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Li L, Badgery-Parker T, Merchant A, Fitzpatrick E, Raban MZ, Mumford V, Metri NJ, Hibbert PD, Mccullagh C, Dickinson M, Westbrook JI. Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system. BMJ Qual Saf 2024; 33:624-633. [PMID: 38621921 DOI: 10.1136/bmjqs-2023-016711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES To compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and severity of errors detected and reported by staff. METHODS This is a comparison study at two tertiary referral paediatric hospitals between 2016 and 2020 in Australia. Prescribing errors were identified from a medication chart audit of 7785 patient records. Medication administration errors were identified from a prospective direct observational study of 5137 medication administration doses to 1530 patients. Medication errors reported to the hospitals' incident reporting system were identified and matched with errors identified at audit and observation. RESULTS Of 11 302 clinical prescribing errors identified at audit, 3.2 per 1000 errors (95% CI 2.3 to 4.4, n=36) had an incident report. Of 2224 potentially serious prescribing errors from audit, 26.1% (95% CI 24.3 to 27.9, n=580) were detected by staff and 11.2 per 1000 errors (95% CI 7.6 to 16.5, n=25) were reported to the incident system. Although the prescribing error detection rates varied between the two hospitals, there was no difference in incident reporting rates regardless of error severity. Of 40 errors associated with actual patient harm, only 7 (17.5%; 95% CI 8.7% to 31.9%) were detected by staff and 4 (10.0%; 95% CI 4.0% to 23.1%) had an incident report. None of the 2883 clinical medication administration errors observed, including 903 potentially serious errors and 144 errors associated with actual patient harm, had incident reports. CONCLUSION Incident reporting data do not provide an accurate reflection of medication errors and related harm to children in hospitals. Failure to detect medication errors is likely to be a significant contributor to low error reporting rates. In an era of electronic health records, new automated approaches to monitor medication safety should be pursued to provide real-time monitoring.
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Affiliation(s)
- Ling Li
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Tim Badgery-Parker
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Alison Merchant
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Erin Fitzpatrick
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Magdalena Z Raban
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Najwa-Joelle Metri
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Peter Damian Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Cheryl Mccullagh
- Executive, Beamtree, Redfern, New South Wales, Australia
- The Sydney Children's Hospitals Network Randwick and Westmead, Sydney, New South Wales, Australia
| | - Michael Dickinson
- The Sydney Children's Hospitals Network Randwick and Westmead, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Myhr K, Ballangrud R, Aase K, Vifladt A. Ambulance professionals' experiences of teamwork in the context of a team training programme - a qualitative study. BMC Emerg Med 2024; 24:108. [PMID: 38956498 PMCID: PMC11218233 DOI: 10.1186/s12873-024-01018-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/04/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Teamwork in the context of ambulance services exhibits unique characteristics, as this environment involves a small core team that must adapt to a dynamic team structure that involves health care professionals and emergency services. It is essential to acquire a deeper understanding of how ambulance teams operate. Therefore, this study aimed to explore the experiences of ambulance professionals with teamwork and how they were influenced by the implementation of a team training programme. METHODS A qualitative descriptive study was conducted involving ambulance professionals who took part in focus group interviews carried out both before and after the implementation of a team training program across seven ambulance stations within a Norwegian hospital trust. The data were analysed using reflexive thematic analysis based on a deductive-inductive approach. RESULTS Our analysis revealed 15 subthemes that characterised ambulance professionals' experiences with teamwork and a team training programme, which were organised according to the five main themes of team structure, communication, leadership, situation monitoring, and mutual support. Ambulance professionals' experiences ranged from the significance of team composition and interpersonal and professional relationships to their preferences regarding different communication styles and the necessity of team leaders within the ambulance service. The team training programme raised awareness of teamwork, while the adoption of teamwork tools was influenced by both individual and contextual factors. The Introduction/Identity, Situation, Background, Assessment and Recommendation (ISBAR) communication tool was identified as the most beneficial aspect of the programme due to its ease of use, which led to improvements in the structure and quality of consultations and information handover. CONCLUSIONS This study documented the diverse characteristics and preferences associated with teamwork among ambulance professionals, emphasising the particular importance of proficient partnerships in this context. Participation in a team training programme was perceived as a valuable reminder of the significance of teamwork, thus providing a foundation for the enhancement of communication skills. TRIAL REGISTRATION ClinicalTrials.gov-ID: NCT05244928.
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Affiliation(s)
- Kjetil Myhr
- Department of Health Sciences Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Gjøvik, 2815, Norway.
- Department of Acute Medicine, Division of Elverum-Hamar, Innlandet Hospital Trust, Brumunddal, 2381, Norway.
| | - Randi Ballangrud
- Department of Health Sciences Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Gjøvik, 2815, Norway
| | - Karina Aase
- Department of Health Sciences Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Gjøvik, 2815, Norway
- Center for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Kjell Arholms Hus, Kjell Arholms Gate 43, Stavanger, 4021, Norway
| | - Anne Vifladt
- Department of Health Sciences Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Gjøvik, 2815, Norway
- Department of Research, Innlandet Hospital Trust, Brumunddal, 2381, Norway
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Westbrook JI, Li L, Woods A, Badgery-Parker T, Mumford V, Merchant A, Fitzpatrick E, Raban MZ. Risk Factors Associated with Medication Administration Errors in Children: A Prospective Direct Observational Study of Paediatric Inpatients. Drug Saf 2024; 47:545-556. [PMID: 38443625 PMCID: PMC11116173 DOI: 10.1007/s40264-024-01408-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Limited evidence exists regarding medication administration errors (MAEs) on general paediatric wards or associated risk factors exists. OBJECTIVE The aim of this study was to identify nurse, medication, and work-environment factors associated with MAEs among paediatric inpatients. METHODS This was a prospective, direct observational study of 298 nurses in a paediatric referral hospital in Sydney, Australia. Trained observers recorded details of 5137 doses prepared and administered to 1530 children between 07:00 h and 22:00 h on weekdays and weekends. Observation data were compared with medication charts to identify errors. Clinical errors, potential severity and actual harm were assessed. Nurse characteristics (e.g. age, sex, experience), medication type (route, high-risk medications, use of solvent/diluent), and work variables (e.g. time of administration, weekday/weekend, use of an electronic medication management system [eMM], presence of a parent/carer) were collected. Multivariable models assessed MAE risk factors for any error, errors by route, potentially serious errors, and errors involving high-risk medication or causing actual harm. RESULTS Errors occurred in 37.0% (n = 1899; 95% confidence interval [CI] 35.7-38.3) of administrations, 25.8% (n = 489; 95% CI 23.8-27.9) of which were rated as potentially serious. Intravenous infusions and injections had high error rates (64.7% [n = 514], 95% CI 61.3-68.0; and 77.4% [n = 188], 95% CI 71.7-82.2, respectively). For intravenous injections, 59.7% (95% CI 53.4-65.6) had potentially serious errors. No nurse characteristics were associated with MAEs. Intravenous route, early morning and weekend administrations, patient age ≥ 11 years, oral medications requiring solvents/diluents and eMM use were all significant risk factors. MAEs causing actual harm were 45% lower using an eMM compared with paper charts. CONCLUSION Medication error prevention strategies should target intravenous administrations and not neglect older children in hospital. Attention to nurses' work environments, including improved design and integration of medication technologies, is warranted.
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Affiliation(s)
- Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, New South Wales, 2109, Australia.
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, New South Wales, 2109, Australia
| | - Amanda Woods
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, New South Wales, 2109, Australia
| | - Tim Badgery-Parker
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, New South Wales, 2109, Australia
| | - Virginia Mumford
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, New South Wales, 2109, Australia
| | - Alison Merchant
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, New South Wales, 2109, Australia
| | - Erin Fitzpatrick
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, New South Wales, 2109, Australia
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, New South Wales, 2109, Australia
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Kuitunen S, Airaksinen M, Holmström AR. Evolution of Intravenous Medication Errors and Preventive Systemic Defenses in Hospital Settings-A Narrative Review of Recent Evidence. J Patient Saf 2024; 20:e29-e39. [PMID: 38536101 DOI: 10.1097/pts.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Intravenous drug administration has been associated with severe medication errors in hospitals. The present narrative review is based on a systematic literature search, and aimed to describe the recent evolution in research on systemic causes and defenses in intravenous medication errors in hospitals. METHODS This narrative review was based on Reason's theory of systems-based risk management. A systematic literature search covering the period from June 2016 to October 2021 was conducted on Medline (Ovid). We used the search strategy and selection criteria developed for our previous systematic reviews. The included articles were analyzed and compared to our previous reviews. RESULTS The updated search found 435 articles. Of the 63 included articles, 16 focused on systemic causes of intravenous medication errors, and 47 on systemic defenses. A high proportion (n = 24, 38%) of the studies were conducted in the United States or Canada. Most of the studies focused on drug administration (n = 21/63, 33%) and preparation (n = 19/63, 30%). Compared to our previous review of error causes, more studies (n = 5/16, 31%) utilized research designs with a prospective risk management approach. Within articles related to systemic defenses, smart infusion pumps remained most widely studied (n = 10/47, 21%), while those related to preparation technologies (n = 7/47, 15%) had increased. CONCLUSIONS This narrative review demonstrates a growing interest in systems-based risk management for intravenous drug therapy and in introducing new technology, particularly smart infusion pumps and preparation systems, as systemic defenses. When introducing new technologies, prospective assessment and continuous monitoring of emerging safety risks should be conducted.
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Affiliation(s)
- Sini Kuitunen
- From the HUS Pharmacy, Hospital Pharmacy of Helsinki University Hospital (HUS)
| | - Marja Airaksinen
- Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
| | - Anna-Riia Holmström
- Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
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Chiu YJ. Automated medication verification system (AMVS): System based on edge detection and CNN classification drug on embedded systems. Heliyon 2024; 10:e30486. [PMID: 38742071 PMCID: PMC11089321 DOI: 10.1016/j.heliyon.2024.e30486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 04/28/2024] [Indexed: 05/16/2024] Open
Abstract
A novel automated medication verification system (AMVS) aims to address the limitation of manual medication verification among healthcare professionals with a high workload, thereby reducing medication errors in hospitals. Specifically, the manual medication verification process is time-consuming and prone to errors, especially in healthcare settings with high workloads. The proposed system strategy is to streamline and automate this process, enhancing efficiency and reducing medication errors. The system employs deep learning models to swiftly and accurately classify multiple medications within a single image without requiring manual labeling during model construction. It comprises edge detection and classification to verify medication types. Unlike previous studies conducted in open spaces, our study takes place in a closed space to minimize the impact of optical changes on image capture. During the experimental process, the system individually identifies each drug within the image by edge detection method and utilizes a classification model to determine each drug type. Our research has successfully developed a fully automated drug recognition system, achieving an accuracy of over 95 % in identifying drug types and conducting segmentation analyses. Specifically, the system demonstrates an accuracy rate of approximately 96 % for drug sets containing fewer than ten types and 93 % for those with ten types. This verification system builds an image classification model quickly. It holds promising potential in assisting nursing staff during AMVS, thereby reducing the likelihood of medication errors and alleviating the burden on nursing staff.
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Affiliation(s)
- Yen-Jung Chiu
- Department of Biomedical Engineering, Ming Chuan University, Taoyuan, 333, Taiwan
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Konwinski L, Steenland C, Miller K, Boville B, Fitzgerald R, Connors R, Sterling E, Stowe A, Rajasekaran S. Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach. J Patient Saf 2024; 20:209-215. [PMID: 38231892 DOI: 10.1097/pts.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVES The goal of this human factors engineering-led improvement initiative was to examine whether the independent double check (IDC) during administration of high alert medications afforded improved patient safety when compared with a single check process. METHODS The initiative was completed at a 24-bed pediatric intensive care unit and included all patients who were on the unit and received a medication historically requiring an IDC. The total review examined 37,968 high-risk medications administrations to 4417 pediatric intensive care unit patients over a 40-month period. The following 5 measures were reviewed: (1) rates of reported medication administration events involving IDC medications; (2) hospital length of stay; (3) patient mortality; (4) nurses' favorability toward single checking; and (5) nursing time spent on administration of IDC medications. RESULTS The rate of reported medication administration events involving IDC medications was not significantly different across the groups (95% confidence interval, 0.02%-0.08%; P = 0.4939). The intervention also did not significantly alter mortality ( P = 0.8784) or length of stay ( P = 0.4763) even after controlling for the patient demographic variables. Nursing favorability for single checking increased from 59% of nurses in favor during the double check phase, to 94% by the end of the single check phase. Each double check took an average of 9.7 minutes, and a single check took an average of 1.94 minutes. CONCLUSIONS Our results suggest that performing independent double checks on high-risk medications administered in a pediatric ICU setting afforded no impact on reported medication events compared with single checking.
