Double checking: a second look

Navigating the 2021 ACPSEM ROMP workforce model: insights from a single institution

Workforce modelling for Radiation Oncology Medical Physicists (ROMPs) is evolving and challenging, prompting the development of the 2021 Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) ROMP Workforce (ARW) Model. In the exploration of this model at Sir Charles Gairdner Hospital, a comprehensive productivity exercise was conducted to obtain a detailed breakdown of ROMP time at a granular level. The results provide valuable insights into ROMP activities and enabled an evaluation of ARW Model calculations. The findings also capture the changing ROMP role as evidenced by an increasing involvement in consultation and advisory tasks with other professionals in the field. They also suggest that CyberKnife QA time requirements in the data utilised by the model may need to be revised. This study emphasises features inherent in the model, that need to be understood if the model is to be applied correctly.

Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach

OBJECTIVES

The goal of this human factors engineering-led improvement initiative was to examine whether the independent double check (IDC) during administration of high alert medications afforded improved patient safety when compared with a single check process.

METHODS

The initiative was completed at a 24-bed pediatric intensive care unit and included all patients who were on the unit and received a medication historically requiring an IDC. The total review examined 37,968 high-risk medications administrations to 4417 pediatric intensive care unit patients over a 40-month period. The following 5 measures were reviewed: (1) rates of reported medication administration events involving IDC medications; (2) hospital length of stay; (3) patient mortality; (4) nurses' favorability toward single checking; and (5) nursing time spent on administration of IDC medications.

RESULTS

The rate of reported medication administration events involving IDC medications was not significantly different across the groups (95% confidence interval, 0.02%-0.08%; P = 0.4939). The intervention also did not significantly alter mortality ( P = 0.8784) or length of stay ( P = 0.4763) even after controlling for the patient demographic variables. Nursing favorability for single checking increased from 59% of nurses in favor during the double check phase, to 94% by the end of the single check phase. Each double check took an average of 9.7 minutes, and a single check took an average of 1.94 minutes.

CONCLUSIONS

Our results suggest that performing independent double checks on high-risk medications administered in a pediatric ICU setting afforded no impact on reported medication events compared with single checking.

Designing Human-Centered AI to Prevent Medication Dispensing Errors: Focus Group Study With Pharmacists

BACKGROUND

Medication errors, including dispensing errors, represent a substantial worldwide health risk with significant implications in terms of morbidity, mortality, and financial costs. Although pharmacists use methods like barcode scanning and double-checking for dispensing verification, these measures exhibit limitations. The application of artificial intelligence (AI) in pharmacy verification emerges as a potential solution, offering precision, rapid data analysis, and the ability to recognize medications through computer vision. For AI to be embraced, it must be designed with the end user in mind, fostering trust, clear communication, and seamless collaboration between AI and pharmacists.

OBJECTIVE

This study aimed to gather pharmacists' feedback in a focus group setting to help inform the initial design of the user interface and iterative designs of the AI prototype.

METHODS

A multidisciplinary research team engaged pharmacists in a 3-stage process to develop a human-centered AI system for medication dispensing verification. To design the AI model, we used a Bayesian neural network that predicts the dispensed pills' National Drug Code (NDC). Discussion scripts regarding how to design the system and feedback in focus groups were collected through audio recordings and professionally transcribed, followed by a content analysis guided by the Systems Engineering Initiative for Patient Safety and Human-Machine Teaming theoretical frameworks.

RESULTS

A total of 8 pharmacists participated in 3 rounds of focus groups to identify current challenges in medication dispensing verification, brainstorm solutions, and provide feedback on our AI prototype. Participants considered several teaming scenarios, generally favoring a hybrid teaming model where the AI assists in the verification process and a pharmacist intervenes based on medication risk level and the AI's confidence level. Pharmacists highlighted the need for improving the interpretability of AI systems, such as adding stepwise checkmarks, probability scores, and details about drugs the AI model frequently confuses with the target drug. Pharmacists emphasized the need for simplicity and accessibility. They favored displaying only essential information to prevent overwhelming users with excessive data. Specific design features, such as juxtaposing pill images with their packaging for quick comparisons, were requested. Pharmacists preferred accept, reject, or unsure options. The final prototype interface included (1) checkmarks to compare pill characteristics between the AI-predicted NDC and the prescription's expected NDC, (2) a histogram showing predicted probabilities for the AI-identified NDC, (3) an image of an AI-provided "confused" pill, and (4) an NDC match status (ie, match, unmatched, or unsure).

CONCLUSIONS

In partnership with pharmacists, we developed a human-centered AI prototype designed to enhance AI interpretability and foster trust. This initiative emphasized human-machine collaboration and positioned AI as an augmentative tool rather than a replacement. This study highlights the process of designing a human-centered AI for dispensing verification, emphasizing its interpretability, confidence visualization, and collaborative human-machine teaming styles.

Reducing potential errors associated with insulin administration: An integrative review

RATIONALE, AIMS, OBJECTIVES

Around one-third of medication errors resulting in death within 48 h involve insulin therapy. Despite a growing number of interventional strategies that have been published over the past decade, it remains unclear which of these interventions is effective in reducing insulin errors. Therefore, the study aimed to synthesize interventions to reduce the frequency of insulin errors in either home or health care settings.

METHODS

This integrative review was conducted based on Whittemore and Knafl's four steps, which includes problem identification, literature search, data analysis and presentation. Six databases including Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, PsychInfo and Cochrane were searched from January 2010 through July 2021. The level of evidence quality was assessed according to the Johns Hopkins Nursing Evidence-Based Practice grading scale.

RESULTS

Sixteen studies meeting inclusion criteria were reviewed. The results provide strong support for teaching patients how to use automated bolus calculators and educating patients to self-administer insulin to prevent insulin errors in the home setting. Computerized protocols, education and double-checking procedures were also found to be effective strategies for minimizing insulin errors in healthcare settings.

CONCLUSION

While the strategies might be effective in reducing insulin administration errors in the home settings, computerized protocols, continuing education and the manual validation of insulin products appear to be the most effective strategies for reducing such insulin errors in healthcare settings. Understanding these findings may help clinicians and patients to decrease the number of insulin errors administration.

Exploring Pakistani Physicians' Knowledge and Practices Regarding High Alert Medications: Findings and Implications

Introduction: While many low-middle income countries (LMICs), including Pakistan, try and ensure patient safety within available resources, there are considerable concerns with medication use. Unsafe and inappropriate medication use, especially high alert medications (HAMs), is one of the important factors compromising patient safety and quality of care. Besides economic loss, HAMs contribute to greater morbidity, hospitalization, and mortality. Physicians as key members of the provision of healthcare are expected to be well aware of the administration and regulations surrounding HAMs. However, the current status is unknown in Pakistan. Consequently, the objectives of this study were to evaluate the knowledge of Pakistani physicians about the administration, regulation, and practices related to HAMs. This builds on our recently published study with nurses.

Methods: An online cross-sectional study design was used, and data were gathered from the physicians throughout Pakistan using previously used self-administered questionnaires during a period of 5 months (January 1 to May 30, 2021). All data were entered and analyzed using SPSS 22 for Windows.

Results: Physicians (847) who provided consent were enrolled in the study. Most physicians (62.2%) were male, aged between 25 and 30 years (75.2%) and had 2- to 5-year work experience (50.9%). About 27% were working in the emergency departments. The median (IQR) knowledge score for HAMs administration and regulation was 5 (3) and 5 (2), respectively. About 46.4% of respondents were found to have moderate knowledge about HAMs; increasing age, work experience, and higher qualifications were significantly associated (p < 0.05) with better HAMs knowledge. Around 58% had good practices relating to HAMs during their routine work. Median practice scores increased significantly (p < 0.05) with age, work experience, and postgraduate qualification.

Conclusion: Most Pakistani physicians possess moderate knowledge about HAMs administration and regulations. However, their practices relating to the HAMs administration and regulations are typically sub-optimal. Consequently, HAMs awareness needs to be improved by including course content in the current curriculum, provision of hospital-based continuous training programs about patient safety and care, and establishment of multi-disciplinary health care teams, including board-certified pharmacists and specialized nurses, for the effective execution of medication use process in Pakistani hospitals in the future.

Application of failure mode and effects analysis (FMEA) to improve medication safety in the dispensing process - a study at a teaching hospital, Sri Lanka

Background

Failure mode and effects analysis (FMEA) is a prospective, team based, structured process used to identify system failures of high risk processes before they occur. Medication dispensing is a risky process that should be analysed for its inherent risks using FMEA. The objective of this study was to identify possible failure modes, their effects, and causes in the dispensing process of a selected tertiary care hospital using FMEA.

Methods

Two independent teams (Team A and Team B) of pharmacists conducted the FMEA for two months in the Department of Pharmacy of a selected teaching hospital, Colombo, Sri Lanka. Each team had five meetings of two hours each, where the dispensing process and sub processes were mapped, and possible failure modes, their effects, and causes, were identified. A score for potential severity (S), frequency (F) and detectability (D) was assigned for each failure mode. Risk Priority Numbers (RPNs) were calculated (RPN=SxFxD), and identified failure modes were prioritised.

Results

Team A identified 48 failure modes while Team B identified 42. Among all 90 failure modes, 69 were common to both teams. Team A prioritised 36 failure modes, while Team B prioritised 30 failure modes for corrective action using the scores. Both teams identified overcrowded dispensing counters as a cause for 57 failure modes. Redesigning of dispensing tables, dispensing labels, the dispensing and medication re-packing processes, and establishing a patient counseling unit, were the major suggestions for correction.

Conclusion

FMEA was successfully used to identify and prioritise possible failure modes of the dispensing process through the active involvement of pharmacists.

Challenges and Potential Solutions for Patient Safety in an Infectious-Agent-Isolation Environment: A Study of 484 COVID-19-Related Event Reports Across 94 Hospitals

Previous research has shown that patients in infectious-agent isolation are at greater risk for certain types of safety-related events. We conducted a study to explore the relationship between the various types of events that occur in an isolation environment and the associated factors, which may have implications for the likelihood of the event and severity of patient harm. We conducted a query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to identify event reports submitted by acute care hospitals between January 1 and September 30, 2020. We identified 484 relevant event reports from 94 hospitals for inclusion in our descriptive study (excluding near-miss events). We measured the frequency of relationship between categories of safety-related event types and 18 categories of associated factors. Among the seven categories of event types, the most frequently identified were skin integrity (141 of 484, 29%), falls (129 of 484, 27%), and medication-related (78 of 484, 16%). Across all 18 categories of associated factors, which had or may have had an influence on the event type, the most frequent were patient’s mental status (80 of 484, 17%), staff’s time to don personal protective equipment (62 of 484, 13%), and patient’s interference with equipment/supplies (45 of 484, 9%). Overall, our results revealed that the frequency of certain associated factors varied considerably from one event type to another, which indicates that the relation between event types and associated factors should guide selection of risk mitigation strategies. We encourage readers to leverage our results along with Table 9, which provides a list of challenges identified in an isolation environment and potential solutions. We envision hospital staff proactively and systematically using the information in our manuscript to facilitate their evaluation of the isolation environment and prioritization of risk mitigation strategies.

The role of organizational factors in how efficiency-thoroughness trade-offs potentially affect clinical quality dimensions – a review of the literature

Purpose

The purpose of this paper is to increase knowledge of the role organizational factors have in how health personnel make efficiency-thoroughness trade-offs, and how these trade-offs potentially affect clinical quality dimensions.

Design/methodology/approach

The paper is a thematic synthesis of the literature concerning health personnel working in clinical, somatic healthcare services, organizational factors and clinical quality.

Findings

Identified organizational factors imposing trade-offs were high workload, time limits, inappropriate staffing and limited resources. The trade-offs done by health personnel were often trade-offs weighing thoroughness (e.g. providing extra handovers or working additional hours) in an environment weighing efficiency (e.g. ward routines of having one single handover and work-hour regulations limiting physicians' work hours). In this context, the health personnel functioned as regulators, balancing efficiency and thoroughness and ensuring patient safety and patient centeredness. However, sometimes organizational factors limited health personnel's flexibility in weighing these aspects, leading to breached medication rules, skipped opportunities for safety debriefings and patients being excluded from medication reviews.

Originality/value

Balancing resources and healthcare demands while maintaining healthcare quality is a large part of health personnel's daily work, and organizational factors are suspected to affect this balancing act. Yet, there is limited research on this subject. With the expected aging of the population and the subsequent pressure on healthcare services' resources, the balancing between efficiency and thoroughness will become crucial in handling increased healthcare demands, while maintaining high-quality care.

Errors in Breast Imaging: How to Reduce Errors and Promote a Safety Environment

Medical errors have a significant impact on patient care, worker safety, and health care finances. Breast imaging has the most common cause of organ-related misdiagnosis subject to malpractice suits. In order to effectively develop strategies to prevent errors, breast imaging radiologists must first understand the underlying causes of the errors that occur in the breast imaging setting. Errors in breast imaging can be related to errors in interpretation, improper workup of imaging findings, procedural errors, or errors in communication to the patient or other medical staff. The Yorkshire contributory factors framework was developed to identify factors that contribute to the errors in a hospital setting and can be adapted for use in the breast imaging setting. Within this framework, active failures refer to errors that directly affect the patient. Active errors include slips (including biases), lapses, and mistakes. The framework describes how active errors often result from factors that occur uphill from these active errors at different levels within the system. Once error causes are understood, there are concrete strategies and tools that breast imaging radiologists can implement to decrease adverse events, reduce medical errors, and promote a safety environment in the breast imaging clinic. Error mitigation tools can be summarized using the acronym SAFE, which includes support the team, ask questions, focus on a task, and effectively communicate/ensure equipment optimization/safe environment. Knowledge of errors commonly seen in a breast imaging clinic represent an opportunity for constructive changes and, ultimately, improved health care delivery.

Smart agent system for insulin infusion protocol management: a simulation-based human factors evaluation study

OBJECTIVE

To compare the insulin infusion management of critically ill patients by nurses using either a common standard (ie, human completion of insulin infusion protocol steps) or smart agent (SA) system that integrates the electronic health record and infusion pump and automates insulin dose selection.

DESIGN

A within subjects design where participants completed 12 simulation scenarios, in 4 blocks of 3 scenarios each. Each block was performed with either the manual standard or the SA system. The initial starting condition was randomised to manual standard or SA and alternated thereafter.

SETTING

A simulation-based human factors evaluation conducted at a large academic medical centre.

SUBJECTS

Twenty critical care nurses.

INTERVENTIONS

A systems engineering intervention, the SA, for insulin infusion management.

MEASUREMENTS

The primary study outcomes were error rates and task completion times. Secondary study outcomes were perceived workload, trust in automation and system usability, all measured with previously validated scales.

MAIN RESULTS

The SA system produced significantly fewer dose errors compared with manual calculation (17% (n=20) vs 0, p<0.001). Participants were significantly faster, completing the protocol using the SA system (p<0.001). Overall ratings of workload for the SA system were significantly lower than with the manual system (p<0.001). For trust ratings, there was a significant interaction between time (first or second exposure) and the system used, such that after their second exposure to the two systems, participants had significantly more trust in the SA system. Participants rated the usability of the SA system significantly higher than the manual system (p<0.001).

CONCLUSIONS

A systems engineering approach jointly optimised safety, efficiency and workload considerations.

Medication errors: a focus on nursing practice

Objectives

Health departments endeavor to give care to individuals to remain in healthy conditions. Medications errors (MEs), one of the most types of medical errors, could be venomous in clinical settings. Patients will be harmed physically and psychologically, in addition to adverse economic consequences. Reviewing and understanding the topic of medication error especially by nurses can help in advancing the medical services to patients.

Methods

A search using search engines such as PubMed and Google scholar were used in finding articles related to the review topic.

Key findings

This review highlighted the classifications of MEs, their types, outcomes, reporting process, and the strategies of error avoidance. This summary can bridge and open gates of awareness on how to deal with and prevent error occurrences. It highlights the importance of reporting strategies as mainstay prevention methods for medication errors.

Conclusions

Medication errors are classified based on multifaceted criteria and there is a need to standardize the recommendations and make them a central goal all over the globe for the best practice. Nurses are the frontlines of clinical settings, encouraged to be one integrated body to prevent the occurrence of medication errors. Thus, systemizing the guidelines are required such as education and training, independent double checks, standardized procedures, follow the five rights, documentation, keep lines of communication open, inform patients of drug they receive, follow strict guidelines, improve labeling and package format, focus on the work environment, reduce workload, ways to avoid distraction, fix the faulty system, enhancing job security for nurses, create a cultural blame-free workspace, as well as hospital administration, should support and revise processes of error reporting, and spread the awareness of the importance of reporting.

PRN Medicines Optimization and Nurse Education

Medicines management is a high-risk and error prone process in healthcare settings, where nurses play an important role to preserve patient safety. In order to create a safe healthcare environment, nurses should recognize challenges that they face in this process, understand factors leading to medication errors, identify errors and systematically address them to prevent their future occurrence. ''Pro re nata'' (PRN, as needed) medicine administration is a relatively neglected area of medicines management in nursing practice, yet has a high potential for medication errors. Currently, the international literature indicates a lack of knowledge of both the competencies required for PRN medicines management and the optimum educational strategies to prepare students for PRN medicines management. To address this deficiency in the literature, the authors have presented a discussion on nurses' roles in medication safety and the significance and purpose of PRN medications, and suggest a model for preparing nursing students in safe PRN medicines management. The discussion takes into account patient participation and nurse competencies required to safeguard PRN medication practice, providing a background for further research on how to improve the safety of PRN medicines management in clinical practice.

What do double-check routines actually detect? An observational assessment and qualitative analysis of identified inconsistencies

OBJECTIVES

Double checking is used in oncology to detect medication errors before administering chemotherapy. The objectives of the study were to determine the frequency of detected potential medication errors, i.e., mismatching information, and to better understand the nature of these inconsistencies.

DESIGN

In observing checking procedures, field noteswere taken of all inconsistencies that nurses identified during double checking the order against the prepared chemotherapy.

SETTING

Oncological wards and ambulatory infusion centres of three Swiss hospitals.

PARTICIPANTS

Nurses' double checking was observed.

OUTCOME MEASURES

In a qualitative analysis, (1) a category system for the inconsistencies was developed and (2) independently applied by two researchers.

RESULTS

In 22 (3.2%) of 690 observed double checks, 28 chemotherapy-related inconsistencies were detected. Half of them related to non-matching information between order and drug label, while the other half was identified because the nurses used their own knowledge. 75% of the inconsistencies could be traced back to inappropriate orders, and the inconsistencies led to 33 subsequent or corrective actions.

CONCLUSIONS

In double check situations, the plausibility of the medication is often reviewed. Additionally, they serve as a correction for errors and that are made much earlier in the medication process, during order. Both results open up new opportunities for improving the medication process.

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.

Detecting Potential Medication Selection Errors During Outpatient Pharmacy Processing of Electronic Prescriptions With the RxNorm Application Programming Interface: Retrospective Observational Cohort Study

BACKGROUND

Medication errors are pervasive. Electronic prescriptions (e-prescriptions) convey secure and computer-readable prescriptions from clinics to outpatient pharmacies for dispensing. Once received, pharmacy staff perform a transcription task to select the medications needed to process e-prescriptions within their dispensing software. Later, pharmacists manually double-check medications selected to fulfill e-prescriptions before dispensing to the patient. Although pharmacist double-checks are mostly effective for catching medication selection mistakes, the cognitive process of medication selection in the computer is still prone to error because of heavy workload, inattention, and fatigue. Leveraging health information technology to identify and recover from medication selection errors can improve patient safety.

OBJECTIVE

This study aimed to determine the performance of an automated double-check of pharmacy prescription records to identify potential medication selection errors made in outpatient pharmacies with the RxNorm application programming interface (API).

METHODS

We conducted a retrospective observational analysis of 537,710 pairs of e-prescription and dispensing records from a mail-order pharmacy for the period January 2017 to October 2018. National Drug Codes (NDCs) for each pair were obtained from the National Library of Medicine's (NLM's) RxNorm API. The API returned RxNorm concept unique identifier (RxCUI) semantic clinical drug (SCD) identifiers associated with every NDC. The SCD identifiers returned for the e-prescription NDC were matched against the corresponding SCD identifiers from the pharmacy dispensing record NDC. An error matrix was created based on the hand-labeling of mismatched SCD pairs. Performance metrics were calculated for the e-prescription-to-dispensing record matching algorithm for both total pairs and unique pairs of NDCs in these data.

RESULTS

We analyzed 527,881 e-prescription and pharmacy dispensing record pairs. Four clinically significant cases of mismatched RxCUI identifiers were detected (ie, three different ingredient selections and one different strength selection). A total of 546 less significant cases of mismatched RxCUIs were found. Nearly all of the NDC pairs had matching RxCUIs (28,787/28,817, 99.90%-525,270/527,009, 99.67%). The RxNorm API had a sensitivity of 1, a false-positive rate of 0.00104 to 0.00312, specificity of 0.99896 to 0.99688, precision of 0.00727 to 0.04255, and F1 score of 0.01444 to 0.08163. We found 872 pairs of records without an RxCUI.

CONCLUSIONS

The NLM's RxNorm API can perform an independent and automatic double-check of correct medication selection to verify e-prescription processing at outpatient pharmacies. RxNorm has near-comprehensive coverage of prescribed medications and can be used to recover from medication selection errors. In the future, tools such as this may be able to perform automated verification of medication selection accurately enough to free pharmacists from having to perform manual double-checks of the medications selected within pharmacy dispensing software to fulfill e-prescriptions.

Effectiveness of double checking to reduce medication administration errors: a systematic review

Background

Double checking medication administration in hospitals is often standard practice, particularly for high-risk drugs, yet its effectiveness in reducing medication administration errors (MAEs) and improving patient outcomes remains unclear. We conducted a systematic review of studies evaluating evidence of the effectiveness of double checking to reduce MAEs.

Methods

Five databases (PubMed, Embase, CINAHL, Ovid@Journals, OpenGrey) were searched for studies evaluating the use and effectiveness of double checking on reducing medication administration errors in a hospital setting. Included studies were required to report any of three outcome measures: an effect estimate such as a risk ratio or risk difference representing the association between double checking and MAEs, or between double checking and patient harm; or a rate representing adherence to the hospital’s double checking policy.

Results

Thirteen studies were identified, including 10 studies using an observational study design, two randomised controlled trials and one randomised trial in a simulated setting. Studies included both paediatric and adult inpatient populations and varied considerably in quality. Among three good quality studies, only one showed a significant association between double checking and a reduction in MAEs, another showed no association, and the third study reported only adherence rates. No studies investigated changes in medication-related harm associated with double checking. Reported double checking adherence rates ranged from 52% to 97% of administrations. Only three studies reported if and how independent and primed double checking were differentiated.

Conclusion

There is insufficient evidence that double versus single checking of medication administration is associated with lower rates of MAEs or reduced harm. Most comparative studies fail to define or investigate the level of adherence to independent double checking, further limiting conclusions regarding effectiveness in error prevention. Higher-quality studies are needed to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required.

CRD42018103436.

Contributing factors to outpatient pharmacy near miss errors: a Malaysian prospective multi-center study

Background Detecting errors before medication dispensed or 'near misses' is a crucial step to combat the incidence of dispensing error. Despite this, no published evidence available in Malaysia relating to these issues. Objective To determine the incidence of medication labeling and filling errors, frequency of each type of the errors and frequency of the contributing factors at the final stage before dispensing. Setting Six Penang public funded hospitals outpatient pharmacies. Methods A prospective multicentre study, over 8 week's period. Pharmacists identified and recorded the details of either medication labeling and/or filling error at the final stage of counter-checking before dispensing. Besides, the contributing factors for each error were determined and recorded in data collection form. Descriptive analysis was used to explain the study data. Main outcome measure The incidence of near misses. Results A total of 187 errors (near misses) detected, with 59.4% (n = 111) were medication filling errors and 40.6% (n = 76) were labeling errors. Wrong drug (n = 44, 39.6%) was identified as the highest type of filling errors while incorrect dose (n = 34, 44.7%) was identified as the highest type of labeling errors. Distracted and interrupted work environment was reported to lead the highest labeling and filling errors, followed by lack of knowledge and skills for filling errors and high workload for labeling errors. Conclusion The occurrence of near misses related to medication filling and labelling errors is substantial at outpatient pharmacy in Penang public funded hospitals. Further research is warranted to evaluate the intervention strategies needed to reduce the near misses.

Searching for the “sacred cow”: a conceptual analysis of the term in nursing literature

Purpose

The idiom “sacred cow” is problematic due to its inaccuracy and cultural insensitivity. The purpose of this paper is to examine the term’s meaning within the nursing literature, describe connotations in religious contexts, explore subject headings applied to research using the phrase, and discuss alternative terminology.

Design/methodology/approach

This paper employs Rodgers’ evolutionary concept analysis methodology to identify the concept “sacred cow” and surrogate terms, collect and analyze sample articles and headings, explore an exemplary case, and look for concept implications.

Findings

The term “sacred cow” appears frequently in the healthcare literature, particularly within the nursing literature. Its meaning within this literature pertains primarily to practices not supported by empirical evidence and performed to maintain a status quo. Headings applied to the relevant literature do not describe this concept, and more accurate headings could not be found within widely used controlled vocabularies.

Research limitations/implications

“Sacred cow” is an inaccurate descriptor for practices not supported by evidence as these practices do not usually apply to holiness or cattle. The term’s implied meaning comes only when viewed within a context satirizing beliefs considered as “other.”

Originality/value

This paper appears to be the first to methodically explore the concept of “sacred cow” within the nursing literature. The paper breaks ground in proposing solutions for the lack of applicable controlled vocabulary. By exploring these topics, it is hoped future authors use more accurate, culturally neutral terminology when discussing non-evidence-based practices and indexers increase discoverability by using more descriptive headings.

Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration

PURPOSE

Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement.

METHODS

We searched the National Center for Patient Safety adverse event reporting database for RCA related to oncology care from October 1, 2013, to September 8, 2017, to identify event types, root causes, severity of outcomes, care processes, and suggested actions. Two independent reviewers coded these variables, and inter-rater agreement was calculated by κ statistic. Variables were evaluated using descriptive statistics.

RESULTS

We identified 48 RCA reports that specifically involved an oncology provider. Event types included care delays (39.5% [n = 19]), issues with chemotherapy (25% [n = 12]) and radiation (12.5% [n = 6]), other (12.5% [n = 6]), and suicide (10.5% [n = 5]). Of the 48 events, 27.1% (n = 13) resulted in death, 4.2% (n = 2) in severe harm, 18.8% (n = 9) in temporary harm, 20.8% (n = 10) in minimal harm, and 2.1% (n = 1) in no harm. The majority of root causes identified a need to improve care processes and policies, interdisciplinary communication, and care coordination.

CONCLUSION

This analysis highlights an opportunity to implement system-wide changes to prevent similar events from reoccurring. These actions include comprehensive cancer clinics, usability testing of medical equipment, and standardization of processes and policies. Additional studies are necessary to assess oncologic adverse events across specialties.

Procedural and documentation variations in intravenous infusion administration: a mixed methods study of policy and practice across 16 hospital trusts in England

Background

Procedural and documentation deviations relating to intravenous (IV) infusion administration can have important safety consequences. However, research on such deviations is limited. To address this we investigated the prevalence of procedural and documentation deviations in IV infusion administration and explored variability in policy and practice across different hospital trusts.

Methods

We conducted a mixed methods study. This involved observations of deviations from local policy including quantitative and qualitative data, and focus groups with clinical staff to explore the causes and contexts of deviations. The observations were conducted across five clinical areas (general medicine, general surgery, critical care, paediatrics and oncology day care) in 16 National Health Service (NHS) trusts in England. All infusions being administered at the time of data collection were included. Deviation rates for procedural and documentation requirements were compared between trusts. Local data collectors and other relevant stakeholders attended focus groups at each trust. Policy details and reasons for deviations were discussed.

Results

At least one procedural or documentation deviation was observed in 961 of 2008 IV infusions (deviation rate 47.9%; 95% confidence interval 45.5–49.8%). Deviation rates at individual trusts ranged from 9.9 to 100% of infusions, with considerable variation in the prevalence of different types of deviation. Focus groups revealed lack of policy awareness, ambiguous policies, safety and practicality concerns, different organisational priorities, and wide variation in policies and practice relating to prescribing and administration of IV flushes and double-checking.

Conclusions

Deviation rates and procedural and documentation requirements varied considerably between hospital trusts. Our findings reveal areas where local policy and practice do not align. Some policies may be impractical and lack utility. We suggest clearer evidence-based standardisation and local procedures that are contextually practical to address these issues.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3025-x) contains supplementary material, which is available to authorized users.

Evaluating team decision-making as an emergent phenomenon

Background

The complexity of modern clinical practice has highlighted the fallibility of individual clinicians’ decision-making, with effective teamwork emerging as a key to patient safety. Dual process theory is widely accepted as a framework for individual decision-making, with type 1 processes responsible for fast, intuitive and automatic decisions and type 2 processes for slow, analytical decisions. However, dual process theory does not explain cognition at the group level, when individuals act in teams. Team cognition resulting from dynamic interaction of individuals is said to be more resilient to decision-making error and greater than simply aggregated cognition.

Methods

Clinicians were paired as teams and asked to solve a cognitive puzzle constructed as a drug calculation. The frequency at which the teams made incorrect decisions was compared with that of individual clinicians answering the same question.

Results

When clinicians acted in pairs, 63% answered the cognitive puzzle correctly, compared with 33% of clinicians as individuals, showing a statistically significant difference in performance (χ2(1, n=116)=24.329, P<0.001). Based on the predicted performance of teams made up of the random pairing of individuals who had the same propensity to answer as previously, there was no statistical difference in the actual and predicted teams’ performance.

Conclusions

Teams are less prone to making errors of decision-making than individuals. However, the improved performance is likely to be owing to the effect of aggregated cognition rather than any improved decision-making as a result of the interaction. There is no evidence of team cognition as an emergent and distinct entity.

Medication Safety in Oncology Care: Mapping Checking Procedures From Prescription to Administration of Chemotherapy

PURPOSE

To increase medication safety in oncology, checking procedures are increasingly applied by nurses, physicians, and pharmacists. However, little is known about the number, types, and consistency of implemented checks. The aim of the study was to assess the number and types of different checking procedures that are performed along the lifecycle of a chemotherapy prescription across three hospitals, different care settings, administration routes, and professional groups.

METHODS

A scheme to evaluate checking procedures and a mapping approach to illustrate the checks along the phases of the medication process were developed. Checking procedures were assessed on the basis of analysis of internal guidelines and interviews with nurses and physicians who work on wards and in ambulatory infusion units of three hospitals.

RESULTS

There were considerable differences in number and type of checking procedures among administration routes, professional groups, wards and ambulatory infusion units, and hospitals. During the prescribing phase, the lowest number of checks was performed. In internal guidelines, checking procedures were documented poorly, though the pharmacy process was an exception.

CONCLUSION

In contrast to the pharmacists, nurse and physician clinician checking procedures are less standardized within and across hospitals. The results point to different checking habits for the professional groups; for example, physicians would rather perform plausibility reviews than checks. Our evaluation scheme to categorize checks and the visualized mapping approach was feasible and understandable for practitioners.

Oncology nurses' beliefs and attitudes towards the double-check of chemotherapy medications: a cross-sectional survey study

BACKGROUND

Double-checking medications is a widely used strategy to enhance safe medication administration in oncology, but there is little evidence to support its effectiveness. The proliferated use of double-checking may be explained by positive attitudes towards checking among nurses. This study investigated oncology nurses' beliefs towards double-checking medication, its relation to beliefs about safety and the influence of nurses' level of experience and proximity to clinical care.

METHODS

This was a survey of all oncology nurses in three Swiss hospitals. The questionnaire contained 41 items on 6 domains. Responses were recorded using a 7-point Likert scale. Multiple regression analysis was used to identify factors linked to strong beliefs in the effectiveness of double-checking.

RESULTS

Overall, 274 (70%) out of 389 nurses responded (91% female, mean age 37 (standard deviation = 10)). Nurses reported very strong beliefs in the effectiveness and utility of double-checking. They were also confident about their own performance in double-checking. Nurses widely believed that double checking produced safety (e.g., 86% believed errors of individuals could be intercepted with double-checks). In contrast, some limitations of double-checking were also recognized, e.g., 33% of nurses reported that double checking caused frequent interruptions and 28% reported that double-checking was done superficially in their unit. Regression analysis revealed that beliefs in effectiveness of double-checking were mainly associated with beliefs in safety production (p < 0.001). Nurses with experience in barcode scanning held less strong beliefs in effectiveness of double-checking (p = 0.006). In contrast to our expectations, there were no differences in beliefs between any professional sub-groups.

CONCLUSION

The widespread and strong believe in the effectiveness of double-checking is linked to beliefs about safety production and co-exists with acknowledgement of the major disadvantages of double-checking by humans. These results are important factors to consider when any existing procedures are adapted or new checking procedures are implemented.

Nurse compliance with a protocol for safe injectable medication administration: comparison of two multicentre observational studies

OBJECTIVES

Medication administration errors with injectable medication have a high risk of causing patient harm. To reduce this risk, all Dutch hospitals implemented a protocol for safe injectable medication administration. Nurse compliance with this protocol was evaluated as low as 19% in 2012. The aim of this second evaluation study was to determine whether nurse compliance had changed over a 4-year period, what factors were associated over time with protocol compliance and which strategies have been implemented by hospitals to increase protocol compliance.

METHODS

In this prospective observational study, conducted between November 2015 and September 2016, nurses from 16 Dutch hospitals were directly observed during intravenous medication administration. Protocol compliance was complete if nine protocol proceedings were conducted correctly. Protocol compliance was compared with results from the first evaluation. Multilevel logistic regression analyses were used to assess the associations over time between explanatory variables and complete protocol compliance. Implemented strategies were classified according to the five components of the Systems Engineering Initiative for Patient Safety (SEIPS) model.

RESULTS

A total of 372 intravenous medication administrations were observed. In comparison with 2012, more proceedings per administration were conducted (mean 7.6, 95% CI 7.5 to 7.7 vs mean 7.3, 95% CI 7.3 to 7.4). No significant change was seen in complete protocol compliance (22% in 2016); compliance with the proceedings 'hand hygiene' and 'check by a second nurse' remained low. In contrast to 2012, the majority of the variance was caused by differences between wards rather than between hospitals. Most implemented improvement strategies targeted the organisation component of the SEIPS model.

CONCLUSIONS

Compliance with 'hand hygiene' and 'check by a second nurse' needs to be further improved in order to increase complete protocol compliance. To do so, interventions focused on nurses and individually tailored to each ward are needed.

Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences

BACKGROUND

Double-checking is widely recommended as an essential method to prevent medication errors. However, prior research has shown that the concept of double-checking is not clearly defined, and that little is known about actual practice in oncology, for example, what kind of checking procedures are applied.

OBJECTIVE

To study the practice of different double-checking procedures in chemotherapy administration and to explore nurses' experiences, for example, how often they actually find errors using a certain procedure. General evaluations regarding double-checking, for example, frequency of interruptions during and caused by a check, or what is regarded as its essential feature was assessed.

METHODS

In a cross-sectional survey, qualified nurses working in oncology departments of 3 hospitals were asked to rate 5 different scenarios of double-checking procedures regarding dimensions such as frequency of use in practice and appropriateness to prevent medication errors; they were also asked general questions about double-checking.

RESULTS

Overall, 274 nurses (70% response rate) participated in the survey. The procedure of jointly double-checking (read-read back) was most commonly used (69% of respondents) and rated as very appropriate to prevent medication errors. Jointly checking medication was seen as the essential characteristic of double-checking-more frequently than 'carrying out checks independently' (54% vs 24%). Most nurses (78%) found the frequency of double-checking in their department appropriate. Being interrupted in one's own current activity for supporting a double-check was reported to occur frequently. Regression analysis revealed a strong preference towards checks that are currently implemented at the responders' workplace.

CONCLUSIONS

Double-checking is well regarded by oncology nurses as a procedure to help prevent errors, with jointly checking being used most frequently. Our results show that the notion of independent checking needs to be transferred more actively into clinical practice. The high frequency of reported interruptions during and caused by double-checks is of concern.

Double checking: a second look

RATIONALE, AIMS AND OBJECTIVES

Double checking is a standard practice in many areas of health care, notwithstanding the lack of evidence supporting its efficacy. We ask in this study: 'How do front line practitioners conceptualize double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?'

METHOD

This is part of a larger qualitative study based on 85 semi-structured interviews of health care practitioners in general internal medicine and obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported.

RESULTS

Weaknesses in the double checking process include inconsistent conceptualization of double checking, double (or more) checking as a costly and time-consuming procedure, double checking trusted as an accepted and stand-alone process, and double checking as preventing reporting of near misses. Alternate views of double checking that would render it a more robust process include recognizing that double checking requires training and a dedicated environment, Introducing automated double checking, and expanding double checking beyond error detection. These results are linked with the concepts of collective efficiency thoroughness trade off (ETTO), an in-family approach, and resilience.

CONCLUSION(S)

Double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged.