Medication error reporting: a survey of nursing staff

Nurses' perception of medication administration errors and factors associated with their reporting in the neonatal intensive care unit

Medication administration is a complex process, and nurses play a central role in this process. Errors during administration are associated with severe patient harm and significant economic burden. However, the prevalence of under-reporting makes it challenging when analysing the current landscape of medication administration error (MAE) and hinders the implementation of improvements to the existing system. The aim of this study is to describe the reasons for the occurrence of MAEs and the reasons behind the under-reporting of MAEs, to determine the estimated percentage of MAE reporting and to identify factors associated with them from the nurses' perspective. This cross-sectional study was conducted using a validated self-administered questionnaire. The questionnaire contained 65 questions which were divided into three sections: (i) reasons for the occurrence of MAEs, which consisted of 29 items; (ii) reasons for not reporting MAEs, which consisted of 16 items; and (iii) percentage of MAEs actually reported, which consisted of 20 items. It was distributed to 143 nurses in the neonatal intensive care units of five public hospitals in Malaysia. Multivariable logistic regression was used to identify the factors associated with MAE reporting. The estimated percentage of MAE reporting was 30.6%. The most common reasons for MAEs were inadequate nursing staff (5.14 [SD 1.25]), followed by drugs which look alike (4.65 [SD 1.06]) and similar drug packaging (4.41 [SD 1.18]). The most common reasons for not reporting MAEs were that nursing administration focuses on the individual rather than looking at the systems as a potential cause of the error (4.56 [SD 1.32]) and that too much emphasis is placed on MAEs as a measure of the quality of nursing care (4.31 [SD 1.23]). Factors statistically significant with MAE reporting were administration response (adjusted odds ratio [AOR] = 6.90; 95% confidence interval (CI) = 2.01-23.67; P = 0.002), reporting effort (AOR = 3.67; 95% CI = 1.68-8.01; P = 0.001), and nurses with advanced diploma (AOR = 0.29; 95% CI = 0.13-0.65; P = 0.003). Our findings show that under-reporting of MAEs is still common and less than a third of the respondents reported MAEs. Therefore, to encourage error reporting, emphasis should be placed on the benefits of reporting, adopting a non-punitive approach, and creating a blame-free culture.

Agent-Based Modeling Simulation of Nurse Medication Administration Errors

It has been 20 years since the National Academy of Medicine released its report, "To Err Is Human," which shocked the healthcare community on the pervasiveness of medical error. While errors in medication administration are a significant contributor to medical error, research seeking to understand the complex systems nature and occurrence of medication administration error is limited. Computer modeling is increasingly being used in the healthcare industry to assess the impact of changes made to healthcare processes. The objective of the study is to evaluate the use of agent-based modeling, a type of computer modeling that allows the simulation of virtual individuals and their behavior, to simulate nurse performance in the medication administration process. The model explores the effect of Just-in-Time information, as an intervention, on the occurrence of medication error. The model demonstrated significant utility in understanding the interplay of the system elements of the nurse medication administration process. Therefore this approach, using systems-level computer simulation such as agent-based models, can help administrators understand the effects of changes to the medication administration process as they work to reduce errors and increase performance.

Prevalence of medical errors in Iran: a systematic review and meta-analysis

BACKGROUND

Medical errors are considered as a major threat to patient safety. To clarify medical errors' status in Iran, a review was conducted to estimate the accurate prevalence of medical errors.

METHODS

A comprehensive search was conducted in international databases (MEDLINE, Scopus and the Web of Science), national databases (SID, Magiran, and Barakat) and Google Scholar search engine. The search was performed without time limitation up to January 2017 using the MeSH terms of Medical "error(s)" and "Iran" in Endnote X5. Article in English and Persian which estimated the prevalence of medical errors in Iran were eligible to be included in this review. The JBI appraisal instrument was used to assess the quality of included studies, by two independent reviewers. The prevalence of medical errors was calculating using random effect model. Stata software was used for data analysis.

RESULTS

In 40 included studies, the most frequent occupational group observed were nursing staff and nursing students (21 studies; 52% of studies). The most reported type of error was medication error (25 studies; 62% of studies, with prevalence ranged from 10 to 80%). University or teaching hospitals (30 studies; 75% of studies) as well as, internal/intensive care wards (10 studies; 25% of studies) were the most frequent hospitals and wards detected. Based on the result of the random effect model, the overall estimated prevalence of medical errors was 50% (95% confidence interval: 0.426, 0.574).

CONCLUSION

Result of the comprehensive literature review of the current studies, found a wide variation in the prevalence of medical errors based on the occupational group, type of error, and health care setting. In this regards, providing enough education to nurses, improvement of patient safety culture and quality of services and attention to special wards, especially in teaching hospitals are suggested.

Anticholinergic medicines use among older adults before and after initiating dementia medicines

AIMS

We investigated anticholinergic medicines use among older adults initiating dementia medicines.

METHODS

We used Pharmaceutical Benefits Scheme dispensing claims to identify patients who initiated donepezil, rivastigmine, galantamine or memantine between 1 January 2013 and 30 June 2017 (after a period of ≥180 days with no dispensing of these medicines) and remained on therapy for ≥180 days (n = 4393), and dispensed anticholinergic medicines in the 180 days before and after initiating dementia medicines. We further examined anticholinergic medicines prescribed by a prescriber other than the one initiating dementia medicines.

