The effectiveness of interventions designed to reduce medication administration errors: a synthesis of findings from systematic reviews

Analysis of medication errors in Neonatal Intensive Care: A systematic review

Medication errors, potentially causing harm and causing harm, increase significantly in newborns cared for in intensive care settings. In this sense, this work carries out a systematic review to analyze the most current evidence in relation to medication errors in neonatal intensive care, discussing the topics that refer to health technology from smart pumps, cost-effectiveness of medications, the practice of nursing professionals on the medication administration process and quality improvement models. In this way, it could be considered a useful tool to promote quality and safety in neonatal intensive care.

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.

Original Research: Exploring Medication Safety Practices from the Nurse's Perspective

BACKGROUND

Medication preparation and administration are complex tasks that nurses must perform daily within today's complicated health care environment. Despite more than two decades of efforts to reduce medication errors, it's well known that such errors remain prevalent. Obtaining insight from direct care nurses may clarify where opportunities for improvement exist and guide future efforts to do so.

PURPOSE

The study purpose was to explore direct care nurses' perspectives on and experiences with medication safety practices and errors.

METHODS

A qualitative descriptive study was conducted among direct care nurses employed across a large health care system. Data were collected using semistructured interview questions with participants in focus groups and one-on-one meetings and were analyzed using qualitative direct content analysis.

RESULTS

A total of 21 direct care nurses participated. Four major themes emerged that impact the medication safety practices of and errors by nurses: the care environment, nurse competency, system influences, and the error paradigm. These themes were often interrelated. Most participants depicted chaotic environments, heavy nursing workloads, and distractions and interruptions as increasing the risk of medication errors. Many seemed unsure about what an error was or could be.

CONCLUSIONS

The complexity of medication safety practices makes it difficult to implement improvement strategies. Understanding the perspectives and experiences of direct care nurses is imperative to implementing such strategies effectively. Based on the study findings, potential solutions should include actively addressing environmental barriers to safe medication practices, ensuring more robust medication management education and training (including guidance regarding the definition of medication errors and the importance of reporting), and revising policies and procedures with input from direct care nurses.

Barriers and enablers for safe medication administration in adult and neonatal intensive care units mapped to the behaviour change wheel

BACKGROUND

Intensive care settings have high rates of medication administration errors. Medications are often administered by nurses and midwives using a specified process (the '5 rights'). Understanding where medication errors occur, the contributing factors and how best practice is delivered may assist in developing interventions to improve medication safety.

AIMS

To identify medication administration errors and context specific barriers and enablers for best practice in an adult and a neonatal intensive care unit. Secondary aims were to identify intervention functions (through the Behaviour Change Wheel).

STUDY DESIGN

A dual methods exploratory descriptive study was conducted (May to June 2021) in a mixed 56-bedded adult intensive care unit and a 6-bedded neonatal intensive care unit in Sydney, Australia. Incident monitoring data were examined. Direct semi-covert observational medication administration audits using the 5 rights (n = 39) were conducted. Brief interviews with patients, parents and nurses were conducted. Data were mapped to the Behaviour Change Wheel.

RESULTS

No medication administration incidents were recorded. Audits (n = 3) for the neonatal intensive care unit revealed no areas for improvement. Adult intensive care unit nurses (n = 36) performed checks for the right medication 35 times (97%) and patient identity 25 times (69%). Sixteen administrations (44%) were interrupted. Four themes were synthesized from the interview data: Trust in the nursing profession; Availability of policies and procedures; Adherence to the '5 rights' and departmental culture; and Adequate staffing. The interventional functions most likely to bring about behaviour change were environmental restructuring, enablement, restrictions, education, persuasion and modelling.

CONCLUSIONS

This study reveals insights about the medication administration practices of nurses in intensive care. Although there were areas for improvement there was widespread awareness among nurses regarding their responsibilities to safely administer medications. Interview data indicated high levels of trust among patients and parents in the nurses.

RELEVANCE TO CLINICAL PRACTICE

This novel study indicated that nurses in intensive care are aware of their responsibilities to safely administer medications. Mapping of contextual data to the Behaviour Change Wheel resulted in the identification of Intervention functions most likely to change medication administration practices in the adult intensive care setting that is environmental restructuring, enablement, restrictions, education, persuasion and modelling.

[Drug Therapy Safety in Outpatient Care Services]

INTRODUCTION

Due to frequent multi-medication, older people are particularly vulnerable to adverse drug reactions (ADRs), which increase hospitalisation and mortality rates. If specially trained pharmacists and nursing staff assume more responsibility in the use of medicines by the elderly, risks can be avoided.

METHODS

A voluntary survey was conducted with care managers of ambulatory care services using a predefined survey questionnaire, and the medicines stored and provided were examined.

