Label Design Affects Medication Safety in an Operating Room Crisis: A Controlled Simulation Study

Evolution of Intravenous Medication Errors and Preventive Systemic Defenses in Hospital Settings-A Narrative Review of Recent Evidence

OBJECTIVES

Intravenous drug administration has been associated with severe medication errors in hospitals. The present narrative review is based on a systematic literature search, and aimed to describe the recent evolution in research on systemic causes and defenses in intravenous medication errors in hospitals.

METHODS

This narrative review was based on Reason's theory of systems-based risk management. A systematic literature search covering the period from June 2016 to October 2021 was conducted on Medline (Ovid). We used the search strategy and selection criteria developed for our previous systematic reviews. The included articles were analyzed and compared to our previous reviews.

RESULTS

The updated search found 435 articles. Of the 63 included articles, 16 focused on systemic causes of intravenous medication errors, and 47 on systemic defenses. A high proportion (n = 24, 38%) of the studies were conducted in the United States or Canada. Most of the studies focused on drug administration (n = 21/63, 33%) and preparation (n = 19/63, 30%). Compared to our previous review of error causes, more studies (n = 5/16, 31%) utilized research designs with a prospective risk management approach. Within articles related to systemic defenses, smart infusion pumps remained most widely studied (n = 10/47, 21%), while those related to preparation technologies (n = 7/47, 15%) had increased.

CONCLUSIONS

This narrative review demonstrates a growing interest in systems-based risk management for intravenous drug therapy and in introducing new technology, particularly smart infusion pumps and preparation systems, as systemic defenses. When introducing new technologies, prospective assessment and continuous monitoring of emerging safety risks should be conducted.

Estimating the impact of label design on reducing the risk of medication errors by applying HEART in drug administration

Medication errors are one of the biggest problems in healthcare. The medicines' poor labelling design (i.e. look-alike labels) is a well-recognised risk for potential confusion, wrong administration, and patient damage. Human factors and ergonomics (HFE) encourages the human-centred design of system elements, which might reduce medication errors and improve people's well-being and system performance.

OBJECTIVE

The aim of the present study is twofold: (i) to use a human reliability analysis technique to evaluate a medication administration task within a simulated scenario of a neonatal intensive care unit (NICU) and (ii) to estimate the impact of a human-centred design (HCD) label in medication administration compared to a look-alike (LA) label.

METHOD

This paper used a modified version of the human error assessment and reduction technique (HEART) to analyse a medication administration task in a simulated NICU scenario. The modified technique involved expert nurses quantifying the likelihood of unreliability of a task and rating the conditions, including medicine labels, which most affect the successful completion of the task.

RESULTS

Findings suggest that error producing conditions (EPCs), such as a shortage of time available for error detection and correction, no independent checking of output, and distractions, might increase human error probability (HEP) in administering medications. Results also showed that the assessed HEP and the relative percentage of contribution to unreliability reduced by more than 40% when the HCD label was evaluated compared to the LA label.

CONCLUSION

Including labelling design based on HFE might help increase human reliability when administering medications under critical conditions.

Labelling of intravenous drug delivery devices in critically ill patients: A scoping review

BACKGROUND

Labelling is a strategy that contributes to the correct and faster identification of drugs, minimizing misidentification. There is a gap in knowledge on optimal labelling standards for intravenous (IV) devices applied to the care of critically ill patients.

AIM

The goal of this article was to map existing knowledge on the labelling of IV drug delivery devices in critically ill patients for the prevention of medication errors.

STUDY DESIGN

This was a scoping review conducted according to the JBI methodology in the LILACS, MEDLINE, CINAHL, IBECS, Scopus, Embase and Web of Science databases, and on the websites of specialized institutions. Searches were conducted up to December 2022 for scientific articles and grey literature that addressed the labelling of IV devices in intensive care units, emergency departments, and anaesthesia units. The data were collected using a structured form and were later classified, summarized, and aggregated to map the knowledge related to the review question.

RESULTS

Twenty-one documents were included, which demonstrated variability in label use with IV drug delivery devices. The following features of structure and design stood out: printed format, colour coding, letter size differentiation, and the use of sturdy material. In terms of information, the name of the drug, dose, date and time of preparation, identification of the patient, and who prepared it were found.

CONCLUSIONS

The identified patterns contributed to the reduction of drug misidentification and the development of timelier drug labelling and administration.

RELEVANCE TO CLINICAL PRACTICE

The evidence supports the development of standardized labels for the prevention of medication errors.

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions

BACKGROUND

Look-alike medications, where ampoules or vials of intravenous medications look similar, may increase the risk of medication errors in the perioperative setting.

AIM

This scoping review aimed to identify and explore the issues related to look-alike medication incidents in the perioperative setting and the reported risk reduction interventions.

METHOD

Eight databases were searched including: CINAHL Complete, Embase, OVID Emcare, Pubmed, Scopus, Informit, Cochrane and Prospero and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR). Key search terms included anaesthesia, adverse drug event, drug error or medication error, look alike sound alike, operating theatres and pharmacy. Title and abstracts were screened independently and findings were extracted using validated tools in collaboration and consensus with co-authors.

RESULTS

A total of 2567 records were identified to 4th July 2022; however only 18 publications met the inclusion criteria. Publication types consisted of case reports, letters to the editor, multimodal quality improvement activities or survey/audits, a controlled simulation study and one randomised clinical trial. Risk reduction intervention themes identified included regulation, procurement, standardisation of storage, labelling, environmental factors, teamwork factors and the safe administration.

CONCLUSION

This review highlighted challenges with look-alike medications in the perioperative setting and identified interventions for risk reduction. Key interventions did not involve technology-based solutions and further research is required to assess their effectiveness in preventing patient harm.

Reminding staff of diligence during the medication process is not enough to ensure safety: Learning from wrong fluid product selection incidents in the care of critically ill patients

Background and objectives

Wrong fluid product selection may cause harm to patients. This study aimed to describe voluntarily reported wrong fluid product selection incidents, including their consequences, the reported latent conditions and active failures leading to these and the suggested safeguards to prevent their occurrence, and to compare the suggested and literature-based safeguards to improve the fluid therapy safety within the intensive care (ICU) environment.

Methods

All voluntarily and anonymously reported wrong fluid product selection incidents in all Finnish ICUs during 2007–2017 were reviewed. The incident reports included categorized data that were analyzed quantitatively, and narratives that were analyzed qualitatively, using content analysis. The results were reported as frequencies and percentages and described by using Reason's model of human error.

Results

Over the eleven years, one wrong fluid product selection incident was reported every six days (n = 663; 584 errors, 79 near misses); most were reported to have occurred during the dispensing/preparing phase (92%). Of the 584 reported selection errors, a quarter (26%) was reported to have caused consequences to patients, and one third (35%) to have required corrective or monitoring actions. The main reported latent conditions to the incidents were Working environment and resources (e.g. workload and time pressure) (29%), Similar-looking and -sounding names or shared features of the product containers (i.e. the LASA phenomenon) (28%) and Working methods (22%); and the main reported active failures were a lack of concentration, or forgetfulness (26%). Some usable suggestions of safeguards were made, e.g. optimizing fluid storage (15%) or utilizing checking practices (21%). While requiring accuracy, i.e. reminding staff of diligence and to be more attentive to detail during the whole medication process, was emphasized in most reports (71%), involving manufacturers in redesigning labels of fluid products, utilizing technology and strengthening pharmacy services are advocated existing literature.

Conclusions

Wrong fluid product selection incidents with various latent conditions and active failures were reported more than once a week. To minimize the serious LASA phenomenon, multi-professional collaboration, coordinated international discussion and agreements of solutions with manufacturers, regulators and end-users, are needed. However, work is also needed to reduce the other latent factors, such as Working environment and resources as well as cognitive biases in daily work that may contribute to the occurrence of LASA related errors.

Intravenous therapy device labeling in Intensive Care Units: an integrative review

OBJECTIVES

to synthesize the evidence on intravenous device labeling used to identify medications administered to patients in Intensive Care Units, with a view to preventing medication errors.

METHODS

an integrative review, in the LILACS, IBECS, Embase, MEDLINE, Scopus, Web of Science and CINAHL databases, from November to December 2021, using descriptors and selection criteria. Data were collected in 11 articles and subsequently classified, summarized and aggregated.

RESULTS

pre-designed labels, with pre-defined colors and information, help to prevent medication identification errors. There is still a lack of standardization in the practice of labeling syringes, intravenous lines, infusion pumps and saline solution bags. There are errors related to the lack of labeling devices or to their performance with incomplete information.

CONCLUSIONS

device labeling is a barrier to defending the medication system safety and should be standardized.

Rotulagem de dispositivos de terapia intravenosa em Unidades de Terapia Intensiva: revisão integrativa

RESUMO Objetivos: sintetizar as evidências sobre a rotulagem de dispositivos intravenosos utilizada para a identificação de medicamentos administrados nos pacientes em Unidades de Terapia Intensiva, com vistas à prevenção dos erros de medicação. Métodos: revisão integrativa, nas bases de dados LILACS, IBECS, Embase, MEDLINE, Scopus, Web of Science e CINAHL, no período de novembro-dezembro de 2021, com uso de descritores e emprego de critérios de seleção. Os dados foram coletados em 11 artigos e, posteriormente, classificados, sumarizados e agregados. Resultados: rótulos pré-desenhados, com cores e informações pré-definidas contribuem para prevenir os erros de identificação dos medicamentos. Persiste a falta de padronização da prática de rotulagem em seringas, linhas intravenosas, bomba infusoras e bolsas de soro. Há erros relacionados à ausência de rotulagem dos dispositivos ou à sua realização com informações incompletas. Conclusões: a rotulagem dos dispositivos é uma barreira para a defesa da segurança do sistema de medicação, devendo ser padronizada.

Optimising antimicrobial use in humans - review of current evidence and an interdisciplinary consensus on key priorities for research

Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.

Effects of Text Enhancement, Identical Prescription-Package Names, Visual Cues, and Verbal Provocation on Visual Searches of Look-Alike Drug Names: A Simulation and Eye-Tracking Study

OBJECTIVE

Simulation and eye tracking were used to examine the effects of text enhancement, identical prescription-package names, visual cues, and verbal provocation on visual searches of look-alike drug names.

BACKGROUND

Look-alike drug names can cause confusion and medication errors, which jeopardize patient safety. The effectiveness of many strategies that may prevent these problems requires evaluation.

METHOD

We conducted two experiments that were based on a four-way, repeated-measures design. The within-subject factors were text enhancement, identical prescription-package names, visual cues, and verbal provocation. In Experiment 1, 40 nurses searched for and selected a target drug from an array of drug packages on a pharmacy shelf mock-up. In Experiment 2, the eye movements of another 40 nurses were tracked while they performed a computer-based drug search task.

RESULTS

Text enhancement had no significant effect on the drug search. Nurses selected the target drugs more quickly and easily when the prescriptions and drug packages shared identical drug name formats. The use of a visual cue to direct nurses' attention facilitated their visual searches and improved their eye gaze behaviors. The nurses reported greater mental effort if they were provoked verbally during the drug search.

CONCLUSION

Efficient and practical strategies should be adopted for designs that facilitate accurate drug search. Among these strategies are using identical name appearances on drug prescriptions and packages, using a visual cue to direct nurses' attention, and avoiding rushing nurses while they are concentrating.

APPLICATION

The findings aim to inspire recommendations for work system designs that will improve the visual search of look-alike drug names.

How to prevent medication errors: a multidimensional scaling study to investigate the distinguishability between self-injection platform device variants

Background: The importance of subcutaneous drug delivery using self-injection devices based on common device platforms continues to grow. The resulting broad adoption of potentially look-alike or similar devices, however, raises concerns over limited device distinguishability and ensuing risk of medication errors. The objective of the study is thus to understand whether and how users effectively distinguish between self-injection device variants. Methods: Seventy-four patients, caregivers, and healthcare professionals were asked to pairwise rate the similarity of eight platform autoinjector variants. Multidimensional scaling was then used to convert individual ratings into spatial configurations and thereby identify the attributes that influence device distinguishability. Results: Five different device attributes driving distinguishability were identified. Three of the attributes corresponded to single design features (the label color, device size and device shape). Two device attributes (the aspect ratio and chromaticity) combined distinct yet interrelated design features. Conclusions: The study provides initial empirical evidence that users are able to distinguish between device variants and as to what device attributes drive distinguishability. Furthermore, the results highlight patterns in how various user groups distinguish between device variants. These patterns relate with the user group characteristics (e.g. age, sight or dexterity) and the context of device usage (e.g. healthcare professionals).

Human-simulation-based learning to prevent medication error: A systematic review

RATIONALE, AIMS AND OBJECTIVES

In the past 2 decades, there has been an increasing interest in simulation-based learning programs to prevent medication error (ME). To improve knowledge, skills, and attitudes in prescribers, nurses, and pharmaceutical staff, these methods enable training without directly involving patients. However, best practices for simulation for healthcare providers are as yet undefined. By analysing the current state of experience in the field, the present review aims to assess whether human simulation in healthcare helps to reduce ME.

METHODS

A systematic review was conducted on Medline from 2000 to June 2015, associating the terms "Patient Simulation," "Medication Errors," and "Simulation Healthcare." Reports of technology-based simulation were excluded, to focus exclusively on human simulation in nontechnical skills learning.

RESULTS

Twenty-one studies assessing simulation-based learning programs were selected, focusing on pharmacy, medicine or nursing students, or concerning programs aimed at reducing administration or preparation errors, managing crises, or learning communication skills for healthcare professionals. The studies varied in design, methodology, and assessment criteria. Few demonstrated that simulation was more effective than didactic learning in reducing ME. This review highlights a lack of long-term assessment and real-life extrapolation, with limited scenarios and participant samples. These various experiences, however, help in identifying the key elements required for an effective human simulation-based learning program for ME prevention: ie, scenario design, debriefing, and perception assessment. The performance of these programs depends on their ability to reflect reality and on professional guidance.

CONCLUSION

Properly regulated simulation is a good way to train staff in events that happen only exceptionally, as well as in standard daily activities. By integrating human factors, simulation seems to be effective in preventing iatrogenic risk related to ME, if the program is well designed.

Package Design Affects Accuracy Recognition for Medications

OBJECTIVE

Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors.

BACKGROUND

An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors.

METHOD

In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated.

RESULTS

The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications.

CONCLUSION

Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications.

APPLICATION

A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose.