Medication errors in prescription and administration in critically ill patients

The pharmacists' interventions after a Drug and Therapeutics Committee (DTC) establishment during the COVID-19 pandemic

Introduction

Healthcare systems in developing countries faced significant challenges during COVID-19, grappling with limited resources and staffing shortages. Assessment of the impact of pharmaceutical care expertise, particularly in critical care units during the pandemics, in developing countries remains poorly explored. The principal aim of our study was to assess the impact of the Drug and Therapeutics Committee (DTC), comprising clinical pharmacists, on the incidence, types, and severity of medication errors and associated costs in using COVID-19 medications, especially antibiotics.

Methods

An interventional pre-post study was carried out at a public isolation hospital in Egypt over 6 months.

Results

Out of 499 medication orders, 238 (47.7%) had medication errors, averaging 2.38 errors per patient. The most frequent were prescribing errors (44.9%), specifically incorrect drug choice (57.9%), excessive dosage (29.9%), treatment duplication (4.5%), inadequate dosage (4.5%), and overlooked indications (3.6%). Linezolid and Remdesivir were the most common medications associated with prescribing errors. Pharmacists intervened 315 times, primarily discontinuing medications, reducing doses, introducing new medications, and increasing doses. These actions led to statistically significant cost reductions (p < 0.05) and better clinical outcomes; improved oxygen saturation, decreased fever, stabilised respiratory rates, and normalised white blood cell counts. So, clinical pharmacist interventions made a notable clinical and economic difference (66.34% reduction of the expenses) in antibiotics usage specifically and other medications used in COVID-19 management during the pandemic.

Conclusion

Crucially, educational initiatives targeting clinical pharmacists can foster judicious prescribing habits.

Predisposing Factors to Medication Errors by Nurses and Prevention Strategies: A Scoping Review of Recent Literature

Medication errors have serious consequences and high costs for the patient and the system. The treatment process and the care required for critically ill patients are complex, and these patients are more vulnerable to errors and potential consequences. A scoping review using the JBI methodology was conducted across PubMed, CINAHL, and MEDLINE databases and reported by the PRISMA-ScR guidelines to explore strategies that can mitigate medication errors by nurses. The search strategy focused on references published between January 2012 and April 2023. Sixteen studies were included, and the results were organized into thematic areas. Medication errors by nurses are in the areas of preparation, administration, and documentation; organizational, system-related, procedural, personal, and knowledge and training factors are predisposing factors for errors; educational intervention, verification and safety methods, organizational changes, and error reporting are the strategic areas to mitigate medication error. The organization of the data could be different, as it depends on the reviewers' experience. Knowledge of the factors that cause medication errors and interventions to mitigate them make it possible to outline strategies to minimize their occurrence and achieve health gains. The protocol preceding this review has been registered in the Open Science Framework and published.

Patient safety culture and medication safety in European intensive care units: a focus group study

BACKGROUND

Patients in intensive care units (ICUs) are susceptible to medication errors (MEs) for many reasons, including the complexity and intensity of care. Little is known about patient safety culture, its relationship to medication safety, and ME prevention strategies used in ICUs. This study explored the attitudes of healthcare professionals (HCPs) working in ICUs or within medication safety towards patient safety culture, medication safety, and factors influencing implementation of ME prevention strategies in ICUs across Europe.

METHODS

This qualitative study employed focus group discussions; ethical approval was obtained. Invitations to participate were distributed to HCPs working in ICUs or as medication safety officers across Europe. In May 2022, online focus group discussions were conducted. Discussions were transcribed verbatim and analysed. The framework analysis employed was inductive, systematic and transparent, and completed through a collaborative and iterative process.

RESULTS

Three nurses and 11 pharmacists, from seven different countries, participated in three focus group discussions. There was a sense of improvement in blame culture leading to more open culture, although it was not the case for all participants. Blame culture, when present, was thought to be prevalent among more senior ICU staff and hospital managers. Facilitators for improving medication safety included communicating with HCPs and providing feedback on MEs and ME prevention strategies, interprofessional working without hierarchies, and having a 'good' culture and environment. Barriers included lack of engagement of HCPs and their attitudes towards medication safety, and an existing blame culture. Participants reported 25 different ME prevention strategies in use including: assessing knowledge; teaching and training; auditing practice; incident reporting; and involvement of pharmacists.

CONCLUSIONS

This study examined the attitudes of HCPs on patient safety culture and medication safety in the ICU setting in Europe and gained their insight into facilitators and barriers to the implementation of ME prevention strategies to improve medication safety.

