Computer based medication error reporting: insights and implications

The Generalizability of a Medication Administration Discrepancy Detection System: Quantitative Comparative Analysis

Background

As a result of the overwhelming proportion of medication errors occurring each year, there has been an increased focus on developing medication error prevention strategies. Recent advances in electronic health record (EHR) technologies allow institutions the opportunity to identify medication administration error events in real time through computerized algorithms. MED.Safe, a software package comprising medication discrepancy detection algorithms, was developed to meet this need by performing an automated comparison of medication orders to medication administration records (MARs). In order to demonstrate generalizability in other care settings, software such as this must be tested and validated in settings distinct from the development site.

Objective

The purpose of this study is to determine the portability and generalizability of the MED.Safe software at a second site by assessing the performance and fit of the algorithms through comparison of discrepancy rates and other metrics across institutions.

Methods

The MED.Safe software package was executed on medication use data from the implementation site to generate prescribing ratios and discrepancy rates. A retrospective analysis of medication prescribing and documentation patterns was then performed on the results and compared to those from the development site to determine the algorithmic performance and fit. Variance in performance from the development site was further explored and characterized.

Results

Compared to the development site, the implementation site had lower audit/order ratios and higher MAR/(order + audit) ratios. The discrepancy rates on the implementation site were consistently higher than those from the development site. Three drivers for the higher discrepancy rates were alternative clinical workflow using orders with dosing ranges; a data extract, transfer, and load issue causing modified order data to overwrite original order values in the EHRs; and delayed EHR documentation of verbal orders. Opportunities for improvement were identified and applied using a software update, which decreased false-positive discrepancies and improved overall fit.

Conclusions

The execution of MED.Safe at a second site was feasible and effective in the detection of medication administration discrepancies. A comparison of medication ordering, administration, and discrepancy rates identified areas where MED.Safe could be improved through customization. One modification of MED.Safe through deployment of a software update improved the overall algorithmic fit at the implementation site. More flexible customizations to accommodate different clinical practice patterns could improve MED.Safe’s fit at new sites.

Adherence to prescription-writing guidelines for outpatients in Southern Gauteng district hospitals

Background

Medical prescription writing is legally and professionally regulated in order to prevent errors that can result in patients being harmed. This study assesses prescriber adherence to such regulations in primary care settings.

Methods

A cross-sectional study of 412 prescriptions from four district hospital outpatient departments (OPDs) was conducted in March 2015. Primary outcome data were obtained by scoring prescriptions for accuracy across four categories: completion of essential elements, use of generic names of medications, use of recommended abbreviations and decimals and legibility. Secondary outcome data sought associations between accuracy scores and characteristics of the OPDs that might influence prescriber adherence.

Results

Completion of the essential elements, including patient identifiers, prescriber identifiers, treatment regimen and date scored 44%, 77%, 99% and 99% respectively. Legibility, the use of generic names of medications and the use of recommended abbreviations and decimals scored 90%, 39% and 35%, respectively. Only 38% of prescriptions achieved a global accuracy score (GAS) of between 80% and 100%. A significant association was found between lower GAS and the number of prescriptions written per day (p = 0.001) as well as with the number of prescribers working on that day (p = 0.005), suggesting a negative impact on prescribers’ performance because of workload pressures.

Conclusion

Low GAS values indicate poor adherence to prescription-writing regulations. Elements requiring substantial improvement include completion of patient and prescriber identifiers, use of generic medication names and the use of recommended abbreviations and decimals. This study provides baseline data for future initiatives for improvement in prescription-writing quality.

Trends in Use of Electronic Health Records in Pediatric Office Settings

OBJECTIVES

To determine the prevalence and functionalities of electronic health records (EHRs) and pediatricians' perceptions of EHRs.

STUDY DESIGN

An 8-page self-administered questionnaire sent to 1619 randomly selected nonretired US American Academy of Pediatrics members in 2016 was completed by 709 (43.8%). Responses were compared with surveys in 2009 and 2012.