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Affiliation(s)
- Leah Konwinski
- From the Department of Quality, Safety and Experience, Corewell Health
| | | | | | | | | | - Robert Connors
- Corewell Health Helen DeVos Children's Hospital (hospital president at time of review)
| | | | - Alicia Stowe
- Office of Research and Education, Corewell Health, Grand Rapids, Michigan
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Fathizadeh H, Mousavi SS, Gharibi Z, Rezaeipour H, Biojmajd AR. Prevalence of medication errors and its related factors in Iranian nurses: an updated systematic review and meta-analysis. BMC Nurs 2024; 23:175. [PMID: 38481264 PMCID: PMC10938711 DOI: 10.1186/s12912-024-01836-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/03/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Nurses may make medication errors during the implementation of therapeutic interventions, which initially threaten the patient's health and safety and prolong their hospital stay. These errors have always been a challenge for healthcare systems. Given that factors such as the timing, type, and causes of medication errors can serve as suitable predictors for their occurrence, we have decided to conduct a review study aiming to investigate the prevalence of medication errors and the associated factors among Iranian nurses. METHODS In this systematic review and meta-analysis, studies were searched on PubMed, Web of Science, Scopus, Google Scholar, IranMedex, Magiran, and SID databases using a combination of keywords and Boolean functions. The study that reported the prevalence of medication errors among nurses in Iran without time limitation up to May 2023 was included in this study. RESULTS A total of 36 studies were included in the analysis. The analysis indicates that 54% (95% CI: 43, 65; I2 = 99.3%) of Iranian nurses experienced medication errors. The most common types of medication errors by nurses were wrong timing 27.3% (95% CI: 19, 36; I2 = 95.8%), and wrong dosage 26.4% (95% CI: 20, 33; I2 = 91%). Additionally, the main causes of medication errors among nurses were workload 43%, fatigue 42.7%, and nursing shortage 38.8%. In this study, just 39% (95% CI: 27, 50; I2 = 97.1%) of nurses with medication errors did report their errors. Moreover, the prevalence of medication errors was more in the night shift at 41.1%. The results of the meta-regression showed that publication year and the female-to-male ratio are good predictors of medical errors, but they are not statistically significant(p > 0.05). CONCLUSIONS To reduce medication errors, nurses need to work in a calm environment that allows for proper nursing interventions and prevents overcrowding in departments. Additionally, considering the low reporting of medication errors to managers, support should be provided to nurses who report medication errors, in order to promote a culture of reporting these errors among Iranian nurses and ensure patient safety is not compromised.
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Affiliation(s)
- Hadis Fathizadeh
- Department of Laboratory Sciences, Sirjan School of Medical Sciences, Sirjan, Iran
| | | | - Zahra Gharibi
- Infectious and Tropical Diseases Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
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Labrague LJ. Nurses' adherence to patient safety protocols and its relationship with adverse patient events. J Nurs Scholarsh 2024; 56:282-290. [PMID: 37950503 DOI: 10.1111/jnu.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Ensuring patient safety is a critical component of healthcare delivery, and nurses play a vital role in adhering to patient safety protocols to prevent adverse events. However, studies linking nurses' adherence to these protocols with patient outcomes is scarce. This study has two-fold purposes: (1) to examine determinants of nurses' adherence to patient safety protocols, and (2) to investigate the relationship between nurses' adherence to patient safety protocols and adverse patient events. DESIGN A cross-sectional design. METHODS A total of 343 clinical nurses from five hospitals in the Philippines were included in this study. Two standardized scales were used to collect data, including the Patient Safety Adherence Scale and the Adverse Patient Events Scale. Data collection took place from April 2022 to August 2022. RESULTS Adherence to patient safety protocols was generally moderate to high (M = 4.483), while nurse-reported adverse events occurred at a lower frequency (M = 1.150). Lower adherence rates were identified in areas such as reporting safety errors (M = 3.950), conducting fall risk assessments (M = 4.299), and adhering to pressure ulcer prevention guidelines (M = 3.979). Patients' and their families' complaints (M = 2.129) and abuses (M = 1.475) were the most frequently reported adverse events. Increased adherence to safety protocols was associated with higher reporting of adverse patient events (β = 0.115, p < 0.001). CONCLUSION Higher adherence to patient safety protocols resulted in an increased reporting of adverse patient events. The factors identified that contributed to nurses' adherence to patient safety protocols can be utilized in the development of strategies aimed at improving compliance, especially in areas where adherence is currently low. CLINICAL RELEVANCE Healthcare organizations should prioritize efforts to enhance adherence to patient safety protocols, particularly in areas with lower compliance rates, through relevant trainings, resource provision, and support systems. Promoting a culture of open communication and reporting can significantly contribute to reducing adverse events and improving patient safety.