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

BACKGROUND

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

AIM/OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Determining Medication Errors in an Adult Intensive Care Unit

INTRODUCTION

Research addressing the costs of Medication errors (MEs) is still scarce despite issues related to patient safety having significant economic and health impacts, making it imperative to analyze the costs and adverse events related to MEs for a better patient, professional, and institutional safety.

AIM

To identify the number of medication errors and verify whether this number was associated with increased hospitalization costs for patients in an Intensive Care Unit (ICU).

METHOD

This retrospective cross-sectional cohort study evaluated secondary data from patients' electronic medical records to compile variables, create a model, and survey hospitalization costs. The statistical analysis included calculating medication error rates, descriptive analysis, and simple and multivariate regression.

RESULTS

The omission error rate showed the highest number of errors per drug dose (59.8%) and total errors observed in the sample (55.31%), followed by the time error rate (26.97%; 24.95%). The omission error had the highest average when analyzing the entire hospitalization (170.40) and day of hospitalization (13.79). Hospitalization costs were significantly and positively correlated with scheduling errors, with an increase of BRL 121.92 (about USD $25.00) (95% CI 43.09; 200.74), and to prescription errors, with an increase of BRL 63.51 (about USD $3.00) (95% CI 29.93; 97.09).

CONCLUSION

We observed an association between two types of medication errors and increased hospitalization costs in an adult ICU (scheduling and prescription errors).

Interventions to Minimize Medication Error by Nurses in Intensive Care: A Scoping Review Protocol

Medication errors represent a concern for healthcare organizations due to their negative consequences. In the nursing context, these errors represent a threat to the quality of care and patient safety. Many factors have been identified as potential causes for these errors in intensive care units. A scoping review will be developed to identify interventions/strategies to minimize the occurrence of medication errors by nurses, considering the Joanna Briggs Institute (JBI) methodology. A search will be conducted in the EbscoHost (CINAHL Complete and MEDLINE), Embase and PubMed databases. Data analysis, extraction and synthesis will be carried out by two reviewers independently. This review will attempt to map which interventions are more specific to minimizing medication error by nurses in intensive care and to recognize which factors influence this type of error to mitigate practices that may lead to error. This protocol acts as the framework for a scoping review in the strategy to map the interventions and which factors contribute to the medication error by intensive care nurses. This study was prospectively registered with the Open Science Framework on 21 April 2023 with registration number DOI 10.17605/OSF.IO/94KH3.

Human Error Analysis and Modeling of Medication-Related Adverse Events in Taiwan Using the Human Factors Analysis and Classification System and Logistic Regression

Medical institutions worldwide strive to avoid adverse medical events, including adverse medication-related events. However, studies on the comprehensive analysis of medication-related adverse events are limited. Therefore, we aimed to identify the error factors contributing to medication-related adverse events using the Human Factors Analysis and Classification System (HFACS) and to develop error models through logistic regression. These models calculate the probability of a medication-related adverse event when a healthcare system defect occurs. Seven experts with at least 12 years of work experience (four nurses and three pharmacists) were recruited to analyze thirty-seven medication-related adverse events. The findings indicate that decision errors, physical/mental limitations, failure to correct problems, and organizational processes were the four factors that most frequently contributed to errors at the four levels of the HFACS. Seven error models of two types (error occurrence and error analysis pathways) were established using logistic regression models, and the relative probabilities of failure factor occurrences were calculated. Based on our results, medical staff can use the error models as a new analytical approach to improve and prevent adverse medication events, thereby improving patient safety.

Evaluating Patient Identification Practices During Intrahospital Transfers: A Human Factors Approach

INTRODUCTION

Reliable patient identification is essential for safe care, and failures may cause patient harm. Identification can be interfered with by system factors, including working conditions, technology, organizational barriers, and inadequate communications protocols. The study aims to explore systems factors contributing to patient identification errors during intrahospital transfers.

METHODS

We conducted a qualitative study through direct observation and interviews with porters during intrahospital patient transfers. Data were analyzed using the Systems Engineering Initiative for Patient Safety human factors model. The patient transfer process was mapped and compared with the institutional Positive Patient Identification policy. Potential system failures were identified using a Failure Modes and Effects Analysis.

RESULTS

A total of 60 patient transfer handovers were observed. In none of the evaluable cases observed, patient identification was conducted correctly according to the hospital policy at every step of the process. The principal system factor responsible was organizational failure, followed by technology and team culture issues. The Failure Modes and Effects Analysis methodology revealed that miscommunication between staff and lack of key patient information put patient safety at risk.

CONCLUSIONS

Patient identification during intrahospital patient transfer is a high-risk event because several factors and many people interact. In this study, the disconnect between the policy and the reality of the workplace left staff and patients vulnerable to the consequences of misidentification. Where a policy is known to be substantially different from work as done, urgent revision is required to eliminate the serious risks associated with the unguided evolution of working practice.

Effects of nursing workload on medication administration errors: A quantitative study

BACKGROUND

Medication administration errors by nurses form a high proportion of medical errors in medical institutions. Studies have shown that such errors are closely linked to nursing workload.

OBJECTIVE

To quantitatively explore the effects of different types of nursing workloads on different medication administration errors.

METHOD

Three medical institutions were selected as the objects of error data collection based on the following criteria: the medical institution experience in error data collection, the complete range of medical departments, and the institution size. Error cases were self-reported from all nurses in all medical departments. The relationship between the error types and nursing workload types were quantitatively examined using partial least squares and structural equation modeling.

RESULTS

The study recorded 290 medication administration errors, and extracted four error types and nine nursing workload types. The workload type for each error type was also identified and the path coefficient was found to be between 0.087 to 0.416.

CONCLUSION

This study confirmed the effect of workload on medication administration errors and determined a theoretical mechanism for this effect. Research results will provide the evidence for nursing managers to reduce workload and ensure quality in the nursing administration process.

Medication Errors in Intensive Care Units: An Umbrella Review of Control Measures

Medication errors are defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.” Such errors account for 30 to 50 percent of all errors in health care. The literature is replete with systematic reviews of medication errors, with a considerable number of studies focusing on systems and strategies to prevent errors in intensive care units, where these errors occur more frequently; however, to date, there appears to be no study that encapsulates and analyzes the various strategies. The aim of this study is to identify the main strategies and interventions for preventing medication errors in intensive care units through an umbrella review. The search was conducted on the following databases: PubMed, CINAHL, PsycInfo, Embase, and Scopus; it was completed in November 2020. Seven systematic reviews were included in this review, with a total of 47 studies selected. All reviews aimed to evaluate the effectiveness of a single intervention or a combination of interventions and strategies to prevent and reduce medication errors. Analysis of the results that emerged identified two macro-areas for the prevention of medication errors: systems and processes. In addition, the findings highlight the importance of adopting an integrated system of interventions in order to protect the system from harm and contain the negative consequences of errors.

Handling Errors in the Use of Inhalation Devices: Inhalation Technique Skills and Knowledge in Pediatric Nurses

BACKGROUND

Children suffering from bronchial diseases need assistance from nurses in the use of inhalation devices.

PURPOSE

We aimed to assess nurses' skills and knowledge concerning drug administration with inhalation devices in hospitalized pediatric patients.

METHODS

An expert panel defined medication errors in drug administration with inhalation devices in children. We monitored 241 inhalation procedures to investigate nurses' inhalation technique skills. Twenty-nine nurses completed a questionnaire to assess nurses' knowledge.

RESULTS

Skills: In 93 of 241 (39%) inhalation procedures, the mask/mouthpiece did not fit airtight. In none of the 11 inhalations administering a glucocorticoid, the patient's mouth was thoroughly cleaned afterward. Knowledge: Ten of 29 nurses (34%) thought a distance between mask and the patient's face was acceptable. Only 16 of 29 (55%) knew that it is necessary to thoroughly clean the patient's mouth after the inhalation of budesonide.

CONCLUSIONS

We found that education on inhalation procedures including practical training is required to increase patient safety.

Medication errors in inquiries to the Poison Information Center Erfurt - a systematic analysis

INTRODUCTION

Poison Information Centers (PICs) fulfil the legal mandate to provide advice and answer inquiries from healthcare professionals and medical nonprofessionals on measures to be taken in the event of an intoxication. Medication errors might be a frequent cause of intoxication. However, hardly any data on medication errors are available from PICs.

AIM

We aimed to investigate the incoming inquiries of a PIC with regard to medication errors.

METHODS

In the PIC database, we identified and analyzed medication errors in a retrospective analysis of inquiries from 2013 to 2020. We distinguished between medication errors committed by (i) laypersons or by healthcare professionals in (iia) medical care facilities or (iib) home care facilities. We evaluated the estimated potential risk of toxicity to assess the potential harm to the patient.

RESULTS

From 152,149 inquiries in total, 43.5% (n = 66,229) dealt with drug exposures. We identified medication error in 19.1% (n = 12,619) of those inquiries. Of those medication errors, 80.1% (n = 10,113) were committed by (i) laypersons and 19.9% (n = 2506) were committed by healthcare professionals, with nearly equal proportions occurring in medical care and in home care [(iia) 49.6% and (iib) 50.4%, respectively]. A total of 18,718 drugs were involved, with most medication errors found for ibuprofen, acetaminophen, and levothyroxine. The medication errors led to a minor estimated risk of toxicity in 46.6% (5,877/12,619); moderate and severe risk occurred in 7.0% (886/12,619) and 2.6% (329/12,619), respectively. Medication errors caused by laypersons or healthcare professionals in home care were associated with a lower risk compared to those caused by healthcare professionals in medical care (p < 0.001).

CONCLUSION

This study identified medication errors that were committed mainly by laypersons in almost 80% of the medication inquiries to a PIC. Medication errors caused by healthcare professionals in medical care led to a higher risk of harm to the patients.

Nursing students' risk perceptions related to medication administration error: A qualitative study

AIM

The purpose of this study was to explore and describe pre-licensure nursing students' perceptions of risk for medication administration errors in fourth-year baccalaureate student nurses from three campuses at a large central Pennsylvania university.

BACKGROUND

Medication administration errors continue to be a significant safety concern in healthcare settings. Pre-licensure nursing education is a critical time period during which to have an impact on future medication administration practices. Perception of risk influences decision making and behavior, including nursing clinical decision making.

DESIGN

This descriptive, exploratory study involved a qualitative design.

METHODS

A thematic analysis of the qualitative data resulting from 60 individual, in-depth semi-structured interviews was conducted.

RESULTS

The participants offered rich, detailed narratives which revealed the following themes: (1) the nature of risk perceptions, (2) more opportunities to learn, (3) experiences with medication administration error, and (4) intrinsic characteristics influence errors.

CONCLUSIONS

The findings provide a broad description of the nature of student nurse risk perceptions for future medication administration errors. Recommendations for nursing education practice and pedagogy include additional clinical experiences, modified pharmacology curricula and instruction, and expanded simulations involving medication administration error.

Nurse-nurse collaboration and performance among nurses in intensive care units

BACKGROUND

An essential element for offering high-quality care in the intensive care units (ICUs) is the intraprofessional collaboration among nurses, which facilitates the exchange of knowledge and information and hence improves performance. More research is needed to understand the relationship between the nurse-nurse collaboration and job performance in the ICUs due to the multidimensionality of both concepts, the complexity of the ICU environment, and the lack of studies.

AIM

To examine the relationship between nurse-nurse collaboration and self-perceived nurse performance among Jordanian nurses in ICUs.

DESIGN

Descriptive, correlational cross-sectional design was used.

METHODS

Data were collected through an online survey including the demographic questionnaire, the nurse-nurse collaboration scale, and six-dimensions scale for nursing performance.

RESULTS

In total, 155 critical care nurses participated (response rate = 46.97%). Self-perceived job performance was significantly associated with gender (t = -3.189, P = .002), age (r = -0.301, P < .01), workplace (F = 28.20, P = .001), the type of ICU (F = 17.70, P = .001), and the number of assigned patients (r = 0.407, P < .01). Among all nurse-nurse collaboration subscales, only the conflict management subscale was an independent significant predictor of self-perceived nursing performance (t = 3.06, B = 3.066, P = .003).

CONCLUSIONS

Effective conflict management is associated with better nurse performance, which could ultimately improve patient care in ICUs.

RELEVANCE TO CLINICAL PRACTICE

Conflict resolution is an important dimension of optimal nurse-nurse collaboration and has an important effect on nursing performance. Nurses and nurse managers in ICUs need to attend workshops and training programs in conflict management.

Individual Circadian Preference, Shift Work, and Risk of Medication Errors: A Cross-Sectional Web Survey among Italian Midwives

Background: In order to explore the possible association between chronotype and risk of medication errors and chronotype in Italian midwives, we conducted a web-based survey. The questionnaire comprised three main components: (1) demographic information, previous working experience, actual working schedule; (2) individual chronotype, either calculated by Morningness–Eveningness Questionnaire (MEQ); (3) self-perception of risk of medication error. Results: Midwives (n = 401) responded “yes, at least once” to the question dealing with self-perception of risk of medication error in 48.1% of cases. Cluster analysis showed that perception of risk of medication errors was associated with class of age 31–35 years, shift work schedule, working experience 6–10 years, and Intermediate-type MEQ score. Conclusions: Perception of the risk of medication errors is present in near one out of two midwives in Italy. In particular, younger midwives with lower working experience, engaged in shift work, and belonging to an Intermediate chronotype, seem to be at higher risk of potential medication error. Since early morning hours seem to represent highest risk frame for female healthcare workers, shift work is not always aligned with individual circadian preference. Assessment of chronotype could represent a method to identify healthcare personnel at higher risk of circadian disruption.