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Takahashi M, Okudera H, Wakasugi M, Sakamoto M, Shimizu H, Wakabayashi T, Yamanouchi T, Nagashima H. Describing and Quantifying Wrong-Patient Medication Errors Through a Study of Incident Reports. Drug Healthc Patient Saf 2022; 14:135-146. [PMID: 36039072 PMCID: PMC9419808 DOI: 10.2147/dhps.s371574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/13/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Our aim was to inform a new definition of wrong-patient errors, obtained through an analysis of incident reports related to medication errors. Methods We investigated wrong-patient medication errors in incident reports voluntarily reported by medical staff using a web-based incident reporting system from 2015 to 2016 at a university hospital in Japan. Incident report content was separately evaluated by four evaluators using investigational methods for clinical incidents from the Clinical Risk Unit and the Association of Litigation and Risk Management. They investigated whether it was the patient or drug that was incorrectly chosen during wrong-patient errors in drug administration in incident reports and assessed contributory factors which affected the error occurrence. The evaluators integrated the results and interpreted them together. Results Out of a total 4337 IRs, only 30 cases (2%) contained wrong-patient errors in medication administration. The cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients through the investigation of wrong targets. After a discussion, the evaluators concluded that the patient - drug/CPOE screen mismatch, caused by choosing the wrong patient, drug, or CPOE screen (mix-ups), occurred in the wrong-patient medication errors. These errors were caused by three conditions: (1) where two patients/drugs were listed next to one another, (2) where two patients’ last names/drugs’ names were the same, and (3) where the patient/drug/CPOE screen in front of the staff involved was believed to be the correct one. Additionally, these errors also involved insufficient confirmation, which led to failure to detect and correct the mismatch occurrences. Conclusion Based on our study, we propose a new definition of wrong-patient medication errors: they consisted of choosing a wrong target and insufficient confirmation. We will investigate other types of wrong-patient errors to apply this definition.
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Affiliation(s)
- Megumi Takahashi
- Department of Quality and Patient Safety, Tokyo Medical University, Tokyo, Japan
- Correspondence: Megumi Takahashi, Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku, Tokyo, Japan, Tel +81 3 3342 6111 Ext 3939, Fax +81 3 5339 3791, Email
| | - Hiroshi Okudera
- Department of Crisis Medicine and Clinical Safety, University of Toyama, Toyama, Japan
| | - Masahiro Wakasugi
- Department of Crisis Medicine and Clinical Safety, University of Toyama, Toyama, Japan
| | - Mie Sakamoto
- Department of Crisis Medicine and Clinical Safety, University of Toyama, Toyama, Japan
| | - Hiromi Shimizu
- Department of Medical Management Office, Toyama University Hospital, Toyama, Japan
| | - Tokie Wakabayashi
- Department of Medical Management Office, Toyama University Hospital, Toyama, Japan
| | - Tsuneaki Yamanouchi
- Department of Medical Management Office, Toyama University Hospital, Toyama, Japan
| | - Hisashi Nagashima
- Department of Crisis Medicine and Clinical Safety, University of Toyama, Toyama, Japan
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Nitro M, Romano R, Marletta G, Sollami A, La Sala R, Artioli G, Sarli L. The safety of care focused on patient identity: an observational study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021038. [PMID: 34328138 PMCID: PMC8383230 DOI: 10.23750/abm.v92is2.11328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/02/2021] [Indexed: 11/23/2022]
Abstract
Background and aim: Healthcare organizations, to reduce errors and extend the number of safe practices, are looking for possible solutions to enhance the clients’ health quality care and trying to spread the culture of safety healthcare. Although in the literature the field of research “patient safety” is very debated, there are few empirical studies that investigate about the strategies undertaken by nursing students for the patients’ identification process during their care pathway. The aim of this study is to investigate the knowledge of the Ministerial Recommendation No. 3/2008 among nursing students, a specific Italian directive that aims to guarantee the safety of cares. Methods: A four-weeks single-centered observational study was conducted, involving a convenient sample of 112 students of the 2nd and 3rd year of the Nursing Course Degree of the University of Parma. The survey was conducted using an ad-hoc questionnaire. Results: The use of the identification wristband is considered one of the most important strategy to make sure the patient identification; unfortunately, it is in practice used just on few occasions and only when performed specific procedures; it is furthermore noted that patients are not enough informed about the use and finalities of the identification wristband. Conclusions: Considering the importance of the patient identification process to guarantee the safety of cares, the results produced, suggest that this investigation field deserves further insights in order to collect more substantial data and expand knowledge on the specific subject, so as to fill knowledge gaps and sensitize nursing students to the correct use of the identification wristband.
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Identifying Risk Areas of Medication Administration Process for Developing an Interactive Three-Dimensional Game Intervention. Comput Inform Nurs 2021; 38:524-533. [PMID: 32732642 DOI: 10.1097/cin.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to describe identified risk areas related to the medication administration process in acute care in order to develop a three-dimensional-game intervention. A secondary analysis was conducted using (1) observed medication administrations (n = 1058) and identified medication errors in 2012 (n = 235), (2) a systematic review including a meta-analysis of previous medication administration educational interventions (n = 14) from 2000 to 2015, (3) incident reports of medication administration errors (n = 1012) from 2013 to 2014, and (4) focus group interviews with RNs' (n = 20) views in 2015. A qualitative content analysis was used to identify risk areas, and the data were organized according to the following main themes: (1) factors related to patients (patient identification, patients' characteristics or symptoms, and patients' allergies and interactions); (2) factors related to medications (medication information, changes in medications, generic substitutes, new drugs, look-alike/sound-alike drugs, demanding drug treatments, medication preparation, and administration techniques); (3) factors related to staffing (workload, skills, interruptions and distractions, division of work, responsibility, attitudes, and guidelines); and (4) factors related to communication (flow of information, communication with the patients, and marking of medication information). Identified risk areas could be used to develop interventions with the aim of increasing the safety of medication administration and nurses' skills.
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Gordo C, Núñez-Córdoba JM, Mateo R. Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention. J Adv Nurs 2021; 77:3168-3175. [PMID: 33624324 DOI: 10.1111/jan.14779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/08/2021] [Accepted: 01/16/2021] [Indexed: 11/29/2022]
Abstract
AIMS To identify and prioritize the root causes of adverse drug events (ADEs) in hospitals and to assess the ability of artificial intelligence (AI) capabilities to prevent ADEs. DESIGN A mixed method design was used. METHODS A cross-sectional study for hospitals in Spain was carried out between February and April 2019 to identify and prioritize the root causes of ADEs. A nominal group technique was also used to assess the ability of AI capabilities to prevent ADEs. RESULTS The main root cause of ADEs was a lack of adherence to safety protocols (64.8%), followed by identification errors (57.4%), and fragile and polymedicated patients (44.4%). An analysis of the AI capabilities to prevent the root causes of ADEs showed that identification and reading are two potentially useful capabilities. CONCLUSION Identification error is one of the main root causes of drug adverse events and AI capabilities could potentially prevent drug adverse events. IMPACT This study highlights the role of AI capabilities in safely identifying both patients and drugs, which is a crucial part of the medication administration process, and how this can prevent ADEs in hospitals.
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Affiliation(s)
- Cristina Gordo
- Healthcare Quality Service, Clínica Universidad de Navarra, Pamplona, Spain
| | - Jorge M Núñez-Córdoba
- Research Support Service, Central Clinical Trials Unit, Clínica Universidad de Navarra, Pamplona, Spain.,Department of Preventive Medicine and Public Health, School of Medicine, University of Navarra, Pamplona, Spain
| | - Ricardo Mateo
- Department of Business, School of Economics and Business, University of Navarra, Pamplona, Spain
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Lappalainen M, Härkänen M, Kvist T. The relationship between nurse manager's transformational leadership style and medication safety. Scand J Caring Sci 2019; 34:357-369. [DOI: 10.1111/scs.12737] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/18/2019] [Accepted: 06/25/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Margit Lappalainen
- Department of Nursing Science University of Eastern Finland Kuopio Finland
| | - Marja Härkänen
- Department of Nursing Science University of Eastern Finland Kuopio Finland
| | - Tarja Kvist
- Department of Nursing Science University of Eastern Finland Kuopio Finland
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Schutijser B, Klopotowska JE, Jongerden I, Spreeuwenberg P, Wagner C, de Bruijne M. Nurse compliance with a protocol for safe injectable medication administration: comparison of two multicentre observational studies. BMJ Open 2018; 8:e019648. [PMID: 29306893 PMCID: PMC5781013 DOI: 10.1136/bmjopen-2017-019648] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Bernadette Schutijser
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Joanna Ewa Klopotowska
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Irene Jongerden
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Peter Spreeuwenberg
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Martine de Bruijne
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
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Härkänen M, Tiainen M, Haatainen K. Wrong-patient incidents during medication administrations. J Clin Nurs 2017; 27:715-724. [PMID: 28815817 DOI: 10.1111/jocn.14021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2017] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To describe the factors pertaining to medication being administered to the wrong patient and to describe how patient identification is mentioned in wrong-patient incident reports. BACKGROUND Although patient identification has been given high priority to improve patient safety, patient misidentifications occur, and wrong-patient incidents are common. DESIGN A descriptive content analysis. METHODS Incident reports related to medication administration (n = 1,012) were collected from two hospitals in Finland between 1 January 2013-31 December 2014. Of those, only incidents involving wrong-patient medication administration (n = 103) were included in this study. RESULTS Wrong-patient incidents occurred due for many reasons, including nurse-related factors (such as tiredness, a lack of skills or negligence) but also system-related factors (such as rushing or heavy workloads). In 77% (n = 79) of wrong-patient incident reports, the process of identifying of the patient was not described at all. CONCLUSIONS There is need to pay more attention to and increase training in correct identification processes to prevent wrong-patient incidents, and it is important to adjust system factors to support nurses. RELEVANCE TO CLINICAL PRACTICE Active patient identification procedures, double-checking and verification at each stage of the medication process should be implemented. More attention should also be paid to organisational factors, such as division of work, rushing and workload, as well as to correct communication. The active participation of nurses in handling incidents could increase risk awareness and facilitate useful protection actions.
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Affiliation(s)
- Marja Härkänen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | | | - Kaisa Haatainen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.,Kuopio University Hospital, Kuopio, Finland
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Thank you for asking: Exploring patient perceptions of barcode medication administration identification practices in inpatient mental health settings. Int J Med Inform 2017; 105:31-37. [PMID: 28750909 DOI: 10.1016/j.ijmedinf.2017.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/08/2017] [Accepted: 05/28/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Barcode medication administration systems have been implemented in a number of healthcare settings in an effort to decrease medication errors. To use the technology, nurses are required to login to an electronic health record, scan a medication and a form of patient identification to ensure that these correspond correctly with the ordered medications prior to medication administration. In acute care settings, patient wristbands have been traditionally used as a form of identification; however, past research has suggested that this method of identification may not be preferred in inpatient mental health settings. If barcode medication administration technology is to be effectively used in this context, healthcare organizations need to understand patient preferences with regards to identification methods. PURPOSE The purpose of this study was to elicit patient perceptions of barcode medication administration identification practices in inpatient mental health settings. Insights gathered can be used to determine patient-centered preferences of identifying patients using barcode medication administration technology. METHODS Using a qualitative descriptive approach, fifty-two (n=52) inpatient interviews were completed by a Peer Support Worker using a semi-structured interview guide over a period of two months. Interviews were conducted in a number of inpatient mental health areas including forensic, youth, geriatric, acute, and rehabilitation services. An interprofessional team, inclusive of a Peer Support Worker, completed a thematic analysis of the interview data. RESULTS Six themes emerged as a result of the inductive data analysis. These included: management of information, privacy and security, stigma, relationships, safety and comfort, and negative associations with the technology. Patients also indicated that they would like a choice in the type of identification method used during barcode medication administration. As well, suggestions were made for how barcode medication administration practices could be modified to become more patient-centered. CONCLUSION The results of this study have a number of implications for healthcare organizations. As patients indicated that they would like a choice in the type of identification method used during barcode medication administration, healthcare organizations will need to determine how they can facilitate this process. Furthermore, many of the concerns that patients had with barcode medication administration technology could be addressed through patient education.
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Shawahna R, Masri D, Al-Gharabeh R, Deek R, Al-Thayba L, Halaweh M. Medication administration errors from a nursing viewpoint: a formal consensus of definition and scenarios using a Delphi technique. J Clin Nurs 2016; 25:412-23. [DOI: 10.1111/jocn.13062] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Ramzi Shawahna
- Department of Physiology and Pharmacology; Faculty of Medicine and Health Sciences; An-Najah BioSciences Unit; Center for Poisons Control, Chemical and Biological Analyses; An-Najah National University; Nablus Palestine
| | - Dina Masri
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
| | - Rawan Al-Gharabeh
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
| | - Rawan Deek
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
| | - Lama Al-Thayba
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
| | - Masa Halaweh
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
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