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Affiliation(s)
- Leodoro J Labrague
- Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, Illinois, USA
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van Stralen SA, van Eikenhorst L, Vonk AS, Schutijser BC, Wagner C. Evaluating deviations and considerations in daily practice when double-checking high-risk medication administration: A qualitative study using the FRAM. Heliyon 2024; 10:e25637. [PMID: 38380025 PMCID: PMC10877242 DOI: 10.1016/j.heliyon.2024.e25637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/22/2024] Open
Abstract
Background Double-check protocol compliance during administration is low. Regardless, most high-risk medication administrations are performed without incidents. The present study investigated the process of preparing and administrating high-risk medication and examined which variations occur in daily practice. Additionally, we investigated which considerations were taken into account when deviating from the guidelines. Methods Ten Dutch hospital wards participated. The Functional Resonance Analysis Method was applied to construct a model depicting the Dutch guidelines and a ward-overarching model visualizing daily practice. To create the ward-overarching model, eight semi-structured interviews were conducted per ward discussing the preparation and administration of high-risk medication. Work related Efficiency-Thoroughness Trade-Off rules were used to structure subconscious considerations. Results In total, 77 nurses were interviewed. Six model deviations were found between the guideline model and ward-overarching model. Notably, four variations in double-check procedures were found. Here, time pressure was an important factor. Nurses made a risk-assessment, considering for patient stability, and difficulty of calculations, to determine whether the double-check would be executed. Additionally, subconscious reasonings, such as trusting their own or colleagues expertise, weighed on the decision. Conclusion Time pressure is the most important factor that withholds nurses from performing the double-check. Nurses instead conduct a risk-assessment to decide if the double-check will be executed. The double-check can thus become habitual or unnecessary for certain medications. In future research, insights of the FRAM could be used to make ward-specific alterations for the double-check procedure of medications, that focus on feasibility in daily practice, while maintaining patient safety.
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Affiliation(s)
- Sharon A. van Stralen
- Netherlands Institute for Health Services Research (Nivel), Organization and Quality of Care, Utrecht, the Netherlands
| | - Linda van Eikenhorst
- Netherlands Institute for Health Services Research (Nivel), Organization and Quality of Care, Utrecht, the Netherlands
| | - Astrid S. Vonk
- Netherlands Institute for Health Services Research (Nivel), Organization and Quality of Care, Utrecht, the Netherlands
| | | | - Cordula Wagner
- Netherlands Institute for Health Services Research (Nivel), Organization and Quality of Care, Utrecht, the Netherlands
- Amsterdam Public Health Research Institute, Department of Quality of Care, Amsterdam, the Netherlands
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Dick-Smith F, Fry MF, Salter R, Tinker M, Leith G, Donoghoe S, Harris C, Murphy S, Elliott R. Barriers and enablers for safe medication administration in adult and neonatal intensive care units mapped to the behaviour change wheel. Nurs Crit Care 2023; 28:1184-1195. [PMID: 37614015 DOI: 10.1111/nicc.12968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Intensive care settings have high rates of medication administration errors. Medications are often administered by nurses and midwives using a specified process (the '5 rights'). Understanding where medication errors occur, the contributing factors and how best practice is delivered may assist in developing interventions to improve medication safety. AIMS To identify medication administration errors and context specific barriers and enablers for best practice in an adult and a neonatal intensive care unit. Secondary aims were to identify intervention functions (through the Behaviour Change Wheel). STUDY DESIGN A dual methods exploratory descriptive study was conducted (May to June 2021) in a mixed 56-bedded adult intensive care unit and a 6-bedded neonatal intensive care unit in Sydney, Australia. Incident monitoring data were examined. Direct semi-covert observational medication administration audits using the 5 rights (n = 39) were conducted. Brief interviews with patients, parents and nurses were conducted. Data were mapped to the Behaviour Change Wheel. RESULTS No medication administration incidents were recorded. Audits (n = 3) for the neonatal intensive care unit revealed no areas for improvement. Adult intensive care unit nurses (n = 36) performed checks for the right medication 35 times (97%) and patient identity 25 times (69%). Sixteen administrations (44%) were interrupted. Four themes were synthesized from the interview data: Trust in the nursing profession; Availability of policies and procedures; Adherence to the '5 rights' and departmental culture; and Adequate staffing. The interventional functions most likely to bring about behaviour change were environmental restructuring, enablement, restrictions, education, persuasion and modelling. CONCLUSIONS This study reveals insights about the medication administration practices of nurses in intensive care. Although there were areas for improvement there was widespread awareness among nurses regarding their responsibilities to safely administer medications. Interview data indicated high levels of trust among patients and parents in the nurses. RELEVANCE TO CLINICAL PRACTICE This novel study indicated that nurses in intensive care are aware of their responsibilities to safely administer medications. Mapping of contextual data to the Behaviour Change Wheel resulted in the identification of Intervention functions most likely to change medication administration practices in the adult intensive care setting that is environmental restructuring, enablement, restrictions, education, persuasion and modelling.
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Affiliation(s)
- Felicity Dick-Smith
- Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Margaret Fry Fry
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Rachel Salter
- Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Matthew Tinker
- Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Grace Leith
- Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Stephanie Donoghoe
- Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Claire Harris
- Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Sandra Murphy
- Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Rosalind Elliott
- Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
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Identifying Safety Practices Perceived as Low Value: An Exploratory Survey of Healthcare Staff in the United Kingdom and Australia. J Patient Saf 2023; 19:143-150. [PMID: 36729436 PMCID: PMC9940841 DOI: 10.1097/pts.0000000000001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Up to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. With increasing recognition of the problem of "safety clutter" in organizations, it is important to consider deimplementing safety practices that do not benefit patients, to create the time needed to deliver effective, person-centered, and safe care. This study surveyed healthcare staff to identify safety practices perceived to be of low value. METHODS Purposive and snowball sampling was used. Data collection was conducted from April 2018 to November 2019 (United Kingdom) and May 2020 to November 2020 (Australia). Participants completed the survey online or in hard copy to identify practices they perceived to not contribute to safe care. Responses were analyzed using content and thematic analysis. RESULTS A total of 1394 responses from 1041 participants were analyzed. Six hundred sixty-three responses were collected from 526 UK participants and 515 Australian participants contributed 731 responses. Frequently identified categories of practices identified included "paperwork," "duplication," and "intentional rounding." Five cross-cutting themes (e.g., covering ourselves) offered an underpinning rationale for why staff perceived the practices to be of low value. CONCLUSIONS Staff identified safety practices that they perceived to be low value. In healthcare systems under strain, removing existing low-value practices should be a priority. Careful evaluation of these identified safety practices is required to determine whether they are appropriate for deimplementation and, if not, to explore how to better support healthcare workers to perform them.
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Henry Basil J, Premakumar CM, Mhd Ali A, Mohd Tahir NA, Seman Z, Mohamed Shah N. Development and validation of a risk prediction model for medication administration errors among neonates in the neonatal intensive care unit: a study protocol. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001765. [PMID: 36754439 PMCID: PMC9923322 DOI: 10.1136/bmjpo-2022-001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/28/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Medication administration errors (MAEs) are the most common type of medication error. Furthermore, they are more common among neonates as compared with adults. MAEs can result in severe patient harm, subsequently causing a significant economic burden to the healthcare system. Targeting and prioritising neonates at high risk of MAEs is crucial in reducing MAEs. To the best of our knowledge, there is no predictive risk score available for the identification of neonates at risk of MAEs. Therefore, this study aims to develop and validate a risk prediction model to identify neonates at risk of MAEs. METHODS AND ANALYSIS This is a prospective direct observational study that will be conducted in five neonatal intensive care units. A minimum sample size of 820 drug preparations and administrations will be observed. Data including patient characteristics, drug preparation-related and administration-related information and other procedures will be recorded. After each round of observation, the observers will compare his/her observations with the prescriber's medication order, hospital policies and manufacturer's recommendations to determine whether MAE has occurred. To ensure reliability, the error identification will be independently performed by two clinical pharmacists after the completion of data collection for all study sites. Any disagreements will be discussed with the research team for consensus. To reduce overfitting and improve the quality of risk predictions, we have prespecified a priori the analytical plan, that is, prespecifying the candidate predictor variables, handling missing data and validation of the developed model. The model's performance will also be assessed. Finally, various modes of presentation formats such as a simplified scoring tool or web-based electronic risk calculators will be considered.
