Frequency of pediatric medication administration errors and contributing factors

Evaluation of the impact of pharmaceutical trainings and tools on the proper use of medicines in pediatrics

Introduction: After six years of medication errors' (MEs) collection and analysis in a pediatric unit of a French University Hospital, the number of MEs was no longer decreasing. We then decided to set up pharmaceutical training and tools and evaluate their impact on the occurrence of ME. Materials and methods: This monocentric prospective study was carried out in the form of audits of prescriptions, preparations, and administrations before and after intervention (A1 and A2). After the analysis of A1 results, feedback was given to the teams, some tools for the proper use of medication (PUM) were distributed, and A2 was conducted. Finally, A1 and A2 results were compared. Results: Each audit included 202 observations. A total of 120 MEs were identified during A1 and 54 for A2 (p < 0.0001). The observation rate with at least 1 ME decreased from 39.11% to 21.29% (p < 0.0001), and no observation had more than two MEs during A2 in contrast to A1 (n = 12). Human factors were responsible for the majority of MEs. The audit feedback allowed professionals to feel concerned about ME. The PUM tools received an average satisfaction rating of 9/10. The staff had never participated in this type of training, and all felt it was useful to apply PUM. Conclusion: This study showed a significant impact of pharmaceutical training and tools on the pediatric PUM. Clinical pharmaceutic actions allowed us to reach our objectives and satisfied all the staff. They must, therefore, be continued to limit human factors' impact and thus contribute to the safety of drug management in pediatrics.

Safety Considerations for the Inpatient Medication-Use Process in Pediatric and Neonatal Patients

The delivery of safe and effective healthcare to pediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events.1 This review will explore the medication-use system for hospitalized children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the pediatric medication-use system.

The effect of the clinical nurses' compassion levels on tendency to make medical error: A cross-sectional study

BACKGROUND

Compassion is considered the cornerstone of nursing practices and professionalism. However, a decrease in compassion may increase medical errors and adversely affect patient safety.

AIMS

The study was conducted to determine clinical nurses' compassion levels and their tendency to make medical errors, and to find whether their compassion levels affect their tendency to make medical errors.

METHODS

A cross-sectional, descriptive and correlational design was used. The study was conducted with 309 nurses working at a university hospital. The study data were collected by using the Compassion Scale and Medical Error Tendency Scale in Nursing.

RESULTS

The nurses' compassion levels were moderate, and their medical error tendency levels were low. The comparison of the mean scores obtained from the Compassion Scale and Medical Error Tendency Scale in Nursing revealed a weak positive significant relationship (p < .001). No statistically significant difference was determined between the mean scores obtained from the Compassion Scale by the participants who made medical errors at least once during their professional life and the mean scores obtained by the participants who did not (p > .05). It was found that the mean score for the mindfulness subscale of the Compassion Scale and the length of service were determined to be the factors that significantly affected the participants' tendency to make medical errors (R = 0.42, R² = 0.181, F = 3.771, p = .000).

CONCLUSION

The nurses' tendency to make medical errors decreased as their compassion levels increased, and that compassion was an important predictor of tendency to make medical errors.

Nurses' Perceived Causes of Medication Administration Errors: A Qualitative Systematic Review

BACKGROUND

Medication administration errors (MAEs) are a critical patient safety issue. Nurses are often responsible for administering medication to patients, thus their perceptions of causes of errors can provide valuable guidance for the development of interventions aimed to mitigate errors. Quantitative research can overlook less overt causes; therefore, a qualitative systematic review was conducted to present a synthesis of qualitative evidence of nurses' perceived causes of MAEs.

METHODS

Publications from 2000 to February 2019 were searched using four electronic databases. Inclusion criteria were articles that (1) presented results from studies that used a qualitative or mixed methods design, (2) reported qualitative data on nurses' perceived causes of MAEs in health care settings, and (3) were published in the English language. Sixteen individual articles satisfied the inclusion criteria. Methodological quality of each article was assessed using the Critical Appraisal Skills Programme (CASP) tool. Thematic analysis of the data was performed. Perceived causes of errors were labeled as knowledge-based, personal, and contextual factors.