RESULTS

One-third of the study cohort (1439/4393) was exposed to anticholinergic medicines up to 180 days before or after initiating dementia medicines. Among patients exposed to anticholinergic medicines, 46% (659/1439) had the same medicine dispensed before and after initiating dementia medicines. The proportion of patients dispensed anticholinergic medicines increased by 2.5% (95% confidence interval [CI]: 1.3-3.7) after initiating dementia medicines. Antipsychotics use increased by 10.1% (95% CI: 7.6-12.7) after initiating dementia medicines; driven by increased risperidone use (7.3%, 95% CI: 5.3-9.3). Nearly half of patients dispensed anticholinergic medicines in the 180 days after (537/1133), were prescribed anticholinergic medicines by a prescriber other than the one initiating dementia medicines.

CONCLUSION

Use of anticholinergic medicines is common among patients initiating dementia medicines and this occurs against a backdrop of widespread campaigns to reduce irrational medicine combinations in this vulnerable population. Decisions about deprescribing medicines with questionable benefit among patients with dementia may be complicated by conflicting recommendations in prescribing guidelines.

Assessment of Frequency and Causes of Medication Errors in Pediatrics and Emergency Wards of Teaching Hospitals Affiliated to Tehran University of Medical Sciences (24 Hospitals)

Introduction and Objective: Medical errors and adverse events are among the major causes of avoidable deaths and costs incurred on health systems all over the world. Medical errors are among the main challenges threatening the safety of patients in all countries and one of the most common types of medical errors is medication errors. This study aimed to determine the frequency, type, and causes of medication errors in the emergency and pediatric wards of hospitals affiliated to Tehran University of Medical Sciences in 2017. Materials and Methods: This study was a cross-sectional descriptive study which was conducted on 423 nurses working in teaching hospitals affiliated to Tehran University of Medical Sciences in 2017. The subjects were selected using the stratified sampling method. A total of 49 teaching hospitals in Tehran are affiliated to Tehran University of Medical Sciences and they are divided into two groups of general and specialized hospitals. Of all, 10 general hospitals and 14 specialized hospitals were randomly selected. The required data was collected using a three-part questionnaire. Using the SPSS software (version 18), the collected data was analyzed by means of ANOVA, Pearson Correlation Coefficient, and t-test and the results were reported as frequency, percentage, mean, and standard deviation. Results: According to the results of this study, the mean total number of medication errors that occurred within one month in the pediatric and emergency wards was roughly 41.9 cases, as stated by the nurses. The mean number of medication errors was higher in men than in women. Also, the two variables of gender and the type of shift work were related to medication errors; specifically, it was higher first in the evening and night shifts and then in the morning and evening shifts, respectively. Also, the number was higher in night shifts than in the morning shifts. The most common types of medication errors were: administration of the drugs at the wrong time, using a wrong technique of administration, wrong dosage, forgetting the dosage of the drug, administrating additional doses, administrating the drug to a wrong patient, and following the oral orders of physicians. On the other hand, the most common causes of medication errors in clinical wards were the following: illegible physician orders, shortage of manpower and high workload, incomplete physician orders, the use of lookalike and sound-alike drugs, absence of pharmacist/pharmaceutical expert in the ward, lack of dosage forms appropriate for children, and lack of adequate training regarding drug therapy. Discussion and Conclusion: Considering the results of this study, it is necessary to reduce the workload and working hours of nurses, increase medical staff's awareness of the significance of medication errors, revise the existing techniques of drug prescription, and update the indices of human resource in hospitals. It is also necessary to correct the process of naming and selecting the dosage forms of drugs by the industry.

Dose-Banding of Intravenous Piperacillin-Tazobactam in Pediatric Surgical Inpatients

BACKGROUND

Antimicrobial doses in children are often prescribed by using an individually calculated dose per weight (e.g., mg/kg) or based on body surface area. Dosing errors are the most commonly reported medication errors in children. A "dose-banding" strategy is frequently used for some over-the-counter drugs to prevent dosing errors. It could also lead to efficiencies by enabling batch preparation of intravenous (IV) medications in hospitals.

OBJECTIVES

To evaluate whether use of dose-banding for IV piperacillin-tazobactam results in acceptable dose variation from standard practice of individualized prescription of 100 mg/kg in children.

METHODS

We conducted a historically controlled intervention study comparing prescriptions of IV piperacillin-tazobactam before vs. after introduction of dose-banding prescribing guidance for surgical inpatients weighing >5 kg and <16 years of age at the tertiary referral pediatric hospital in Western Australia.

RESULTS

Dose-banding of IV piperacillin-tazobactam (with a maximum of 15% departure from the recommended milligram-per-weight dose of 100 mg/kg) resulted in similar overall variation of prescribed dose in comparison to individualized milligram-per-weight (non-dose-banded) prescribing. There was a trend toward fewer prescriptions with large variance (>30% variation from the 100-mg/kg dose) in the dose-banded compared to the non-dose-banded group (1/140 vs. 5/105; p = 0.09).

CONCLUSIONS

Our study showed dose-banding of IV piperacillin-tazobactam resulted in acceptable variation when compared to individualized milligram-per-weight dosing in children. Prospectively designed controlled trials are warranted to determine whether dose-banding could reduce medication errors and optimize use of hospital resources. Implications for future practice could include faster batch preparation, shorter checking and dispensing time, and reduction in drug wastage.

Medication errors in home care: a qualitative focus group study

AIMS AND OBJECTIVES

To explore registered nurses' experiences of medication errors and patient safety in home care.

BACKGROUND

The focus of care for older patients has shifted from institutional care towards a model of home care. Medication errors are common in this situation and can result in patient morbidity and mortality.

DESIGN

An exploratory qualitative design with focus group interviews was used.

METHODS

Four focus group interviews were conducted with 20 registered nurses in home care. The data were analysed using content analysis.

RESULTS

Five categories were identified as follows: lack of information, lack of competence, reporting medication errors, trade name products vs. generic name products, and improving routines.

CONCLUSION

Medication errors occur frequently in home care and can threaten the safety of patients. Insufficient exchange of information and poor communication between the specialist and home-care health services, and between general practitioners and healthcare workers can lead to medication errors. A lack of competence in healthcare workers can also lead to medication errors. To prevent these, it is important that there should be up-to-date information and communication between healthcare workers during the transfer of patients from specialist to home care. Ensuring competence among healthcare workers with regard to medication is also important. In addition, there should be openness and accurate reporting of medication errors, as well as in setting routines for the preparation, alteration and administration of medicines.

RELEVANCE TO CLINICAL PRACTICE

To prevent medication errors in home care, up-to-date information and communication between healthcare workers is important when patients are transferred from specialist to home care. It is also important to ensure adequate competence with regard to medication, and that there should be openness when medication errors occur, as well as in setting routines for the preparation, alteration and administration of medications.

Improving Self-Reporting of Adverse Drug Events in a West Virginia Hospital

Adverse drug events significantly increase length of stay and costs of hospitalization but are underreported in health care institutions. We hypothesized that hospitals could improve the accuracy of adverse drug event self-reporting by comparing adverse drug events recorded in an occurrence reporting tool with those detected by surveillance of "rescue" drugs administered to treat adverse drug events. We conducted a prospective cohort study of all adult inpatient discharges from a 200-bed rural acute care hospital in West Virginia during a 6-month period. We performed 3572 chart audits, of which 1011 included rescue drug administration. Our outcome measure was the proportion of adverse drug events in the rescue drug surveillance that were found in the occurrence reporting tool. We found that less than 4% of all adverse drug events involving use of rescue drugs were reported. We concluded that underreporting of preventable adverse drug events in this hospital is comparable to published rates and that surveillance of adverse drug events to detect underreporting is feasible.

Patient and Staff Safety: Voluntary Reporting

Central to efforts to assure the quality of patient care in hospitals is having accurate data about quality and patient problems. The purpose was to describe the reporting rates of medication administration errors (MAE), patient falls, and occupational injuries. A questionnaire was distributed to staff nurses (N = 1105 respondents) in a national sample of 25 hospitals. This addressed voluntary reporting, work environment factors, and reasons for not reporting occurrences. More than 80% indicated that all MAEs should be reported, but only 36% indicated that near misses should be reported. Perceived levels of actual reporting were: 47% of MAEs, 77% of patient falls, 48% of needlesticks, 22% of other exposures to body fluids, and 17% of back injuries. Administrative response to reports, personal fears, and unit quality management were related to reporting. Patient and staff safety occurrences are underreported. Strong quality management processes and positive responses to reports of occurrences may increase reporting and enhance safety.

Knowledge of healthcare professionals about medication errors in hospitals

CONTEXT

Medication errors are the most common types of medical errors in hospitals and leading cause of morbidity and mortality among patients.

AIMS

The aim of the present study was to assess the knowledge of healthcare professionals about medication errors in hospitals.

SETTINGS AND DESIGN

A self-administered questionnaire was distributed to randomly selected healthcare professionals in eight hospitals in Madinah, Saudi Arabia.

SUBJECTS AND METHODS

An 18-item survey was designed and comprised questions on demographic data, knowledge of medication errors, availability of reporting systems in hospitals, attitudes toward error reporting, causes of medication errors.

STATISTICAL ANALYSIS USED

Data were analyzed with Statistical Package for the Social Sciences software Version 17.

RESULTS

A total of 323 of healthcare professionals completed the questionnaire with 64.6% response rate of 138 (42.72%) physicians, 34 (10.53%) pharmacists, and 151 (46.75%) nurses. A majority of the participants had a good knowledge about medication errors concept and their dangers on patients. Only 68.7% of them were aware of reporting systems in hospitals. Healthcare professionals revealed that there was no clear mechanism available for reporting of errors in most hospitals. Prescribing (46.5%) and administration (29%) errors were the main causes of errors. The most frequently encountered medication errors were anti-hypertensives, antidiabetics, antibiotics, digoxin, and insulin.

CONCLUSIONS

This study revealed differences in the awareness among healthcare professionals toward medication errors in hospitals. The poor knowledge about medication errors emphasized the urgent necessity to adopt appropriate measures to raise awareness about medication errors in Saudi hospitals.

Barriers to Medical Error Reporting

BACKGROUND

This study was conducted to explore the prevalence of medical error underreporting and associated barriers.

METHODS

This cross-sectional study was performed from September to December 2012. Five hospitals, affiliated with Hamadan University of Medical Sciences, in Hamedan, Iran were investigated. A self-administered questionnaire was used for data collection. Participants consisted of physicians, nurses, midwives, residents, interns, and staffs of radiology and laboratory departments.

RESULTS

Overall, 50.26% of subjects had committed but not reported medical errors. The main reasons mentioned for underreporting were lack of effective medical error reporting system (60.0%), lack of proper reporting form (51.8%), lack of peer supporting a person who has committed an error (56.0%), and lack of personal attention to the importance of medical errors (62.9%). The rate of committing medical errors was higher in men (71.4%), age of 50-40 years (67.6%), less-experienced personnel (58.7%), educational level of MSc (87.5%), and staff of radiology department (88.9%).

CONCLUSIONS

This study outlined the main barriers to reporting medical errors and associated factors that may be helpful for healthcare organizations in improving medical error reporting as an essential component for patient safety enhancement.

Incidence and treatment costs attributable to medication errors in hospitalized patients

BACKGROUND

A significant financial burden arises from medication errors that cause direct injury and those without patient harm that represent waste and inefficiency.

OBJECTIVE

To estimate the incidence, types, and causes of medication errors as well as their attributable costs in a hospital setting.