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Affiliation(s)
- Josephine Henry Basil
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chandini Menon Premakumar
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adliah Mhd Ali
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Ain Mohd Tahir
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Zamtira Seman
- Sector for Biostatistics & Data Repository, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - Noraida Mohamed Shah
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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D'Errico S, Zanon M, Radaelli D, Padovano M, Santurro A, Scopetti M, Frati P, Fineschi V. Medication Errors in Pediatrics: Proposals to Improve the Quality and Safety of Care Through Clinical Risk Management. Front Med (Lausanne) 2022; 8:814100. [PMID: 35096903 PMCID: PMC8795662 DOI: 10.3389/fmed.2021.814100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Medication errors represent one of the most common causes of adverse events in pediatrics and are widely reported in the literature. Despite the awareness that children are at increased risk for medication errors, little is known about the real incidence of the phenomenon. Most studies have focused on prescription, although medication errors also include transcription, dispensing, dosage, administration, and certification errors. Known risk factors for therapeutic errors include parenteral infusions, oral fluid administration, and tablet splitting, as well as the off-label use of drugs with dosages taken from adult literature. Emergency Departments and Intensive Care Units constitute the care areas mainly affected by the phenomenon in the hospital setting. The present paper aims to identify the risk profiles in pediatric therapy to outline adequate preventive strategies. Precisely, through the analysis of the available evidence, solutions such as standardization of recommended doses for children, electronic prescribing, targeted training of healthcare professionals, and implementation of reporting systems will be indicated for the prevention of medication errors.
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Affiliation(s)
- Stefano D'Errico
- Department of Medicine, Surgery, and Health, University of Trieste, Trieste, Italy
| | - Martina Zanon
- Department of Medicine, Surgery, and Health, University of Trieste, Trieste, Italy
| | - Davide Radaelli
- Department of Medicine, Surgery, and Health, University of Trieste, Trieste, Italy
| | - Martina Padovano
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessandro Santurro
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
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Mulac A, Hagesaether E, Granas AG. Medication dose calculation errors and other numeracy mishaps in hospitals: Analysis of the nature and enablers of incident reports. J Adv Nurs 2022; 78:224-238. [PMID: 34632614 DOI: 10.1111/jan.15072] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/30/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022]
Abstract
AIMS To investigate medication dose calculation errors and other numeracy mishaps in hospitals and examine mechanisms and enablers which lead to such errors. DESIGN A retrospective study using descriptive statistics and thematic analysis of the nature and enablers of reported incidents. METHODS Medication dose calculation errors and other numeracy mishaps were identified from medication-related incidents reported to the Norwegian Incident Reporting System in 2016 and 2017. The main outcome measures were medications and medication classes involved, severity of harm, outcome, and error enablers. RESULTS In total, we identified 100 numeracy errors, of which most involved intravenous administration route (n = 70). Analgesics were the most commonly reported drug class and morphine was the most common individual medication. Overall, 78 incidents described patient harm. Frequent mechanisms were 10- or 100-fold errors, mixing up units, and incorrect strength/rate entered into infusion pumps. The most frequent error enablers were: double check omitted or deviated (n = 40), lack of safety barriers to intercept prescribing errors (n = 25), and emergency/stress (n = 21). CONCLUSION Numeracy errors due to lack of or improper safeguards occurred during all medication management stages. Dose miscalculation after dilution of intravenous solutions, infusion pump programming, and double-checking were identified as unsafe practices. We discuss measures to prevent future calculation and numeracy errors. IMPACT Our analysis of medication dose calculation errors and other numeracy mishaps demonstrates the need for improving safety steps and increase standardization for medication management procedures. We discuss organizational, technological, and educational measures to prevent harm from numeracy errors.