RESULTS

The primary knowledge-based factor was lack of medication knowledge. Personal factors included fatigue and complacency. Contextual factors included heavy workloads and interruptions. Contextual factors were reported in all the studies reviewed and were often interconnected with personal and knowledge-based factors.

CONCLUSION

Causes of MAEs are perceived by nurses to be multifactorial and interconnected and often stem from systems issues. Multifactorial interventions aimed at mitigating medication errors are required with an emphasis on systems changes. Findings in this review can be used to guide efforts aimed at identifying and modifying factors contributing to MAEs.

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 Prevalence of Dose Errors Among Paediatric Patients in Hospital Wards with and without Health Information Technology: A Systematic Review and Meta-Analysis

INTRODUCTION

The risk of dose errors is high in paediatric inpatient settings. Computerized provider order entry (CPOE) systems with clinical decision support (CDS) may assist in reducing the risk of dosing errors. Although a frequent type of medication error, the prevalence of dose errors is not well described. Dosing error rates in hospitals with or without CPOE have not been compared.

OBJECTIVE

Our aim was to conduct a systematic review assessing the prevalence and impact of dose errors in paediatric wards with and without CPOE and/or CDS.

METHODS

We systematically searched five databases to identify studies published between January 2000 and December 2017 that assessed dose error rates by medication chart audit or direct observation.

RESULTS

We identified 39 studies, nine of which involved paediatric wards using CPOE with or without CDS. Studies of paediatric wards using paper medication charts reported approximately 8-25% of patients experiencing a dose error, and approximately 2-6% of medication orders and approximately 3-8% of dose administrations contained a dose error, with estimates varying by ward type. The nine studies of paediatric wards using CPOE reported approximately 22% of patients experiencing a dose error, and approximately 1-6% of medication orders and approximately 3-8% of dose administrations contained a dose error. Few studies provided data for individual wards. The severity and prevalence of harm associated with dose errors was rarely assessed and showed inconsistent results.

CONCLUSIONS

Dose errors occur in approximately 1 in 20 medication orders. Hospitals using CPOE with or without CDS had a lower rate of dose errors compared with those using paper charts. However, few pre/post studies have been conducted and none reported a significant reduction in dose error rates associated with the introduction of CPOE. Future research employing controlled designs is needed to determine the true impact of CPOE on dosing errors among children, and any associated patient harm.

Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units

Purpose

To determine the type, frequency, and factors associated with medication preparation and administration errors in adult intensive care units (ICUs) and neonatal ICUs (NICUs)/pediatric ICUs (PICUs).

Patients and methods

We conducted a prospective direct observation study in an adult ICU and NICU/PICU in a tertiary university hospital. Between June 2012 and June 2013, a clinical pharmacist and medical student observed the nursing care staff on weekdays during the preparation and administration of intravenous drugs. We analyzed the frequency and type of preparation and administration errors and factors associated with errors.

Results

Six hundred and three preparations in the adult ICU and 281 in the NICU/PICU were observed. Three hundred and eighty-five errors occurred in the adult ICU and 38 in the NICU/PICU. There were 5,040 and 2,514 error opportunities, with overall error rates of 7.6% and 1.5%, respectively. The total opportunities for error meant each single step of preparation and administration that was relevant for the drug. Most errors applied to the category “uniform mixing” (adult ICU: n=227, 59%; NICU/PICU: n=14, 37%). The multivariate logistic regression results showed a significantly different influence of the “preparation type” for the adult ICU compared with the NICU/PICU with regard to the occurrence of an error. Preparations for adult patients of the LCD type (liquid concentrate with diluent into syringe or infusion bag) were more often associated with errors than the P (powder in a glass vial that must be reconstituted and diluted if necessary), P=0.012, and LC (liquid concentrate into syringe), P=0.002 type.

