Errors in administration of parenteral drugs in intensive care units: multinational prospective study

Safe practices in Intensive Care Medicine, is zero risk possible?

Incidents related to patient safety are a problem of great impact in Intensive Care Medicine (ICM). Multiple strategies have been developed to identify them, analyze, and develop policies aim at reducing their incidence and minimizing their effects and consequences. The development of a safety culture, an adequate organizational and structural design of the ICM, which contemplates the implementation of effective safe practices, with a provision of human resources adjusted to the care activity carried out and the periodic analysis of the different events and their factors, will allow us to bring the risk of critical patient care closer to zero, as would be desirable.

Epidemiology of adverse events in Intensive Medicine units

The severity of the critically ill patient, the practice of diagnostic procedures and invasive treatments, the high number of drugs administered, a high volume of data generated during the care of the critically ill patient along with a technical work environment, the stress and workload of work of professionals, are circumstances that favor the appearance of errors, turning Intensive Medicine Services into risk areas for adverse events to occur. Knowing their epidemiology is the first step to improve the safety of the care we provide to our patients, because it allows us to identify risk areas, analyze them and develop strategies to prevent the adverse events, or if this is not possible, be able to manage them. This article analyzes the main studies published to date on incidents related to safety in the field of critically ill patients.

Prescription patterns in an intensive care unit of COVID-19 patients in Bangladesh: A cross-sectional study

Background and Aims

To reduce death rates for critical patients hospitalized in intensive care units (ICUs), coronavirus (COVID-19) lacks proven and efficient treatment methods. This cross-sectional study aims to evaluate how physicians treat severe and suspected COVID-19 patients in the ICU department in the absence of an established approach, as well as assess the rational use of the medication in the ICU department.

Methods

Between June 16, 2021, and December 10, 2022, a total of 428 prescriptions were randomly gathered, including both suspected (yellow zone) and confirmed (red zone) COVID-19 patients. For data management, Microsoft Excel 2021 was utilized, while STATA 17 provided statistical analysis. To find associations between patients' admission status and demographic details, exploratory and bivariate analyses were conducted.

Results

Of the 428 patients admitted to the ICU, 228 (53.27%) were in the yellow zone and 200 (46.73%) were in the verified COVID-19 red zone. The majority of patients were male (54.44%), and the age range from 41 to 60 was the most common (41.82%). No significant deviation was detected to the yellow and red groups' prescription patterns. A total of 4001 medicines (mean 9.35/patient) were prescribed. Antiulcerants, antibiotics, respiratory, analgesics, anticoagulants, vitamins and minerals, steroids, cardiovascular, antidiabetic drugs, antivirals, antihistamines, muscle relaxants, and antifungal treatments were widely prescribed drugs. Enoxaparin (67.06%) appeared as the most prescribed medicine, followed by montelukast (60.51%), paracetamol (58.41%), and dexamethasone (51.64%).

Conclusion

The prescription patterns for the yellow and red groups were comparable and mostly included symptomatic treatment. Respiratory drugs constituted the most frequent therapeutic class. Polypharmacy should be taken under considerations. In ICU settings, the outcomes emphasize the need of correct diagnosis, cautious antibiotic usage, suitable therapy, and attentive monitoring.

Anticoagulation-Associated Adverse Drug Events in Hospitalized Patients Across Two Time Periods

PURPOSE

Anticoagulants often cause adverse drug events (ADEs), comprised of medication errors and adverse drug reactions, in patients. Our study objective was to determine the clinical characteristics, types, severity, cause, and outcomes of anticoagulation-associated ADEs from 2015-2020 (a contemporary period following implementation of an electronic health record, infusion device technology, and anticoagulant dosing nomograms) and to compare them with those of a historical period (2004-2009).

METHODS

We reviewed all anticoagulant-associated ADEs reported as part of our hospital-wide safety system. Reviewers classified type, severity, root cause, and outcomes for each ADE according to standard definitions. Reviewers also assessed events for patient harm. Patients were followed up to 30 days after the event.

RESULTS

Despite implementation of enhanced patient safety technology and procedure, ADEs increased in the contemporary period. In the contemporary period, we found 925 patients who had 984 anticoagulation-associated ADEs, including 811 isolated medication errors (82.4%); 13 isolated adverse drug reactions (1.4%); and 160 combined medication errors, adverse drug reactions, or both (16.2%). Unfractionated heparin was the most frequent ADE-related anticoagulant (77.7%, contemporary period vs 58.3%, historical period). The most frequent anticoagulation-associated medication error in the contemporary period was wrong rate or frequency of administration (26.1%, n = 253), with the most frequent root cause being prescribing errors (21.3%, n = 207). The type, root cause, and harm from ADEs were similar between periods.

CONCLUSIONS

We found that anticoagulation-associated ADEs occurred despite advances in patient safety technologies and practices. Events were common, suggesting marginal improvements in anticoagulant safety over time and ample opportunities for improvement.

Co-administration of Intravenous Drugs: Rapidly Troubleshooting the Solid Form Composition of a Precipitate in a Multi-drug Mixture Using On-Site Raman Spectroscopy

Intravenous drugs are often co-administrated in the same intravenous catheter line due to which compatibility issues, such as complex precipitation processes in the catheter line, may occur. A well-known example that led to several neonatal deaths is the precipitation due to co-administration of ceftriaxone- and calcium-containing solutions. The current study is exploring the applicability of Raman spectroscopy for testing intravenous drug compatibility in hospital settings. The precipitation of ceftriaxone calcium was used as a model system and explored in several multi-drug mixtures containing both structurally similar and clinically relevant drugs for co-infusion. Equal molar concentrations of solutions containing ceftriaxone and calcium chloride dihydrate were mixed with solutions of cefotaxime, ampicillin, paracetamol, and metoclopramide. The precipitate formed was collected as an "unknown" material, dried, and analyzed. Several solid-state analytical methods, including X-ray powder diffraction, Raman spectroscopy, and thermogravimetric analysis, were used to characterize the precipitate. Raman microscopy was used to investigate the identity of single sub-visual particles precipitated from a mixture of ceftriaxone, cefotaxime, and calcium chloride. X-ray powder diffraction suggested that the precipitate was partially crystalline; however, the identity of the solid form of the precipitate could not be confirmed with this standard method. Raman spectroscopy combined with multi-variate analyses (principal component analysis and soft independent modelling class analogy) enabled the correct detection and identification of the precipitate as ceftriaxone calcium. Raman microscopy enabled the identification of ceftriaxone calcium single particles of sub-visual size (around 25 μm), which is in the size range that may occlude capillaries. This study indicates that Raman spectroscopy is a promising approach for supporting clinical decisions and especially for compatibility assessments of drug infusions in hospital settings.

WireSafeTM - A pilot study of a novel safety engineered device designed to prevent guidewire retention and reduce sharps injuries during central venous catheter insertion

Background

Guidewire retention and sharps injury during central venous catheter insertion are errors that cause patient and healthcare professional harm. The WireSafeTM is a novel procedure safety pack engineered to prevent guidewire retention and sharps injury during central venous catheter insertion. This is a pilot study aimed to determine its acceptability, usability and safety during clinical practice.

Methods

An observational time and motion study was conducted comparing central venous catheter insertion and sharps disposal practice using standard versus WireSafeTM techniques. One-year following implementation, a structured survey was conducted to determine clinician opinion and experiences of using the WireSafeTM.