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Affiliation(s)
- Alma Mulac
- Department of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Ellen Hagesaether
- Department of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Anne Gerd Granas
- Department of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
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Gee JP, Palmer M, Friel BA, Collingridge DS. Challenging tradition: Nurses' attitudes toward single checking of subcutaneous insulin. Nursing 2022; 52:52-57. [PMID: 34979015 DOI: 10.1097/01.nurse.0000803528.94354.6d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Julie Peila Gee
- Julie Peila Gee is a clinical associate professor at the University of Utah's College of Nursing. At Intermountain Healthcare, Maryanne Palmer is a continuous improvement consultant, Beth Ann Friel is a professional practice consultant, and Dave S. Collingridge is a senior research statistician
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Manias E, Street M, Lowe G, Low JK, Gray K, Botti M. Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit. BMC Health Serv Res 2021; 21:1025. [PMID: 34583681 PMCID: PMC8480109 DOI: 10.1186/s12913-021-07033-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Efforts to ensure safe and optimal medication management are crucial in reducing the prevalence of medication errors. The aim of this study was to determine the associations of person-related, environment-related and communication-related factors on the severity of medication errors occurring in two health services. METHODS A retrospective clinical audit of medication errors was undertaken over an 18-month period at two Australian health services comprising 16 hospitals. Descriptive statistical analysis, and univariate and multivariable regression analysis were undertaken. RESULTS There were 11,540 medication errors reported to the online facility of both health services. Medication errors caused by doctors (Odds Ratio (OR) 0.690, 95% CI 0.618-0.771), or by pharmacists (OR 0.327, 95% CI 0.267-0.401), or by patients or families (OR 0.641, 95% CI 0.472-0.870) compared to those caused by nurses or midwives were significantly associated with reduced odds of possibly or probably harmful medication errors. The presence of double-checking of medication orders compared to single-checking (OR 0.905, 95% CI 0.826-0.991) was significantly associated with reduced odds of possibly or probably harmful medication errors. The presence of electronic systems for prescribing (OR 0.580, 95% CI 0.480-0.705) and dispensing (OR 0.350, 95% CI 0.199-0.618) were significantly associated with reduced odds of possibly or probably harmful medication errors compared to the absence of these systems. Conversely, insufficient counselling of patients (OR 3.511, 95% CI 2.512-4.908), movement across transitions of care (OR 1.461, 95% CI 1.190-1.793), presence of interruptions (OR 1.432, 95% CI 1.012-2.027), presence of covering personnel (OR 1.490, 95% 1.113-1.995), misread or unread orders (OR 2.411, 95% CI 2.162-2.690), informal bedside conversations (OR 1.221, 95% CI 1.085-1.373), and problems with clinical handovers (OR 1.559, 95% CI 1.136-2.139) were associated with increased odds of medication errors causing possible or probable harm. Patients or families were involved in the detection of 1100 (9.5%) medication errors. CONCLUSIONS Patients and families need to be engaged in discussions about medications, and health professionals need to provide teachable opportunities during bedside conversations, admission and discharge consultations, and medication administration activities. Patient counselling needs to be more targeted in effort to reduce medication errors associated with possible or probable harm.
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Affiliation(s)
- Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Maryann Street
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia
| | - Grainne Lowe
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia
| | - Jac Kee Low
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia
| | - Kathleen Gray
- Centre for Digital Transformation of Health, The University of Melbourne, Grattan Street, Parkville, Victoria, 3010, Australia
| | - Mari Botti
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia
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Rosen MA, Romig M, Demko Z, Barasch N, Dwyer C, Pronovost PJ, Sapirstein A. Smart agent system for insulin infusion protocol management: a simulation-based human factors evaluation study. BMJ Qual Saf 2021; 30:893-900. [PMID: 33692190 PMCID: PMC8543218 DOI: 10.1136/bmjqs-2020-011420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 02/09/2021] [Accepted: 02/18/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To compare the insulin infusion management of critically ill patients by nurses using either a common standard (ie, human completion of insulin infusion protocol steps) or smart agent (SA) system that integrates the electronic health record and infusion pump and automates insulin dose selection. DESIGN A within subjects design where participants completed 12 simulation scenarios, in 4 blocks of 3 scenarios each. Each block was performed with either the manual standard or the SA system. The initial starting condition was randomised to manual standard or SA and alternated thereafter. SETTING A simulation-based human factors evaluation conducted at a large academic medical centre. SUBJECTS Twenty critical care nurses. INTERVENTIONS A systems engineering intervention, the SA, for insulin infusion management. MEASUREMENTS The primary study outcomes were error rates and task completion times. Secondary study outcomes were perceived workload, trust in automation and system usability, all measured with previously validated scales. MAIN RESULTS The SA system produced significantly fewer dose errors compared with manual calculation (17% (n=20) vs 0, p<0.001). Participants were significantly faster, completing the protocol using the SA system (p<0.001). Overall ratings of workload for the SA system were significantly lower than with the manual system (p<0.001). For trust ratings, there was a significant interaction between time (first or second exposure) and the system used, such that after their second exposure to the two systems, participants had significantly more trust in the SA system. Participants rated the usability of the SA system significantly higher than the manual system (p<0.001). CONCLUSIONS A systems engineering approach jointly optimised safety, efficiency and workload considerations.
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Affiliation(s)
- Michael A Rosen
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA .,Department of Health Policy and Management, Bloomberg School of Public Health, School of Nursing; Institute for Clinical and Translational Research, Baltimore, Maryland, USA
| | - Mark Romig
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zoe Demko
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Noah Barasch
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cynthia Dwyer
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J Pronovost
- University Hospitals of Cleveland, Shaker Heights, Ohio, USA.,Anesthesiology and Critical Care Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Adam Sapirstein
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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