The pathophysiology of medication errors: how and where they arise

The movement of syringes and medication during anesthesiology delivery: An observational study in laparoscopic surgeries

The movements of syringes and medications during an anesthetic case have yet to be systematically documented. We examine how syringes and medication move through the anesthesia work area during a case. We conducted a video-based observational study of 14 laparoscopic surgeries. We defined 'syringe events' as when syringe was picked up and moved. Medications were administered to the patient in only 48 (23.6%) of the 203 medication or syringe events. On average, 14.5 syringe movements occurred in each case. We estimate approximately 4.2 syringe movements for each medication administration. When a medication was administered to the patient (either through the IV pump or the patient port), it was picked up from one of 8 locations in the work area. Our study suggests that the syringe storage locations vary and include irregular locations (e.g., patient bed or provider's pockets). Our study contributes to understanding the complexity in the anesthesia work practices.

Polymyoclonus, ventricular fibrillation and Takotsubo after accidental spinal injection of tranexamic acid

Several factors have been identified as contributing to medication administration errors, including look-alike, sound-alike (LASA) errors. LASA errors are important causes of serious adverse events arising from spinal injection of tranexamic acid, which can be confused with ampoules of local anaesthesia.We present a case of accidental injection of 250 mg of tranexamic acid rather than prilocaine during spinal anaesthesia. The patient developed lower extremities myoclonus, followed by generalised convulsions and ventricular fibrillation, that was reverted within 6 min. Severe cardiogenic shock requiring both inotropic and vasopressor therapy followed, along with a classic apical ballooning pattern on echocardiography and elevated myocardial injury markers, indicating Takotsubo cardiomyopathy. The patient's condition progressively improved to full recovery, and she was discharged from hospital after 1 month with no neurological deficit or cardiac dysfunction.To our knowledge, this is the 28th reported case of accidental spinal injection of tranexamic acid. We present a brief review of previously published cases.

Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the National Reporting and Learning System

INTRODUCTION

Direct oral anticoagulants (DOACs) are considered high risk medicines and are frequently associated with medication errors. The nature of incidents and associated outcomes of such incidents are poorly understood.

AREAS COVERED

Using a national patient safety reporting database, the National Reporting and Learning System (NRLS), this study aimed to report the contributory factors and outcomes including severe harm and deaths related to all safety incidents involving DOACs reported in England and Wales between 2017-2019. Reason's accident causation model was used to classify the incidents.

EXPERT OPINION

A total of 15,730 incident reports were analyzed. A total of 25 deaths were reported with a further 270 and 55 incidents leading to moderate and severe harm, respectively. A further 8.8% (n = 1381) of incidents were associated with low degree of harm. The majority of the incidents involved active failures (n = 13776; 87.58) including duplication of anticoagulant therapies, patients being discharged without DOACs, non-consideration of renal function, and lack of commencement of DOACs post-surgery suggesting preventability of such reported incidents. This study shows that medication incidents involving DOACs have the potential to cause severe harm and deaths, and there is a need to promote guideline adherence through education, training, and decision support technologies.

Electronic monitoring of potential adverse drug events related to lopinavir/ritonavir and hydroxychloroquine during the first wave of COVID-19

During Switzerland's first wave of COVID-19, clinical pharmacy activities during medical rounds in Geneva University Hospitals were replaced by targeted remote interventions. We describe using the electronic PharmaCheck system to screen high-risk situations of adverse drug events (ADEs), particularly targeting prescriptions of lopinavir/ritonavir (LPVr) and hydroxychloroquine (HCQ) in the presence of contraindications or prescriptions outside institutional guidelines. Of 416 patients receiving LPVr and/or HCQ, 182 alerts were triggered for 164 (39.4%) patients. The main associated risk factors of ADEs were drug-drug interactions, QTc interval prolongation, electrolyte disorder and inadequate LPVr dosage. Therapeutic optimisation recommended by a pharmacist or proposals for additional monitoring were accepted in 80% (n=36) of cases. Combined with pharmacist contextualisation to the clinical context, PharmaCheck made it possible to successfully adapt clinical pharmacist activities by switching from a global to a targeted analysis mode in an emergency context.

Self-reported work-related accumulative fatigue of nurses: A cross-sectional study in public hospitals in China

Objectives

Work-related fatigue is a serious safety risk to nurses and their patients. This study aimed to assess self-reported work-related accumulative fatigue of nurses and its associated factors.

Methods

A questionnaire survey of 2,918 clinical nurses conveniently sampled from 48 public hospitals across six provinces in China was conducted. The "Self-diagnosis Checklist for Assessment of Workers' Accumulated Fatigue" was adopted to assess the level of work-related accumulative fatigue of the study participants. Chi-square tests and ordinal regression analyses were performed to determine the sociodemographic characteristics associated with work-related accumulative fatigue.

Results

About one third of respondents reported low work-related accumulative fatigue, compared with 23.1% reporting high and 24.6% reporting very high levels of work-related accumulative fatigue. Higher levels of work-related accumulative fatigue were associated with female gender (AOR = 0.614 for male relative to female, p = 0.005), age between 30 and 40 years (AOR = 1.346 relative to >40 years, p = 0.034), 5-10 years of work experience (AOR = 1.277 relative to >10 years, p = 0.034), and bachelor or above degree qualifications (AOR = 0.806 for associate degree relative to bachelor or above degree, p = 0.007). Those who worked in rural county hospitals (AOR = 0.816 for metropolitan relative to rural county hospitals, p = 0.006) and resided in central China (AOR = 1.276 relative to western China, p = 0.004) had higher odds of reporting higher levels of work-related accumulative fatigue.

Conclusion

High levels of work-related accumulative fatigue are evident in nurses of public hospitals in China. The problem is more serious in the female nurses in their mid-career and those who worked in the central region and rural setting.

Antibiotic prescription errors: the relationship with clinical competence in junior medical residents

BACKGROUND

A large portion of prescribing errors can be attributed to deficiencies in medication knowledge. These errors are preventable and most often occur at the time of prescription. Antimicrobials are the drug class most common incorrectly prescribed.

OBJECTIVE

To characterize the relationship between clinical competence and antibiotic prescription errors. We also investigated the frequency and severity of antibiotic prescription errors to identify items and attributes of clinical competence which are correlated with the antibiotic prescription error ratio.

METHOD

A cross-sectional study was applied to assess clinical competence of junior medical residents in two reference academic hospitals and a regional hospital in Mexico City. It was conducted during February 2019. We used an infectious disease Objective Structured Clinical Examination (OSCE) to assess clinical competence and a measure of frequency, and severity of antibiotic prescription errors.

RESULTS

The number of eligible participants was ~ 255 (hospital meeting attendance), and the number of residents in this study were 51 (~ 20%), 31 were female (60.8%). The mean OSCE score was 0.692 ± 0.073. The inter-item (Cronbach's alpha = 0.927) and inter-station internal consistency was adequate (Cronbach's alpha = 0.774). The G coefficient in generalizability theory analysis was 0.84. The antibiotic prescription error ratio was 45.1% ± 7%. The most frequent category of severity of antibiotic prescription errors was category E (errors that may contribute to or result in temporary harm to the patient and require intervention), 235 (65.2%). We observed a negative and significant correlation between clinical competence and antibiotic prescription errors (r = -0.33, p < 0.05, CI95% -0.57 to -0.07), which remained significant after controlling for the effect of gender and time since graduation from medical school (r = -0.39, p < 0.01, CI95% -0.625 to -0.118). Using exploratory factor analysis we identified two factors, which explained 69% of the variance in clinical competence, factor 1 evaluated socio-clinical skills and factor 2 evaluated diagnostic-therapeutic skills. Factor 2 was correlated with antibiotic prescription error ratio (r = -0.536, p < 0.001).

CONCLUSIONS

We observed a negative correlation between clinical competence and antibiotic prescription error ratio in graduated physicians who have been accepted in a medical specialty. The therapeutic plan, which is a component of the clinical competence score, and the prescription skills had a negative correlation with antibiotic prescription errors. The most frequent errors in antibiotic prescriptions would require a second intervention.

Evaluation of medication reconciliation process in internal medicine wards of an academic medical center by a pharmacist: errors and risk factors

Medication reconciliation based on complete medication histories has been introduced to minimize medication errors and its associated healthcare costs in the transitions of care. In this study, to evaluate the routine process of medication reconciliation in an academic medical center, medication history taken at the time of admission by physicians and the first order prescribed in the hospital was compared to a comprehensive reconciliation form filled by a pharmacist using direct interview of the patients and caregivers, patient's insurance records and medication packages they brought from home. Two hundred and fifty-seven patients admitted in the internal wards of an academic medical center between June and September 2019 were investigated. In 6% of the patients, drug history was not included in the medical history form. Other patients were using 8.59 drugs in average, with a mean of 3.55 medication discrepancies in the history-taking process. Most commonly occurring errors were drug omissions (2.23 per patient on average) and incorrect frequency (0.96 per patient on average). There was a mean of 0.7 potentially harmful discrepancies for each patient. The mean number of drug discrepancies in new prescriptions from the hospital was 1.25, and almost half of patients had a potentially harmful discrepancies reordered in the hospital. There was no statistically meaningful relationship between patients' gender, physicians' gender, or the time of history taking and the total number of medication errors. History of ischemic heart disease was significantly associated with higher number of medication errors (p = 0.05). The results suggest that the medication reconciliation process in this academic center is inefficient. Using a systematic approach in medication reconciliation and gathering the best possible medication history, with a pharmacist who has better understanding of drugs' potential interactions and harmful errors can improve this process and prevent such errors in the future.

Integration of Medication Safety Training and Development of a Culture of Safety in Pharmacy Education

Medication safety events with the potential for patient harm do occur in health care settings. Pharmacists are regularly tasked with utilizing their medication knowledge to optimize the medication use process and reduce the likelihood of error. To prepare for these responsibilities in professional practice, it is important to introduce patient safety principles during educational experiences. The Accreditation Council for Pharmacy Education (ACPE) and the American Society of Health-System Pharmacists (ASHP) have set forth accreditation standards focused on the management of medication use processes to ensure these competencies during pharmacy didactic learning and postgraduate training. The experience described here provides perspective on educational and experiential opportunities across the continuum of pharmacy education, with a focus on a relationship between a college of pharmacy and healthcare system. Various activities, including discussions, medication event reviews, audits, and continuous quality improvement efforts, have provided the experiences to achieve standards for these pharmacy learners. These activities support a culture of safety from early training.

Impact of a Mobile App on Paramedics' Perceived and Physiologic Stress Response During Simulated Prehospital Pediatric Cardiopulmonary Resuscitation: Study Nested Within a Multicenter Randomized Controlled Trial

BACKGROUND

Out-of-hospital cardiac arrests (OHCAs) are stressful, high-stake events that are associated with low survival rates. Acute stress experienced in this situation is associated with lower cardiopulmonary resuscitation performance in calculating drug dosages by emergency medical services. Children are particularly vulnerable to such errors. To date, no app has been validated to specifically support emergency drug preparation by paramedics through reducing the stress level of this procedure and medication errors.

OBJECTIVE

This study aims to determine the effectiveness of an evidence-based mobile app compared with that of the conventional preparation methods in reducing acute stress in paramedics at the psychological and physiological levels while safely preparing emergency drugs during simulated pediatric OHCA scenarios.

METHODS

In a parent, multicenter, randomized controlled trial of 14 emergency medical services, perceived and physiologic stress of advanced paramedics with drug preparation autonomy was assessed during a 20-minute, standardized, fully video-recorded, and highly realistic pediatric OHCA scenario in an 18-month-old child. The primary outcome was participants' self-reported psychological stress perceived during sequential preparations of 4 intravenous emergency drugs (epinephrine, midazolam, 10% dextrose, and sodium bicarbonate) with the support of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app designed to help pediatric drug preparation (intervention) or conventional methods (control). The State-Trait Anxiety Inventory and Visual Analog Scale questionnaires were used to measure perceived stress. The secondary outcome was physiologic stress, measured by a single continuous measurement of the participants' heart rate with optical photoplethysmography.

RESULTS

From September 3, 2019, to January 21, 2020, 150 advanced paramedics underwent randomization. A total of 74 participants were assigned to the mobile app (intervention group), and 76 did not use the app (control group). A total of 600 drug doses were prepared. Higher State-Trait Anxiety Inventory-perceived stress increase from baseline was observed during the scenario using the conventional methods (mean 35.4, SD 8.2 to mean 49.8, SD 13.2; a 41.3%, 35.0 increase) than when using the app (mean 36.1, SD 8.1 to mean 39.0, SD 8.4; a 12.3%, 29.0 increase). This revealed a 30.1% (95% CI 20.5%-39.8%; P<.001) lower relative change in stress response in participants who used the app. On the Visual Analog Scale questionnaire, participants in the control group reported a higher increase in stress at the peak of the scenario (mean 7.1, SD 1.8 vs mean 6.4, SD 1.9; difference: -0.8, 95% CI -1.3 to -0.2; P=.005). Increase in heart rate during the scenario and over the 4 drugs was not different between the 2 groups.

CONCLUSIONS

Compared with the conventional method, dedicated mobile apps can reduce acute perceived stress during the preparation of emergency drugs in the prehospital setting during critical situations. These findings can help advance the development and evaluation of mobile apps for OHCA management and should be encouraged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3726-4.

Associations of physicians' prescribing experience, work hours, and workload with prescription errors

OBJECTIVE

We aimed to assess associations of physician's work overload, successive work shifts, and work experience with physicians' risk to err.

MATERIALS AND METHODS

This large-scale study included physicians who prescribed at least 100 systemic medications at Sheba Medical Center during 2012-2017 in all acute care departments, excluding intensive care units. Presumed medication errors were flagged by a high-accuracy computerized decision support system that uses machine-learning algorithms to detect potential medication prescription errors. Physicians' successive work shifts (first or only shift, second, and third shifts), workload (assessed by the number of prescriptions during a shift) and work-experience, as well as a novel measurement of physicians' prescribing experience with a specific drug, were assessed per prescription. The risk to err was determined for various work conditions.

RESULTS

1 652 896 medical orders were prescribed by 1066 physicians; The system flagged 3738 (0.23%) prescriptions as erroneous. Physicians were 8.2 times more likely to err during high than normal-low workload shifts (5.19% vs 0.63%, P < .0001). Physicians on their third or second successive shift (compared to a first or single shift) were more likely to err (2.1%, 1.8%, and 0.88%, respectively, P < .001). Lack of experience in prescribing a specific medication was associated with higher error rate (0.37% for the first 5 prescriptions vs 0.13% after over 40, P < .001).

DISCUSSION

Longer hours and less experience in prescribing a specific medication increase risk of erroneous prescribing.

CONCLUSION

Restricting successive shifts, reducing workload, increasing training and supervision, and implementing smart clinical decision support systems may help reduce prescription errors.

The Association Between Cognitive Medical Errors and Their Contributing Organizational and Individual Factors

BACKGROUND

Examining cognitive medical errors (MEs) and their contributing factors is vital in health systems research, as it provides baseline data that can be used to develop appropriate interventions to prevent and/or minimize errors. The primary aim of this study was to investigate the association between cognitive MEs and hospitals' organizational factors and the individual psychological and functional factors.

METHODS

This cross-sectional study was conducted in three main hospitals in Northern Jordan. A proportional sampling technique was employed to decide the number of participants from each hospital. Data from physicians and nurses (n=400) were collected using a self-administered questionnaire, which was developed based on pertinent literature review. Exploratory and confirmatory factor analyses were conducted to validate the study instrument. The relationships between the variables were analyzed through structural equation modeling (SEM) using AMOS. Multi-group analysis was also performed to examine the differences in the participants' perceptions towards the respective variables between the three selected hospitals.

RESULTS

Our results showed a non-significant negative association between MEs and hospital organizational factors. Also, the SEM analysis showed a positive significant correlation between MEs and psychological and functional factors, whereby excessive workload, complexity of tasks, stress, sleep deprivation, and fatigue were found to be predictors of MEs occurrence. In comparison to the results from the university hospital, the multi-group analysis results from the governmental public hospital and the private hospital showed a significant impact of psychological and functional factors on MEs.

CONCLUSION

To reduce the occurrence of MEs in hospitals, there is a need to enhance organizational safety culture. Efforts should be directed at both organizational and individual levels. Also, it is essential that health decision makers develop strategies to reduce work-related stress and improve healthcare staff well-being, as work stress may cause cognitive impairments among healthcare workers and hence threaten patients' safety.

Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets

OBJECTIVES

Automated dispensing cabinets (ADCs) are used in hospitals to improve medication safety and decrease costs. However, ADCs do not completely eliminate the risk of mistakes between look-alike, sound-alike (LASA) medicines. The aim of this study was to identify the characteristics of LASA medicines and determine the factors related to their safe storage in ADCs.

METHODS

The medication selection of one hospital pharmacy's ADC located in an intensive care unit was observed. The study consisted of five parts: a determination of criteria to identify LASA medications, an analysis of an ADCs' inventory reports, assessment of the storage of identified LASA medicines, a visual observation of the medicine packages stored in the same storage compartment and qualitative analysis of the medication-use process from prescribing a medicine to removing it from an ADC.

RESULTS

Approximately 70% (n=355/488) of the ADCs selection had a LASA risk with at least one product. Moreover, 20% (n=84/355) of the LASA medicines identified were high-alert medications. Approximately 16% (n=58/355) of the identified LASA medicines were stored unsafely close to at least one other LASA medicine. Less than 4% (n=13/355) of the LASA medicines were unsafely stored high-alert medications.

CONCLUSIONS

ADCs reduce the risks of LASA medication errors when used correctly, but automation can also increase them, for example, when placing multiple LASA medicines in the same storage compartment. Attention should be paid to the identification and safe storage of LASA medicines to promote safe use of ADCs in hospitals.

Medication Dosing Safety for Pediatric Patients: Recognizing Gaps, Safety Threats, and Best Practices in the Emergency Medical Services Setting. A Position Statement and Resource Document from NAEMSP

BACKGROUND

Millions of patients receive medications in the Emergency Medical Services (EMS) setting annually, and dosing safety is critically important. The need for weight-based dosing in pediatric patients and variability in medication concentrations available in the EMS setting may require EMS providers to perform complex calculations to derive the appropriate dose to deliver. These factors can significantly increase the risk for harm when dose calculations are inaccurate or incorrect.

METHODS

We conducted a scoping review of the EMS, interfacility transport and emergency medicine literature regarding pediatric medication dosing safety. A priori, the authors identified four research topics: (1) what are the greatest safety threats that result in significant dosing errors that potentially result in harm to patients, (2) what practices or technologies are known to enhance dosing safety, (3) can data from other settings be extrapolated to the EMS environment to inform dosing safety, and (4) what impact could standardization of medication formularies have on enhancing dosing safety. To address these topics, 17 PICO (Patient, Intervention, Comparison, Outcome) questions were developed and a literature search was performed.

RESULTS

After applying exclusion criteria, 70 articles were reviewed. The methods for the investigation, findings from these articles and how they inform EMS medication dosing safety are summarized here. This review yielded 11 recommendations to improve safety of medication delivery in the EMS setting.

CONCLUSION

These recommendations are summarized in the National Association of EMS Physicians® position statement: Medication Dosing Safety for Pediatric Patients in Emergency Medical Services.

Cost-effective innovation of locally assembled mannequins for undergraduate skill development in parenteral drug administration

INTRODUCTION:

The new competencybased curriculum for undergraduate medical education by the Medical Council of India mandates simulation using mannequins for teaching parenteral drug administration. Traditional education tends to focus on textbook learning, whereas competencybased education concentrates on the outcomes that directly guide the assessment of learners.

OBJECTIVE:

To introduce a module for the development of the core competency of parenteral drug administration using costeffective locally assembled mannequins for handson skill development in administering injections to be assessed using objective structured practical examination (OSPE).

MATERIALS AND METHODS:

Costeffective and durable fiberglass arms from mannequins used for fashion display were prepared for parenteral drug administration. The padding is easily done with wadding and gauze/crepe bandages, and the assembling requires only 15 minutes per arm. The training can be conducted in the department, giving students adequate opportunity for handson learning on individual arms during the practical sessions. As initial investment and recurring costs are low, it is possible for the department to obtain enough number of mannequins for each student to practice individually on an injection arm.

RESULTS:

Students practice injection technique freely, without fear of damaging the mannequin or having to do it on a patient. This helps them to assimilate the steps and sub-steps of doing the task in a much more realistic way and builds their confidence. Assessment of the performance of injection technique, infection control practices, and drug delivery are possible.

CONCLUSION:

We have observed a greater trend toward selflearning and selfefficacy and better adherence to the protocol of injection technique because of the handson training the students receive.

Foundation doctor knowledge of wounds and dressings is improved by a simple intervention: An audit cycle-based quality improvement study

BACKGROUND

Many foundation year 1 and 2 doctors (FYs) have limited knowledge experience in wound management. Wound dressing formularies exist in many NHS Trusts, though awareness of and adherence to them by FYs is not known. This quality improvement study described baseline FY knowledge of wound management, and investigated whether this could be improved through educational intervention.

METHODS

A single-centre, prospective, baseline audit was conducted following local approval. This assessed knowledge of wound types and appropriate dressings alongside individual confidence providing wound care. The educational intervention involved the distribution of an ID-badge sized quick reference guide that could be attached to the FYs' lanyards, and an introduction to the formulary during routine teaching. The audit loop was closed by repeating the questionnaire.

RESULTS

Pre- (n = 43) and post- (n = 35) intervention questions were completed by FYs. The mean score post-intervention was significantly higher than the pre-intervention score across all knowledge questions (from 32% correct to 71% correct, p < 0.0001). There was no change in participant confidence, which remained low.

CONCLUSION

FYs lack confidence and knowledge about wounds and dressings. The latter can be improved through a simple and practical educational intervention that could be deployed nationally.

Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors

BACKGROUND

Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty.

METHODS

With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution.

RESULTS

A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P < .001). The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty. Error rates varied among institutions ranged from 12% to 22% (P = .021).

CONCLUSIONS

Anesthesiology residents and faculty erred frequently on a computational test, with junior residents and faculty with more experience committing errors more frequently. Residents committed more serious errors twice as frequently as faculty.

Female low dose tip syringes-increased complexity of use may compromise dosing accuracy in paediatric patients

WHAT IS KNOWN AND OBJECTIVE

The International Organization for Standardization (ISO) created enteral device specifications to reduce tubing misconnections. The Global Enteral Device Supplier Association (GEDSA) supports a female design: standard and low dose tip (LDT). Concerns include increased complexity of use with adapters, dosing accuracy and workflow. No peer-reviewed studies have evaluated dosing accuracy of the complete female system with adapters. The objective of this study was to compare dosing accuracy of the female design to legacy syringes.

METHODS

An in vitro study was conducted at the University of Florida College of Pharmacy pharmaceutics laboratory. Assessments were completed for syringe size, dispense methods and volumes, and adapters when applicable. A gravimetric scale and specific gravity were used to calculate administration volumes. The primary outcome was frequency administration volume exceeded 10% expected amount.

RESULTS AND DISCUSSION

A total of 576 tests were performed. The LDT resulted in significantly higher rates of unacceptable dosing variance compared to legacy (21.2% vs 7.4%, P = 0.003). Variance exceeding 10% occurred more frequently with LDT 0.5 and 1 mL syringes, medication cup dispensing (liquid or tablet) and inappropriate LDT adapter use. Unapproved adapter processes compared to FDA-approved processes held a higher likelihood of unacceptable dosing variance (28% vs 7.4%, P < 0.001). FDA-approved use of adapters with prefilled syringes compared to bedside administration may result in higher rates of dosing inaccuracy (18.8% vs 5.6%, P = 0.06).

WHAT IS NEW AND CONCLUSIONS

This study raises clinical concerns of dosing inaccuracies with the LDT syringes, particularly with 0.5 and 1 mL sizes. The use of adapters significantly increases the opportunity for inaccurate dosing.

Assessment of the clinical relevance of pharmacists' interventions performed during medication review in a rheumatology ward

BACKGROUND

Pharmacists contribute to reduce the number of medication errors during medication review. Nevertheless, few French studies report the potential clinical impact of pharmacists' interventions performed after detecting drug-related problems. The objective was to evaluate the clinical relevance of pharmacists' interventions in a rheumatology ward from medical and pharmaceutical perspectives.

METHOD

The analysis was conducted on pharmacists' interventions performed between January 1 and December 31, 2015 in a French teaching hospital. Similar pharmacists' interventions were grouped in one item and they were analysed according to 11 drug categories. The clinical significance of pharmacists' interventions was considered independently by a pharmacist and a rheumatologist using a validated French scale that categorises drug-related problems from minor to catastrophic. The agreement between the two professionals was analysed using the weighted kappa coefficient.

RESULTS

Of 1313 prescriptions reviewed, 461 pharmacists' interventions (171 items) were formulated for drug-related problems with an acceptance rate of 67.2%. Of the 418 interventions selected for clinical significance analysis, 235 interventions (56.2%) for the physician and 400 interventions (95.7%) for the pharmacist were at least significant. The two professionals evaluated equally the clinical relevance of 90 items (50.6%). The categories with the most similarities were the analgesics/anti-inflammatory drugs (78.1%), the antidiabetics (75.0%) and the anticoagulants (71.4%). The agreement was estimated by a weighted kappa coefficient of 0.29.

CONCLUSION

This work highlights the positive clinical relevance of pharmacists' interventions in rheumatology and the importance of medico-pharmaceutical collaboration to prevent medication errors.

Population Pharmacokinetics and Exploratory Exposure-Response Relationships of Diazepam in Children Treated for Status Epilepticus

Diazepam is labeled for status epilepticus (SE) in children, but there are limited data characterizing its disposition in pediatric patients. We developed a population pharmacokinetic (PK) model of i.v. diazepam in children with SE. We evaluated relationships between PK parameters and both safety and efficacy, and simulated exposures using dosing regimens from the product label and clinical practice. The model was developed using prospective data from a pediatric clinical trial comparing diazepam to lorazepam for treatment of SE. Altogether, 87 patients aged ≥ 3 months to < 18 years contributed 162 diazepam concentrations. Diazepam PKs were well characterized by a two‐compartment model scaled by body size. No significant or clinically important relationships were observed between diazepam PKs and safety or efficacy. Simulations demonstrated that, compared with label dosing, the study dose (0.2 mg/kg i.v., maximum 8 mg) resulted in greater frequency in rapidly achieving the target therapeutic range of 200–600 ng/mL.

Evaluation of Multimedia Medication Reconciliation Software: A Randomized Controlled, Single-Blind Trial to Measure Diagnostic Accuracy for Discrepancy Detection

BACKGROUND

The Veterans Affairs Portland Healthcare System developed a medication history collection software that displays prescription names and medication images.

OBJECTIVE

This article measures the frequency of medication discrepancy reporting using the medication history collection software and compares with the frequency of reporting using a paper-based process. This article also determines the accuracy of each method by comparing both strategies to a best possible medication history.

STUDY DESIGN

Randomized, controlled, single-blind trial.

SETTING

Three community-based primary care clinics associated with the Veterans Affairs Portland Healthcare System: a 300-bed teaching facility and ambulatory care network serving Veteran soldiers in the Pacific Northwest United States.

PARTICIPANTS

Of 212 patients with primary care appointments, 209 patients fulfilled the study requirements.

INTERVENTION

Patients randomized to a software-directed medication history or a paper-based medication history. Randomization and allocation to treatment groups were performed using a computer-based random number generator. Assignments were placed in a sealed envelope and opened after participant consent. The research coordinator did not know or have access to the treatment assignment until the time of presentation.

MAIN OUTCOME MEASURES

The primary analysis compared the discrepancy detection rates between groups with respect to the health record and a best possible medication history.

RESULTS

Of 3,500 medications reviewed, we detected 1,435 discrepancies. Forty-six percent of those discrepancies were potentially high risk for causing an adverse drug event. There was no difference in detection rates between treatment arms. Software sensitivity was 83% and specificity was 91%; paper sensitivity was 81% and specificity was 94%. No participants were lost to follow-up.

CONCLUSION

The medication history collection software is an efficient and scalable method for gathering a medication history and detecting high-risk discrepancies. Although it included medication images, the technology did not improve accuracy over a paper list when compared with a best possible medication history.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02135731.

Physicians' Perspectives on Causes of Health Care Errors and Preventive Strategies: A Study in a Developing Country

BACKGROUND

To prevent health care errors, the main causes and preventive strategies should be identified. The purpose of this study was to identify the causes and preventive strategies of health care errors from the perspectives of physicians.

METHODS

We surveyed 250 randomly selected physicians in five teaching hospitals in Tehran, Iran, in 2015. We used a questionnaire with 29 questions regarding causes and 17 ones regarding the preventive strategies. The participants were asked to answer the questions based on Likert's five-point score (1=very low to 5= very high). The data was analyzed using descriptive (frequency, and mean scores) and inferential statistics in SPSS.

RESULTS

Managerial factors (3.6±0.7), personal factors of providers (3.5±0.6), factors related to the patients (3.4±0.71), and the factors pertinent to laboratory and pharmacy (3.2±0.8) were the main causes respectively. The most important preventive strategies were improvement of academic education, better taking past medical history, implementing electronic prescription and increasing healthcare budget.

CONCLUSION

Heavy workloads, long work shifts, failure to do thorough examination and to collect detailed history information, providers' fatigue, patients' reluctance to follow orders or to give their complete information, failure to give detailed instruction to patients about the medications, lack or insufficient monitoring and supervising systems, and lack of enough budget were some of the most important causes of errors. Using IT to access patients' information, improving patients' adherence, reducing workload, developing efficient methods for collecting patients' information, dedicating adequate budget for improvement programs are recommended.

Pharmacists as vaccinators: An analysis of their experiences and perceptions of their new role

OBJECTIVES

In 2012, Ontario pharmacists were granted immunization privileges to administer influenza vaccines to the public. This study explored the experiences and practices of pharmacist vaccinators and the impact of vaccination pain on their practice.

METHODS

Semi-structured interviews were conducted with 12 pharmacists in the Greater Toronto Area. Transcribed interview data were coded and analyzed via thematic analysis.

KEY FINDINGS

Data analysis revealed 4 main themes: 1) expanded scope of practice as an enhancement and challenge to relationships; 2) professional satisfaction and workload demands; 3) knowledge and attitudes regarding pain and fear; 4) practices regarding pain and fear management. Pharmacists reported satisfaction in their new role, despite the associated increased workload. Pharmacists felt that vaccination pain was not a key consideration when administering vaccines and that pain management was generally not necessary. Fear was identified as more important than pain and vaccinating children was challenging and time intensive. Pharmacists' main focus was on injection techniques in managing pain.

CONCLUSION

These findings suggest that pharmacists are accepting of their role as vaccinators but more research is needed to examine impact on workload and pharmacist knowledge and perceptions of injection-related pain and fear.

The use of a contextual, modal and psychological classification of medication errors in the emergency department: a retrospective descriptive study

AIMS AND OBJECTIVES

To describe the contextual, modal and psychological classification of medication errors in the emergency department to know the factors associated with the reported medication errors.

BACKGROUND

The causes of medication errors are unique in every clinical setting; hence, error minimisation strategies are not always effective. For this reason, it is fundamental to understand the causes specific to the emergency department so that targeted strategies can be implemented.

DESIGN

Retrospective analysis of reported medication errors in the emergency department.

METHODS

All voluntarily staff-reported medication-related incidents from 2010-2015 from the hospital's electronic incident management system were retrieved for analysis. Contextual classification involved the time, place and the type of medications involved. Modal classification pertained to the stage and issue (e.g. wrong medication, wrong patient). Psychological classification categorised the errors in planning (knowledge-based and rule-based errors) and skill (slips and lapses).

RESULTS

There were 405 errors reported. Most errors occurred in the acute care area, short-stay unit and resuscitation area, during the busiest shifts (0800-1559, 1600-2259). Half of the errors involved high-alert medications. Many of the errors occurred during administration (62·7%), prescribing (28·6%) and commonly during both stages (18·5%). Wrong dose, wrong medication and omission were the issues that dominated. Knowledge-based errors characterised the errors that occurred in prescribing and administration. The highest proportion of slips (79·5%) and lapses (76·1%) occurred during medication administration. It is likely that some of the errors occurred due to the lack of adherence to safety protocols.

CONCLUSION

Technology such as computerised prescribing, barcode medication administration and reminder systems could potentially decrease the medication errors in the emergency department. There was a possibility that some of the errors could be prevented if safety protocols were adhered to, which highlights the need to also address clinicians' attitudes towards safety.

RELEVANCE TO CLINICAL PRACTICE

Technology can be implemented to help minimise errors in the ED, but this must be coupled with efforts to enhance the culture of safety.

Potential underreporting of medication errors in a psychiatric general hospital in Japan

The purpose of this study was to explore a pattern of underreporting within a psychiatric general hospital in Japan. All the medication errors reported online in 2010 were analysed. This research was approved by the university and the study hospital. There were 651 incidents related to medication errors. Medication error rate per 1000 patient days was 2.14 (range: 0.45-6.05). Medication error rates between two acute care wards with comparable case and staff mix differed. A low proportion of intercepted near-misses and low medication error rates around mealtime in acute care 1 were suggestive of under-reporting. Two dementia care wards with low medication error rates had no report of intercepted errors, which was also suggestive of underreporting. Ward-specific medication error rates and patterns are useful to identify wards with potential underreporting of medication error within the hospital.

Perception of the risk of adverse reactions to analgesics: differences between medical students and residents

Background. Medications are not exempt from adverse drug reactions (ADR) and how the physician perceives the risk of prescription drugs could influence their availability to report ADR and their prescription behavior.

Methods. We assess the perception of risk and the perception of ADR associated with COX2-Inbitors, paracetamol, NSAIDs, and morphine in medical students and residents of northeast of Mexico.

Results. The analgesic with the highest risk perception in both group of students was morphine, while the drug with the least risk perceived was paracetamol. Addiction and gastrointestinal bleeding were the ADR with the highest score for morphine and NSAIDs respectively.

Discussion. Our findings show that medical students give higher risk scores than residents toward risk due to analgesics. Continuing training and informing physicians about ADRs is necessary since the lack of training is known to induce inadequate use of drugs.

Does electronic medication reconciliation at hospital discharge decrease prescription medication errors?

PURPOSE

Medication errors are an important patient safety issue. Electronic medication reconciliation is a system designed to correct medication discrepancies at transitions in healthcare. The purpose of this paper is to measure types and prevalence of intravenous antibiotic errors at hospital discharge before and after the addition of an electronic discharge medication reconciliation tool (EDMRT).

DESIGN/METHODOLOGY/APPROACH

A retrospective study was conducted at a tertiary hospital where house officers order discharge medications. In total, 100 pre-EDMRT and 100 post-EDMRT subjects were randomly recruited from the study center's clinical Outpatient Parenteral Antimicrobial Therapy (OPAT) program. Using infectious disease consultant recommendations as gold standard, each antibiotic listed in these consultant notes was compared to the hospital discharge orders to ascertain the primary outcome: presence of an intravenous antibiotic error in the discharge orders. The primary covariate of interest was pre- vs post-EDMRT group. After generating the crude prevalence of antibiotic errors, logistic regression accounted for potential confounding: discharge day (weekend vs weekday), average years of practice by prescribing physician, inpatient service (medicine vs surgery) and number of discharge mediations per patient.

FINDINGS

Prevalence of medication errors decreased from 30 percent (30/100) among pre-EDMRT subjects to 15 percent (15/100) errors among post-EDMRT subjects. Dosage errors were the most common type of medication error. The adjusted odds ratio of discharge with intravenous antibiotic error in the post-EDMRT era was 0.39 (0.18, 0.87) compared to the pre-EDMRT era. In the adjusted model, the total number of discharge medications was associated with increased OR of discharge error.

ORIGINALITY/VALUE

To the authors' knowledge, no other study has examined the impact of reconciliation on types and prevalence of medication errors at hospital discharge. The focus on intravenous antibiotics as a class of high-stakes medications with serious risks to patient safety during error events highlights the clinical importance of the findings. Electronic medication reconciliation may be an important tool in efforts to improve patient safety.

An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit

Aim

To assess the impact of the implementation of a Computerized Physician Order Entry (CPOE) associated with a pharmaceutical checking of medication orders on medication errors in the 3 stages of drug management (i.e. prescription, dispensing and administration) in an orthopaedic surgery unit.

Methods

A before-after observational study was conducted in the 66-bed orthopaedic surgery unit of a teaching hospital (700 beds) in Paris France. Direct disguised observation was used to detect errors in prescription, dispensing and administration of drugs, before and after the introduction of computerized prescriptions. Compliance between dispensing and administration on the one hand and the medical prescription on the other hand was studied. The frequencies and types of errors in prescribing, dispensing and administration were investigated.

Results

During the pre and post-CPOE period (two days for each period) 111 and 86 patients were observed, respectively, with corresponding 1,593 and 1,388 prescribed drugs. The use of electronic prescribing led to a significant 92% decrease in prescribing errors (479/1593 prescribed drugs (30.1%) vs 33/1388 (2.4%), p < 0.0001) and to a 17.5% significant decrease in administration errors (209/1222 opportunities (17.1%) vs 200/1413 (14.2%), p < 0.05). No significant difference was found in regards to dispensing errors (430/1219 opportunities (35.3%) vs 449/1407 (31.9%), p = 0.07).

Conclusion

The use of CPOE and a pharmacist checking medication orders in an orthopaedic surgery unit reduced the incidence of medication errors in the prescribing and administration stages. The study results suggest that CPOE is a convenient system for improving the quality and safety of drug management.

Medication-administration errors in an urban mental health hospital: a direct observation study

In the present study, we aimed to identify the incidence, type, and potential clinical consequence of medication-administration errors made in a mental health hospital, and to investigate factors that might increase the risk of error. A prospective, direct observational technique was used to collect data from nurse medication rounds on each of the hospital's 43 inpatient wards. Regression analysis was used to identify potential error predictors. During the 172 medication rounds observed, 139 errors were detected in 4177 (3.3%) opportunities. The most common error was incorrect dose omission (52/139, 37%). Other common errors included incorrect dose (25/139, 18%), incorrect form (16/139, 12%), and incorrect time (12/139, 9%). Fifteen (11%) of the errors were of serious clinical severity; the rest were of negligible or minor severity. Factors that increased the risk of error included the nurse interrupting the medication round to attend to another activity, an increased number of 'when required' doses of medication administered, a higher number of patients on the ward, and an increased number of doses of medication due. These findings suggest that providers of inpatient mental health-care services should adopt medicine-administration systems that minimize task interruption and the use of 'when required' medication, as well as taking steps to reduce nursing workload.

Current and future directions in clinical fatigue management: An update for emergency medicine practitioners

Physicians worldwide are working round the clock to meet the demands of healthcare systems, especially in acute medical settings such as EDs. Demanding shift work schedules cause fatigue and thus deterioration in mood and motor performance. This article explores the effects of sleep deprivation, focusing on cognition, executive decision-making and the implications for clinical care. Humans are capable of functioning and even adapting to sleep restriction; however, clinicians should be aware of pitfalls and absolute minimums for sleep. Fatigue management training shows promise in enhancing safety in aviation and might have a role in medical shift work. Strategic napping improves performance during night shift in the ED, but does not fully negate fatigue. Drugs offer limited benefit for performance under sleep-deprived conditions, and whenever possible, sleep and/or strategic napping takes precedence.

Preventing medication errors in neonatology: Is it a dream?

Since 1999, the problem of patient safety has drawn particular attention, becoming a priority in health care. A “medication error” (ME) is any preventable event occurring at any phase of the pharmacotherapy process (ordering, transcribing, dispensing, administering, and monitoring) that leads to, or can lead to, harm to the patient. Hence, MEs can involve every professional of the clinical team. MEs range from those with severe consequences to those with little or no impact on the patient. Although a high ME rate has been found in neonatal wards, newborn safety issues have not been adequately studied until now. Healthcare professionals working in neonatal wards are particularly susceptible to committing MEs due to the peculiarities of newborn patients and of the neonatal intensive care unit (NICU) environment. Current neonatal prevention strategies for MEs have been borrowed from adult wards, but many factors such as high costs and organizational barriers have hindered their diffusion. In general, two types of strategies have been proposed: the first strategy consists of identifying human factors that result in errors and redesigning the work in the NICU in order to minimize them; the second one suggests to design and implement effective systems for preventing errors or intercepting them before reaching the patient. In the future, prevention strategies for MEs need to be improved and tailored to the special neonatal population and the NICU environment and, at the same time, every effort will have to be made to support their clinical application.

Integrated therapy safety management system

AIMS

The aim is to demonstrate the benefit of the medico-ergonomic approach for the redesign of clinical work systems. Based on the six layer model, a concept for an 'integrated therapy safety management' is drafted. This concept could serve as a basis to improve resilience.

METHODS

The concept is developed through a concept-based approach. The state of the art of safety and complexity research in human factors and ergonomics forms the basis. The findings are synthesized to a concept for 'integrated therapy safety management'. The concept is applied by way of example for the 'medication process' to demonstrate its practical implementation.

RESULTS

The 'integrated therapy safety management' is drafted in accordance with the six layer model. This model supports a detailed description of specific work tasks, the corresponding responsibilities and related workflows at different layers by using the concept of 'bridge managers'. 'Bridge managers' anticipate potential errors and monitor the controlled system continuously. If disruptions or disturbances occur, they respond with corrective actions which ensure that no harm results and they initiate preventive measures for future procedures. The concept demonstrates that in a complex work system, the human factor is the key element and final authority to cope with the residual complexity. The expertise of the 'bridge managers' and the recursive hierarchical structure results in highly adaptive clinical work systems and increases their resilience.

CONCLUSIONS

The medico-ergonomic approach is a highly promising way of coping with two complexities. It offers a systematic framework for comprehensive analyses of clinical work systems and promotes interdisciplinary collaboration.

A review of medication errors in iran: sources, underreporting reasons and preventive measures

Medication error (ME) is the most common preventable cause of adverse drug events which negatively affects patient safety. Inadequate, low-quality studies plus wide estimation variations in ME from developing countries including Iran, decreases the reliability of ME evaluations. To clarify sources, underreporting reasons and preventive measures of MEs, we reviewed Iran current available literature. We searched Scopus, WOS, PubMed, CINAHL, EBSCOHOST and Persian databases (IranMedex, and SID) up to October 2012. Two authors independently selected and one reviewed and extracted data. Results reported by more than 30% of studies considered as the most important topics. Finally 25 articles were included. All study designs were cross-sectional (except for two interventional studies) and in hospital settings. Nursing staff and students were the most observed populations. Individual factor, with "inadequate knowledge of medication" as its most frequent reason, were the mostly reported source of MEs. Fear and reporting process were two most important reporting barriers. The sense of being reprimanded and ignoring to report respectively were their most frequent factors. Anti-infectives were the most frequent drugs involved in MEs. Preventive measures were varied and reporting of their effectiveness was inconsistent. There are still many research gaps which need to be explored by further studies. Based on our findings, further researches may be focused on design, implementation, and evaluation of a ME reporting system as groundwork, assessing systems-related factors to ME alongside individual factors and evaluating the effectiveness of preventive measures for MEs in trials.

Development of a teaching module for parenteral drug administration and objective structured practical examination stations in pharmacology

OBJECTIVES

Safe parenteral drug administration includes preparation of safe medication for administration. Training medical students is crucial to minimize medication administration errors. The study aims to develop a module to teach drug preparation skills and to develop objective structured practical examination (OSPE) stations to assess these skills. Students' perceptions regarding the module were also assessed.

MATERIALS AND METHODS

A module was developed to teach following skills to 2(nd) year medical students: Aspiration of a drug from the ampule, aspiration of the drug from the vial, aspiration of the drug in powdered form from vial (reconstitution), and setting up an intravenous (IV) infusion. A randomized case control study design was used to establish the validity of OSPE stations. Student volunteers were grouped into case (n = 20) and control groups (n = 20) by simple randomization. The test group watched videos of skills and received demonstration of skills and a practice session before OSPE, whereas the control group watched videos before the OSPE and received demonstration and a practice session only after the OSPE. Each student was assessed by two faculty members during OSPE using a validated checklist. Mean OSPE scores of control and test groups were compared using independent samples t-test. Interrater reliability and concurrent validity of stations were analyzed using interclass correlation coefficient (ICC) and Pearson correlation, respectively. Students' responses were expressed as median and interquartile range.

RESULTS

The response rate in the questionnaire was 100%. Significant difference between mean scores (P < 0.05) of test and control groups revealed fulfillment of construct validity of OSPE stations. Interrater reliability (ICC > 0.7) and concurrent validity (r value > 7) of all the stations was high. Perceptions revealed acceptability of module and OSPE stations by students (median 4, scale 1-5).

CONCLUSIONS

A module to teach drug preparation skills was developed and along with valid and reliable OSPE stations that were acceptable to students. The study demonstrated that students acquire better skills through teaching than merely watching these skills in videos.

Reducing the risk of harm from intravenous potassium: a multi-factorial approach in the haematology setting

AIMS

To describe the implementation of safety systems for the use of intravenous potassium chloride in haematology patients.

METHODS

We assessed the use of intravenous potassium in a haematology ward at a tertiary hospital. Initially, we prospectively analysed the prescribing and administration of intravenous potassium to all patients over a two-week period. To complement this data, we retrospectively analysed all clinical incidents involving intravenous potassium and the dispensing patterns of potassium ampoules for the past 12 months. Drawing on evidence and recommendations from international safety literature, gaps in the safe use of potassium were identified, and a multi-factorial approach to system change was implemented.

RESULTS

A total of 18 patients were analysed with 90 intravenous bags of potassium prepared on the ward using 624 ampoules. We identified multiple opportunities for error and a lack of standardisation of therapy. The following safety systems were introduced: (i) a new prescribing and monitoring form that included dose calculation, prescriber support and pre-printed orders; (ii) removal of potassium ampoules and introduction of premixed bags; (iii) independent double checking by nursing staff at point of administration; (iv) dedicated labelling of intravenous lines; (v) extensive clinician training supported by guidelines; and (vi) introduction of 'smart pump' infusion software. The number of incidents significantly reduced from 23 to 9 (p < 0.001), and the number of ampoules dispensed reduced from 10,100 to 0.

CONCLUSIONS

A multi-factorial approach to the safe prescribing, dispensing and administration of intravenous potassium has reduced the potential for patient harm in the haematology setting.

Medication Error Minimization Scheme (MEMS) in an adult tertiary intensive care unit (ICU) 2009-2011

INTRODUCTION

The Medication Error Minimisation Scheme (MEMS) is a locally based ongoing multidisciplinary, multifaceted quality improvement (QI) project within an Australian adult tertiary level Intensive Care Unit (ICU). The project commenced in 2009. Its primary aim is to enhance medication safety within this ICU by utilising existing resources. The aim of this paper is to provide a descriptive account of the various activities, interventions and results of this project within the first three years.

METHODS

The research design for this project was based upon Plan-Do-Study-Act (PDSA) cycles associated with QI projects. Medication error rates and audits of: intravenous infusions, incompatible intravenous medications and incorrect documentation of withheld medications were analyzed according to simple statistical techniques. Initial and follow up medication safety surveys were compared using basic statistical analysis. Focus groups exploring barriers and enablers of medication incident reporting were analyzed according to qualitative techniques associated with focus group discussions. Other interventions included: regular education sessions; discussions within other departmental meetings such as nursing staff meetings and Morbidity and Mortality meetings; and bedside discussions and demonstrations. Promotion of medication safety occurred within a number of forums; activities and findings were advertised and displayed; a recognizable Logo for MEMS was employed; and incentives were provided for staff.

RESULTS

Reported Medication Incidents (MIs) increased from 6.2 to 14.9 MIs per 1000 patient days. Audits and chart reviews confirmed that more MIs are uncovered by employing a variety of techniques in addition to incident reporting. Staff surveys provided a rich source of information regarding medication safety. Audits of intravenous infusions revealed a reduced error rate from 38/331 (11.5%) to 15/468 (3.2%). Chart review of incorrect documentation of omitted medications decreased from 105/347 (30.3%) to 104/486 (21.4%). Focus groups provided information that was able to be used in a number of hospital forums in order to explain the impact of existing systems upon ICU staff.

CONCLUSION

This ongoing QI project was able to achieve its targeted goals. The MI reporting rate was increased. This project demonstrated that measurable, "non-incident report" errors can be reduced by focusing upon and promoting medication safety in the ICU. These activities demonstrated a workplace that values medication safety, the discovery of shortfalls and the benefits of ongoing improvement.

Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit

PURPOSE

To establish the baseline prescribing error rate in a tertiary paediatric intensive care unit (PICU) and to determine the impact of a zero tolerance prescribing (ZTP) policy incorporating a dedicated prescribing area and daily feedback of prescribing errors.

METHODS

A prospective, non-blinded, observational study was undertaken in a 12-bed tertiary PICU over a period of 134 weeks. Baseline prescribing error data were collected on weekdays for all patients for a period of 32 weeks, following which the ZTP policy was introduced. Daily error feedback was introduced after a further 12 months. Errors were sub-classified as 'clinical', 'non-clinical' and 'infusion prescription' errors and the effects of interventions considered separately.

RESULTS

The baseline combined prescribing error rate was 892 (95 % confidence interval (CI) 765-1,019) errors per 1,000 PICU occupied bed days (OBDs), comprising 25.6 % clinical, 44 % non-clinical and 30.4 % infusion prescription errors. The combined interventions of ZTP plus daily error feedback were associated with a reduction in the combined prescribing error rate to 447 (95 % CI 389-504) errors per 1,000 OBDs (p < 0.0001), an absolute risk reduction of 44.5 % (95 % CI 40.8-48.0 %). Introduction of the ZTP policy was associated with a significant decrease in clinical and infusion prescription errors, while the introduction of daily error feedback was associated with a significant reduction in non-clinical prescribing errors.

CONCLUSION

The combined interventions of ZTP and daily error feedback were associated with a significant reduction in prescribing errors in the PICU, in line with Department of Health requirements of a 40 % reduction within 5 years.

Errors during the preparation of drug infusions: a randomized controlled trial

BACKGROUND

We investigated the extent and frequency of dose errors and treatment delays made as a consequence of preparing drug infusions at the bedside, rather than using pre-filled syringes.

METHODS

Forty-eight nurses with critical care experience volunteered to take part in this randomized, blinded, controlled study conducted in the simulation centre of an urban hospital. They assisted in the management of a simulated patient with septic shock. Vasopressor infusions were prepared either by diluting concentrated drugs from ampoules or were provided in syringes pre-filled beforehand by an intensive care unit resident.

RESULTS

The time taken for the infusion to be started and the final concentration of the drugs were measured. We also measured the concentration of infusions prepared by a pharmacist and a pharmaceutical company. Nurses took 156 s to start infusions when using pre-filled syringes compared with 276 s when preparing them de novo, a mean delay of 106 s [95% confidence interval (CI) 73-140 s, P<0.0001]. One infusion prepared from ampoules contained one-fifth of the expected concentration of epinephrine; another contained none at all. Medication errors were 17.0 times less likely when pre-filled syringes were used (95% CI 5.2-55.5), and infusions prepared by pharmacy and industry were significantly more likely to contain the expected concentration (P<0.001 for norepinephrine and P=0.001 for epinephrine).

CONCLUSIONS

Providing drug infusions in syringes pre-filled by pharmacists or pharmaceutical companies would reduce medication errors and treatment delays, and improve patient safety. However, this approach would have substantial financial implications for healthcare providers, especially in less developed countries.

The effectiveness and clinical usability of a handheld information appliance

Clinical environments are complex, stressful, and safety critical—heightening the demand for technological solutions that will help clinicians manage health information efficiently and safely. The industry has responded by creating numerous, increasingly compact and powerful health IT devices that fit in a pocket, hook to a belt, attach to eyeglasses, or wheel around on a cart. Untethering a provider from a physical “place” with compact, mobile technology while delivering the right information at the right time and at the right location are generally welcomed in clinical environments. These developments however, must be looked at ecumenically. The cognitive load of clinicians who are occupied with managing or operating several different devices during the process of a patient encounter is increased, and we know from decades of research that cognitive overload frequently leads to error. “Technology crowding,” enhanced by the plethora of mobile health IT, can actually become an additional millstone for busy clinicians. This study was designed to gain a deeper understanding of clinicians' interactions with a mobile clinical computing appliance (Motion Computing C5) designed to consolidate numerous technological functions into an all-in-one device. Features of usability and comparisons to current methods of documentation and task performance were undertaken and results are described.