RESULTS

Medicines were stored in 76% of the 104 ambulatory care services surveyed. In 63% of these, medicines in stock were examined, and in 55% a comparison was made between prescribed and provided medicines. Deficiencies were found in about half of the inspected boxes and dosettes. On average, 1.5 errors were found per checked unit; 40% of the nursing services left the medicines in the vehicle for 3 to 6 hours when transporting them to the client. Regular meetings with doctors' practices or pharmacies were conducted by less than 35% of the these services. In 41 out of the 104 services surveyed, investigators monitoring therapy rated the performance of the nursing staff positively.

CONCLUSIONS

Therapy monitoring and cooperation of ambulatory care services with other health professionals, especially with pharmacists, needs to be improved. More care and control (e. g., through the four-eyes principle) should be exercised, especially in the provision of medicines. In future, further precisely conducted and representative surveys on medication processes in outpatient care need to be carried out. Analogous to existing studies, there were indications of quality and communication problems as well as weaknesses in therapy monitoring in ambulatory care services. Sources of error were mainly found in storage and transport of medicines. Errors were also evident in the provision of medicines. Due to the lack of participation obligations, the results of the study are limited.

Exploring Nurses' Attitudes, Skills, and Beliefs of Medication Safety Practices

BACKGROUND

Medication errors exist within health care systems despite efforts to reduce their incidence. These errors may result in patient harm including morbidity, mortality, and increased health care costs.

PURPOSE

The purpose of this study was to explore direct care nurses' attitudes, skills, and beliefs about medication safety practice.

METHODS

Researchers conducted a descriptive exploratory study using the Nurses' Attitudes and Skills around Updated Safety Concepts (NASUS) scale and the Nurse Beliefs about Errors Questionnaire (NBEQ).

RESULTS

Responses from 191 surveys were analyzed. Of the participants, 70% were bachelor's prepared registered nurses and 88% were female. Results of the NASUS scale revealed the median of means of the Perceived Skills subscale was 79.2 out of 100 and the Attitudes subscale was 65.8 out of 100. The mean of the belief questions related to severity of error was 7.66 out of 10; most participants agreed with reporting of severe errors, reporting errors with moderate or major adverse events, and reporting of incorrect intravenous fluids.

CONCLUSIONS

Understanding direct care nurses' attitudes, skills, and beliefs about medication safety practices provides a foundation for development of improvement strategies.

Patient safety in home care: A multicenter cross-sectional study about medication errors and medication management of nurses

Studies assume that up to 30% of home care recipients are exposed to a possible medication error. For the home care sector, the study situation regarding such errors is limited. The aim of the study was to find out how often medication errors occur and whether they are related to training, quality assurance measures (use of the double-check principle (DCP)), and other structural conditions of home care services. A cross-sectional study was conducted, comprising 485 fully trained nurses of 107 randomly selected home care services. Potential influencing factors were analyzed in a multiple logistic regression model. Of 485 fully qualified nurses, 41.6% reported medication errors within a 12-month period, while 14.8% did not answer this question. Nurses who had attended medication training within the last 2 years compared to a longer period (frequently to rather rarely applied DCP); the odds ratio of not making medication-related errors was 1.79[1.42-3.09] (OR 3.13; [1.88-5.20]). Years of professional experience, amount of patients per shift, and type of work contract (full/part-time) were not statistically significantly associated with reported medication errors. Medication-related errors occur frequently in home care. Regular training and adequate quality management measures increase patient safety. Nursing managers and other responsible individuals of home care institutions have to make sure that nursing staff take part in regular medication training and apply the DCP when they give out medication in home care.

The impact of a novel medication scanner on administration errors in the hospital setting: a before and after feasibility study

Objective

The medication administration process is complex and consequently prone to errors. Closed Loop Medication Administration solutions aim to improve patient safety. We assessed the impact of a novel medication scanning device (MedEye) on the rate of medication administration errors in a large UK Hospital.

Methods

We performed a feasibility before and after study on one ward at a tertiary-care teaching hospital that used a commercial electronic prescribing and medication administration system. We conducted direct observations of nursing drug administration rounds before and after the MedEye implementation. We calculated the rate and type (‘timing’, ‘omission’ or ‘other’ error) of medication administration errors (MAEs) before and after the MedEye implementation.

Results

We observed a total of 1069 administrations before and 432 after the MedEye intervention was implemented. Data suggested that MedEye could support a reduction in MAEs. After adjusting for heterogeneity, we detected a decreasing effect of MedEye on overall errors (p = 0.0753). Non-timing errors (‘omission’ and ‘other’ errors) reduced from 51 (4.77%) to 11 (2.55%), a reduction of 46.5%, which had borderline significance at the 5% level, although this was lost after adjusting for confounders.

