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Booth JP, Hartman AD. Developing a Comprehensive Framework of Safeguarding Strategies to Address Anticipated Errors With Organizational High-Alert Medications. Hosp Pharm 2024; 59:47-55. [PMID: 38223857 PMCID: PMC10786060 DOI: 10.1177/00185787231185871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Purpose: To describe the development of a comprehensive framework of safeguarding strategies to address observed/anticipated errors with organizational high-alert medications. Methods: Observed/anticipated errors were identified for organizational high-alert medications and medication classes based on a review of external literature and alerts as well as internal voluntary error reporting. Anticipated or frequently reported errors were categorized into common cause error types. Error reduction strategies to address each common cause error were identified in collaboration with medication safety specialists and specialty practice pharmacists. Results: The review of externally and internally reported errors identified 101 observed/anticipated common cause errors across the 19 high-alert medication classes (median 5 error types per medication class, interquartile range 3-6). Safeguarding strategies specific to high-alert medications were identified in the following domains: separate or sequestered storage; restricted ordering; active alerts; dispensing in patient-specific dosing, unit of use, or unit-dose packaging; dispensing from pharmacy only; auxiliary labeling; level of care restriction; required monitoring; independent double checks; certification/privileging of staff; specific guidelines for use/monitoring; and other/miscellaneous. Identification of the observed/anticipated errors and the associated safeguarding strategies facilitated the development of a comprehensive tool and visual framework for addressing common cause errors associated with organizational high-alert medications. Conclusion: A comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications is proposed. Although individual safeguards are institution-specific, the framework can be leveraged by all hospitals in order to take inventory of error-reduction strategies and prospectively identify gaps to address common cause errors.
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Affiliation(s)
| | - Amber D. Hartman
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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2
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Stevens EL, Hulme A, Goode N, Coventon L, Read G, Salmon PM. Understanding complexity in a safety critical setting: A systems approach to medication administration. APPLIED ERGONOMICS 2023; 110:104000. [PMID: 36958252 DOI: 10.1016/j.apergo.2023.104000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 06/18/2023]
Abstract
'Medication errors' are a significant concern and are associated with a higher incidence of adverse events and unintentional patient harm than any other aspect of healthcare. While much research has focused on adverse medication errors, limited studies have specifically examined 'normal' medication delivery performance and the interactions between tasks, agents, and information within the medication administration system. This article describes a study that applied the Event Analysis of Systemic Teamwork (EAST) model to study the hospital medication administration system to identify opportunities to optimise performance and patient safety. Key findings of this study demonstrate that this is a highly complex system, comprising many social agents and a relatively closely linked series of tasks and information. However, most of the workload relies on a small proportion of healthcare professionals. Significantly, the patient has a minimal role in the medication administration system during their hospital stay. The research has shown that this approach enables mapping networks and their interdependencies to optimise the system as a whole rather than its parts in isolation.
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Affiliation(s)
- Erin L Stevens
- Centre for Human Factors and Sociotechnical Systems, School of Law and Society, University of the Sunshine Coast, Sippy Downs, 4558, Queensland, Australia.
| | - Adam Hulme
- Southern Queensland Rural Health, Faculty of Health and Behavioural Sciences, The University of Queensland, Toowoomba, 4350, Queensland, Australia
| | | | - Lauren Coventon
- Centre for Human Factors and Sociotechnical Systems, School of Law and Society, University of the Sunshine Coast, Sippy Downs, 4558, Queensland, Australia
| | - Gemma Read
- Centre for Human Factors and Sociotechnical Systems, School of Law and Society, University of the Sunshine Coast, Sippy Downs, 4558, Queensland, Australia
| | - Paul M Salmon
- Centre for Human Factors and Sociotechnical Systems, School of Law and Society, University of the Sunshine Coast, Sippy Downs, 4558, Queensland, Australia
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Cho I. Frameworks for Evaluating the Impact of Safety Technology Use. Healthc Inform Res 2023; 29:89-92. [PMID: 37190732 DOI: 10.4258/hir.2023.29.2.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Affiliation(s)
- Insook Cho
- Department of Nursing, Inha University, Incheon, Korea
- The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Khan SA, Zilbermint M. Centers for Medicare & Medicaid Services' Hospital Harm Measures for Severe Hypoglycemia and Hyperglycemia: Is Your Hospital Ready? Diabetes Spectr 2022; 35:391-397. [PMID: 36561656 PMCID: PMC9668722 DOI: 10.2337/dsi22-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Poor inpatient glycemic management is associated with increased lengths of stay and in-hospital morbidity and mortality. Improving inpatient glycemic outcomes can be difficult because there are no standardized benchmarks, and many hospitals lack the capacity to electronically extract and analyze glucose data. The Centers for Medicare & Medicaid Services recently proposed new electronic clinical quality measures to be incorporated into its mandatory Hospital Inpatient Quality Reporting Program. Among these measures is an assessment of hospital harm from severe hypoglycemia and severe hyperglycemia. Hospitals must be ready to collect the necessary data for these new measures by January 2023. The new measures could bring welcome attention to the need to implement guideline-based inpatient glycemic management. However, some hospitals that serve high-risk populations may be at risk for losing funding if they are unable to comply.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes, and Metabolism, University of Maryland School of Medicine, Baltimore, MD
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, University of Maryland School of Medicine, Baltimore, MD
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Baltimore, MD
- Division of Endocrinology, Diabetes and Metabolism, Suburban Hospital, Bethesda, MD
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Park S, Kim AJ, Ah YM, Lee MY, Lee YJ, Chae J, Rho JH, Kim DS, Lee JY. Prevalence and predictors of medication-related emergency department visit in older adults: A multicenter study linking national claim database and hospital medical records. Front Pharmacol 2022; 13:1009485. [PMID: 36313329 PMCID: PMC9614024 DOI: 10.3389/fphar.2022.1009485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: Older adults are more likely to experience drug-related problems (DRP), which could lead to medication-related emergency department visits (MRED). To properly evaluate MRED, the entire history of drug use should be evaluated in a structured manner. However, limited studies have identified MRED with complete prescription records. We aimed to evaluate the prevalence and risk factors of MRED among community-dwelling older patients by linking national claims data and electronic medical records using a standardized medication related admission identification method.Methods: We included older patients who visited the emergency departments of four participating hospitals in 2019. Among the 54,034 emergency department (ED) visitors, we randomly selected 6,000 patients and structurally reviewed their medical records using a standardized MRED identification method after linking national claims data and electronic medical records. We defined and categorized MRED as ED visits associated with adverse drug events and those caused by the underuse of medication, including treatment omission and noncompliance and assessed as having probable or higher causality. We assessed preventability using Schumock and Thornton criteria.Results: MRED was observed in 14.3% of ED visits, of which 76% were preventable. In addition, 32.5% of MRED cases were related to underuse or noncompliance, and the rest were related to adverse drug events. Use of antipsychotics, benzodiazepines, anticoagulants, traditional nonsteroidal anti-inflammatory drugs without the use of proton pump inhibitors, P2Y12 inhibitors, insulin, diuretics, and multiple strong anticholinergic drugs were identified as predictors of MRED.Conclusion: One in seven cases of ED visits by older adults were medication related and over three-quarters of them were preventable. These findings suggest that DRPs need to be systemically screened and intervened in older adults who visit ED.
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Affiliation(s)
- Soyoung Park
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, South Korea
| | - A Jeong Kim
- Department of Pharmacy, Seoul National University Hospital, Seoul, South Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsan, South Korea
| | - Mee Yeon Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, South Korea
- Department of Pharmacy, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Yu Jeong Lee
- Department of Pharmacy, Pusan National University Hospital, Busan, South Korea
| | - Jungmi Chae
- Department of Research, Health Insurance Review and Assessment Service, Chuncheon, South Korea
| | - Ju Hyun Rho
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong-Sook Kim
- Department of Research, Health Insurance Review and Assessment Service, Chuncheon, South Korea
- *Correspondence: Dong-Sook Kim, ; Ju-Yeun Lee,
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, South Korea
- *Correspondence: Dong-Sook Kim, ; Ju-Yeun Lee,
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Nunes GDK, Campos JF, da Silva RC. Intravenous therapy device labeling in Intensive Care Units: an integrative review. Rev Bras Enferm 2022; 75:e20220049. [PMID: 36197432 PMCID: PMC9730860 DOI: 10.1590/0034-7167-2022-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/27/2022] [Indexed: 12/23/2022] Open
Abstract
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.
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Mustafa ZU, Haroon S, Aslam N, Saeed A, Salman M, Hayat K, Shehzadi N, Hussain K, Khan AH. Exploring Pakistani Physicians' Knowledge and Practices Regarding High Alert Medications: Findings and Implications. Front Pharmacol 2022; 13:744038. [PMID: 35359861 PMCID: PMC8960238 DOI: 10.3389/fphar.2022.744038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/24/2022] [Indexed: 12/16/2022] Open
Abstract
Introduction: While many low-middle income countries (LMICs), including Pakistan, try and ensure patient safety within available resources, there are considerable concerns with medication use. Unsafe and inappropriate medication use, especially high alert medications (HAMs), is one of the important factors compromising patient safety and quality of care. Besides economic loss, HAMs contribute to greater morbidity, hospitalization, and mortality. Physicians as key members of the provision of healthcare are expected to be well aware of the administration and regulations surrounding HAMs. However, the current status is unknown in Pakistan. Consequently, the objectives of this study were to evaluate the knowledge of Pakistani physicians about the administration, regulation, and practices related to HAMs. This builds on our recently published study with nurses. Methods: An online cross-sectional study design was used, and data were gathered from the physicians throughout Pakistan using previously used self-administered questionnaires during a period of 5 months (January 1 to May 30, 2021). All data were entered and analyzed using SPSS 22 for Windows. Results: Physicians (847) who provided consent were enrolled in the study. Most physicians (62.2%) were male, aged between 25 and 30 years (75.2%) and had 2- to 5-year work experience (50.9%). About 27% were working in the emergency departments. The median (IQR) knowledge score for HAMs administration and regulation was 5 (3) and 5 (2), respectively. About 46.4% of respondents were found to have moderate knowledge about HAMs; increasing age, work experience, and higher qualifications were significantly associated (p < 0.05) with better HAMs knowledge. Around 58% had good practices relating to HAMs during their routine work. Median practice scores increased significantly (p < 0.05) with age, work experience, and postgraduate qualification. Conclusion: Most Pakistani physicians possess moderate knowledge about HAMs administration and regulations. However, their practices relating to the HAMs administration and regulations are typically sub-optimal. Consequently, HAMs awareness needs to be improved by including course content in the current curriculum, provision of hospital-based continuous training programs about patient safety and care, and establishment of multi-disciplinary health care teams, including board-certified pharmacists and specialized nurses, for the effective execution of medication use process in Pakistani hospitals in the future.
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Affiliation(s)
- Zia Ul Mustafa
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Malaysia
- Department of Pharmacy Services, District Headquarter (DHQ) Hospital, Pakpattan, Pakistan
- *Correspondence: Zia Ul Mustafa, ; Muhammad Salman,
| | - Shahzaib Haroon
- Department of Medicine, Faisalabad Medical University, Faisalabad, Pakistan
| | - Naeem Aslam
- Department of Surgery and Allied, District Headquarter Hospital (DHQ), Pakpattan, Pakistan
| | - Ahsan Saeed
- Department of Surgery and Allied, DHQ Teaching Hospital, Sahiwal, Pakistan
| | - Muhammad Salman
- Department of Pharmacy, The University of Lahore, Lahore, Pakistan
- *Correspondence: Zia Ul Mustafa, ; Muhammad Salman,
| | - Khezar Hayat
- Institute of Pharmaceutical Sciences, University of Veterinary and AnimalSciences, Lahore, Pakistan
| | | | - Khalid Hussain
- College of Pharmacy, Punjab University, Lahore, Pakistan
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Malaysia
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ÖZTÜRK F, ALTIPARMAK Ö, TORUN B, BEKTAY MY, SANCAR M, OKUYAN B. Reliability of High-Alert Medications Questionnaire in Turkish Healthcare Professionals. BEZMIALEM SCIENCE 2022. [DOI: 10.14235/bas.galenos.2020.5238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Nunes GDK, Campos JF, Silva RCD. Rotulagem de dispositivos de terapia intravenosa em Unidades de Terapia Intensiva: revisão integrativa. Rev Bras Enferm 2022. [DOI: 10.1590/0034-7167-2022-0049pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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