METHODS

For a retrospective case-control study, data were collected for 57,554 patients admitted to two New Jersey (U.S. State) hospitals during 2005-2006 as well as hospital-specific voluntary error reports from these two hospitals for the same period. Medication errors were classified into categories of stage, error type, and proximal cause, and the incidence was estimated. The costs attributable to medication errors were calculated using both the recycled prediction method, and the Blinder-Oaxaca decomposition method after propensity score matching.

RESULTS

Medication errors occurred at a rate of 0.8 per 100 admissions, or 1.6 per 1000 patient days. Most errors occurred at the administration stage of the medication use process. The most frequent types of errors were wrong time, wrong medication, wrong dose, and omission errors. Treatment costs attributable to medication errors were in the range of $8,439 using the Blinder-Oaxaca decomposition method and $8,898 using the recycled prediction method.

CONCLUSIONS

Medication errors are associated with significant additional costs, even without patient harm. Considering the substantial costs associated with adverse drug events, the elimination of medication errors should be further emphasized and promoted, and guidelines should be developed to facilitate this goal.

Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol

Background

Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals’ medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to:

1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses

2. Test the feedback reporting mechanism to determine its utility and effect

3. Identify characteristics of organisational context associated with error reporting in response to feedback

Methods/design

A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.

Evaluation of the attitudes of the nurses related to rational drug use in Gaziantep University Sahinbey Research and Practice Hospital in Turkey

BACKGROUND AND OBJECTIVES

This study aimed to evaluate the attitude of nurses about rational drug use in Gaziantep University Sahinbey Research and Practice Hospital. There are a limited number of studies available on this issue and no studies of this scale were conducted among the nurses in our region.

DESIGN AND SETTING

A questionnaire generated by the Rational Drug Use Unit of Turkish Ministry of Health General Directorate of Pharmaceuticals and Pharmacy was carried out to nurses.

PARTICIPANTS

The study was carried out to 162 nurses.

METHODS

The data obtained from nurses by questionnaire were determined as count, percentage and Chi-square test by SPSS statistical package program.

RESULTS

The most common type of medication error was giving the medicine at the wrong time. Medication errors were least common among the 36-50-year age group and with a professional experience of 11 years or longer. Nurses had the highest level of knowledge in the areas of drug administration routes and the intended use. The number of nurses reported having good/very good knowledge was higher with 4 to 10 years of professional experience and with a university degree. The nurses aged between 26 and 35 years and those with professional experience of 4 to 10 years provided drug information to patients more often than others. Forty two percent of the nurses were found to actively report any adverse events. Reporting of adverse events and reporting more than 6 adverse events were most common among university degree holders.

CONCLUSIONS

Nurses required a more comprehensive education on pharmacology both during their training years and working life since the requests for medicinal products are received by the nurses and preparation and administration of drugs are under the control of nurses.

Caregivers' perception of drug administration safety for pediatric oncology patients

Medication errors (MEs) are reported to be between 1.5% and 90% depending on many factors, such as type of the institution where data were collected and the method to identify the errors. More significantly, the risk for errors with potential for harm is 3 times higher for children, especially those receiving chemotherapy. Few studies have been published on averting such errors with children and none on how caregivers perceive their role in preventing such errors. The purpose of this study was to evaluate pediatric oncology patient's caregivers' perception of drug administration safety and their willingness to be involved in averting such errors. A cross-sectional design was used to study a nonrandomized sample of 100 caregivers of pediatric oncology patients. Ninety-six of the caregivers surveyed were well informed about the medications their children receive and were ready to participate in error prevention strategies. However, an underestimation of potential errors uncovered a high level of "trust" for the staff. Caregivers echoed their apprehension for being responsible for potential errors. Caregivers are a valuable resource to intercept medication errors. However, caregivers may be hesitant to actively communicate their fears with health professionals. Interventions that aim at encouraging caregivers to engage in the safety of their children are recommended.

Study of medication errors on a community hospital oncology ward

PURPOSE

Medication errors (MEs) have been a significant problem resulting in excessive patient morbidity and cost, especially for cancer chemotherapeutic agents. Although some progress has been made, ME measurement methods and prevention strategies remain important areas of research.

METHODS

During a 2-year period (2003-2004), we conducted a prospective study on the oncology ward of a large community hospital, with the goals of (1) complete nurse reporting of observed medication administration errors (MAEs), (2) classifying observed MAEs, and (3) formulating improvement strategies. We also conducted a retrospective review of a randomly chosen sample of 200 chemotherapy orders to assess the appropriateness of ordering, dispensing, and administration.

RESULTS

Our nurses reported 141 MAEs during the study period, for a reported rate of 0.04% of medication administrations. Twenty-one percent of these were order writing and transcribing errors, 38% were nurse or pharmacy dispensing errors, and 41% were nurse administration errors. Only three MAEs resulted in adverse drug events. Nurses were less likely to report MAEs that they felt were innocuous, especially late-arriving medications from the pharmacy. A retrospective review of 200 chemotherapy administrations found only one clear MAE, a miscalculated dose that should have been intercepted.

CONCLUSIONS

Significant reported MAE rates on our ward (0.04% of drug administrations and 0.03 MAEs/patient admission) appear to be relatively low due to application of current safety guidelines. An emphasis on studying MAEs at individual institutions is likely to result in meaningful process changes, improved efficiency of MAE reporting, and other benefits.

Attitudes and perceived barriers influencing incident reporting by nurses and their correlation with reported incidents: A systematic review

BACKGROUND

Clinical incident reporting is an integral feature of risk management system in the healthcare sector. By reporting clinical incidents, nurses allow for learning from errors, identification of error patterns and development of error preventive strategies. The need to understand attitudes to reporting, perceived barriers and incident reporting patterns by nurses are the core highlights of this review.

OBJECTIVES

INCLUSION CRITERIA: This review considered descriptive quantitative studies that examined nurses' attitudes or perceived barriers towards incident reporting.The participants in this review were nurses working in acute care settings or step-down care settings. Studies that included non-nursing healthcare personnel were excluded.This review considered studies which examined nurses' attitudes towards incident reporting, perceived barriers and incident reporting practices.The outcomes of interest were the attitudes that nurses have towards incident reporting, perceived barriers and the types of reported incidents in correlation with nurses' attitudes and barriers.

SEARCH STRATEGY

A three-step search strategy was utilised in this review. An initial limited search of CINAHL and MEDLINE was undertaken. Search strategies were then developed using identified keywords and index terms. Lastly, the reference lists of all identified articles were examined. All searches were limited to studies published in English, between 1991 and 2010.

METHODOLOGICAL QUALITY

The studies were independently assessed by two reviewers using the Joanna Briggs Institute Critical Appraisal Checklist for Descriptive/ Case Series studies.

DATA EXTRACTION

The reviewers extracted data independently from included studies using the Joanna Briggs Institute Data Extraction Form for Descriptive/ Case Series studies.

DATA SYNTHESIS

Due to the descriptive nature of the study designs, statistical pooling was not possible. Therefore, the findings of this systematic review are presented in a narrative summary.

MAIN FINDINGS

Fifty-five papers were identified from the searches based on their titles and abstracts. Nine studies were included in this review. Cultural and demographic factors were the most significant factors in affecting nurses' attitudes towards incident reporting. Major perceived barriers included fear, administrative issues, and the reporting process. Also, nurses were more likely to report incidents that caused direct harm, and if reporting was kept anonymous.

CONCLUSIONS

This review demonstrated that attitudes of nurses towards incident reporting vary across different study settings, with perceived barriers hindering the reporting process. Using the findings, interventions can be customised to increase reporting rates can be developed to curb the problem of underreporting.A non-punitive culture towards incident reporting has to be cultivated, and nursing authorities should provide frequent positive feedback to staff who reported incidents. Investigating system errors should be the focus rather than individual blame.Further research should target the development and evaluation of strategies to increase rates of incident reporting. Any differences between actual and perceived reporting rates should also be explored.

Avoidable interruptions during drug administration in an intensive rehabilitation ward: improvement project

AIMS

To record the frequency of interruptions and their causes, to identify 'avoidable' interruptions and to build an improvement project to reduce 'avoidable' interruptions.

BACKGROUND

In Italy each year 30,000-35,000 deaths per year are attributed to health-care system errors, of which 19% are caused by medication errors. The factors that contribute to drug management error also include interruptions and carelessness during treatment administration.

METHODS

A descriptive study design was used to record the frequency of interruptions and their causes and to identify 'avoidable' interruptions in an intensive rehabilitation ward in Northern Italy. A data collection grid was used to record the data over a 6-month period.

RESULTS

A total of 3000 work hours were observed. During the study period 1170 interruptions were observed. The study identified 14 causes of interruption.

CONCLUSIONS

The study shows that of the 14 cases of interruptions at least nine can be defined as 'avoidable'. An improvement project has been proposed to reduce unnecessary interruptions and distractions to avoid making errors.

IMPLICATIONS FOR NURSING MANAGEMENT

An additional useful step to reduce the incidence of treatment errors would be to implement the use of a single patient medication sheet for the recording of drug prescription, preparation and administration and also the incident reporting.

The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland

INTRODUCTION

Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum.

AIM

The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland.

METHODS

A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time.

RESULTS

Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication classes included anti-pyretics and non-opioid analgesics, psychoanaleptics, and psychleptic agents. Approximately 97% (n = 2279) of medication errors were as a result of drug administration errors (comprising a double dose [n = 1040], wrong dose [n = 395], wrong medication [n = 597], wrong route [n = 133], and wrong time [n = 110]). Prescribing and dispensing errors accounted for 0.68% (n = 16) and 2.26% (n = 53) of errors, respectively.

CONCLUSION

Empirical data from poisons information centres facilitate the characterisation of medication errors occurring in the community and across the healthcare spectrum. Poison centre data facilitate the detection of subtle trends in medication errors and can contribute to pharmacovigilance. Collaboration between pharmaceutical manufacturers, consumers, medical, and regulatory communities is needed to advance patient safety and reduce medication errors.

Medication administration errors and the pediatric population: a systematic search of the literature

There are a variety of factors that make the pediatric population more susceptible to medication errors and potential complications resulting from medication administration including the availability of different dosage forms of the same medication, incorrect dosing, lack of standardized dosing regimen, and organ system maturity. A systematic literature search on medication administration errors in the pediatric population was conducted. Five themes obtained from the systematic literature search include incidence rate of medication administration errors; specific medications involved in medication administration errors and classification of the errors; why medication administration errors occur; medication error reporting; and interventions to reduce medication errors.

Medication errors in psychiatry: a comprehensive review

Medication errors are among the most common medical errors and cause significant morbidity and in some cases mortality. The objective of this article is to review the literature on medication errors in psychiatry. We completed a comprehensive search of both peer- and non-peer-reviewed articles that investigated medication errors in psychiatry. Our primary focus was to examine patient-, provider- and system-related factors that contributed to medication errors. Due to differences in research design and denominators used to determine error rates, the reported prevalence rates of medication errors in psychiatry vary widely. Patient-related factors identified as contributing to medication errors included non-adherence to medication, failure of patients to inform their various care providers about the medications they are taking and symptoms of psychiatric illnesses. Provider-related factors identified as contributing to medication errors were also identified and included clinical practices associated with prescribing, transcription, dispensing, administration and monitoring. Finally, the healthcare system also has a major role to play in reducing medication errors by ensuring seamless continuity of care, mandating medication reconciliation programmes, ensuring adequate clinical pharmacy services and supporting a nonpunitive medication error reporting system. Although the literature raises awareness of these specific contributing factors, there is still a great need for more systematic evaluations of the problem including root cause analysis. Medication errors in psychiatry have been studied almost exclusively in the inpatient setting and thus little is known about the incidence and significance in outpatient and community settings.

Factors determining hospital nurses' failures in reporting medication errors in Taiwan

This study examined factors that were determined to lead to failures in reporting medication administration errors (MAEs) for 838 frontline nurses from 5 teaching hospitals in Taiwan. The underreporting of these errors is a challenge to medication safety improvement. Results showed that 337 (47%) participating nurses had failed to report self- or coworker-MAEs and 376 nurses (52.4%) had not failed to report. The strongest predictors of the failure were experience of making MAEs, differences in attitude toward reporting self- and coworker-MAEs, and perceived MAE reporting rate in current work. The reporting barriers of fear, perception of nursing quality, and perception of nursing professional development significantly contributed to failure to report. Educating nurses about the goals of incident reporting systems and using MAE data to enhance patient safety culture is recommended. Further, hospital administrators should provide information and encouragement to nurses whose responsibility it is to report MAEs.

Medication error reporting and the work environment in a military setting

This study examined nurses' reasons for medication errors, reasons for not reporting errors, and perceived unit-reporting practices. It compared nurses' anonymous reports of medication errors with those from institutional reporting mechanisms. Qualities of the work environment, staffing, and workload were evaluated to determine associations with perceived error-reporting practices. The study findings have immediate applicability as a baseline for system improvements.

A literature review of the individual and systems factors that contribute to medication errors in nursing practice

AIM

This paper reports a review of the empirical literature on factors that contribute to medication errors.

BACKGROUND

Medication errors are a significant cause of morbidity and mortality in hospitalized patients. This creates an imperative to reduce medication errors to deliver safe and ethical care to patients.

METHOD

The databases CINAHL, PubMed, Science Direct and Synergy were searched from 1988 to 2007 using the keywords medication errors, medication management, medication reconciliation, medication knowledge and mathematical skills, and reporting medication errors. RESULTS Contributory factors to nursing medication errors are manifold, and include both individual and systems issues. These include medication reconciliation, the types of drug distribution system, the quality of prescriptions, and deviation from procedures including distractions during administration, excessive workloads, and nurse's knowledge of medications.

IMPLICATIONS FOR NURSING MANAGEMENT

It is imperative that managers implement strategies to reduce medication errors including the establishment of reporting mechanisms at international and national levels to include the evaluation and audit of practice at a local level. Systematic approaches to medication reconciliation can also reduce medication error significantly. Promoting consistency between health care professionals as to what constitutes medication error will contribute to increased accuracy and compliance in reporting of medication errors, thereby informing health care policies aimed at reducing the occurrence of medication errors. Acquisition and maintenance of mathematical competency for nurses in practice is an important issue in the prevention of medication error. The health care industry can benefit from learning from other high-risk industries such as aviation in the prevention and management of systems errors.

Willingness of nurses to report medication administration errors in southern Taiwan: a cross-sectional survey

BACKGROUND

Underreporting of medication administering errors (MAEs) is a threat to the quality of nursing care. The reasons for MAEs are complex and vary by health professional and institution.

AIMS

The purpose of this study was to explore the prevalence of MAEs and the willingness of nurses to report them.

METHODS

A cross-sectional study was conducted involving a survey of 14 medical surgical hospitals in southern Taiwan. Nurses voluntarily participated in this study. A structured questionnaire was completed by 605 participants. Data were collected from February 1, 2005 to March 15, 2005 using the following instruments: MAEs Unwillingness to Report Scale, Medication Errors Etiology Questionnaire, and Personal Features Questionnaire. One additional question was used to identify the willingness of nurses to report medication errors: "When medication errors occur, should they be reported to the department?" This question helped to identify the willingness or lack thereof, to report incident errors.

RESULTS

The results indicated that 66.9% of the nurses reported experiencing MAEs and 87.7% of the nurses had a willingness to report the MAEs if there were no consequences for reporting. The nurses' willingness to report MAEs differed by job position, nursing grade, type of hospital, and hospital funding. The final logistic regression model demonstrated hospital funding to be the only statistically significant factor. The odds of a willingness to report MAEs increased 2.66-fold in private hospitals (p = 0.032, CI = 1.09 to 6.49), and 3.28 in nonprofit hospitals (p = 0.00, CI = 1.73 to 6.21) when compared to public hospitals.

CONCLUSIONS

This study demonstrates that reporting of MAEs should be anonymous and without negative consequences in order to monitor and guide improvements in hospital medication systems.

Safety and protection for hospitalized children: literature review

This narrative-descriptive review is about the safety/protection of hospitalized children who, due to their fragility, vulnerability and peculiar growth and development conditions need special attention from health professionals. This study aimed to identify knowledge production on safety, protection and violence to hospitalized children between 1997 and 2007. In total, 15 national and international articles were analyzed, using the key words: hospitalized child, safety, violence and nursing. This qualitative approach enabled the development of four categories: adverse occurrences; medication errors; notification of adverse occurrences; and safety of pediatric patients. Results indicate the need to develop strategies to reduce the probability of these events occurring during children's hospitalization, so that they do not suffer any problem neither violation of their fundamental rights.

Factors affecting incident reporting by registered nurses: the relationship of perceptions of the environment for reporting errors, knowledge of the nursing practice act, and demographics on intent to report errors

Patient safety has assumed an international focus. In the past, the focus on detecting and preventing errors was up to the individual clinician, often the registered nurse. With impetus from the Institute of Medicine and other national agencies, a shift to emphasis on systems and processes and near miss and error reporting has occurred. Information from caregiver reporting has taken on new importance. This study was conducted to explore nurses' willingness to report errors of varying degrees of severity and the factors that impacted that intent. Registered nurses were selected randomly from the Texas Board of Nurse Examiners' roster and surveyed regarding perceptions of the environment for reporting, perceptions of reasons for not reporting, knowledge of the nursing practice act, and demographic variables. A majority of nurses were willing to report all levels of errors. Primary position, reasons for not reporting, and years since initial licensure were predictors of intent to report incidents with no injury and those with minimal injury. All but four nurses (99%) indicated that they would report incidents resulting in moderate to severe injury or death.

Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit

Adverse event reporting is a key element for improving patient safety. This study describes a new voluntary, anonymous reporting system that facilitates reporting of near-miss and patient harm events and an assessment of patient harm by the bedside care provider in a pediatric intensive care unit. The results demonstrated the effectiveness of the Patient Safety Report as a method to capture near-miss and patient harm events.

Preventable harm occurring to critically ill children

OBJECTIVE

To develop a trigger tool for identifying adverse events occurring in critically ill pediatric patients; to identify and characterize adverse events and preventable adverse events experienced by critically ill pediatric patients; and to characterize the patients who experience preventable adverse events.

DESIGN

Retrospective chart review using a trigger tool.

SETTING

Pediatric intensive care unit of a tertiary, university-affiliated pediatric hospital.

PATIENTS

A systematic sample of 259 pediatric intensive care unit patients from a 1-yr period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured frequency of occurrence (0.19 preventable adverse events per patient-day), severity of harm (78% minor, 19% moderate, 3% serious, no deaths), and type of event (sedation, 22%; skin, 16%; medical device complication, 14%; pulmonary, 13%; and cardiovascular, 11%). Patients who experienced preventable adverse events were younger, had longer lengths of stay, and had higher illness burdens. Preventable adverse events occurred more frequently among surgical patients than medical patients.

CONCLUSIONS

Preventable adverse events occurred fairly frequently in the pediatric intensive care unit, but serious harm was rare. Conditions that increased the likelihood of a preventable adverse event were a) need for sedation or pain control; b) relative immobility; and c) need for vascular devices, feeding tubes, or ventilators. Adverse event prevention strategies that focus on improving patient monitoring under increased-risk conditions and improving early detection and treatment of potential harm will likely be more effective than strategies aimed at general error prevention.

A review of medical error reporting system design considerations and a proposed cross-level systems research framework

OBJECTIVE

To review the literature on medical error reporting systems, identify gaps in the literature, and present an integrative cross-level systems model of reporting to address the gaps and to serve as a framework for understanding and guiding reporting system design and research.

BACKGROUND

Medical errors are thought to be a leading cause of death among adults in the United States. However, no review exists summarizing what is known about the barriers and facilitators for successful reporting systems, and no integrated model exists to guide further research into and development of medical error reporting systems.

METHOD

Relevant literature was identified using online databases; references in relevant articles were searched for additional relevant articles.

RESULTS

The literature review identified components of medical error reporting systems, error reporting system design choices, barriers and incentives for reporting, and suggestions for successful reporting system design. Little theory was found to guide the published research. An integrative cross-level model of medical error reporting system design was developed and is proposed as a framework for understanding the medical error reporting literature, addressing existing limitations, and guiding future design and research.

CONCLUSION

The medical error reporting research provides some guidance for designing and implementing successful reporting systems. The proposed cross-level systems model provides a way to understand this existing research. However, additional research is needed on reporting and related safety actions. The proposed model provides a framework for such future research.

APPLICATION

This work can be used to guide the design, implementation, and study of medical error reporting systems.

Health care work environments, employee satisfaction, and patient safety: Care provider perspectives

BACKGROUND

Experts continue to decry the lack of progress made in decreasing the alarming frequency of medical errors in health care organizations (Leape, L. L., & Berwick, D. M. (2005). Five years after to err is human: What have we learned?. Journal of the American Medical Association, 293(19), 2384-2390). At the same time, other experts are concerned about the lack of job satisfaction and turnover among nurses (. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press). Research and theory suggest that a work environment that facilitates patient-centered care should increase patient safety and nurse satisfaction.

PURPOSES

The present study began with a conceptual model that specifies how work environment variables should be related to both nurse and patient outcomes. Specifically, we proposed that health care work units with climates for patient-centered care should have nurses who are more satisfied with their jobs. Such units should also have higher levels of patient safety, with fewer medication errors.

METHODOLOGY/APPROACH

We examined perceptions of nurses from three acute care hospitals in the eastern United States.

FINDINGS

Nurses who perceived their work units as more patient centered were significantly more satisfied with their jobs than were those whose units were perceived as less patient centered. Those whose work units were more patient centered reported that medication errors occurred less frequently in their units and said that they felt more comfortable reporting errors and near-misses than those in less patient-centered units.

PRACTICE IMPLICATIONS

Patients and quality leaders continue to call for delivery of patient-centered care. If climates that facilitate such care are also related to improved patient safety and nurse satisfaction, proactive, patient-centered management of the work environment could result in improved patient, employee, and organizational outcomes.

Systematic review of medication errors in pediatric patients

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Safety Culture in a Childrenʼs Hospital

Efforts to improve patient safety require an understanding of organizational culture. In a survey of inpatient healthcare providers in a children's hospital, physician perceptions of teamwork were higher than those of all other staff (P < .001). Recognition of the impact of stress and fatigue was low, and job satisfaction was high for all groups. A majority of respondents did not feel rewarded for incident reporting. Information on hospital-level safety culture can lead to targeted system improvement.

Improving Medication Calculation Skills of Practicing Nurses and Senior Nursing Students

Medication administration is an essential nursing competency as calculation difficulties can lead to serious medication errors. Nurses involved in staff education need to be aware of methods to assess for computation difficulty and develop strategies for nurses to improve their computation abilities. The purposes of this quasi-experimental pilot study were to assess the medication calculation skills of nurses and nursing students and to determine the effectiveness of teaching strategies aimed at improving these skills.

The ethics and practical importance of defining, distinguishing and disclosing nursing errors: A discussion paper

Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of 'nursing error', the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of 'nursing error' fits with the new 'system approach' to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is 'right' for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients

OBJECTIVE

To determine if combining standard drug concentrations with "smart-pump" technology reduces reported medication-infusion errors.

DESIGN

Preintervention and postintervention comparison of reported medication errors related to infusion therapies during the calendar years 2002 and 2003.

SETTING

A 242-bed university-affiliated tertiary pediatric hospital.

INTERVENTION

Change in continuous-medication-infusion process, comprising the adoption of (1) standard drug concentrations, (2) "smart" syringe pumps, and (3) human-engineered medication labels.

MAIN OUTCOME MEASURES

Comparison of reported continuous-medication-infusion errors before and after the intervention.

RESULTS

The number of reported errors dropped by 73% for an absolute risk reduction of 3.1 to 0.8 per 1000 doses. Preparation errors that occurred in the pharmacy decreased from 0.66 to 0.16 per 1000 doses; the number of 10-fold errors in dosage decreased from 0.41 to 0.08 per 1000 doses.

CONCLUSIONS

The use of standard drug concentrations, smart syringe pumps, and user-friendly labels reduces reported errors associated with continuous medication infusions. Standard drug concentrations can be chosen to allow most neonates to receive needed medications without concerns related to excess fluid administration.

Reporting of medication errors by pediatric nurses

Medication administration errors can threaten patient outcomes and are a dimension of patient safety directly linked to nursing care. Children are particularly vulnerable to medication errors because of their unique physiology and developmental needs. This descriptive study surveyed a convenience sample of 57 pediatric and 227 adult hospital nurses regarding their perceptions of the proportion of medication errors reported on their units, why medication errors occur, and why medication errors are not always reported. In this study, which focuses on pediatric data, pediatric nurses indicated that a higher proportion of errors were reported (67%) than adult nurses indicated (56%). The medication error rates per 1,000 patient-days computed from actual occurrence reports were also higher on pediatric (14.80) as compared with adult units (5.66). Pediatric nurses selected distractions/interruptions and RN-to-patient ratios as major reasons medication errors occurred. Nursing administration's focus on the person rather than the system and the fear of adverse consequences (reprimand) were primary reasons selected for not reporting medication errors. Results suggest the need to explore both individual and systematic safeguards to focus on the reported causes and underreporting of medication errors.

Discrepancies between ordered and delivered concentrations of opiate infusions in critical care

OBJECTIVES

We sought to test the assumption that the measured concentrations of medication infusions are within pharmaceutical standards (+/-10% of intended concentrations) and whether, at the time the infusion was mixed, the professional background of persons preparing the infusion or the unit for which the infusion was prepared were related to the observed variation.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, observational study was conducted in the neonatal and pediatric intensive care units of a university-affiliated tertiary pediatric center. Morphine infusions prepared for clinical use were randomly sampled over a 7-month period. Those with no error between labeled and ordered concentration were further analyzed. High-performance liquid chromatography was used to determine the concentration of morphine infusions. The primary outcome was a difference of >10% between ordered and measured concentrations.

MEASUREMENTS AND MAIN RESULTS

The measured concentration of 65% of the 232 infusions was >10% different from the ordered concentration (95% confidence interval, 58-71%). The concentrations of 6% of infusions represented two-fold errors (95% confidence interval, 3-9%). The difference was normally distributed around zero, suggesting a cumulative effect of random errors, rather than a systematic bias. The time that the infusion was prepared, the professional background of the persons preparing the infusion, and the unit for which the infusion was mixed were not significant predictors of discrepancy (p =.74, analysis of variance).

CONCLUSIONS

The concentration of two thirds of infusions prepared for clinical use was outside accepted industry standards. These findings are likely to be broadly representative of intravenous drug administration in hospitalized children and pediatric pharmacokinetic studies. Further study of the causes and clinical impact is required.

Adverse events in drug administration: a literature review

Discussions between the children's services manager at an National Health Service trust, and a children's nursing lecturer from the trust's partnering university clarified that there was a need to establish a greater understanding of the local circumstances surrounding adverse events in drug administration - particularly when those events involved nurses. Indeed it is claimed that nurses spend up to 40% of their time administering drugs. It was agreed that a collaborative research study, specifically designed to explore the nature of drug administration errors, could inform future trust policies and procedures around both drug administration and error, as well as the various university curricula concerning drug administration. This study, supported by senior management in the trust, and the chair of the local research ethics committee, has commenced. The first part of this study -- an introductory literature review, is presented here. The work of O'Shea [J Clin Nurs (1999)8:496-504] is significant in structuring the review that bears a number of recurring themes. It is not the intention of this literature review to reappraise O'Shea's original critique but to expand on her work, offer a contemporaneous perspective in the light of studies and reports published since 1999, and reset the topic in the context of clinical governance. This literature review has already provided an underpinning framework for a pilot questionnaire to staff who have been involved in drug administration errors and is also the basis for curricular input to preregistration students on the subject of risk management and drug administration. In conclusion, several recommendations about the shape of future research are offered.