Conclusions

This pilot study detected a decreasing effect of MedEye on overall errors and a reduction in non-timing error rates that was clinically important as such errors are more likely to be associated with harm. Further research is needed to investigate the impact on a larger sample of medications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01828-3.

Vaccine events raising public concern and associated immunization program policy and practice changes, China, 2005-2021

INTRODUCTION

Several vaccine events causing public concern have occurred in China that were investigated and responded to by the central government. We describe causes, influences, and policy or practice changes associated with vaccine events that occurred between 2005 and 2021. We make recommendations to foster resilience in China's Expanded Program of Immunization (EPI) system and vaccination enterprises and to sustain vaccine and program confidence.

METHODS

Our study included all vaccine events since 2005 that were investigated and responded to by the central government of China. We verified mainstream and social media visibility of the events through Internet search. We extracted event times, causes, investigation processes, results, actions, and policy or practice regulation changes from official reports of government meetings and from official websites with media briefings.

RESULTS

Seven vaccine events were identified, each of which caused more than 100,000 mainstream or social media reports nationally or nationally and internationally. The events ranged in magnitude from 145 children receiving out-of-date oral poliovirus vaccine to a measles supplementary immunization activity involving 103 million children. Few, if any, children were directly harmed by vaccines in the events. Government responded to each event with program or policy changes, and in one case, with legislation. Responses affected the conduct of campaigns and supplementary immunization activities, use of schools as vaccination venues, financial incentives for vaccinating with non-program vaccines, vaccine procurement and distribution, and program policy making. The most fundamental response was enacting the country's first vaccine law, the 2019 Vaccine Administration Law, which guides virtually all aspects of vaccination work, from vaccine development through regulation, program implementation, and safety and impact monitoring.

CONCLUSIONS

All seven events generated substantial national and international mainstream and social media criticism and discussion, most commonly expressed through concerns of vaccine safety or vaccine effectiveness. Most had temporally associated temporary declines in vaccine confidence and coverage, jeopardizing decades of vaccination effort. The central government responded to each event by attempting to address root causes. Faithful implementation of the Vaccine Administration Law is fundamental to program strengthening and sustaining confidence of families, stakeholders, and government in vaccines and immunization in China.

The art of making the right exception to the "rule": Nurses' experiences with drug dispensing in nursing homes

Nurses are key professionals in ensuring safe drug management in nursing homes, and their practice is regulated by a number of guidelines. The present study aimed to explore nurses' experiences of dispensing drugs to older people in nursing homes by using an exploratory qualitative design. Focus group interviews were conducted in three nursing homes in central Norway; the data were analyzed using qualitative content analysis. The results indicated that drug dispensing was perceived as a complicated process during which both anticipated and unforeseen challenges arose that influenced the nurses' abilities to follow professional standards. In these situations, the nurses had to apply their knowledge and make various adjustments based on conditions in the organization and the needs of individual patients. The findings have implications for facilitating nurses' working conditions and resources to avoid drug administration that limit the discretion of nurses and threaten patient safety in nursing homes.

Assessing the impact of a mixed intervention model on the reduction of medication administration errors in an Australian hospital

BACKGROUND

Medication errors remain one of the most common types of incidents reported in Australian hospitals. Studies have reported that for every 10 medication administrations, a medication administration error is likely to occur and reach the patient, potentially contributing to a preventable patient harm.

OBJECTIVE

To assess the impact of a mixed intervention model on medication administration errors in an Australian hospital.

METHODS

Two types of intervention model (human and system orientated) were implemented through collaboration with key stakeholders (nurses, educators, and policy makers) to reduce medication administration errors across this 650-bed multisite Australian hospital from August 2018 to June 2019. To assess the impact of the mixed intervention model, the total number of reported medication errors and the number of medication administration errors were retrieved from the hospital electronic medication management system for 12 months before (from June 2017 to July 2018) and after (from July 2019 to June 2020) implementation of all interventions.

RESULTS

Implementation of a mixed intervention model through collaboration with stakeholders resulted in significant reduction in the number of medication administration errors, and those with harm (from 68 to 55%, P < 0.0001 and from 12 to 8%, P = 0.0001 respectively). Additionally, the severity of medication administration errors was also reduced (HR 0.562, 95% CI (0.298-1.062)) in the post-intervention phase.

CONCLUSION

Introducing a mixed intervention model reduces medication administration errors across health settings and has the potential to drive excellence in healthcare.

Clinician attitude towards safety in medication management: a participatory action research study in an emergency department

OBJECTIVES

Edication management is a process in which medications are selected, procured, delivered, prescribed, reviewed, administered and monitored to assure high-quality patient care and safety. This paper explores clinicians' attitudes towards medication management which is both open to influence and strongly linked to successful changes in mediation behaviour. We aimed to investigate effects of engaging in participatory action research to improve emergency medicine clinicians' attitudes to safety in medication management.

SETTING

Emergency department of one university affiliated hospital.

PARTICIPANTS

A total of 85 clinicians including nurses and physicians partook as participants. Eight managers and clinicians participated as representatives.

DESIGN

Data are drawn from two-cycle participatory action research. Initially, a situation analysis on the current medication management and clinician views regarding medication management was conducted using three focus groups. Evaluation and reflection data were obtained through qualitative interviews. All qualitative data were analysed using content analysis.

RESULTS

Clinicians initially expressed negative attitudes towards existing and new plans for medication management, in that they were critical of current medication-related policy and procedures, as well as wary of the potential relevance and utility of potential changes to medication management. Through the action research, improvement actions were implemented including interprofessional courses, pharmacist-led interventions and the development of new guidelines regarding medication management. Participants and their representatives were engaged in all participatory action research stages with different levels of involvement. Extracted results from evaluation and reflection stages revealed that by engaging in the action research and practice new interventions, clinicians' attitude towards medication management was improved.

CONCLUSIONS

The results support the impact of participatory action research on enhancing clinicians' positive attitudes through their involvement in planning and implementing safety enhancing aspects of medication management.

Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Background Intravenous admixture preparation errors (IAPEs) may lead to patient harm. Insight into the prevalence as well as the determinants associated with these IAPEs is needed to elicit preventive measures. Aim The primary aim of this study was to assess the prevalence of IAPEs. Secondary aims were to identify the type, severity, and determinants of IAPEs. Method A prospective observational study was performed in a Dutch university hospital. IAPE data were collected by disguised observation. The primary outcome was the proportion of admixtures with one or more IAPEs. Descriptive statistics were used for the prevalence, type, and severity of IAPEs. Mixed-effects logistic regression analyses were used to estimate the determinants of IAPEs. Results A total of 533 IAPEs occurred in 367 of 614 admixtures (59.8%) prepared by nursing staff. The most prevalent errors were wrong preparation technique (n = 257) and wrong volume of infusion fluid (n = 107). Fifty-nine IAPEs (11.1%) were potentially harmful. The following variables were associated with IAPEs: multistep versus single-step preparations (adjusted odds ratio [OR_adj] 4.08, 95% confidence interval [CI] 2.27–7.35); interruption versus no interruption (OR_adj 2.32, CI 1.13–4.74); weekend versus weekdays (OR_adj 2.12, CI 1.14–3.95); time window 2 p.m.-6 p.m. versus 7 a.m.-10 a.m. (OR_adj 3.38, CI 1.60–7.15); and paediatric versus adult wards (OR_adj 0.14, CI 0.06–0.37). Conclusion IAPEs, including harmful IAPEs, occurred frequently. The determinants associated with IAPEs point to factors associated with preparation complexity and working conditions. Strategies to reduce the occurrence of IAPEs and therefore patient harm should target the identified determinants.

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS.

MATERIALS AND METHODS

We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed.

RESULTS

There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18-8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72-0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence.

DISCUSSION AND CONCLUSION

Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.

Nurse's Achilles Heel: Using Big Data to Determine Workload Factors That Impact Near Misses

PURPOSE

To explore how big data can be used to identify the contribution or influence of six specific workload variables: patient count, medication count, task count call lights, patient sepsis score, and hours worked on the occurrence of a near miss (NM) by individual nurses.

DESIGN

A correlational and cross-section research design was used to collect over 82,000 useable data points of historical workload data from the three unique systems on a medical-surgical unit in a midsized hospital in the southeast United States over a 60-day period. Data were collected prior to the start of the Covid-19 pandemic in the United States.

METHODS

Combined data were analyzed using JMP Pro version 12. Mean responses from two groups were compared using a t-test and those from more than two groups using analysis of variance. Logistic regression was used to determine the significance of impact each workload variable had on individual nurses' ability to administer medications successfully as measured by occurrence of NMs.

FINDINGS

The mean outcome of each of the six workload factors measured differed significantly (p < .0001) among nurses. The mean outcome for all workload factors except the hours worked was found to be significantly higher (p < .0001) for those who committed an NM compared to those who did not. At least one workload variable was observed to be significantly associated (p < .05) with the occurrence or nonoccurrence of NMs in 82.6% of the nurses in the study.

CONCLUSIONS

For the majority of the nurses in our study, the occurrence of an NM was significantly impacted by at least one workload variable. Because the specific variables that impact performance are different for each individual nurse, decreasing only one variable, such as patient load, will not adequately address the risk for NMs. Other variables not studied here, such as education and experience, might be associated with the occurrence of NMs.

