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Henry Basil J, Premakumar CM, Mhd Ali A, Mohd Tahir NA, Seman Z, Voo JYH, Ishak S, Mohamed Shah N. Prevalence and factors associated with medication administration errors in the neonatal intensive care unit: A multicentre, nationwide direct observational study. J Adv Nurs 2024. [PMID: 38803148 DOI: 10.1111/jan.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
AIM(S) To determine the prevalence of medication administration errors and identify factors associated with medication administration errors among neonates in the neonatal intensive care units. DESIGN Prospective direct observational study. METHODS The study was conducted in the neonatal intensive care units of five public hospitals in Malaysia from April 2022 to March 2023. The preparation and administration of medications were observed using a standardized data collection form followed by chart review. After data collection, error identification was independently performed by two clinical pharmacists. Multivariable logistic regression was used to identify factors associated with medication administration errors. RESULTS A total of 743 out of 1093 observed doses had at least one error, affecting 92.4% (157/170) neonates. The rate of medication administration errors was 68.0%. The top three most frequently occurring types of medication administration errors were wrong rate of administration (21.2%), wrong drug preparation (17.9%) and wrong dose (17.0%). Factors significantly associated with medication administration errors were medications administered intravenously, unavailability of a protocol, the number of prescribed medications, nursing experience, non-ventilated neonates and gestational age in weeks. CONCLUSION Medication administration errors among neonates in the neonatal intensive care units are still common. The intravenous route of administration, absence of a protocol, younger gestational age, non-ventilated neonates, higher number of medications prescribed and increased years of nursing experience were significantly associated with medication administration errors. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The findings of this study will enable the implementation of effective and sustainable interventions to target the factors identified in reducing medication administration errors among neonates in the neonatal intensive care unit. REPORTING METHOD We adhered to the STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION An expert panel consisting of healthcare professionals was involved in the identification of independent variables.
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Affiliation(s)
- Josephine Henry Basil
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chandini Menon Premakumar
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adliah Mhd Ali
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Ain Mohd Tahir
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Zamtira Seman
- Sector for Biostatistics & Data Repository, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - James Yau Hon Voo
- Department of Pharmacy, Hospital Duchess of Kent, Ministry of Health Malaysia, Sabah, Malaysia
| | - Shareena Ishak
- Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noraida Mohamed Shah
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Konwinski L, Steenland C, Miller K, Boville B, Fitzgerald R, Connors R, Sterling E, Stowe A, Rajasekaran S. Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach. J Patient Saf 2024; 20:209-215. [PMID: 38231892 DOI: 10.1097/pts.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVES The goal of this human factors engineering-led improvement initiative was to examine whether the independent double check (IDC) during administration of high alert medications afforded improved patient safety when compared with a single check process. METHODS The initiative was completed at a 24-bed pediatric intensive care unit and included all patients who were on the unit and received a medication historically requiring an IDC. The total review examined 37,968 high-risk medications administrations to 4417 pediatric intensive care unit patients over a 40-month period. The following 5 measures were reviewed: (1) rates of reported medication administration events involving IDC medications; (2) hospital length of stay; (3) patient mortality; (4) nurses' favorability toward single checking; and (5) nursing time spent on administration of IDC medications. RESULTS The rate of reported medication administration events involving IDC medications was not significantly different across the groups (95% confidence interval, 0.02%-0.08%; P = 0.4939). The intervention also did not significantly alter mortality ( P = 0.8784) or length of stay ( P = 0.4763) even after controlling for the patient demographic variables. Nursing favorability for single checking increased from 59% of nurses in favor during the double check phase, to 94% by the end of the single check phase. Each double check took an average of 9.7 minutes, and a single check took an average of 1.94 minutes. CONCLUSIONS Our results suggest that performing independent double checks on high-risk medications administered in a pediatric ICU setting afforded no impact on reported medication events compared with single checking.
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Affiliation(s)
- Leah Konwinski
- From the Department of Quality, Safety and Experience, Corewell Health
| | | | | | | | | | - Robert Connors
- Corewell Health Helen DeVos Children's Hospital (hospital president at time of review)
| | | | - Alicia Stowe
- Office of Research and Education, Corewell Health, Grand Rapids, Michigan
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Alyami MH, Naser AY, Alswar HS, Alyami HS, Alyami AH, Al Sulayyim HJ. Medication errors in Najran, Saudi Arabia: reporting, responsibility, and characteristics: a cross-sectional study. Saudi Pharm J 2022; 30:329-336. [PMID: 35527831 PMCID: PMC9068573 DOI: 10.1016/j.jsps.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022] Open
Abstract
Background Medication error is a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient. Disclosure of medication errors and improvement of patient safety are inexorably related, and they provide one of the strongest reasons to report and disclose errors, including near misses in which no harm comes to the patient. This study aimed to identify medication errors at the southern province of Saudi Arabia. Methods A cross-sectional retrospective study was conducted by reviewing all medical records in the King Khaled Hospital in Najran, Saudi Arabia. Medication errors related information were extracted from the electronic medical system for the duration between 2018 and 2020. Results During the study period of 2018 to 2020, a total of 4860 medication errors were identified. More than half of the reported medication errors (66.9%) were linked to ordering, prescribing, or transcribing medications. The most commonly reported medication errors connected to ordering/prescribing/transcribing were inappropriate dosage, dosage units, and therapeutic duplication of medication. The most commonly reported medication errors linked to administration were missing documentation during administration, not performing independent double-checks during the administration of high alert medications, and the administration of look-alike sound-alike (LASA) medications. The intensive care unit (ICU), female medical ward, and male medical ward were the most commonly reported locations for medication errors. Pharmacists detected more than half of the reported medication errors. Physicians were found to be responsible for 66.0% of reported medication errors, followed by nurses. Conclusion Medication errors are common in hospital settings in Saudi Arabia's southern provinces. Efforts should be made to improve drug ordering, prescribing, and transcription in hospital settings. To guarantee optimum practices, the entire medical team should take responsibility for the patient's optimal medication administration.
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Lew SQ, Cheng YL, Tzamaloukas AH, Ing TS. A new approach to individualize dialysis fluid sodium concentration using a four-stream, bicarbonate-based fluid delivery system. Artif Organs 2021; 45:779-783. [PMID: 33534933 DOI: 10.1111/aor.13929] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 11/28/2022]
Abstract
We propose a new 45X, four-stream, triple-concentrate, bicarbonate-based dialysis fluid delivery system, allowing a wide range of dialysis fluid sodium concentrations\\ (DFNa ) without affecting the concentrations of other crucial solutes. The four streams consist of product water (W), and concentrates with sodium chloride (S), acid (A), and sodium bicarbonate (B). An adjustment in the DFNa in this new system requires changes only in the W and S concentrate streams. The ingredients in A and B concentrates do not change.
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Affiliation(s)
- Susie Q Lew
- Department of Medicine, George Washington University, Washington, DC, USA
| | - Yuk-Lun Cheng
- Department of Medicine and ICU, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Antonios H Tzamaloukas
- Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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Treiber LA, Jones JH. After the Medication Error: Recent Nursing Graduates' Reflections on Adequacy of Education. J Nurs Educ 2018; 57:275-280. [PMID: 29718516 DOI: 10.3928/01484834-20180420-04] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/13/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this study was to better understand individual- and system-level factors surrounding making a medication error from the perspective of recent Bachelor of Science in Nursing graduates. METHOD Online survey mixed-methods items included perceptions of adequacy of preparatory nursing education, contributory variables, emotional responses, and treatment by employer following the error. RESULTS Of the 168 respondents, 55% had made a medication error. Errors resulted from inexperience, rushing, technology, staffing, and patient acuity. Twenty-four percent did not report their errors. Key themes for improving education included more practice in varied clinical areas, intensive pharmacological preparation, practical instruction in functioning within the health care environment, and coping after making medication errors. CONCLUSION Errors generally caused emotional distress in the error maker. Overall, perceived treatment after the error reflected supportive environments, where nurses were generally treated with respect, fair treatment, and understanding. Opportunities for nursing education include second victim awareness and reinforcing professional practice standards. [J Nurs Educ. 2018;57(5):275-280.].
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Reis MASD, Gabriel CS, Zanetti ACB, Bernardes A, Laus AM, Pereira LRL. MEDICAMENTOS POTENCIALMENTE PERIGOSOS: IDENTIFICAÇÃO DE RISCOS E BARREIRAS DE PREVENÇÃO DE ERROS EM TERAPIA INTENSIVA. TEXTO & CONTEXTO ENFERMAGEM 2018. [DOI: 10.1590/0104-07072018005710016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: investigar o conhecimento dos profissionais de enfermagem e farmacêuticos em relação à identificação de medicamentos potencialmente perigosos, bem como verificar o reconhecimento das barreiras de prevenção de erros nas instituições hospitalares. Método: estudo transversal, tipo inquérito, realizado em unidades de terapia intensiva de quatro hospitais. Um questionário construído e validado com base nas informações disponibilizadas pelo Instituto para Práticas Seguras no Uso de Medicamentos foi utilizado para coleta de dados. Para análise dos dados utilizou-se o software Statistical Package for the Social Sciences, versão 22.0 e o teste de Kruskal-Wallis para investigar diferença dos resultados entre as categorias profissionais. Adotou-se o nível significância de 0,05. Resultados: foram incluídos 126 profissionais, entre os elegíveis para participação. Dentre os 33 medicamentos potencialmente perigosos indicados no instrumento, nenhum foi identificado como tal pela totalidade de respondentes, embora 17 fossem utilizados por mais de 95% dos entrevistados. Não foi observada diferença estatisticamente significante nas respostas das diferentes categorias profissionais quanto à identificação desses medicamentos. Em relação às medidas de prevenção de erros, os enfermeiros constituíram a categoria profissional que distinguiu em maior número a existência de barreiras. Conclusão: este estudo apontou importantes lacunas no reconhecimento dos medicamentos potencialmente perigosos e adoção incipiente de barreiras para prevenção de incidentes, caracterizando situações de fragilidade nos hospitais por implicar na ruptura inicial das barreiras, especialmente quando os profissionais de saúde estão inseridos em um ambiente de alta complexidade.
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Wong SSM, Kwaan HC, Ing TS. Venous air embolism related to the use of central catheters revisited: with emphasis on dialysis catheters. Clin Kidney J 2017; 10:797-803. [PMID: 29225809 PMCID: PMC5716215 DOI: 10.1093/ckj/sfx064] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/26/2017] [Indexed: 12/21/2022] Open
Abstract
Venous air embolism is a dreaded condition particularly relevant to the field of nephrology. In the face of a favourable, air-to-blood pressure gradient and an abnormal communication between the atmosphere and the veins, air entrance into the circulation is common and can bring about venous air embolism. These air emboli can migrate to different areas through three major routes: pulmonary circulation, paradoxical embolism and retrograde ascension to the cerebral venous system. The frequent undesirable outcome of this disease entity, despite timely and aggressive treatment, signifies the importance of understanding the underlying pathophysiological mechanism and of the implementation of various preventive measures. The not-that-uncommon occurrence of venous air embolism, often precipitated by improper patient positioning during cervical catheter procedures, suggests that awareness of this procedure-related complication among health care workers is not universal. This review aims to update the pathophysiology of venous air embolism and to emphasize the importance of observing the necessary precautionary measures during central catheter use in hopes of eliminating this unfortunate but easily avoidable mishap in nephrology practice.
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Affiliation(s)
- Steve Siu-Man Wong
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Hau C Kwaan
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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Feng XQ, Zhu LL, Zhou Q. The checking methods before medication administration: A perspective from a Joint Commission International-accredited academic medical center hospital in China. J Eval Clin Pract 2017; 23:676-678. [PMID: 28026088 DOI: 10.1111/jep.12684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Xiu-Qin Feng
- Division of Nursing, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Ling-Ling Zhu
- Division of Nursing, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Quan Zhou
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
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Abstract
RATIONALE, AIMS AND OBJECTIVES Double checking is a standard practice in many areas of health care, notwithstanding the lack of evidence supporting its efficacy. We ask in this study: 'How do front line practitioners conceptualize double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?' METHOD This is part of a larger qualitative study based on 85 semi-structured interviews of health care practitioners in general internal medicine and obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. RESULTS Weaknesses in the double checking process include inconsistent conceptualization of double checking, double (or more) checking as a costly and time-consuming procedure, double checking trusted as an accepted and stand-alone process, and double checking as preventing reporting of near misses. Alternate views of double checking that would render it a more robust process include recognizing that double checking requires training and a dedicated environment, Introducing automated double checking, and expanding double checking beyond error detection. These results are linked with the concepts of collective efficiency thoroughness trade off (ETTO), an in-family approach, and resilience. CONCLUSION(S) Double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged.
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Affiliation(s)
- Tanya Hewitt
- Population Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Samia Chreim
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Forster
- Faculty of Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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