Results

15 procedures were observed using standard practice and 16 using the WireSafeTM technique. The WireSafeTM technique decreased the time taken from removal of the guidewire to disposal of sharps (standard 11.4 ± 5.6 min vs WireSafeTM 8.7 ± 1.4 min, p = 0.035), as well as total procedure time (standard 16 ± 7 min vs WireSafeTM 14.2 ± 2 min, p = 0.17), although this latter trend did not reach significance. Clinicians frequently practiced unsafe behaviour during sharps disposal in the standard group (53%), but when using the WireSafeTM technique, 100% exhibited safe practice by transferring sharps to the bin inside the sealed WireSafeTM box. One-year following implementation, 20 clinicians participated in the structured survey. Clinicians across three different departments used the WireSafeTM in varying clinical situations and reported that its use for central line insertion was either easier (10/20) or no different (10/20) compared to standard practice. All clinicians (20/20) felt that the WireSafeTM reduced the risk of guidewire retention and all stated that they approved of the WireSafeTM technique, and supported its use for convenience and safety benefits.

Conclusion

Utilising the WireSafeTM for central line insertion facilitated earlier and safer sharps disposal, and the device was well supported by clinicians for its convenience and safety benefits.

Long-term stability of 10 mg/mL dobutamine injectable solutions in 5% dextrose and normal saline solution stored in polypropylene syringes and cyclic-oleofin-copolymer vials

OBJECTIVE

Dobutamine is an inotropic agent given to patients with low cardiac output or undergoing cardiac surgery in intensive care units. Routine clinical care protocols recommend a target dilution concentration of 10 mg/mL dobutamine from the 250 mg/20 mL commercial solution.This study aimed to assess the 1-year stability of ready-to-use 10 mg/mL diluted dobutamine solutions. Two types of 50 mL conditioning, polypropylene (PP) syringes or cyclic-oleofin-copolymer (COC) vials and two diluents (5% dextrose (D5W) and normal saline (NS)) were tested.

METHODS

Reversed-phase liquid chromatography coupled with an ultraviolet detection stability-indicating method was developed for dobutamine and validated according to selectivity, linearity, sensitivity, accuracy and precision. Chemical stability was considered to have been maintained if the measured concentrations were >90% of the initial concentration with no colour change. Physical stability was assessed through sterility tests, pH and osmolality monitoring, and subvisible particle counting. Containers were stored at -20±5°C, +5±3°C and +25±2°C with 60%±5% relative humidity in a dark, closed environment.

RESULTS

According to this study, the physicochemical stability of 10 mg/mL dobutamine solutions prepared with D5W or NS is constant throughout a 365-day period when stored in COC vials, at all the aforementioned temperatures, whereas solutions in PP syringes required a refrigerated temperature and should not be administered after 21 days or 3 months when prepared with D5W or NS, respectively, or after 1 month at ambient temperature whatever the diluent.

CONCLUSION

Our results argue in favour of adopting the compounding of ready-to-use 10 mg/mL dobutamine solutions in COC vials in centralised intravenous additive services.

The Impact of Nursing Skill-mix on Adverse Events in Intensive Care: A Single Centre Cohort Study

BACKGROUND

The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed.

OBJECTIVE

To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE.

DESIGN & SETTING

We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient.

RESULTS

A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003).

CONCLUSION

An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

Medication errors and associated factors among pediatric inpatients in public hospitals of gamo zone, southern Ethiopia

Background

Medication errors are the most common medical errors in the world. In particular, pediatric patients are more susceptible to severe injuries and death. Despite their multidimensional impact, medication errors are not recognized well in developing nations, including Ethiopia. Thus, this study aimed to assess the prevalence of medication errors and associated factors among pediatric inpatients in public hospitals of Gamo zone, southern Ethiopia.

Methods

A facility-based cross-sectional study was conducted among 416 pediatric inpatients from August 1, 2020, to February 30, 2021. Open data kit tools and Stata version 16.0 were used for data collection and analysis, respectively. Bivariable and multivariable analyses were performed to identify factors associated with medication errors. An adjusted odds ratio with a 95% confidence interval was computed and a P-value of <0.05 in the multivariable analysis was set to declare statistical significance.

Results

Overall, 69.5% (95% CI: 64.80, 73.86) of pediatric inpatients experienced medication errors. Unsuitable working environment (aOR: 2.40, 95% CI: 1.48, 3.91), child weight <5 Kg (aOR: 3.72, 95% CI: 1.79, 7.73), medication administered by diploma professionals (aOR: 2.10, 95% CI: 1.31, 3.36), parent involvement (aOR: 0.55, 95% CI: 0.33, 0.95), non-adherence with medication administration rights (aOR: 2.68, 95% CI: 1.32, 5.44) and hospital stay for >5 days (aOR: 1.83, 95% CI: 1.15, 2.93) were significantly associated with medication errors.

Conclusion

Medication errors were high among pediatric inpatients as compared to previous national studies. To reduce the occurrences of medication errors, it is critical to create a suitable working environment, arrange education and training opportunities for providers, involve families in the medication administration process, and strictly adhere to medication administration rights.

Patient safety culture in Austria and recommendations of evidence-based instruments for improving patient safety

This study aimed to investigate the patient safety culture in Austria. We identified factors that contributed to a higher degree of patient safety and subsequently developed evidence-based suggestions on how to improve patient safety culture in hospitals. Moreover, we examined differences in the perception of patient safety culture among different professional groups. This study used a cross-sectional design in ten Austrian hospitals (N = 1,525). We analyzed the correlation between ten patient safety culture factors, three background characteristics (descriptive variables), and three outcome variables (patient safety grade, number of adverse events reported, and influence on patient safety). We also conducted an analysis of variance to determine the differences in patient safety culture factors among the various professional groups in hospitals. The findings revealed that all ten factors have considerable potential for improvement. The most highly rated patient safety culture factors were communication openness and supervisor/manager’s expectations and actions promoting safety; whereas, the lowest rated factor was non-punitive response to error. A comparison of the various professional groups showed significant differences in the perception of patient safety culture between nurses, doctors, and other groups. Patient safety culture in Austria seems to have considerable potential for improvement, and patient safety culture factors significantly contribute to patient safety. We determined evidence-based practices as recommendations for improving each of the patient safety factors.

Perceptions of Patient Safety Culture Dimensions among Hospital Nurses: A Systematic Review

Background

Patient safety culture, an important aspect in the field of patient safety, plays an important role in the promotion of healthcare quality. Improved patient safety culture decreases patient readmission rates, lengths of hospital stay, and patient safety issues. Patient safety culture includes a set of dimensions. This review focuses on the differing perceptions of these dimensions among healthcare providers in hospitals.

Aims

This study aimed to identify studies examining healthcare providers’ perceptions of patient safety culture in hospitals and to summarize the data from these studies.

Method

Electronic database searching was based on the research question. Two electronic databases were used: CINHAL and Scopus. The search was limited to the period 2005–2012, and studies examining healthcare providers’ perceptions of patient safety culture were identified. Key terms were used to search the articles that were selected on the basis of inclusion and exclusion criteria. Articles examining healthcare providers’ perceptions of patient safety culture in hospitals without comparison between nurses and other healthcare professionals were selected.

Results

Eight articles were reviewed. Several questionnaires were used to assess healthcare providers’ perceptions of patient safety culture in these articles. Our review indicated differences in healthcare providers’ perceptions. In two articles, participants reported a high positive response to teamwork. In addition, participants in the other two articles reported a high positive response to job satisfaction.

Conclusion

The results of the current review reveal healthcare providers’ perceptions of patient safety culture. The results highlight that careful recognition and committed work on various scales/dimensions of patient safety culture can improve healthcare quality and consequently decrease patient safety issues associated with nursing care. Our findings also encourage hospital management and decision-makers to focus on and establish improvements in areas that will positively affect the quality of healthcare.

The Reduction in Medical Errors on Implementing an Intensive Care Information System in a Setting Where a Hospital Electronic Medical Record System is Already in Use: Retrospective Analysis

Background

Although the various advantages of clinical information systems in intensive care units (ICUs), such as intensive care information systems (ICISs), have been reported, their role in preventing medical errors remains unclear.

Objective

This study aimed to investigate the changes in the incidence and type of errors in the ICU before and after ICIS implementation in a setting where a hospital electronic medical record system is already in use.

Methods

An ICIS was introduced to the general ICU of a university hospital. After a step-by-step implementation lasting 3 months, the ICIS was used for all patients starting from April 2019. We performed a retrospective analysis of the errors in the ICU during the 6-month period before and after ICIS implementation by using data from an incident reporting system, and the number, incidence rate, type, and patient outcome level of errors were determined.

Results

From April 2018 to September 2018, 755 patients were admitted to the ICU, and 719 patients were admitted from April 2019 to September 2019. The number of errors was 153 in the 2018 study period and 71 in the 2019 study period. The error incidence rates in 2018 and 2019 were 54.1 (95% CI 45.9-63.4) and 27.3 (95% CI 21.3-34.4) events per 1000 patient-days, respectively (P<.001). During both periods, there were no significant changes in the composition of the types of errors (P=.16), and the most common type of error was medication error.

Conclusions

ICIS implementation was temporally associated with a 50% reduction in the number and incidence rate of errors in the ICU. Although the most common type of error was medication error in both study periods, ICIS implementation significantly reduced the number and incidence rate of medication errors.

Trial Registration

University Hospital Medical Information Network Clinical Trials Registry UMIN000041471; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047345

Exploration of an Alarm Sensor to Detect Infusion Failure Administered by Syringe Pumps

Incorrect medication administration causes millions of undesirable complications worldwide every year. The problem is severe and there are many control systems in the market, yet the exact molecular composition of the solution is not monitored. Here, we propose an alarm sensor based on UV-Vis spectroscopy and refractometry. Both methods are non-invasive and non-destructive as they utilize visible light for the analysis. Moreover, they can be used for on-site or point-of-care diagnosis. UV-Vis-spectrometer detect the absorption of light caused by an electronic transition in an atom or molecule. In contrast a refractometer measures the extent of light refraction as part of a refractive index of transparent substances. Both methods can be used for quantification of dissolved analytes in transparent substances. We show that a sensor combining both methods is capable to discern most standard medications that are used in intensive care medicine. Furthermore, an integration of the alarm sensor in already existing monitoring systems is possible.

An Economic Analysis of Critical Care Nurse Resourcing Following the Uptake of Ready-to-Administer Noradrenaline for Hypotensive Shock in Adults in England

Introduction

Ready-to-administer formulations for intravenous administration of noradrenaline are now broadly recommended and predicted to reduce pressure on critical care nursing. This analysis sought to quantify the nurse resource released from national level transition.

Methods

The annual number of noradrenaline support days for hypotensive shock was determined and the administration of noradrenaline was simulated over 24 h using a decision tree. A ‘best-practice’ ready-to-administer strategy (RtA) of volumetrically pumped noradrenaline was compared to a ‘nil uptake’ strategy (AfC) of bedside prepared solution delivered either volumetrically or using a double syringe pump. A mix of noradrenaline concentrations, flow rates, product sizes, and preferences for ampoule pooling, preparation volume, and sterility were included. The consumption of nurse days and product units was then projected over 1 year for a population of adults in critical care in England.

Results

Noradrenaline was administered over 231,011 days per year across 4123 critical care beds in England. Implementing a transition from AfC to RtA strategies on this scale released 35,791 nurse days or 176 whole-time nurse equivalents at 50/50 NHS band 5 and 6, a monetised release of £11.6 million. There was an increase in drug acquisition cost of £2.1 million using the licensed commercial product Sinora^®. Annual net monetary benefit was + £9.5 million, or + £65,961 per critical care unit (CCU) of 29 beds, equivalent to one nurse released per unit for patient care.

Conclusions

This modelling of ready-to-administer noradrenaline with volumetric delivery quantifies and bears out the recommendations of the Lord Carter review, the Royal Pharmaceutical Society, and the NHS Specialist Pharmacy Service in their encouragement of ready-to-administer formulations for safe and resource-effective critical care.

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

BACKGROUND

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

AIM

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

DESIGN

Descriptive, correlational cross-sectional design was used.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review

OBJECTIVES

Delivery of intravenous medications in hospitals is a complex process posing to systemic risks for errors. The aim of this study was to identify systemic causes of in-hospital intravenous medication errors.

METHODS

A systematic review adhering to PRISMA guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the GRADE system and the evidence analyzed using qualitative content analysis.

RESULTS

Eleven studies from six countries were included in the analysis. We identified systemic causes related to prescribing (n = 6 studies), preparation (n = 6), administration (n = 6), dispensing and storage (n = 5), and treatment monitoring (n = 2). Administration, prescribing, and preparation were the process phases most prone to systemic errors. Insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, calculation tasks, failure in double-checking procedures, and confusion between look-alike, sound-alike medications were the leading causes of intravenous medication errors. The number of the included studies was limited, all of them being observational studies and graded as low quality.

CONCLUSIONS

Current intravenous medication systems remain vulnerable, which can result in patient harm. Our findings suggest further focus on medication safety activities related to administration, prescribing, and preparation of intravenous medications. This study provides healthcare organizations with preliminary knowledge about systemic causes of intravenous medication errors, but more rigorous evidence is needed.

Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals: A Systematic Review

OBJECTIVES

Intravenous medication delivery is a complex process that poses systemic risks of errors. The objective of our study was to identify systemic defenses that can prevent in-hospital intravenous (IV) medication errors.

METHODS

A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the Grading of Recommendations Assessment, Development and Evaluation system, and the evidence was analyzed using qualitative content analysis.

RESULTS

Forty-six studies from 11 countries were included in the analysis. We identified systemic defenses related to administration (n = 24 studies), prescribing (n = 8), preparation (n = 6), treatment monitoring (n = 2), and dispensing (n = 1). In addition, 5 studies explored defenses related to multiple stages of the drug delivery process. Systemic defenses including features of closed-loop medication management systems appeared in 61% of the studies, with smart pumps being the defense most widely studied (24%). The evidence quality of the included articles was limited, as 83% were graded as low quality, 13% were of moderate quality, and only 4% were of high quality.

CONCLUSIONS

In-hospital IV medication processes are developing toward closed-loop medication management systems. Our study provides health care organizations with preliminary knowledge about systemic defenses that can prevent IV medication errors, but more rigorous evidence is needed. There is a need for further studies to explore combinations of different systemic defenses and their effectiveness in error prevention throughout the drug delivery process.

Analysis of Critical Incident Reporting System as an indicator of quality healthcare in a cardiology center in Tbilisi, Georgia

Critical Incident Reporting System (CIRS) have become most common patient safety tools in healthcare. The purpose of this study was to determine how effectively CIRS is used and how well healthcare professionals recognize it as a risk management tool. A quantitative approach using a cross sectional survey was adopted. The most common critical incidents were due to lack of personal attention and related to individual errors. The most of the critical incidents arise from non-adherence to guidelines and standards. CIRS can be seen as an effective clinical risk management tool that can be used to identify potential sources of critical incidents and help ensure patient safety at a healthcare organization.

Evaluation of Intravenous Diphenhydramine Use in Patients with Sickle Cell Vaso-Occlusive Crisis

Purpose: To compare the incidence of oversedation between oral and parenteral diphenhydramine therapy for treatment of opioid-induced pruritus in patients with sickle cell disease vaso-occlusive crisis (SCD VOC). Methods: This retrospective, single-center, cohort study included patients greater than or equal to 18 years old with sickle cell disease admitted for vaso-occlusive crisis who received either intravenous or oral diphenhydramine for opioid-induced pruritus. Patients were identified through ICD-9 and ICD-10 codes from June 1, 2016 through July 1, 2017. Rates of oversedation were compared between the 2 formulations. Secondary endpoints included length of stay, amount and duration of diphenhydramine, rate of acute chest and indication for IV therapy. Results: Fifty unique patients were included in the analysis representing 121 admissions. Seven patients received both formulations on separate admissions and were included in both groups. Twenty-nine percent of patients in the IV diphenhydramine group experienced oversedation (12/42) versus 13% in the oral diphenhydramine group (2/15, P = .312). The average number of admissions was significantly higher in the IV versus oral group (2.45 vs 1.20; P = .005) with average and median length of stay also significantly higher in the IV versus oral group (30.57, 16.0 vs 10.67, 10.0; P = .003). Conclusion: While there was no statistically significant difference in the rates of oversedation with use of IV versus oral diphenhydramine formulations, patients with SCD VOC who received IV diphenhydramine had more frequent admissions and a longer length of stay. Clinicians may consider oral diphenhydramine preferentially in appropriate patients over IV administration.

Intravenous Administration Errors Intercepted by Smart Infusion Technology in an Adult Intensive Care Unit

OBJECTIVES

The aim of the study was to investigate the efficacy of intravenous (IV) smart pumps with drug libraries and dose error reduction system (DERS) to intercept programming errors entailing high risk for patients in an adult intensive care unit (ICU).

METHODS

A 2-year retrospective study was conducted in the adult ICU of the Hospital Juárez de México in Mexico City to evaluate the impact of IV smart pump/DERS (Hospira MedNet) technology implementation. We conducted a descriptive analysis of the reports generated by the system's software from April 2014 through May 2016. Our study focused on the upper hard limit alerts and used the systems' variance reports and IV Medication Harm Index methodology to determine the severity of the averted overdoses for medications with the highest number of edits.

RESULTS

The system monitored 124,229 infusion programs and averted on 36,942 deviations of the preset safe limits. Upper hard limit alerts accounted for 26.4% of pump reprogramming events. One hundred sixty-six significant administration errors were intercepted and prevented, and IV Medication Harm Index analysis identified 83 of them as highest-risk averted overdoses with insulin accounting for 51.8% of those. The rate of compliance with the safety software during the study period was 69.8%.

CONCLUSIONS

Our study contributes additional evidence of the impact of IV smart pump/DERS technology. These pumps effectively intercepted severe infusion errors and significantly prevented adverse drug events related to dosing. Our results support the implementation of this technology in ICUs as a minimum safety standard and could help drive an IV infusion safety initiative in Mexico.

Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level

Background

Fluid therapy is a common intervention in critically ill patients. Fluid therapy errors may cause harm to patients. Thus, understanding of reported fluid therapy incidents is required in order to learn from them and develop protective measures, including utilizing expertise of pharmacists and technology to improve patient safety at the national level.

Objectives

To describe fluid therapy incidents voluntarily reported in intensive care and high dependency units (ICUs) to a national incident reporting system, by investigating the error types, fluid products, consequences to patients and actions taken to alleviate them, and to identify at which phase of the medication process the incidents had occurred and had been detected.

Methods

Medication related voluntarily reported incident (n = 7623) reports were obtained from all ICUs in 2007–2017. Incidents concerning fluid therapy (n = 2201) were selected. The retrospective analysis utilized categorized data and narrative descriptions of the incidents. The results were expressed as frequencies and percentages.

Results

Most voluntarily reported incidents had occurred during the dispensing/preparing phase (n = 1306, 59%) of the medication process: a point of risk. Most incidents (n = 1975, 90%) had reached the patient and passed through many phases in the medication process and nursing shift change checks before detection. One third of the errors (n = 596, 30%) were reported to have caused consequences to patients. One quarter (n = 492, 25%) of the errors were reported to have required an additional procedure to alleviate or monitor the consequences.

Conclusions

Utilizing national incident report data enabled identifying systemic points of risk in the medication process and learning to improve patient safety. To prevent similar incidents, initial interventions should focus on the dispensing/preparing phase before implementing active medication identification procedures at each phase of the medication process and nursing shift changes. Strengthening clinical pharmacy services, utilizing technology, coordinated by IV Fluid Coordinators and Medication Safety Officers, could improve patient safety in the ICUs.

Development and Validation of the Safe Parenteral Medication Administration Self-Efficacy Scale

BACKGROUND

This study aimed to develop a valid and reliable measurement instrument for determining the self-efficacy perceptions of nurses concerning safe medication practices.

METHOD

The study was conducted at the hospital of a state university in Istanbul, Turkey, between August and December 2016. The sample consisted of 278 nurses.

RESULTS

The exploratory factor analysis indicated the scale had a single-factor structure that explained 47.92% of the total variance. The remaining 76 items had factor loads ranging from .50 to .87. The item-total correlations varied between .49 and .86, and Cronbach's alpha coefficient for the scale was .98.

CONCLUSION

The results of the analysis show the items constituting the scale have validity and reliability criteria that can measure the self-efficacy of nurses related to parenteral medication administration. [J Contin Educ Nurs. 2021;52(6):267-273.].

Introducing Critical Incident Reporting System as an Indicator of Quality Healthcare in Georgia

Critical incident reporting systems (CIRS) have become the most common patient safety tools in healthcare. The purpose of this study was to present the development of CIRS in Georgia. A quantitative approach using a cross-sectional survey was adopted. Critical incidents were mainly derived from surgical disciplines. The highest number of cases was registered by nurses. The most common critical incidents were due to lack of personal attention. CIRS can be seen as an effective clinical risk management tool that can be used to identify potential sources of critical incidents and help ensure patient safety at a healthcare organization.

Stability and Compatibility Aspects of Drugs: The Case of Selected Cephalosporins

Intravenous drug incompatibilities are a common cause of medical errors, contributing to ineffective therapy and even life-threatening events. The co-administration of drugs must always be supported by studies confirming compatibility and thus guarantee the therapy's safety. Particular attention should be paid to the possible incompatibilities or degradation of intravenous cephalosporins in different infusion regimens since the administration of drugs with inadequate quality may cause treatment failure. Therefore, an appropriate stability test should be performed. The study aimed to present various aspects of the stability and compatibility of five cephalosporins: cefepime (CFE), cefuroxime (CFU), ceftriaxone (CFX), ceftazidime (CFZ), and cefazoline (CFL). The degradation studies in parenteral infusion fluids and PN admixtures were conducted for CFE and CFU. The interactions between CFX or CFZ and PN admixtures, as well as the compatibility of CFL with five commercial parenteral nutrition (PN) admixtures, were investigated. The content of CFX and CFZ in PN admixture after 24 h was >90%. CFL administered simultaneously with PN admixture by the same infusion set using Y-site was compatible only with Nutriflex Lipid Special. CFE and CFU were stable in all tested infusion fluids for a minimum of 48 h and decomposed in PN admixtures during storage.

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.

Dissemination of Direct Healthcare Professional Communications on Medication Errors for Medicinal Products in the EU: An Explorative Study on Relevant Factors

INTRODUCTION

When serious medication errors (ME) are identified, communication to the field may be necessary. In the EU, communication of serious safety issues, such as medication errors associated with adverse drug reactions, is done through direct healthcare professional communications (DHPCs). We aimed to identify how often DHPCs about medication errors are distributed, and we explored factors associated with these ME DHPCs.

METHODS

We performed a descriptive study of all centrally authorised products (CAPs) approved before 1 May 2019 in the EU. All DHPCs issued between 1 January 2001 and 1 May 2019 were reviewed for ME content. Characteristics of CAPs were collected from the website of the European Medicines Agency. A Kaplan-Meier survival analysis was performed to estimate the 5- and 10-year probability of the occurrence of a first ME DHPC. A logistic regression was performed to explore risk factors for ME DHPCs.

RESULTS

A total of 678 CAPs were included, of which 35 required an ME DHPC during the study period. The 5-year probability for a CAP to have a first ME DHPC was 2.5% (95% CI 1.1-3.9) and the 10-year probability was 4.4% (95% CI 2.2-6.5). Among products with an ME DHPC, the 5-year probability of a second ME DHPC was 21.3% (95% CI 0.2-38.0). The risk of ME DHPCs was increased for products with multiple pharmaceutical formulations, enteral liquid or parenteral injection preparations, and products classified as nervous system agents or antineoplastic and immunomodulating agents.

CONCLUSIONS

The absolute number of ME DHPCs for CAPs is low and does not give rise to immediate concern. We identified potential risk factors for ME DHPCs that should be taken into account during approval procedures or line extensions.

Co-Administration of Drugs and Parenteral Nutrition: In Vitro Compatibility Studies of Loop Diuretics for Safer Clinical Practice

Parenteral nutrition (PN) admixtures are prone to interacting with drugs administered intravenously via a common catheter. This may cause a threat to a patient’s health and life. The literature that has been reported on the compatibility of loop diuretics with PN presents conflicting results. This work aimed to study the compatibility of furosemide and torsemide with PN used in clinical practice. Undiluted solutions of drugs were mixed with PN at various ratios determined by flow rates. In order to assess compatibility, visual control was followed by pH measurement, osmolality, mean emulsion droplet diameter (MDD), and zeta potential upon mixing and at 4 h of storage. No macroscopic changes that indicated lipid emulsion degradation were observed. After the addition of the drugs, the value of pH ranged from 6.37 ± 0.01 to 7.38 ± 0.01. The zeta potential was in reverse proportion to the drug concentration. The addition of the drugs did not affect the MDD. It may be suggested that the co-administration of furosemide or torsemide and PN caused no interaction. The absence of such signs of unwanted interactions allowed for the co-administration of the mentioned loop diuretics and PN at each of the studied ratios.

The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique*

Background

Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia.

Methods

Following a near-miss and subsequent educational and training efforts at our institution, we conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination.

Results

(1) Only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique.

Conclusion

Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.

Twelve-Month Review of Infusion Pump Near-Miss Medication and Dose Selection Errors and User-Initiated "Good Save" Corrections: Retrospective Study

BACKGROUND

There is a paucity of quantitative evidence in the current literature on the incidence of wrong medication and wrong dose administration of intravenous medications by clinicians. The difficulties of obtaining reliable data are related to the fact that at this stage of the medication administration chain, detection of errors is extremely difficult. Smart pump medication library logs and their reporting software record medication and dose selections made by users, as well as cancellations of selections and the time between these actions. Analysis of these data adds quantitative data to the detection of these kinds of errors.

OBJECTIVE

We aimed to establish, in a reproducible and reliable study, baseline data to show how metrics in the set-up and programming phase of intravenous medication administration can be produced from medication library near-miss error reports from infusion pumps.

METHODS

We performed a 12-month retrospective review of medication library reports from infusion pumps from across a facility to obtain metrics on the set-up phase of intravenous medication administration. Cancelled infusions and resolutions of all infusion alerts by users were analyzed. Decision times of clinicians were calculated from the time-date stamps of the pumps' logs.

RESULTS

Incorrect medication selections represented 3.45% (10,017/290,807) of all medication library alerts and 22.40% (10,017/44,721) of all cancelled infusions. Of these cancelled medications, all high-risk medications, oncology medications, and all intravenous medications delivered to pediatric patients and neonates required a two-nurse check according to the local policy. Wrong dose selection was responsible for 2.93% (8533/290,807) of all alarms and 19.08% (8533/44,721) of infusion cancellations. Average error recognition to cancellation and correction times were 27.00 s (SD 22.25) for medication error correction and 26.52 s (SD 24.71) for dose correction. The mean character count of medications corrected from initial lookalike-soundalike selection errors was 13.04, with a heavier distribution toward higher character counts. The position of the word/phrase error was spread among name beginning (6991/10,017, 69.79%), middle (2144/10,017, 21.40%), and end (882/10,017, 8.80%).

CONCLUSIONS

The study identified a high number of lookalike-soundalike near miss errors, with cancellation of one medication being rapidly followed by the programming of a second. This phenomenon was largely centered on initial misreadings of the beginning of the medication name, with some incidences of misreading in the middle and end portions of medication nomenclature. The value of an infusion pump showing the entire medication name complete with TALLman lettering on the interface matching that of medication labeling is supported by these findings. The study provides a quantitative appraisal of an area that has been resistant to study and measurement, which is the number of intravenous medication administration errors of wrong medication and wrong dose that occur in clinical settings.

The acceptance of CIRS among orthopedic and trauma surgeons in Germany-Significant gap between positive perception and actual implementation in daily routine

PURPOSE

Medical errors are the third leading cause of death in the United States after malignant tumors and cardiovascular disease. Handling of errors becomes more and more eclectic due to the implementation of incident reporting systems and the use of checklists. Since 2015, any German hospital would have a critical incident reporting system (CIRS). The aim of this study is to discover the nationwide utilization and attitude toward CIRS of orthopedic and trauma surgeons.

METHODS

Between April 10, 2015 and May 22, 2015, a web-based questionnaire, which was designed by an expert team consisting of orthopedic and trauma surgeons, aeronautic human factors specialists, and psychologists (Lufthansa Aviation Training), was sent to all members of the German Society for Orthopedic and Trauma Surgery. The survey consisted of three questions regarding CIRS and its use in German hospitals.

RESULTS

A total of 669 orthopedic and trauma surgeons working in German hospitals completed the questionnaire. All participants rated CIRS as useful, although 71.3% of participants did not report a critical incident in the last 12 months. In that time period, only 13.4% of participating residents reported at least one incident, but 44.7% of chief physicians reported one incident within the same period.

CONCLUSION

The present study demonstrates that even though CIRS as a tool is positively appreciated by orthopedic and trauma surgeons working in German hospitals, many do not know about its existence at their own hospital. This can be a reason for the low number of critical incidents reported.

Parenteral nutrition: a call to action for harmonization of policies to increase patient safety

Unsafe medication practices and medication errors are leading causes of injury and avoidable harm worldwide and are highest in vulnerable groups. In 2017, the World Health Organization launched the third Medication Without Harm Global Patient Safety Challenge to try to reduce risks related to medical treatment. Parenteral nutrition (PN) is in the unique position that, although licensed products are available from manufacturers, formulas may be prepared ad hoc for first-line use that might not be subject to the same regulatory oversight. Safety issues around PN can arise through lack of harmonization in practices, misinterpretation and product unfamiliarity and can occur at any stage from prescription to preparation to administration. Government legislation and regulation vary considerably, with PN not explicitly handled in many countries. We therefore call on policy leaders in all countries to establish policies that ensure patient safety, and that these include PN along with medicines. The available evidence supports obtaining industry prepared PN as first-line therapy for reasons of safety, primarily, and of cost. If a suitable industry prepared ready-to-use PN is not available, standardized all-in-one PN admixtures should be the next line of care, with individualized PN being reserved for patients whose complex nutritional needs cannot be met using standardized admixtures.

Microbiological validation of a robot for the sterile compounding of injectable non-hazardous medications in a hospital environment

Objectives

To design and execute a comprehensive microbiological validation protocol to assess a brand-new sterile compounding robot in a hospital pharmacy environment, according to ISO and EU GMP standards.

Methods

Qualification of the Class-A inner environment of the robot was performed through microbial air and surface quality assessment utilising contact plates, swabs and particulate matter monitoring. To evaluate the effectiveness of the microbial decontamination process (UV rays) challenge test against Pseudomonas aeruginosa, Staphylococcus aureus, Bacillus subtilis spores and Candida albicans was used. The challenge Media Fill test was used to validate the aseptic processing.

Results

After 3 hours, no microorganisms retained viability. Monitoring inside the equipment evidenced complete absence of microorganisms. The Media Fill test was always negative.

Conclusions

According to our results, the APOTECAunit meets the requirements for advanced aseptic processing in the hospital pharmacies and the pharmaceutical industry in general, providing advantages in terms of safety for patients compared with conventional procedures of parenteral preparation production. The protocol has demonstrated to be a comprehensive and valuable tool in validating, from a microbial point of view, a sterile-compounding technology. This study might represent an important benchmark in developing a contamination control strategy, as required, for example, in the Performance Qualification of the GMP in the case of drug manufacturing.

Long-term stability of ready-to-use 1-mg/mL midazolam solution

Purpose

Midazolam is a benzodiazepine derivative commonly used in intensive care units to control sedation. Its use requires dilution of a 5-mg/mL commercial solution to a target concentration of 1 mg/mL. A study was conducted to evaluate the stability of diluted ready-to-use 1-mg/mL midazolam solutions over 365 days when stored in cyclic olefin copolymer vials or polypropylene syringes.

Methods

A specific stability-indicating high-performance liquid chromatography coupled with UV detection method was developed for midazolam hydrochloride and validated for selectivity, linearity, sensitivity, precision, and accuracy. Three storage conditions were tested: –20°C ± 5°C, 5°C ± 3°C, and 25°C ± 2°C at 60% ± 5% relative humidity. Half of the vials were stored upside down to test for the absence of interaction between midazolam and the stopper. Particle contamination, sterility, and pH were assessed.

Results

The limit of stability was set at 90% of the initial concentration. After 1 year’s storage at –20°C and 5°C, concentrations remained superior to 90% under all storage conditions. At 25°C, stability was maintained up to day 90 in syringes (mean [SD], 92.71% [1.43%]) and to day 180 in upright and upside-down vials (92.12% [0.15%] and 91.57% [0.15%], respectively). No degradation products were apparent, no variations in pH values were detected, and containers retained their sterility and conformity with regard to any specific contamination during the study.

Conclusion

The evaluated 1-mg/mL midazolam solution was stable over a 1-year period when stored at a refrigerated (5°C) or frozen (–20°C) temperature in both vials and syringes; with storage at 25°C, the stability duration was lower. The preparation of ready-to-use midazolam solutions by a hospital pharmacy is compatible with clinical practice and could help to decrease risks inherent in dilution in care units.

Medication errors among registered nurses in Jordan

Objectives

Medication error (ME) is like a venom dispersing in clinical practice, particularly the process of drugs’ administration. Nurses, as the direct drug administrators, are in critical defense lines to prevent its occurrence. Therefore, our aims were to explore nurses’ understanding, perception, attitude and prevalence of MEs and thereafter defining the main factors associated with its occurrence and needed for designing proper policies for its sufficient prevention.

Methods

Self-reported questionnaires were obtained from 156 nurses distributed almost equally between the 3 major teaching hospitals in Jordan. The questionnaires aimed at measuring their understanding, attitudes, and the prevalence of MEs.

Key findings

The majority of respondents were males (51.3%), young (25–34, 75%), hold a BSc degree (84.6%). Most of their experiences were less than 5 years (67.3%). The level of understanding of the definition, associated factors, and the consequences of ME was acceptable between registered nurses in Jordanian teaching hospitals. Nurses who had the lowest experience (0–5 years) were the highest in committing MEs (P-value = 0.006). Otherwise, gender, age, and education were not significantly associated with MEs. The participants reported that the most common causes of medication error were setting the infusion devices incorrectly, distraction, labeling and packaging problems. Participants declared that the incidents of MEs are underreported (Reporting rate (28.3%)) and they believed that it was most likely due to the fear of losing their job, misjudgment on the seriousness of the incidence that warrant reporting, and fear from coworkers' actions.

Conclusions

MEs are common and may be underreported among registered nurses in Jordan. National policymakers should take critical steps to encourage the nurses to report any error in medication administration and therefore reducing its occurrence.

Long-term stability of ready-to-use norepinephrine solution at 0.2 and 0.5 mg/mL

Objectives

Norepinephrine is a vasopressor frequently administered after dilution to treat hypotension and shocks in intensive care units. The stability of norepinephrine is known to be highly sensitive to storage conditions. Moreover, medication errors linked to the dilution step are frequent and may be deleterious for critically-ill patients, especially in intensive care units. This study aimed to evaluate the stability of ready-to-use diluted norepinephrine solutions prepared at two target concentrations (0.2 and 0.5 mg/mL), according to the summary of product characteristics, and stored for 365 days in two containers: AT-closed cyclic olefin copolymer vials, and polypropylene syringes.

Methods

A fast reversed-phase liquid chromatography method coupled with an ultra-violet detector was developed to assess the chemical stability of norepinephrine solutions. Validation was conducted according to the linearity of the calibration ranges, selectivity, sensitivity, accuracy and precision. Dosage, sub-visible particle contamination, pH monitoring and sterility assays were performed. Chemical stability was maintained if the measured concentration respected the lower limit of 90% of the initial concentration. Containers were stored at -20±5°C, +5±3°C and +25±2°C with 60±5% relative humidity in a dark closed enclosure.

Results

Stability was successfully maintained for every concentration and container tested when stored at -20±5°C and +5±3°C. In these storage conditions, particle contamination, pH monitoring and sterility assay respected the required criteria. Chemical degradation and colouring of solutions appeared before the end of the 1 year study period for most norepinephrine solutions stored at room temperature.

Conclusions

Ready-to-use solutions containing 0.2 and 0.5 mg/mL norepinephrine in polypropylene syringes or cyclic olefin copolymer vials must be stored at refrigerated or frozen temperatures to obtain acceptable 1 year shelf-stability. Exposure to higher temperatures significantly decreases shelf-stability. Our study protocol for compounding polypropylene syringes and cyclic olefin copolymer vials containing norepinephrine is adapted to implementation in centralised intravenous additive services.

Descriptive Epidemiology of Safety Events at an Academic Medical Center

Background: Adverse safety events in healthcare are of great concern, and despite an increasing focus on the prevention of error and harm mitigation, the epidemiology of safety events remains incomplete. Methods: We performed an analysis of all reported safety events in an academic medical center using a voluntary incident reporting surveillance system for patient safety. Safety events were classified as: serious (reached the patient and resulted in moderate to severe harm or death); precursor (reached the patient and resulted in minimal or no detectable harm); and near miss (did not reach the patient). Results: During a three-year period, there were 31,817 events reported. Most of the safety events were precursor safety events (reached the patient and resulted in minimal harm or no detectable harm), corresponding to 77.3%. Near misses accounted for 10.8%, and unsafe conditions for 11.8%. The number of reported serious safety events was low, accounting for only 0.1% of all safety events. Conclusions: The reports analysis of these events should lead to a better understanding of risks in patient care and ways to mitigate it.

Nurse management of vasoactive medications in intensive care: A systematic review

AIM AND OBJECTIVE

To investigate how intensive care nurses prepare, initiate, administer, titrate, and wean vasoactive medications.

BACKGROUND

The management of vasoactive medications is core business for intensive care nurses, but little is known on how nurses manage these ubiquitous and potentially harmful medications.

DESIGN

A systematic review of the literature with narrative synthesis of data.

METHODS

The databases CINAHL Complete, Medline Complete and EMBASE were searched from 1965 to January 2019 with keywords under five concept headings and in a variety of configurations. This systematic review was conducted according to the PRISMA guidelines. Studies were assessed for quality and bias, and a modified narrative synthesis was used to analyse data, investigate findings and explore relationships within and between studies.

RESULTS

The review identified 13 studies: two observational studies, two pre and post intervention studies, four survey studies, two quasi-experimental studies, one longitudinal time series, one prospective controlled trial, and one interview incorporating content analysis. Four studies on preparing and initiating vasoactive medications described a lack of standardisation in infusion preparation and inconsistencies in dosing units and patient weights. Five of six studies on vasoactive medication administration examined nurses' use of syringe changeovers to reduce patient haemodynamic compromise and there were three studies on titration and weaning.

CONCLUSION

Further research on nurse management of vasoactive medications is needed to develop an evidence base for specialist education and standardised practices aimed at reducing risk for patient harm.

RELEVANCE TO CLINICAL PRACTICE

Nurses working in intensive care units in many parts of the world are responsible for the management of vasoactive medications. There is great variation in practices that include preparation, initiation, administration, titration and weaning of vasoactive medications, which increases the risk for medication errors and adverse events in a vulnerable population of critically ill patients.

Comparative Safety, Efficiency, and Nursing Preference Among 3 Methods for Intravenous Push Medication Preparation: A Randomized Crossover Simulation Study

OBJECTIVE

The aim of this study was to compare total time for drug preparation, associated errors, and nurses' preferences among 3 different intravenous (IV) push medication methods.

RESEARCH DESIGN

A randomized crossover simulation design was used to compare total time for drug preparation and incidence of medication preparation errors between BD Simplist (BDS), Carpuject (CJ), and traditional vial-and-syringe process (TVSP). Three medication preparation areas were created to mimic a hospital setting. Twenty-four critical care nurses were asked to prepare an IV dose of diphenhydramine, ketorolac, and morphine in random order using BDS, CJ, and TVSP, also in random order. Total time for the preparation of each drug was measured. Medication preparation errors were noted. At the start of the study, nurses were surveyed about their stress levels regarding aspects of IV push medications. At completion, nurses were asked to rank order from the most to the least preferred administration method.

RESULTS

Mean time in seconds for drug preparation was significantly shorter (P < 0.004) with BDS (28.7; 95% confidence interval [CI], 23.3-34.2) and CJ (28.3; 95% CI, 23.1-33.5) compared with TSVP (65.8; 95% CI, 57.7-73.9). The time difference between BDS and CJ was not statistically significant. Medication preparation errors were significantly reduced with BDS compared with both CJ and TVSP (1.4% versus 77.8% versus 73.6%; P < 0.001). The BDS was ranked by nurses as the most preferred method.

CONCLUSIONS

The BD Simplist system for IV push medications may offer nurses an opportunity to reduce steps and reduce errors during medication preparation.

Deployment of Critical Incident Reporting System (CIRS) in public Styrian hospitals: a five year perspective

BACKGROUND

To increase patient safety, so-called Critical Incident Reporting Systems (CIRS) were implemented. For Austria, no data are available on how CIRS is used within a healthcare facility. Therefore, the aim of this study was to present the development of CIRS within one of the biggest hospital providers in Austria.

METHODS

In the province of Styria, CIRS was introduced in 2012 within KAGes (holder of public hospitals) in 22 regional hospitals and one tertiary university hospital. CIRS is available in all of these hospitals using the same software solution. For reporting a CIRS case an overall guideline exists.

RESULTS

As of 2013, 2.504 CIRS cases were reported. Predominantly, CIRS-cases derived from surgical and associated disciplines (ranging from 35 to 45%). According to the list of hazards (also called "risk atlas"), errors in patient identification (ranging from 7 to 12%), errors in management of medicinal products (ranging from < 5 to 9%), errors in management of medical devices (ranging from < 5 to 10%) and errors in communication (ranging from < 5 to 6%) occurred most frequently. Most often, a CIRS case was reported due to individual error-related reasons (48%), followed by errors caused by organization, team factors, communication or documentation failures (34%).

CONCLUSIONS

In summary, CIRS has been used for 5 years and 2.504 CIRS-cases were reported. There is a steady increase of reported CIRS cases per year. It became also obvious that disregarding guidelines or standards are a very common reason for reporting a CIRS case. CIRS can be regarded as a helpful supportive tool in clinical risk management and supports organizational learning and thereby collective knowledge management.

Clinicians' perceptions of opioid error-contributing factors in inpatient palliative care services: A qualitative study

BACKGROUND

Opioid errors are a leading cause of patient harm and adversely impact palliative care inpatients' pain and symptom management. Yet, the factors contributing to opioid errors in palliative care are poorly understood. Identifying and better understanding the individual and system factors contributing to these errors is required to inform targeted strategies.

OBJECTIVES

To explore palliative care clinicians' perceptions of the factors contributing to opioid errors in Australian inpatient palliative care services.

DESIGN

A qualitative study using focus groups or semi-structured interviews.

SETTINGS

Three specialist palliative care inpatient services in New South Wales, Australia.

PARTICIPANTS

Inpatient palliative care clinicians who are involved with, and/or have oversight of, the services' opioid delivery or quality and safety processes.

METHODS

Deductive thematic content analysis of the qualitative data. The Yorkshire Contributory Factors Framework was applied to identify error-contributing factors.

FINDINGS

A total of 58 clinicians participated in eight focus groups and 20 semi-structured interviews. Nine key error contributory factor domains were identified, including: active failures; task characteristics of opioid preparation; clinician inexperience; sub-optimal skill mix; gaps in support from central functions; the drug preparation environment; and sub-optimal clinical communication.

CONCLUSION

This study identified multiple system-level factors contributing to opioid errors in inpatient palliative care services. Any quality and safety initiatives targeting safe opioid delivery in specialist palliative care services needs to consider the full range of contributing factors, from individual to systems/latent factors, which promote error-causing conditions.

Evaluating a handheld decision support device in pediatric intensive care settings

OBJECTIVE

To evaluate end-user acceptance and the effect of a commercial handheld decision support device in pediatric intensive care settings. The technology, pac2, was designed to assist nurses in calculating medication dose volumes and infusion rates at the bedside.

MATERIALS AND METHODS

The devices, manufactured by InformMed Inc., were deployed in the pediatric and neonatal intensive care units in 2 health systems. This mixed methods study assessed end-user acceptance, as well as pac2's effect on the cognitive load associated with bedside dose calculations and the rate of administration errors. Towards this end, data were collected in both pre- and postimplementation phases, including through ethnographic observations, semistructured interviews, and surveys.

RESULTS

Although participants desired a handheld decision support tool such as pac2, their use of pac2 was limited. The nature of the critical care environment, nurses' risk perceptions, and the usability of the technology emerged as major barriers to use. Data did not reveal significant differences in cognitive load or administration errors after pac2 was deployed.

DISCUSSION AND CONCLUSION

Despite its potential for reducing adverse medication events, the commercial standalone device evaluated in the study was not used by the nursing participants and thus had very limited effect. Our results have implications for the development and deployment of similar mobile decision support technologies. For example, they suggest that integrating the technology into hospitals' existing IT infrastructure and employing targeted implementation strategies may facilitate nurse acceptance. Ultimately, the usability of the design will be essential to reaping any potential benefits.

Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units

Purpose

To determine the type, frequency, and factors associated with medication preparation and administration errors in adult intensive care units (ICUs) and neonatal ICUs (NICUs)/pediatric ICUs (PICUs).

Patients and methods

We conducted a prospective direct observation study in an adult ICU and NICU/PICU in a tertiary university hospital. Between June 2012 and June 2013, a clinical pharmacist and medical student observed the nursing care staff on weekdays during the preparation and administration of intravenous drugs. We analyzed the frequency and type of preparation and administration errors and factors associated with errors.

Results

Six hundred and three preparations in the adult ICU and 281 in the NICU/PICU were observed. Three hundred and eighty-five errors occurred in the adult ICU and 38 in the NICU/PICU. There were 5,040 and 2,514 error opportunities, with overall error rates of 7.6% and 1.5%, respectively. The total opportunities for error meant each single step of preparation and administration that was relevant for the drug. Most errors applied to the category “uniform mixing” (adult ICU: n=227, 59%; NICU/PICU: n=14, 37%). The multivariate logistic regression results showed a significantly different influence of the “preparation type” for the adult ICU compared with the NICU/PICU with regard to the occurrence of an error. Preparations for adult patients of the LCD type (liquid concentrate with diluent into syringe or infusion bag) were more often associated with errors than the P (powder in a glass vial that must be reconstituted and diluted if necessary), P=0.012, and LC (liquid concentrate into syringe), P=0.002 type.

Conclusion

“Uniform mixing” was the most erroneous preparation step in intravenous drug preparations in two ICUs. Improvement of nurse training and the preparation of prefilled syringes in the pharmacy might reduce errors and improve the quality and safety of drug therapy.

A systematic review and meta-analysis of microbial contamination of parenteral medication prepared in a clinical versus pharmacy environment

PURPOSE

Preparation of parenteral medication in hospitals is a complex process with a risk of microbial contamination of the product, especially when inappropriately prepared. Contaminated parenteral medications can cause severe complications to patients and increase morbidity in hospitals. The aim of this literature review is to systematically evaluate the contamination rate of parenteral medications in hospitals prepared in a pharmacy environment and a clinical environment.

METHODS

A literature search of PubMed and EMBASE from 2000 to 2018 was performed. Two different environments where preparation may be carried out were defined. Point estimates and 95% confidence intervals for contamination rates were calculated for each environment of medication preparation. The meta-analysis was performed using a random effects model.

RESULTS

The contamination rates in the clinical environment (n = 13 studies) varied between 1.09 and 20.70%. In the pharmacy environment (n = 5), all contamination rates were 0.00% except for one study (0.66%). The point estimates (random effect model) for the overall contamination rate of doses prepared in the clinical environment was 7.47% (5.16-9.79%), and 0.08% for doses prepared in the pharmacy environment. The point estimates (random effect model) for the overall contamination rate of doses prepared by nursing/ medical staff was 7.85% (5.18-10.53%), and 0.08% for doses prepared by pharmacy staff.

CONCLUSIONS

Significantly higher contamination rates were found for the preparation of parenteral medication in the clinical environment compared to pharmacy environment. In accordance with recent guidance, the almost 100-fold higher changes of contamination when reconstitution is performed in the clinical environment should urge hospitals to review their reconstitution process and apply risk-reducing measures to improve patient safety of parenteral therapy.

Incidence and prevalence of intravenous medication errors in the UK: a systematic review

Objectives

Medication error is the most common type of medical error, and intravenous medicines are at a higher risk as they are complex to prepare and administer. The WHO advocates a 50% reduction of harmful medication errors by 2022, but there is a lack of data in the UK that accurately estimates the true rate of intravenous medication errors. This study aimed to estimate the number of intravenous medication errors per 1000 administrations in the UK National Health Service and their associated economic costs. The rate of errors in prescribing, preparation and administration, and rate of different types of errors were also extracted.

Methods

MEDLINE, Embase, Cochrane central register of clinical trials, Database of Abstracts of Reviews of Effectiveness, National Health Service Economic Evaluation Database and the Health Technology Appraisals Database were searched from inception to July 2017. Epidemiological studies to determine the incidence of intravenous medication errors set wholly or in part in the UK were included. 228 studies were identified, and after screening, eight papers were included, presenting 2576 infusions. Data were reviewed and extracted by a team of five reviewers with discrepancies in data extraction agreed by consensus.

Results

Five of eight studies used a comparable denominator, and these data were pooled to determine a weighted mean incidence of 101 intravenous medication errors per 1000 administrations (95% CI 84 to 121). Three studies presented prevalence data but these were based on spontaneous reports only; therefore it did not support a true estimate. 32.1% (95% CI 30.6% to 33.7%) of intravenous medication errors were administration errors and ‘wrong rate’ errors accounted for 57.9% (95% CI 54.7% to 61.1%) of these.

Conclusion

Intravenous medication errors in the UK are common, with half these of errors related to medication administration. National strategies are aimed at mitigating errors in prescribing and preparation. It is now time to focus on reducing administration error, particularly wrong rate errors.

[Medication safety in hospitals : Integration of clinical pharmacists to reduce drug-related problems in the inpatient setting]

Drug-related problems (DRPs) are a significant and often preventable cause for morbidity and mortality. Hospitalization is associated with a high risk for DRPs, especially due to a lack of information transfer at transitions of care. At the same time, interventions during inpatient treatment usually require a change in drug therapy and additionally increase the risk of DRPs. Thereby, DRPs can occur at all levels of the medication process and can be caused by different groups of professionals. One way to improve medication safety in hospitals is to integrate clinical pharmacists into the medication process.According to available data, the integration of a clinical pharmacist in multi-professional teams during admission, hospitalization and discharge can significantly reduce DRPs, costs and increases efficacy of drug therapy. In addition, drug supply with unit-dose systems in combination with digitalization of the medication process can achieve an improvement in medication safety. Improvement in continuity of medical care through a structured medication review and seamless transmission of medically relevant information upon discharge contribute to a significant reduction of hospital readmissions and emergency admissions due to ABPs, as well as health costs. With a university education, the hospital pharmacist specialized in clinical pharmacy is the only professional group that can comprehensively support the physician in the field of drug therapy.

Medication Errors Caused by Nurses and Physicians in a Swiss Acute Care Community Hospital: Frequency and Correlation to Nurses’ Reported Workload / Von Pflegefachpersonen und Ärzten/-innen verursachte Medikamentenfehler in einem Schweizer Akutspital: Häufigkeit und Korrelation zur Arbeitsbelastung von Pflegefachpersonen

Objectives

This study was carried out in a Swiss acute care community hospital to investigate the frequency, type, causes and potential clinical consequences of medication errors (MEs) caused by nurses and physicians in all stages of a technology-supported medication process, the relationship between the nurses’ workload and the medication administration errors (MAEs) and their reason for workload.

Methods

In this descriptive cross-sectional study, a questionnaire, the adapted Medication Error Self Reporting Tool (A-MESRT), was used to identify MEs in all stages of the medication process and record nurses’ self-perceived workload during medication administration.

Results

A total of 1936 completed A-MESRTs were returned. A total of 751 (38.8%) respondents reported different MEs. The highest number of errors occurred during medication administration (43%), followed by errors during dispensing (34%) and physician ordering errors using a computerised physician order entry (CPOE) system (23%). Of the 768 (100%) handwritten orders, 232 (30.2%) were erroneous. Moreover, the greater the individual nurse’s workload during a shift, the higher was the relative probability of committing an MAE (χ2 = 85.479, df = 1, OR = 2.129, p < 0.001). Furthermore, the three main causes of high or very high workload were revealed: (1) many newly operated patients to monitor; (2) complex multimorbid patients, for example, those with delirium; and (3) patients with complications after surgery.

Conclusion

The A-MESRT showed that the highest rate of MEs caused by nurses and physicians is in the non-technologically supported steps, demonstrating the potential benefits of a technology-supported medication process. Moreover, this study revealed a statistically significant correlation between nurses’ workload and MAEs.

[Risk management in anesthesia and critical care medicine]

Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. As a result, we do not always fully perceive the risks involved in our daily activity. A survey performed in Swiss hospitals identified a total of 169 hot spots which endanger patient safety. It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.