CLINICAL RELEVANCE

In the majority of nurses, different workload variables increase their risk for an NM, suggesting that interventions addressing medication errors should be implemented based on the individual's risk profile.

Psychometric design and validation of a tool to assess the medication administration process through simulation in undergraduate nursing students

BACKGROUND

Medication errors account for 38% of adverse events reported among undergraduate nursing students. Simulation provides training for nursing students in the medication administration process. However, there is a lack of reliable and valid instruments to measure its assessment.

OBJECTIVES

To design and validate a new tool (MEDICORRECT) to assess undergraduate nursing students in the medication administration process using a high-fidelity simulation scenario.

DESIGN AND METHODS

Study participants were fourth year undergraduate nursing students at the University of Barcelona. Phase 1 consisted of tool design and drafting, and content validity and feasibility analyses. Phase 2 covered construct validity and interrater reliability. A factor analysis was conducted, involving a principal component analysis and varimax rotation.

FINDINGS

Of 21 initial items, 11 were eliminated because of low content validity ratio, 4 of which assessed cognitive skills such as administering the right medicine at the right dose, which were impossible to observe in the simulation scenario. The final version of MEDICORRECT contained 10 items. The exploratory factor analysis identified a four-factorial model explaining 67.3% of the variance. Interrater agreement measured with Kappa was greater than 0.70 for 80% of items.

CONCLUSIONS

The 10 items in MEDICORRECT are relevant and feasible, have suitable psychometric properties and reflect the practical skills identified in the medication administration process. The tool excludes cognitive skills, which should be included and assessed during prebriefing.

Hospital medication errors: a cross-sectional study

BACKGROUND

Medication errors (MEs) are among the most common types of incidents reported in Australian and international hospitals. There is no uniform method of reporting and reducing these errors. This study aims to identify the incidence, time trends, types and factors associated with MEs in a large regional hospital in Australia.

METHODS

A 5-year cross-sectional study.

RESULTS

The incidence of MEs was 1.05 per 100 admitted patients. The highest frequency of errors was observed during the colder months of May-August. When distributed by day of the week, Mondays and Tuesdays had the highest frequency of errors. When distributed by hour of the day, time intervals from 7 am to 8 am and from 7 pm to 8 pm showed a sharp increase in the frequency of errors. One thousand and eighty-eight (57.8%) MEs belonged to incidence severity rating (ISR) level 4 and 787 (41.8%) belonged to ISR level 3. There were six incidents of ISR level 2 and only one incident of ISR level 1 reported during the five-year period 2014-2018. Administration-only errors were the most common accounting for 1070 (56.8%) followed by prescribing-only errors (433, 23%). High-risk medications were associated with half the number of errors, the most common of which were narcotics (17.9%) and antimicrobials (13.2%).

CONCLUSIONS

MEs continue to be a problem faced by international hospitals. Inexperience of health professionals and nurse-patient ratios might be the fundamental challenges to overcome. Specific training of junior staff in prescribing and administering medication and nurse workload management could be possible solutions to reducing MEs in hospitals.

Nurses' Perceived Causes of Medication Administration Errors: A Qualitative Systematic Review

BACKGROUND

Medication administration errors (MAEs) are a critical patient safety issue. Nurses are often responsible for administering medication to patients, thus their perceptions of causes of errors can provide valuable guidance for the development of interventions aimed to mitigate errors. Quantitative research can overlook less overt causes; therefore, a qualitative systematic review was conducted to present a synthesis of qualitative evidence of nurses' perceived causes of MAEs.

METHODS

Publications from 2000 to February 2019 were searched using four electronic databases. Inclusion criteria were articles that (1) presented results from studies that used a qualitative or mixed methods design, (2) reported qualitative data on nurses' perceived causes of MAEs in health care settings, and (3) were published in the English language. Sixteen individual articles satisfied the inclusion criteria. Methodological quality of each article was assessed using the Critical Appraisal Skills Programme (CASP) tool. Thematic analysis of the data was performed. Perceived causes of errors were labeled as knowledge-based, personal, and contextual factors.

RESULTS

The primary knowledge-based factor was lack of medication knowledge. Personal factors included fatigue and complacency. Contextual factors included heavy workloads and interruptions. Contextual factors were reported in all the studies reviewed and were often interconnected with personal and knowledge-based factors.

CONCLUSION

Causes of MAEs are perceived by nurses to be multifactorial and interconnected and often stem from systems issues. Multifactorial interventions aimed at mitigating medication errors are required with an emphasis on systems changes. Findings in this review can be used to guide efforts aimed at identifying and modifying factors contributing to MAEs.

A work system analysis of the medication administration process in a Norwegian nursing home ward

Nursing home patients often have multiple diagnoses and a high prevalence of polypharmacy and are at risk of experiencing adverse drug events. The study aims to explore the dynamic interactions of stakeholders and work system elements in the medication administration process in a nursing home ward. Data were collected using observations and interviews. A deductive content analysis led to a SEIPS-based process map and an accompanying work system analysis. The study increases knowledge of the complexity of the medication administration process by portraying the dynamic interactions between the major stakeholders in the work system, and the temporal flow of the activities involved. Secondly, it identifies facilitators and barriers in the work system linked to the medication administration process. Most barriers and facilitators are associated with the work system elements - tools & technology, organisation and tasks - and occur early in the medication administration process.

Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis

INTRODUCTION

The risk of medication errors is high in paediatric inpatient settings. However, estimates of the prevalence of medication errors have not accounted for heterogeneity across studies in error identification methods and definitions, nor contextual differences across wards and the use of electronic or paper medication charts.

OBJECTIVE

Our aim was to conduct a systematic review and meta-analysis to provide separate estimates of the prevalence of medication errors among paediatric inpatients, depending on hospital ward and the use of electronic or paper medication charts, that address differences in error identification methods and definitions.

METHODS

We systematically searched five databases to identify studies published between January 2000 and December 2018 that assessed medication error rates by medication chart audit, direct observation or a combination of methods.

RESULTS

We identified 71 studies, 19 involved paediatric wards using electronic charts. Most studies assessed prescribing errors with few studies assessing administration errors. Estimates varied by ward type. Studies of paediatric wards using electronic charts generally reported a reduced error prevalence compared to those using paper, although there were some inconsistencies. Error detection methods impacted the rate of administration errors in studies of multiple wards, however, no other difference was found. Definition of medication error did not have a consistent impact on reported error rates.

CONCLUSIONS

Medication errors are a frequent occurrence in paediatric inpatient settings, particularly in intensive care wards and emergency departments. Hospitals using electronic charts tended to have a lower rate of medication errors compared to those using paper charts. Future research employing controlled designs is needed to determine the true impact of electronic charts and other interventions on medication errors and associated harm among hospitalized children.

Self-administration of medication: a pragmatic randomized controlled trial of the impact on dispensing errors, perceptions, and satisfaction

BACKGROUND

Our aim was to investigate whether self-administration of medication (SAM) during hospitalization affects the number of dispensing errors, perceptions regarding medication, and participant satisfaction when compared with nurse-led medication dispensing.

METHODS

A pragmatic randomized controlled trial was performed in a Danish cardiology unit. Patients aged ⩾ 18 years capable of SAM were eligible for inclusion. Patients were excluded if they did not self-administer medication at home, were not prescribed medication suitable for self-administration, or did not speak Danish.Intervention group participants self-administered their medication. In the control group, medication was dispensed and administered by nurses.The primary outcome was the proportion of dispensing errors collected through modified disguised observation of participants and nurses. Dispensing errors were divided into clinical and procedural errors.Secondary outcomes were explored through telephone calls to determine participant perceptions regarding medication and satisfaction, and finally, deviations in their medication list two weeks after discharge.

RESULTS

Significantly fewer dispensing errors were observed in the intervention group, with 100 errors/1033 opportunities for error (9.7%), compared with 132 errors/1028 opportunities for error (12.8%) in the control group. The number of clinical errors was significantly reduced, whereas no difference in procedural errors was observed. At follow up, those who were self-administering medication had fewer concerns regarding their medication, found medication to be less harmful, were more satisfied, preferred this opportunity in the future, and had fewer deviations in their medication list after discharge compared with the control group.

CONCLUSION

In conclusion, the reduced number of dispensing errors in the intervention group, indicate that SAM is safe. In addition, SAM had a positive impact on (a) perceptions regarding medication, thus suggesting increased medication adherence, (b) deviations in medication list after discharge, and (c) participant satisfaction related to medication management at the hospital.

Prevalence and types of vaccination errors from 2009 to 2018: A systematic review of the medical literature

INTRODUCTION

Vaccination practices and the programmatic factors that influence them are essential for public health. Several barriers impact vaccination efforts, including vaccination errors, which pose the risk of reduced population-wide vaccination efficacy and individual adverse drug events. This study aimed to define the prevalence of vaccination errors documented in English language medical literature between 2009 and 2018 and to identify the common types of errors that occurred during this period.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. The study protocol was registered with the International Prospective Register of Systematic Reviews prior to research activities. The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Google Scholar, ProQuest Central, PubMed, Scopus, and Web of Science were searched using predetermined search terms. Included data were from primary studies or retrospective analyses that assessed the prevalence and/or type of vaccination errors and that were peer-reviewed, conducted between 2009 and 2018, and published in English. Data were extracted using the Cochrane Data Extraction and Assessment Template and assessed using the Appraisal tool for Cross-Sectional Studies. Pooled vaccination error prevalence was then calculated.

RESULTS

Of the 1310 independent records that were identified and screened, 17 studies from five countries met all inclusion criteria. Pooled vaccination error prevalence was calculated to be 1.15 per 10,000 vaccine doses (range, 0.005-141.69 per 10,000 doses). The most commonly reported vaccination errors were "wrong vaccine administered" and "off-schedule administration."

CONCLUSIONS

International rates of vaccination error reporting remain low, with few reports of significant adverse reactions. Vaccination programs should consider the impact of vaccination errors on individual and population health, particularly focusing on the impact of "wrong vaccine" administration. Continued monitoring and promotion of error reporting will enable further understanding of this topic.

Reducing interruptions during medication preparation and administration

PURPOSE

According to literature, interruptions during drug administration lead to a significant proportion of medication errors. Evidence on the effectiveness of interventions to reduce interruption is still limited. The purpose of this paper is to explore main reasons for interruptions during drug administration rounds in a geriatric ward of an Italian secondary hospital and test the effectiveness of a combined intervention.

DESIGN/METHODOLOGY/APPROACH

This is a pre and post-intervention observational study based on direct observation. All nurse staff (24) participated to the study that lead to observe a total of 44 drug dispensing rounds with 945 drugs administered to 491 patients in T0 and 994 drugs to 506 patients in T1.

FINDINGS

A significant reduction of raw number of interruptions (mean per round from 17.31 in T0 to 9.09 in T1, p<0.01), interruptions/patient rate (from 0.78 in T0 to 0.40 in T1, p<0.01) and interruptions/drugs rate (from 0.44 in T0 to 0.22 in T1, p<0.01) were observed. Needs for further improvements were elicited (e.g. a greater involvement of support staff).

PRACTICAL IMPLICATIONS

Nurse staff should be adequately trained on the risks related to interruptions during drug administration since routine activity is at high risk of distractions due to its repetitive and skill-based nature.

ORIGINALITY/VALUE

A strong involvement of both MB and leadership, together with the frontline staff, helped to raise staff motivation and guide a bottom-up approach, able to identify tailored interventions and serve concurrently as training instrument tool.

Medication administration in nursing homes: A qualitative study of the nurse role

AIMS

The objective of this study was to expand the knowledge of the nurse role during medication administration in the context of nursing homes. The following research question guided the study: How can the nurse role during medication administration in nursing homes be described?

DESIGN

A QUAL-qual mixed study design was applied.

METHODS

Data were collected using partial participant observations and semi-structured interviews of all staff members involved in medication administration. An inductive content analysis was performed.

RESULTS

Medication administration is a pervasive process ingrained in the day-to-day activities of providing care to the patients. The nurse role is compensating, flexible and adaptable. There is a dynamic interaction between several contributory factors, those being shifting responsibility, a need for competence, invisible leadership, varying available competence, staff stability and vulnerable shifts.

Validation of Pictograms for Safer Handling of Medications: Comprehension and Recall among Pharmacy Students

BACKGROUND

Medication preparation and administration are higher-risk steps in the medication management process. Therefore, medication management strategies, such as warnings and education about medication safety, are essential in preventing errors and improving the safe handling of medications by health care workers.

OBJECTIVES

To validate comprehension of 9 pictograms designed to improve medication safety, and to assess long-term recall of these pictograms in a sample of pharmacy students.

METHODS

First- and second-year pharmacy students were recruited as participants. The study was divided into 2 phases: comprehension (Phase 1) and long-term recall (Phase 2). In Phase 1, a slideshow of the 9 pictograms was presented to participants, who were asked to write the meaning of and required action for each pictogram. The intended meaning of each pictogram was then presented to the participants. Four weeks later, long-term recall was assessed in Phase 2 of the study using the same method. The meaning and required action that participants provided for each pictogram were reviewed by 3 independent raters. A pictogram was considered to be validated in the pharmacy student population if at least 67% of participants identified the correct meaning or required action during the recall phase.

RESULTS

A total of 101 pharmacy students participated in Phase 1 and 67 in Phase 2. In Phase 1, 4 pictograms met the 67% threshold for comprehension. In Phase 2, after training, 7 of the 9 pictograms were validated.

CONCLUSIONS

Given the results obtained with pharmacy students, redesign may be necessary for 2 of the pictograms. The use of validated medication safety pictograms on medication labels and other identifiers may prevent errors during medication handling and administration; this is an important avenue of investigation for future studies.

Development of Pictograms to Enhance Medication Safety Practices of Health Care Workers and International Preferences

BACKGROUND

A panel of medication management experts previously identified 9 key medication safety issues and high-alert drug classes as representing the most pressing medication-handling issues in health care.

OBJECTIVE

To develop medication safety pictograms depicting medication safety issues and high-alert drug classes that represent medication-handling risks for health care personnel.

METHODS

An iterative design process, including activities such as semiotic analysis, design/redesign, and evaluation, was used to develop medication safety pictograms. Nurses, physicians, pharmacists, and students listed and drew graphic elements to depict each of the 9 key medication safety issues. Graduate students in graphic design developed the preliminary pictograms for the study. A Delphi survey was then conducted with experts recruited from the International Pharmaceutical Federation to reach consensus on the pictograms and provide feedback to the graphic designers. Health care providers from around the world were invited to participate in a survey to determine a preferred pictogram for each safety warning.

RESULTS

For each medication safety issue, 3 to 5 pictograms were developed on the basis of graphic elements suggested by 52 health care providers. These pictograms were then presented to 58 experts in 2 rounds of a Delphi process. For each medication safety issue, consensus on the 2 best pictograms was reached and feedback provided. A total of 799 participants from 61 countries responded to the international preference survey. Most of the participants (n = 536, 67.1%) were Canadian, and of those, 385 (71.8%) were pharmacists. In 8 categories, consensus on the preferred pictogram was reached across the health care professions; however, a difference in preference was apparent for the pictogram representing "neuromuscular blocking agent", with nurses' preferred pictogram differing from the preference of other participants.

CONCLUSION

This project produced pictograms to illustrate 9 important medication safety issues, which can now be validated through comprehension and recall assessments. Further study can also determine their potential to reduce medication administration errors.

Medication administration and interruptions in nursing homes: A qualitative observational study

AIMS AND OBJECTIVES

To contribute in-depth knowledge of the characteristics of medication administration and interruptions in nursing homes. The following research questions guided the study: How can the medication administration process in nursing homes be described? How can interruptions during the medication administration process in nursing homes be characterized?

BACKGROUND

Medication administration is a vital process across healthcare settings, and earlier research in nursing homes is sparse. The medication administration process is prone to interruptions that may lead to adverse drug events. On the other hand, interruptions may also have positive effects on patient safety.

DESIGN

A qualitative observational study design was applied.

METHODS

Data were collected using partial participant observations. An inductive content analysis was performed.

RESULTS

Factors that contributed to the observed complexity of medication administration in nursing homes were the high number of single tasks, varying degree of linearity, the variability of technological solutions, demands regarding documentation and staff's apparent freedom as to how and where to perform medication-related activities. Interruptions during medication administration are prevalent and can be characterised as passive (e.g., alarm and background noises), active (e.g., discussions) or technological interruptions (e.g., use of mobile applications). Most interruptions have negative outcomes, while some have positive outcomes.

CONCLUSIONS

A process of normalisation has taken place whereby staff put up with second-rate technological solutions, noise and interruptions when they are performing medication-related tasks. Before seeking to minimise interruptions during the medication administration process, it is important to understand the interconnectivity of the elements using a systems approach.

RELEVANCE TO CLINICAL PRACTICE

Staff and management need to be aware of the normalisation of interruptions. Knowledge of the complexity of medication administration may raise awareness and highlight the importance of maintaining and enhancing staff competence.

Medication Errors in the Emergency Department: Knowledge, Attitude, Behavior, and Training Needs of Nurses

Aim:

The aim was to describe which elements of nurses' knowledge, training needs, behavior, and attitude can prevent Medication errors (Acronym MEs) in the emergency department during all steps of the administration of intravenous (IV) medications.

Methods:

An anonymous questionnaire made up of 43 items has been drafted and delivered to a sample of 103 nurses of a university hospital in Rome. The study has been supported by specific literature review.

Results:

Majority of the sample (94%) answered that topics related to the preparation and administration of IV medications were covered during the basic course while 63.2% only during the postbasic course. Only 15.6% of nurses judged excellent their level of knowledge about preparation and administration of IV medications while 89.3% considered that it is important to improve their knowledge; 85.6% said that the teaching about the use of IV medications should be increased during the degree course they attended; 30.3% agreed that specific postgraduate courses on the use of IV drugs should be designed. Moreover, only 22% of the sample believed that the coaching of new recruit nurses is critical to prevent errors.

Conclusion:

The sample showed appropriate knowledge, positive attitudes, and right behavior related to the preparation and administration of IV medications. The skills that nurses must have in pharmacology are still rising, both due to the safety of drug therapy and to the increasing number of drugs available; the result is that nurses have to update their knowledge regularly.