Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units

Understanding an epidemiological view of a retrospective audit of medication errors in an intensive care unit

BACKGROUND

Medication errors in the intensive care setting continue to occur at significant rates and are often associated with adverse events and potentially life-threatening repercussions.

AIM/OBJECTIVE

The aim of this study was to (i) determine the frequency and severity of medication errors reported in the incident management reporting system; (ii) examine the antecedent events, their nature, the circumstances, risk factors, and contributing factors leading to medication errors; and (iii) identify strategies to improve medication safety in the intensive care unit (ICU).

METHOD

A retrospective, exploratory, descriptive design was selected. Retrospective data were collected from the incident report management system and electronic medical records over a 13-month period from a major metropolitan teaching hospital ICU.

RESULTS

A total of 162 medication errors were reported during a 13-month period, of which, 150 were eligible for inclusion. Most medication errors occurred during the administration (89.4%) and dispensing phases (23.3%). The highest reported errors included incorrect doses (25.3%), incorrect medications (12.7%), omissions (10.7%), and documentation errors (9.3%). Narcotic analgesics (20%), anaesthetics (13.3%), and immunomodifiers (10.7%) were the most frequently reported medication classes associated with medication errors. Prevention strategies were found to be focussed on active errors (67.7%) as opposed to latent errors (32.3%) and included various and infrequent levels of education and follow-up. Active antecedent events included action-based errors (39%) and rule-based errors (29.5%), whereas latent antecedent events were most associated with a breakdown in system safety (39.3%) and education (25%).

CONCLUSION

This study presents an epidemiological view and understanding of medication errors in an Australian ICU. This study highlighted the preventable nature of most medication errors in this study. Improving administration-checking procedures would prevent the occurrence of many medication errors. Approaches aimed at both individual- and organisational-level improvements are recommended to address administration errors and inconsistent medication-checking procedures. Areas for further research include determining the most effective system developments for improving administration-checking procedures and verifying the risk and prevalence of immunomodifier administration errors in the ICU as this is an area not reported previously in the literature. In addition, the impact of single- versus two-person checking procedures on medication errors in the ICU should be prioritised to address current evidence gaps.

Understanding Patient and Clinician Reported Nonroutine Events in Ambulatory Surgery

OBJECTIVE

Nonroutine events (NREs, i.e., deviations from optimal care) can identify care process deficiencies and safety risks. Nonroutine events reported by clinicians have been shown to identify systems failures, but this methodology fails to capture the patient perspective. The objective of this prospective observational study is to understand the incidence and nature of patient- and clinician-reported NREs in ambulatory surgery.

METHODS

We interviewed patients about NREs that occurred during their perioperative care using a structured interview tool before discharge and in a 7-day follow-up call. Concurrently, we interviewed the clinicians caring for these patients immediately postoperatively to collect NREs. We trained 2 experienced clinicians and 2 patients to assess and code each reported NRE for type, theme, severity, and likelihood of reoccurrence (i.e., likelihood that the same event would occur for another patient).

RESULTS

One hundred one of 145 ambulatory surgery cases (70%) contained at least one NRE. Overall, 214 NREs were reported-88 by patients and 126 by clinicians. Cases containing clinician-reported NREs were associated with increased patient body mass index ( P = 0.023) and lower postcase patient ratings of being treated with respect ( P = 0.032). Cases containing patient-reported NREs were associated with longer case duration ( P = 0.040), higher postcase clinician frustration ratings ( P < 0.001), higher ratings of patient stress ( P = 0.019), and lower patient ratings of their quality of life ( P = 0.010), of the quality of clinician teamwork ( P = 0.010), being treated with respect ( P = 0.003), and being listened to carefully ( P = 0.012). Trained patient raters evaluated NRE severity significantly higher than did clinician raters ( P < 0.001), while clinicians rated recurrence likelihood significantly higher than patients for both clinician ( P = 0.032) and patient-reported NREs ( P = 0.001).

CONCLUSIONS

Both patients and clinicians readily report events during clinical care that they believe deviate from optimal care expectations. These 2 primary stakeholders in safe, high-quality surgical care have different experiences and perspectives regarding NREs. The combination of patient- and clinician-reported NREs seems to be a promising patient-centered method of identifying healthcare system deficiencies and opportunities for improvement.

The Construction and Effect Analysis of Nursing Safety Quality Management Based on Data Mining

Data mining belongs to knowledge discovery, which is the process of revealing hidden, unknown, and valuable information from a large amount of fuzzy application data. The potential information revealed by data mining can help decision-makers adjust market strategies and reduce market risks. The information mined can be the discovery of a particular study and little known, which must be based on the principle of truth. Nursing safety means that during nursing work, the nursing staff must strictly follow the nursing system and operating procedures, accurately execute doctor's orders, implement nursing plans, and ensure that patients get physical and mental safety during treatment and recovery. This paper aims to explore the construction of nursing safety quality management system and its effect analysis based on data mining. It is hoped that improvements in hospital nursing processes will provide better nursing services for patients using data mining techniques. This paper uses the FP algorithm to mine the data set and generates frequent itemsets, proposes and implements the association rule mining algorithm, and obtains the association rules with practical reference value. This article analyzes the current status and existing problems of nursing management, and puts forward some problems existing in the current nursing management staff's own quality, nursing quality system standards, and nursing management system. The experimental results in this article show that there are 42 cases of poor nursing due to lack of basic medical knowledge, accounting for 52%; there are 12 cases of poor nursing due to their own diseases, accounting for 15%; there were 7 cases of poor nursing due to lack of communication, accounting for 9%; there were 15 cases of poor nursing caused by unreasonable use of restraint devices, accounting for 19%. From these data, it can be seen that patients need to have basic medical knowledge and act in strict accordance with doctors' orders. Family members also need to accompany the patients more and cooperate with all parties in order to maximize the effectiveness of care.

Defining the Epidemiology of Safety Risks in Neonatal Intensive Care Unit Patients Requiring Surgery

OBJECTIVE

The aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)-events perceived by care providers or skilled observers as a deviations from optimal care based on the clinical situation-in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room.

METHODS

A prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic children's hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in 109 neonates were observed. The incidence and description of NREs were collected via structured researcher-administered survey tool of involved clinicians. Primary measurements included clinicians' ratings of NRE severity and contributory factors and trained research assistants' ratings of preventability.

RESULTS

One or more NREs were reported in 101 (78%) of 129 observed cases for 247 total NREs. Clinicians reported 2 (2) (median, interquartile range) NREs per NRE case with a maximum severity of 3 (1) (possible range = 1-5). Trained research assistants rated 47% of NREs as preventable and 11% as severe and preventable. The relative risks for National Surgical Quality Improvement Program - pediatric major morbidity and 30-day mortality were 1.17 (95% confidence interval = 0.92-1.48) and 1.04 (95% confidence interval = 1.00-1.08) in NRE cases versus non-NRE cases.

CONCLUSIONS

The incidence of NREs in neonatal perioperative care at an academic children's hospital was high and of variable severity with a myriad of contributory factors.

Evaluation of medication administration timing variance using information from a large health system's clinical data warehouse

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

An analysis to determine the frequency of medication administration timing variances for specific therapeutic classes of high-risk medications using data extracted from a health-system clinical data warehouse (CDW) is presented.

Methods

This multicenter retrospective, observational analysis of 1 year of medication administration data from 14 hospitals was conducted using a large enterprise health-system CDW. The primary objective was to assess medication administration timing variance for focused therapeutic classes using medication orders and electronic medication administration records data extracted from the electronic health record (EHR). Administration timing variance patterns between standard hospital staffing shifts, within therapeutic drug classes, and for as-needed (PRN) medications were also studied. Calculated variables for delayed medication administration (ie, administration time variance) were created for documented administration time intervals of 30-59, 60-120, and more than 120 minutes before or after medication orders.

Results

A total of 5,690,770 medication administrations (3,418,275 scheduled and 2,272,495 PRN) were included in the normalized data set. Scheduled medications were frequently subject to delays of ≥60 minutes (15% of administrations, n = 275,257) when scheduled for administration between 9-10 AM and between 9-10 PM. By therapeutic drug class, scheduled administrations of insulins, heparin products, and platelet aggregation inhibitors (most commonly heparin flushes and line-management preparations) were the most commonly delayed. For PRN medications, medications in the anticoagulant and antiplatelet agent class were most likely to be administered early (<60 minutes from the scheduled time of first administration).

Conclusion

The findings of this study assist in understanding patterns of delayed medication administration. Medication class, time of day of scheduled administration, and frequency were factors that influenced medication administration timing variance.

Nurses and Pharmaceutical Care: Interprofessional, Evidence-Based Working to Improve Patient Care and Outcomes

Pharmaceutical care necessitates significant efforts from patients, informal caregivers, the interprofessional team of health care professionals and health care system administrators. Collaboration, mutual respect and agreement amongst all stakeholders regarding responsibilities throughout the complex process of pharmaceutical care is needed before patients can take full advantage of modern medicine. Based on the literature and policy documents, in this position paper, we reflect on opportunities for integrated evidence-based pharmaceutical care to improve care quality and patient outcomes from a nursing perspective. Despite the consensus that interprofessional collaboration is essential, in clinical practice, research, education and policy-making challenges are often not addressed interprofessionally. This paper concludes with specific advises to move towards the implementation of more interprofessional, evidence-based pharmaceutical care.

Incidence and Classification of Nonroutine Events during Anesthesia Care

BACKGROUND

A nonroutine event is any aspect of clinical care perceived by clinicians or trained observers as a deviation from optimal care based on the context of the clinical situation. The authors sought to delineate the incidence and nature of intraoperative nonroutine events during anesthesia care.

METHODS

The authors prospectively collected audio, video, and relevant clinical information on 556 cases at three academic hospitals from 1998 to 2004. In addition to direct observation, anesthesia providers were surveyed for nonroutine event occurrence and details at the end of each study case. For the 511 cases with reviewable video, 400 cases had no reported nonroutine events and 111 cases had at least one nonroutine event reported. Each nonroutine event was analyzed by trained anesthesiologists. Rater reliability assessment, comparisons (nonroutine event vs. no event) of patient and case variables were performed.

RESULTS

Of 511 cases, 111 (21.7%) contained 173 nonroutine events; 35.1% of event-containing cases had more than one nonroutine event. Of the 173 events, 69.4% were rated as having patient impact and 12.7% involved patient injury. Longer case duration (25th vs. 75th percentile; odds ratio, 1.83; 95% CI, 1.15 to 2.93; P = 0.032) and presence of a comorbid diagnosis (odds ratio, 2.14; 95% CI, 1.35 to 3.40; P = 0.001) were associated with nonroutine events. Common contributory factors were related to the patient (63.6% [110 of 173]) and anesthesia provider (59.0% [102 of 173]) categories. The most common patient impact events involved the cardiovascular system (37.4% [64 of 171]), airway (33.3% [57 of 171]), and human factors, drugs, or equipment (31.0% [53 of 171]).

CONCLUSIONS

This study describes characteristics of intraoperative nonroutine events in a cohort of cases at three academic hospitals. Nonroutine event-containing cases were commonly associated with patient impact and injury. Thus, nonroutine event monitoring in conjunction with traditional error reporting may enhance our understanding of potential intraoperative failure modes to guide prospective safety interventions.

Whose experience is it anyway? Toward a constructive engagement of tensions in patient-centered health care

Purpose

Healthcare delivery faces increasing pressure to move from a provider-centered approach to become more consumer-driven and patient-centered. However, many of the actions taken by clinicians, patients and organizations fail to achieve that aim. This paper aims to take a paradox-based perspective to explore five specific tensions that emerge from this shift and provides implications for patient experience research and practice.

Design/methodology/approach

This paper uses a conceptual approach that synthesizes literature in health services and administration, organizational behavior, services marketing and management and service operations to illuminate five patient experience tensions and explore mitigation strategies.

Findings

The paper makes three key contributions. First, it identifies five tensions that result from the shift to more patient-centered care: patient focus vs employee focus, provider incentives vs provider motivations, care customization vs standardization, patient workload vs organizational workload and service recovery vs organizational risk. Second, it highlights multiple theories that provide insight into the existence of the tensions and how they may be navigated. Third, specific organizational practices that engage the tensions and associated examples of leading organizations are identified. Relevant measures for research and practice are also suggested.

Originality/value

The authors develop a novel analysis of five persistent tensions facing healthcare organizations as a result of a shift to a more consumer-driven, patient-centered approach to care. The authors detail each tension, discuss an existing theory from organizational behavior or services marketing that helps make sense of the tension, suggest potential solutions for managing or resolving the tension and provide representative case illustrations and useful measures.

Exploring Inpatient Medication Patterns: A Big Data and Multilevel Approach

PURPOSE

Exploratory study to examine inpatient medication administration patterns.

METHODS

Data from multiple sources were utilized for this study. The outcome was time difference between medication schedule and administration. A 3-level hierarchical linear regression approach, both unadjusted and adjusted, was considered for this study where medication administration events are nested within patients nested within nurses or units. Intraclass correlation coefficients (ICCs) were calculated and compared.

RESULTS

On average, medications were delayed by 12 (SD, 48.8) minutes. From the full model, patient ICCs decreased when "unit" replaced "nurse" as the 3rd level (0.541 vs 0.444). Patients who spoke Spanish had a significant 2.3- to 4.2-minute delay in medication administration. Certified nurses significantly give medications earlier compared with noncertified nurses by 1.6 minutes.

DISCUSSION

Optimal medication administration is a multifactorial concern with nurses playing a role. Nursing leaders should also consider patient demographics and unit conditions, such as culture, for medication administration optimization.