Conclusion

“Uniform mixing” was the most erroneous preparation step in intravenous drug preparations in two ICUs. Improvement of nurse training and the preparation of prefilled syringes in the pharmacy might reduce errors and improve the quality and safety of drug therapy.

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff

Objective

Medication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England.

Methods

Registered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants’ experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason’s model of accident causation.

Results

A total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication.

Conclusions

To our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent ‘system’ failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational ‘systems’ failures to reduce error.

Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana

OBJECTIVES

This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana.

METHODS

This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes.

RESULTS

Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems.

CONCLUSIONS

This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.

Pediatric Nurses' Perceptions of Medication Safety and Medication Error: A Mixed Methods Study

This study aims to outline the current workplace culture of medication practice in a pediatric medical ward. The objective is to explore the perceptions of nurses in a pediatric clinical setting as to why medication administration errors occur. As nurses have a central role in the medication process, it is essential to explore nurses' perceptions of the factors influencing the medication process. Without this understanding, it is difficult to develop effective prevention strategies aimed at reducing medication administration errors. Previous studies were limited to exploring a single and specific aspect of medication safety. The methods used in these studies were limited to survey designs which may lead to incomplete or inadequate information being provided. This study is phase 1 on an action research project. Data collection included a direct observation of nurses during medication preparation and administration, audit based on the medication policy, and guidelines and focus groups with nursing staff. A thematic analysis was undertaken by each author independently to analyze the observation notes and focus group transcripts. Simple descriptive statistics were used to analyze the audit data. The study was conducted in a specialized pediatric medical ward. Four key themes were identified from the combined quantitative and qualitative data: (1) understanding medication errors, (2) the busy-ness of nurses, (3) the physical environment, and (4) compliance with medication policy and practice guidelines. Workload, frequent interruptions to process, poor physical environment design, lack of preparation space, and impractical medication policies are identified as barriers to safe medication practice. Overcoming these barriers requires organizations to review medication process policies and engage nurses more in medication safety research and in designing clinical guidelines for their own practice.

Effects of sharing information on drug administration errors in pediatric wards: a pre-post intervention study

BACKGROUND AND PURPOSE

Drug administration errors are more likely to reach the patient than other medication errors. The main aim of this study was to determine whether the sharing of information on drug administration errors among health care providers would reduce such problems.

PATIENTS AND METHODS

This study involved direct, undisguised observations of drug administrations in two pediatric wards of a major teaching hospital in Kuala Lumpur, Malaysia. This study consisted of two phases: Phase 1 (pre-intervention) and Phase 2 (post-intervention). Data were collected by two observers over a 40-day period in both Phase 1 and Phase 2 of the study. Both observers were pharmacy graduates: Observer 1 just completed her undergraduate pharmacy degree, whereas Observer 2 was doing her one-year internship as a provisionally registered pharmacist in the hospital under study. A drug administration error was defined as a discrepancy between the drug regimen received by the patient and that intended by the prescriber and also drug administration procedures that did not follow standard hospital policies and procedures. Results from Phase 1 of the study were analyzed, presented and discussed with the ward staff before commencement of data collection in Phase 2.

RESULTS

A total of 1,284 and 1,401 doses of drugs were administered in Phase 1 and Phase 2, respectively. The rate of drug administration errors reduced significantly from Phase 1 to Phase 2 (44.3% versus 28.6%, respectively; P<0.001). Logistic regression analysis showed that the adjusted odds of drug administration errors in Phase 1 of the study were almost three times that in Phase 2 (P<0.001). The most common types of errors were incorrect administration technique and incorrect drug preparation. Nasogastric and intravenous routes of drug administration contributed significantly to the rate of drug administration errors.

CONCLUSION

This study showed that sharing of the types of errors that had occurred was significantly associated with a reduction in drug administration errors.

Medication safety in neonatal care: a review of medication errors among neonates

OBJECTIVE

The objective of this study was to describe the medication errors in hospitalized patients, comparing those in neonates with medication errors across the age spectrum.

METHOD

In tier 1, PubMed, Embase and Google Scholar were searched, using selected MeSH terms relating to hospitalized paediatric, adult and elderly populations. Tier 2 involved a search of the same electronic databases for literature relating to hospitalized neonatal patients.

RESULTS

A total of 58 articles were reviewed. Medication errors were well documented in each patient group. Overall, prescribing and administration errors were most commonly identified across each population, and mostly related to errors in dosing. Errors due to patient misidentification and overdosing were particularly prevalent in neonates, with 47% of administration errors involving at least tenfold overdoses. Unique errors were identified in elderly patients, comprising duplication of therapy and unnecessary prescribing of medicines. Overall, the medicines most frequently identified with error across each patient group included: heparin, antibiotics, insulin, morphine and parenteral nutrition. While neonatal patients experience the same types of medication errors as other hospitalized patients, the medication-use process within this group is more complex and has greater consequences resulting from error. Suggested strategies to help overcome medication error most commonly involved the integration of a clinical pharmacist into the treating team.

CONCLUSION

This review highlights that each step of the medication-use process is prone to error across the age spectrum. Further research is required to develop targeted strategies relevant to specific patient groups that integrate key pharmacy services into wards.

Systematic literature review of hospital medication administration errors in children

Objective

Medication administration is the last step in the medication process. It can act as a safety net to prevent unintended harm to patients if detected. However, medication administration errors (MAEs) during this process have been documented and thought to be preventable. In pediatric medicine, doses are usually administered based on the child’s weight or body surface area. This in turn increases the risk of drug miscalculations and therefore MAEs. The aim of this review is to report MAEs occurring in pediatric inpatients.

Methods

Twelve bibliographic databases were searched for studies published between January 2000 and February 2015 using “medication administration errors”, “hospital”, and “children” related terminologies. Handsearching of relevant publications was also carried out. A second reviewer screened articles for eligibility and quality in accordance with the inclusion/exclusion criteria.

Key findings

A total of 44 studies were systematically reviewed. MAEs were generally defined as a deviation of dose given from that prescribed; this included omitted doses and administration at the wrong time. Hospital MAEs in children accounted for a mean of 50% of all reported medication error reports (n=12,588). It was also identified in a mean of 29% of doses observed (n=8,894). The most prevalent type of MAEs related to preparation, infusion rate, dose, and time. This review has identified five types of interventions to reduce hospital MAEs in children: barcode medicine administration, electronic prescribing, education, use of smart pumps, and standard concentration.

Conclusion

This review has identified a wide variation in the prevalence of hospital MAEs in children. This is attributed to the definition and method used to investigate MAEs. The review also illustrated the complexity and multifaceted nature of MAEs. Therefore, there is a need to develop a set of safety measures to tackle these errors in pediatric practice.

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study

OBJECTIVES

To investigate the underlying causes of intravenous medication administration errors (MAEs) in National Health Service (NHS) hospitals.

SETTING

Two NHS teaching hospitals in the North West of England.

PARTICIPANTS

Twenty nurses working in a range of inpatient clinical environments were identified and recruited using purposive sampling at each study site.

PRIMARY OUTCOME MEASURES

Semistructured interviews were conducted with nurse participants using the critical incident technique, where they were asked to discuss perceived causes of intravenous MAEs that they had been directly involved with. Transcribed interviews were analysed using the Framework approach and emerging themes were categorised according to Reason's model of accident causation.

RESULTS

In total, 21 intravenous MAEs were discussed containing 23 individual active failures which included slips and lapses (n=11), mistakes (n=8) and deliberate violations of policy (n=4). Each active failure was associated with a range of error and violation provoking conditions. The working environment was implicated when nurses lacked healthcare team support and/or were exposed to a perceived increased workload during ward rounds, shift changes or emergencies. Nurses frequently reported that the quality of intravenous dose-checking activities was compromised due to high perceived workload and working relationships. Nurses described using approaches such as subconscious functioning and prioritising to manage their duties, which at times contributed to errors.

CONCLUSIONS

Complex interactions between active and latent failures can lead to intravenous MAEs in hospitals. Future interventions may need to be multimodal in design in order to mitigate these risks and reduce the burden of intravenous MAEs.

Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence

BACKGROUND

Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence.

OBJECTIVE

This study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings.

DATA SOURCES

Nine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013.

STUDY SELECTION

Inclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail.

DATA APPRAISAL AND SYNTHESIS METHODS

A total of 54 unique studies were included. Causes of MAEs were categorised according to Reason's model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used.

RESULTS

Slips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality), patient factors (availability, acuity), staff health status (fatigue, stress) and interruptions/distractions during drug administration. Few studies sought to determine the causes of intravenous MAEs. A number of latent pathway conditions were less well explored, including local working culture and high-level managerial decisions. Causes were often described superficially; this may be related to the use of quantitative surveys and observation methods in many studies, limited use of established error causation frameworks to analyse data and a predominant focus on issues other than the causes of MAEs among studies.

LIMITATIONS

As only English language publications were included, some relevant studies may have been missed.

CONCLUSIONS

Limited evidence from studies included in this systematic review suggests that MAEs are influenced by multiple systems factors, but if and how these arise and interconnect to lead to errors remains to be fully determined. Further research with a theoretical focus is needed to investigate the MAE causation pathway, with an emphasis on ensuring interventions designed to minimise MAEs target recognised underlying causes of errors to maximise their impact.

Drug administration errors in hospital inpatients: a systematic review

CONTEXT

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE:

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

DATA SOURCES:

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

STUDY SELECTION AND DATA EXTRACTION:

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

DATA SYNTHESIS:

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

CONCLUSIONS:

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

A systematic approach to improving medication safety in a pediatric intensive care unit

Safety and quality improvement are major issues in children's hospitals. Improving pediatric medication safety often takes on a larger role in pediatric units than in adult units due to the larger size differences and dose ranges found in a pediatric intensive care unit. This article reviews the literature and our own experience at the CS Mott Children's Hospital, University of Michigan, to improve medication safety. The issues identified include (1) an effective pediatric medication safety governance structure within a larger hospital, (2) practice standardization strategies for physicians, nurses, and pharmacists, (3) use of pharmacy technicians as unit medication managers, which reduces medication costs and decreases nursing time spent hunting for medications, and (4) methods to improve the safety culture in a pediatric intensive care unit.

Implementation of a standardized process for ordering and dispensing of high-alert emergency medication infusions

OBJECTIVES

Pharmacies encounter challenges when ensuring safe, timely medication dispensing to patients in the pediatric intensive care unit, when high-alert medications are needed in emergent situations. Removal of these medications from nursing stock presented challenges to providing timely administration to critical patients. The project's purpose was to develop a new method for reducing dispensing time while improving patient safety in pediatric intensive care units.

METHODS

A committee of physicians, nurses, a clinical pharmacist, and pharmacy administration collaborated for process development. The process established a list of compounded, ready-to-use infusions stored in the pharmacy, immediately available for dispensing. The dispensing mechanism includes ordering and dispensing processes using an "Urgent Drip Request" form. Most frequently ordered infusions (dopamine, epinephrine, norepinephrine) were added to automated dispensing cabinets in critical care units in concentrations that could be safely infused centrally or peripherally.

RESULTS

During the initial 4 months, 71 "Urgent Drip Request" sheets were processed. Drug utilization evaluation demonstrated a dispensing time of less than 1 minute for drip medications leaving the pharmacy after the form was received. No sheets processed exceeded the institutional 30-minute turnaround time, nor were errors or delays documented. Limited turnaround time data existed preimplementation but was not robust enough for analysis. It was not ethically feasible to perform a head-to-head comparison with the previous method, as it might have resulted in delay of therapy and negative patient outcomes.

CONCLUSIONS

This program allows high-alert medication infusion availability in an expedited manner, removes potential for compounding errors at the bedside, and assures clean room preparation. This has improved pharmacy efficiency in provision of safe patient care to critically ill pediatric patients.