence (p<0.05).

CONCLUSIONS

This study sheds light on the need to establish national strategies for preventing dispensing errors in community pharmacies to maintain drug therapy safety, considering identified underlying causes and associated factors.

A cross-sectional study of errors in physicians orders' of antiseizure medications among people with epilepsy from rural India

AIMS

To enumerate and classify errors in physicians' orders of antiseizure medications (ASMs) to people with epilepsy presenting to neurology clinic.

METHODS

This cross-sectional study was conducted in the neurology clinic of a teaching hospital catering to a predominantly rural population. People in whom a diagnosis of epilepsy was confirmed and who presented for the first time with a prior prescription for antiseizure medication/s were included. Their immediate previous prescriptions were assessed for errors, enumerated and classified according to WHO guidelines for prescription writing.

RESULTS

Hundred prescriptions of 334 patients screened were analyzed. The number of ASMs prescribed to a participant was 2 ± 0.6 (mean ± SD). We identified a mean of 5 ± 4 (median: 3; range: 1-7) errors in each order. These included superscription errors, e.g., missing information on seizure control and frequency (n = 90, 90%), generic name (n = 62, 62%), patient identifiers (n = 57, 57%), prescribers' identifiers (n = 29, 29%) and diagnosis or indication for prescribing the medication/s (n = 55, 55%). The most common inscription and subscription errors were dosing errors (22%) and pharmaceutical form errors (20%) followed by omission (13%), duplication (13%), substitution (12%), commission (9%) and frequency errors (8%). Errors were more common among prescriptions provided by primary-care and Ayurvedic, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) physicians compared to specialists (P < 0.05).

CONCLUSIONS

Errors are common among medication orders provided by non-specialist and specialist physicians. Primary care and AYUSH are more liable to make errors underscoring the need to educate them in basic epilepsy treatment.

Effects of stratified medication review in high-risk patients at admission to hospital: a randomised controlled trial

Background:

Patients at high risk of medication errors will potentially benefit most from medication reviews. An algorithm, MERIS, can identify the patients who are at highest risk of medication errors. The aim of this study was to examine the effects of performing stratified medication reviews on patients who according to MERIS were at highest risk of medication errors.

Methods:

A randomised controlled trial was performed at the Acute Admissions Unit, Aarhus University Hospital, Denmark. Patients were included at admission to the hospital and were randomised to control or intervention. The intervention consisted of stratified medication review at admission on patients with a high MERIS score. Clinical pharmacists and clinical pharmacologists performed the medication reviews; the clinical pharmacologists performed the reviews on patients with the highest MERIS score. The primary outcome measure was the number of prescribing errors during the hospitalisation. Secondary outcomes included self-experienced quality of life, health-care utilisation and mortality measured at follow-up 90 days after discharge.

Results:

A total of 375 patients were included, of which medication reviews were performed in 64 patients. The medication reviews addressed 63 prescribing errors in 37 patients and 60 other drug-related problems. No difference in the number of prescribing errors during hospitalisation between the intervention group (n = 165) and control group (n = 153) was found, corresponding to 0.11 prescribing errors per drug (95% confidence interval (CI): 0.08–0.14) versus 0.13 per drug (95% CI: 0.09–0.16), respectively. No differences in secondary outcomes were observed.

Conclusion:

A stratified medication review approach based on the individual patient’s risk of medication errors did not show impact on the chosen outcomes.

Plain language summary

How does a medication review at admission affect patients who are in high risk of medication errors?

Patients are at risk of medication errors at admission to hospital. Medication reviews aim to detect and solve these. Yet, due to limited resources in healthcare, it would be beneficial to detect the patients who are most at risk of medication errors and perform medication reviews on those patients.

In this study we investigated whether an algorithm, MERIS, could detect patients who are at highest risk of medication errors; we also studied whether performing medication reviews on patients at highest risk of medication errors would have an effect on, for example, the number of medication errors during hospitalisation, qualify of life and number of readmissions. We included 375 patients in a Danish acute admission unit and they were divided into control group and intervention group. Patients in the intervention group received a medication review at admission if they were considered at high risk of medication errors, assessed with the aid of MERIS. In summary, 64 patients in the intervention group were most at risk of medication errors and therefore received a medication review.

We conclude in the study that MERIS was useful in identifying relevant patients for medication reviews. Yet, the medication reviews performed at admission did not impact on the chosen outcomes.

Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis

INTRODUCTION

The risk of medication errors is high in paediatric inpatient settings. However, estimates of the prevalence of medication errors have not accounted for heterogeneity across studies in error identification methods and definitions, nor contextual differences across wards and the use of electronic or paper medication charts.

OBJECTIVE

Our aim was to conduct a systematic review and meta-analysis to provide separate estimates of the prevalence of medication errors among paediatric inpatients, depending on hospital ward and the use of electronic or paper medication charts, that address differences in error identification methods and definitions.

METHODS

We systematically searched five databases to identify studies published between January 2000 and December 2018 that assessed medication error rates by medication chart audit, direct observation or a combination of methods.

RESULTS

We identified 71 studies, 19 involved paediatric wards using electronic charts. Most studies assessed prescribing errors with few studies assessing administration errors. Estimates varied by ward type. Studies of paediatric wards using electronic charts generally reported a reduced error prevalence compared to those using paper, although there were some inconsistencies. Error detection methods impacted the rate of administration errors in studies of multiple wards, however, no other difference was found. Definition of medication error did not have a consistent impact on reported error rates.

CONCLUSIONS

Medication errors are a frequent occurrence in paediatric inpatient settings, particularly in intensive care wards and emergency departments. Hospitals using electronic charts tended to have a lower rate of medication errors compared to those using paper charts. Future research employing controlled designs is needed to determine the true impact of electronic charts and other interventions on medication errors and associated harm among hospitalized children.

The Impact of Technology on Prescribing Errors in Pediatric Intensive Care: A Before and After Study

BACKGROUND

Increased use of health information technology (HIT) has been advocated as a medication error reduction strategy. Evidence of its benefits in the pediatric setting remains limited. In 2012, electronic prescribing (ICCA, Philips, United Kingdom) and standard concentration infusions (SCIs)-facilitated by smart-pump technology-were introduced into the pediatric intensive care unit (PICU) of an Irish tertiary-care pediatric hospital.

OBJECTIVE

The aim of this study is to assess the impact of the new technology on the rate and severity of PICU prescribing errors and identify technology-generated errors.

METHODS

A retrospective, before and after study design, was employed. Medication orders were reviewed over 24 weeks distributed across four time periods: preimplementation (Epoch 1); postimplementation of SCIs (Epoch 2); immediate postimplementation of electronic prescribing (Epoch 3); and 1 year postimplementation (Epoch 4). Only orders reviewed by a clinical pharmacist were included. Prespecified definitions, multidisciplinary consensus and validated grading methods were utilized.

RESULTS

A total of 3,356 medication orders for 288 patients were included. Overall error rates were similar in Epoch 1 and 4 (10.2 vs. 9.8%; p = 0.8), but error types differed (p < 0.001). Incomplete and wrong unit errors were eradicated; duplicate orders increased. Dosing errors remained most common. A total of 27% of postimplementation errors were technology-generated. Implementation of SCIs alone was associated with significant reductions in infusion-related prescribing errors (29.0% [Epoch 1] to 14.6% [Epoch 2]; p < 0.001). Further reductions (8.4% [Epoch 4]) were identified after implementation of electronically generated infusion orders. Non-infusion error severity was unchanged (p = 0.13); fewer infusion errors reached the patient (p < 0.01). No errors causing harm were identified.

CONCLUSION

The limitations of electronic prescribing in reducing overall prescribing errors in PICU have been demonstrated. The replacement of weight-based infusions with SCIs was associated with significant reductions in infusion prescribing errors. Technology-generated errors were common, highlighting the need for on-going research on HIT implementation in pediatric settings.

Bibliometric Analysis of Medication Errors and Adverse Drug Events Studies

OBJECTIVES

Medication errors and adverse drug events are a key concern of the health-care industry. The objectives of this study were to map the intellectual structure of the studies of medication errors and adverse drug events and to investigate the developing path of this literature and interrelationships among the main topics.

METHODS

The Web of Science database was searched for documentation of medication errors and adverse drug events from 1961 to 2013. The most cited articles and references were profiled and analyzed using HistCite software to draw a historiograph and Ucinet software to draw a sociogram.

RESULTS

The database search revealed 3343 medication errors and 3342 adverse drug event documents. The most cited articles on medication errors focused on 3 key themes from 1961 to 2013, namely, medication errors in adult inpatients, computerized physician order entry in medication error studies, and medication errors in pediatric inpatients. The developing path for the most cited articles about adverse drug events from 1987 to 2013 was as follows: detection, analysis, effect, and prevention from adult inpatient to pediatric inpatient settings and from hospitalized care to ambulatory care. In addition, social network analysis based on the most cited references revealed a close relationship between medication errors and adverse drug events.

CONCLUSIONS

The mapping results provide a valuable tool for researchers to access the literature in this field and can be used to help identify the direction of medication errors and adverse drug events research.

The problem of look-alike, sound-alike name errors: Drivers and solutions

Look-alike or sound-alike (LASA) medication names may be mistaken for each other, e.g. mercaptamine and mercaptopurine. If an error of this sort is not intercepted, it can reach the patient and may result in harm. LASA errors occur because of shared linguistic properties between names (phonetic or orthographic), and potential for error is compounded by similar packaging, tablet appearance, tablet strength, route of administration or therapeutic indication. Estimates of prevalence range from 0.00003 to 0.0022% of all prescriptions, 7% of near misses, and between 6.2 and 14.7% of all medication error events. Solutions to LASA errors can target people or systems, and include reducing interruptions or distractions during medication administration, typographic tweaks, such as selective capitalization (Tall Man letters) or boldface, barcoding, and computerized physician order entry.

Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC)

Classifying harm associated with a medication error can be time consuming and labour intensive and limited studies undertake this step. There is no standardised process, and few studies that report harm assessment provide adequate methods to allow for study replication. Studies typically mention that a clinical review panel classified patient harm and provide a reference to a classification tool. Moreover, in many studies it is unclear whether potential or actual harm was classified as studies refer only to ‘error severity’. The tools used to categorise the severity of patient harm vary widely across studies and few have been assessed for inter-rater reliability and criterion validity. In this paper, we describe the systematic process we undertook to synthesise the defining elements and strengths, while mitigating the limitations, of existing harm classification tools to derive the Harm Associated with Medication Error Classification (HAMEC). This new tool provides a harm classification for use across clinical and research settings. The provision of an explicit process for its application and guiding category descriptors are designed to reduce the risk of misclassification and produce results that are comparable across studies. As the World Health Organisation embarks on its international safety challenge of reducing medication-related harm by 50%, accompanying methodological advances are required to measure progress.

Registered Nurses' Experiences of Medication Errors-An Original Research Protocol: Methodology, Methods, and Ethics

BACKGROUND

The investigation of medication errors in nursing includes both methodological and ethical considerations because it is a sensitive field of research.

PURPOSE

To present an original research protocol for the investigation of nurses' experiences of medication errors with interpretative phenomenological analysis and the relevant methodological and ethical considerations.

METHODS

A discursive paper which presents an original research protocol about nurses' experiences of medication errors with interpretative phenomenological analysis followed by a literature review and personal reflections about the relevant methodological and ethical considerations. The review included papers published in English from 1990 to February 2019 on PubMed, BNI (British Nursing Index), CINAHL (Cumulative Index to Allied Health Literature), ScienceDirect, and Wiley Online Library.

RESULTS

The following methodological considerations were identified: recruitment of participants, data collection, and data analysis, and the ethical considerations included researcher's morality, ethics committees, sensitivity, phrasing of sentences and words, recruitment of participants, location of interviews, type of interviews, emotionality management, medication error incidents' management, researcher, or nurse?

CONCLUSION

By facing as many as possible methodological and ethical considerations and establishing solutions for them, the study's validity, reliability, and rigor are enhanced, and the study is ethically robust. Finally, their understanding enables researchers to uncover nurses' experiences and interpret the meanings they generate in depth.

Interventions to improve reporting of medication errors in hospitals: A systematic review and narrative synthesis

BACKGROUND

In 2017, the World Health Organisation pledged to halve medication errors by 2022. In order to learn from medication errors and prevent their recurrence, it is essential that medication errors are reported when they occur.

OBJECTIVES

The aim of this systematic review was to identify studies in which interventions were carried out in hospitals to improve medication error reporting, to summarise the findings of these studies, and to make recommendations for future investigations.

METHODS

A comprehensive search of five electronic databases (PubMed, Medline (OVID), Embase (OVID), Web of Science, and CINAHL) was conducted from inception up to and including December 2018. Studies were included if they described an intervention aiming to increase the reporting of medication errors by healthcare providers in hospitals and excluded if there was no full-text English language version available, or if the reporting rate in the hospital prior to the intervention was not available. Data extracted from included studies were described using narrative synthesis.

RESULTS

Of 12,025 identified studies, seventeen were included in this review - fifteen uncontrolled before versus after studies, one survey and one non-equivalent group controlled trial. Five studies carried out a single intervention and twelve studies conducted multifaceted interventions. The most common intervention types were critical incident reporting, implemented in fifteen studies, and audit and feedback, implemented in seven studies. Other intervention types included educational materials, educational meetings, and role expansion and task shifting. As only one study compared a control and intervention group, the effectiveness of the different intervention types could not be evaluated.

CONCLUSION

This is the first review to address the evidence on medication error reporting in hospitals on a global scale. The review has identified interventions to improve medication error reporting that were implemented without evidence of their effectiveness. Due to the essential role played by incident reporting in learning from and preventing the recurrence of medication errors more research needs to be done in this area.

Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis

INTRODUCTION

Medication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.

OBJECTIVES

To describe the incidence, nature and severity of medication errors in simulated paediatric resuscitations, and to employ human reliability analysis to understand the contribution of discrepancies in individual process steps to the occurrence of these errors.

METHODS

We conducted a prospective observational study of simulated resuscitations subjected to video microanalysis, identification of medication errors, severity assessment and human reliability analysis in a large English teaching hospital. Fifteen resuscitation teams of two doctors and two nurses each conducted one of two simulated paediatric resuscitation scenarios.

RESULTS

At least one medication error was observed in every simulated case, and a large magnitude (>25% discrepant) or clinically significant error in 11 of 15 cases. Medication errors were observed in 29% of 180 simulated medication administrations, 40% of which considered to be moderate or severe. These errors were the result of 884 observed discrepancies at a number of steps in the drug ordering, preparation and administration stages of medication use, 8% of which made a major contribution to a resultant medication error. Most errors were introduced by discrepancies during drug preparation and administration.

CONCLUSIONS

Medication errors were common with a considerable proportion likely to result in patient harm. There is an urgent need to optimise existing systems and to commission research into new approaches to increase the reliability of human interactions during administration of medication in the paediatric emergency setting.

Using the HALT model in an exploratory quality improvement initiative to reduce medication errors

Medication errors can have deleterious effects on patient safety and care. Interruptions, patient acuity and time pressures have all been cited as contributing factors in the incidence of medication errors. Yet, despite the number of different strategies that can be taken to reduce the incidence of medication errors, they still occur. The strategies often focus on refining systems and processes, depending on the root cause of the error. However, less recognised as contributory elements are human factors such as anger, hunger or tiredness. The aim of this quality improvement initiative was to reduce medication errors by 25% on a medical ward, through the introduction of the hunger, angry, lonely, tired (HALT) model to address the human factors associated with medication errors. Post-implementation, the HALT model appeared to have resulted in a total reduction in medication errors over a 2-month period by 31%. Mistakes related to human error were reduced by 25%, and those linked to communication and documentation errors by 22%. While this was a small-scale study, this is a significant reduction in medication errors. However, caution should be used when addressing other contributing factors associated with medication errors as using HALT alone will not address these.

Medication Review and Patient Outcomes in an Orthopedic Department: A Randomized Controlled Study

OBJECTIVE

We investigated the health-related effect of systematic medication review performed by a clinical pharmacist and a clinical pharmacologist on nonelective elderly orthopedic patients.

METHODS

This is a nonblinded randomized controlled study of 108 patients 65 years or older treated with at least 4 drugs. For the intervention, the clinical pharmacist reviewed the participants' medication after completion of the usual medication routine. Information was collected from medical charts, interviews with participants, and database registrations of drug purchase. Results were conferred with the clinical pharmacologist, and recommendations were delivered directly to the ward physicians. The control was usual medication routine, that is, physicians prescribing admitting orders. The primary outcome was time to the first unplanned contact to a physician after discharge (i.e., general practitioner, emergency department visit, or readmission) during 3-month follow-up. Secondary outcomes included other health-related outcomes, for example, length of in-hospital stay, mortality, and quality of life.

RESULTS

Time to the first unplanned contact to a physician was 14.9 days (95% confidence interval, 8.9-21.0) in the intervention group compared with 27.3 days (95% confidence interval, 18.9-35.7) in the controls (P = 0.05). Overall, no statistically significant differences were seen in the secondary outcomes apart from "number of" and "time to first" emergency department visits, which were in favor of the intervention group. A marked hesitation of the ward physicians to comply with recommendations was noted (18%).

CONCLUSIONS

The study showed that the patients receiving usual care had a significantly longer time to the first unplanned contact to a physician after discharge; however, the fact that less than 1 of 5 recommendations was adopted by the physicians raises concerns as to whether this finding could be attributable to the intervention.

Medication transcription errors in hospitalized patient settings: a consensual study in the Palestinian nursing practice

BACKGROUND

Medication transcription errors (MTEs) are frequent in hospitalized patient settings. Definitions and scenarios that represent potential MTEs in the Palestinian nursing practice were not previously approached using formal consensus techniques. This investigation was conducted to develop a consensual definition of MTEs and scenarios that represent different MTE situations by a panel of nurses and other healthcare professionals.

METHODS

In this observational study, consensus was sought using the Delphi technique. Panelists (n = 64) were invited and recruited from different hospitals in Palestine and a two-iterative rounds Delphi technique was used to achieve consensus on a proposed definition of MTEs and 76 different scenarios representing potential MTEs.

RESULTS

Consensus was achieve to accept the definition and to consider 69 of the 76 proposed scenarios (77.6%) as MTEs, exclude 3 scenarios (3.9%), and 4 scenarios (5.3%) remained equivocal. Equivocal scenarios might be considered as MTEs or not depending on the clinical situation.

CONCLUSIONS

Consensus was achieved on a definition of MTEs and scenarios representing MTEs by a panel of nurses and other healthcare professionals. This study showed that it was possible to develop and achieve consensus on a definition and scenarios representing MTE situations using formal consensus techniques. Such consensual definitions could be useful in future epidemiological studies investigating MTEs. Using consensual definitions might reduce methodological variations, promote congruence in error counting and reporting, and permit comparing error rates in different hospital settings.

Medical errors: Healthcare professionals' perspective at a tertiary hospital in Kuwait

Medical errors are of economic importance and can contribute to serious adverse events for patients. Medical errors refer to preventable events resulting from healthcare interactions, whether these events harm the patient or not. In Kuwait, there is a paucity literature detailing the causes, forms, and risks of medical errors in their state-funded healthcare facilities. This study aimed to explore medical errors, their causes and preventive strategies in a Kuwait tertiary hospital based on the perceptions and experience of a cross-section of healthcare professionals using a questionnaire with 27 open (n = 10) and closed (n = 17) questions. The recruited healthcare professionals in this study included pharmacists, nurses, physicians, dentists, radiographers, hospital administrators, surgeons, nutritionists, and physiotherapists. The collected data were analysed quantitatively using descriptive statistics. A total of 203 participants filled and completed the survey questionnaire. The frequency of medical errors in Kuwait was found to be high at 60.3% ranging from incidences of prolonged hospital stays (32.9%), adverse events and life-threatening complications (32.3%), and fatalities (20.9%). The common medical errors result from incomplete instructions, incorrect dosage, and incorrect route of administration, diagnosis errors, and labelling errors. The perceived causes of these medical errors include high workload, lack of support systems, stress, medical negligence, inadequate training, miscommunication, poor collaboration, and non-adherence to safety guidelines among the healthcare professionals.

Student observations of medication error reporting practices in community pharmacy settings

BACKGROUND

Medication safety practices and methods for reporting errors in community pharmacies are relatively unknown.

OBJECTIVE

(s): The primary objective of this study was to describe student-reported data on medication safety and error reporting practices in community pharmacies, and secondarily describe student learning from this assignment.

METHODS

Second professional year pharmacy students enrolled at Purdue University College of Pharmacy in the United States observed and recorded medication safety and error reporting practices as part of an experiential assignment. Data were collected from 170 unique pharmacy settings between the years 2016-2018 and analyzed using descriptive statistics and a paired t-test to assess student learning.

RESULTS

51% of students reported documentation of 1-10 errors or near misses annually, with an additional 30% reporting 11-30. Near misses were only reported 26% of the time. Errors were most commonly reported to a pharmacy-specific reporting system (84%) and the Institute for Safe Medication Practices National Medication Errors Reporting Program (84%). The most frequently reported error types included wrong directions (34%), wrong drug (14%), wrong strength (13%), and wrong patient (12%). Pharmacists were observed to be interrupted approximately 19 times every hour. Anonymous error reporting was typically not allowed to the pharmacy's preferred error reporting system (71%). A policy requiring that the prescriber is contacted about errors was observed at 77% of the sites. The most common consequences of committing an error were education/training (72%) or progressive discipline (41%). Students reported a statistically significant increase in understanding of medication safety practices and methods for reporting errors in community pharmacies. (p < 0.01).

CONCLUSION

This data supplements existing literature on medication safety practices and error reporting in community pharmacy settings, as well as highlights knowledge gaps outside the scope of this study.

Agreeing on global research priorities for medication safety: an international prioritisation exercise

Objectives

Medication errors continue to contribute substantially to global morbidity and mortality. In the context of the recent launch of the World Health Organization’s (WHO) Third Global Patient Safety Challenge: Medication Without Harm, we sought to establish agreement on research priorities for medication safety.

Methods

We undertook a consensus prioritisation exercise using an approach developed by the Child Health and Nutrition Research Initiative. Based on a combination of productivity and citations, we identified leading researchers in patient and medication safety and invited them to participate. We also extended the invitation to a further pool of experts from the WHO Global Patient Safety Network. All experts independently generated research ideas, which they then independently scored based on the criteria of: answerability, effectiveness, innovativeness, implementation, burden reduction and equity. An overall Research Priority Score and Average Expert Agreement were calculated for each research question.

Findings

131 experts submitted 333 research ideas, and 42 experts then scored the proposed research questions. The top prioritised research areas were: (1) deploying and scaling technology to enhance medication safety; (2) developing guidelines and standard operating procedures for high-risk patients, medications and contexts; (3) score-based approaches to predicting high-risk patients and situations; (4) interventions to increase patient medication literacy; (5) focused training courses for health professionals; and (6) universally applicable pictograms to avoid medication-related harm. Whilst there was a focus on promoting patient education and involvement across resource settings, priorities identified in high-resource settings centred on the optimisation of existing systems through technology. In low- and middle-resource settings, priorities focused on identifying systemic issues contributing to high-risk situations.

Conclusions

WHO now plans to work with global, regional and national research funding agencies to catalyse the investment needed to enable teams to pursue these research priorities in medication safety across high-, middle- and low-resource country settings.

Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 1

For decades, the dental profession has provided anesthesia services in office-based, ambulatory settings to alleviate pain and anxiety, ranging from local anesthesia to general anesthesia. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a substantial lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article will illuminate the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medicine has implemented to manage such problems, and introduce a method for addressing these issues with the dental anesthesia medication safety paradigm.

Physicians' and Nurses' Attitudes and Actions Regarding Perioperative Medication Management

PURPOSE

To investigate physicians' and nurses' attitudes and actions related to the prescription and administration of perioperative antibiotics and opioids during a 2-week period.

DESIGN

A quantitative descriptive and analytical research design performed at a Danish University Hospital.

METHODS

An email survey using an 18-item questionnaire was sent to 163 nurses and physicians involved in the perioperative period.

FINDINGS

Of 163 participants, 114 (69.9%) returned the questionnaire. Between 12% and 29% of the respondents reported that they did not correctly manage the medication, although they thought it to be important. Between 41% and 68% of the respondents experienced incorrect medication management with significant differences among professions and specialties.

CONCLUSIONS

The study confirms a knowing-doing gap in medication management in perioperative settings, highlighting the need to address this issue, to ensure that physicians and nurses act in accordance with their beliefs and consider the importance of medication safety in interdisciplinary work across specialties.

Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries

BACKGROUND

Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries.

METHODS

A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included.

RESULTS

Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5-16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists' interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists' recommendations.

CONCLUSIONS

Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.