RESULTS

The percent of pediatricians who were using EHRs increased from 58% in 2009 and 79% in 2012 to 94% in 2016. Those with fully functional EHRs, including pediatric functionality, more than doubled from 8.2% in 2012 to 16.9% in 2016 (P = .01). Fully functional EHRs lacking pediatric functionality increased slightly from 7.8% to 11.1% (P = .3), and the percentage of pediatricians with basic EHRs remained stable (30.4% to 31.0%; P < .3). The percentage of pediatricians who lacked basic EHR functionality or who reported no EHR decreased (from 53.6% to 41.0%; P < .001). On average, pediatricians spent 3.4 hours per day documenting care.

CONCLUSIONS

Although the adoption of EHRs has increased, >80% of pediatricians are working with EHRs that lack optimal functionality and 41% of pediatricians are not using EHRs with even basic functionality. EHRs lacking pediatric functionality impact the health of children through increased medical errors, missed diagnoses, lack of adherence to guidelines, and reduced availability of child-specific information. The pediatric certification outlined in the 21st Century Cures Act may result in improved EHR products for pediatricians.

Quality-related events reported by community pharmacies in Nova Scotia over a 7-year period: a descriptive analysis

BACKGROUND

Quality-related events are defined as medication errors that reach the patient (e.g., incorrect drug, dose and quantity), in addition to medication errors that are intercepted before dispensing (i.e., near misses). The aim of this study is to quantify and characterize such events as reported by community pharmacies in a Canadian province.

METHODS

A retrospective analysis was conducted on quality-related events reported to the Community Pharmacy Incident Reporting system from 301 community pharmacies in Nova Scotia between Oct. 1, 2010, and June 30, 2017. We performed a descriptive analysis on these events with respect to the discoverer, patient outcome, medication system stages and type.

RESULTS

We identified 131 031 events reported by community pharmacies in Nova Scotia over the study period, 98 097 of which were quality-related events. Overall, 82.0% (n = 80 488) quality-related events did not reach the patient, and 0.95% (n = 928) were associated with patient harm. Incorrect dose or frequency, incorrect quantity and incorrect drug were the most common types of quality-related events reported. Most of the quality-related events occurred at order entry, followed by preparation and dispensing, and prescribing.

INTERPRETATION

Quality-related events reported by community pharmacies differ from those reported in institutional settings with respect to patient outcome, medication system stages and type. This analysis provides valuable information to guide quality improvement initiatives to strengthen medication safety in community pharmacies.

Record of the circumstances of falls in the community: perspective in the Iberian Peninsula

Objective:

to determine the diagnosis of the situation regarding documentation of falls and risk of falls in people older than 75 years in basic health units in Spain and Portugal.

Method:

mixed exploratory study in two stages: (i) quantitative descriptive of randomly selected fall records produced in one year (597 records; 197 Spanish and 400 Portuguese); and (ii) qualitative, with the purpose of knowing the perception of health professionals employing semi-structured interviews (72 professionals, 16 Spanish and 56 Portuguese). The study areas were two basic health units in southern Spain and northern Portugal.

Results:

in the fall records, the number of women was higher. The presence of fall was associated with the variables age, presence of dementia, osteoarticular disease, previous falls and consumption of antivertiginous medication. Health professionals perceived an absence of risk assessment instruments, as well as lack of prevention programs and lack of awareness of this event.

Conclusion:

falls are perceived as an area of ​​priority attention for health professionals. Nonetheless, there is a lack of adherence to the registration of falls and risk assessment, due to organizational, logistical and motivational problems.

Prevalence and pattern of prescription errors in a Nigerian kidney hospital

OBJECTIVES

To determine (i) the prevalence and pattern of prescription errors in our Centre and, (ii) appraise pharmacists' intervention and correction of identified prescription errors.

DESIGN

A descriptive, single blinded cross-sectional study.

SETTING

Kidney Care Centre is a public Specialist hospital. The monthly patient load averages 60 General Out-patient cases and 17.4 in-patients.

PARTICIPANTS

A total of 31 medical doctors (comprising of 2 Consultant Nephrologists, 15 Medical Officers, 14 House Officers), 40 nurses and 24 ward assistants participated in the study. One pharmacist runs the daily call schedule. Prescribers were blinded to the study. Prescriptions containing only galenicals were excluded.

INTERVENTIONS

An error detection mechanism was set up to identify and correct prescription errors. Life-threatening prescriptions were discussed with the Quality Assurance Team of the Centre who conveyed such errors to the prescriber without revealing the on-going study.

MAIN OUTCOME MEASURES

Prevalence of prescription errors, pattern of prescription errors, pharmacist's intervention.

RESULTS

A total of 2,660 (75.0%) combined prescription errors were found to have one form of error or the other; illegitimacy 1,388 (52.18%), omission 1,221(45.90%), wrong dose 51(1.92%) and no error of style was detected. Life-threatening errors were low (1.1-2.2%). Errors were found more commonly among junior doctors and non-medical doctors. Only 56 (1.6%) of the errors were detected and corrected during the process of dispensing.

CONCLUSION

Prescription errors related to illegitimacy and omissions were highly prevalent. There is a need to improve on patient-to-healthcare giver ratio. A medication quality assurance unit is needed in our hospitals.

FUNDING

No financial support was received by any of the authors for this study.

Measuring non-administration of ordered medications in the pediatric inpatient setting

OBJECTIVE

Medication compliance in inpatient settings shows some significant gaps for adult patients. In pediatric settings prescribing and other administration errors have been studied but missed doses have not been specifically studied in the pediatric inpatient setting. We intended to apply health information technology and data processing methods to study the medication compliance for pediatric patients at our institution.

STUDY DESIGN

We collected medication ordering, dispensing, and administration data spanning 42 months (7/1/2010 through 12/31/2013) for pediatric inpatients admitted to a major tertiary pediatric hospital. We analyzed the orders for which either the corresponding administration record was missing or the records indicated non-administration.

RESULTS

There were only 596 medication orders without corresponding administration records, accounting for less than 0.05% of 1.6 Million orders for 56,000 patients. There were 40,999 orders with corresponding administration records indicating non-administration (or less than 3% of all orders). Overall order compliance of the nursing staff was 97.35%, with another 2.6% of orders having a documented reason for non-administration The top two medication classes comprising the missed and non-administered orders were "Alimentary tract and metabolism drugs" and "Nervous system drugs".

CONCLUSION

Measurement of medication compliance is an important quality measure of patient safety and quality of care. Our study found a small proportion of non-administered medication orders and discovered corresponding reasons illustrating how health information technology can help to measure the quality of the medication process from ordering and dispensing to administration at a major healthcare institution.

Impact on process results of clinical decision support systems (CDSSs) applied to medication use: overview of systematic reviews

Objective

The purpose of this overview (systematic review of systematic reviews) is to evaluate the impact of clinical decision support systems (CDSS) applied to medication use in the care process.

Methods

A search for systematic reviews that address CDSS was performed on Medline following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane recommendations. Terms related to CDSS and systematic reviews were used in combination with Boolean operators and search field tags to build the electronic search strategy. There was no limitation of date or language for inclusion. We included revisions that investigated, as a main or secondary objective, changes in process outcomes. The Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) score was used to evaluate the quality of the studies.

Results

The search retrieved 954 articles. Five articles were added through manual search, totaling an initial sample of 959 articles. After screening and reading in full, 44 systematic reviews met the inclusion criteria. In the medication-use processes where CDSS was used, the most common stages were prescribing (n=38 (86.36%) and administering (n=12 (27.27%)). Most of the systematic reviews demonstrated improvement in the health care process (30/44 - 68.2%). The main positive results were related to improvement of the quality of prescription by the physicians (14/30 - 46.6%) and reduction of errors in prescribing (5/30 - 16.6%). However, the quality of the studies was poor, according to the score used.

Conclusion

CDSSs represent a promising technology to optimize the medication-use process, especially related to improvement in the quality of prescriptions and reduction of prescribing errors, although higher quality studies are needed to establish the predictors of success in these systems.

The Unintended Consequences of Health Information Technology Revisited

INTRODUCTION

The introduction of health information technology into clinical settings is associated with unintended negative consequences, some with the potential to lead to error and patient harm. As adoption rates soar, the impact of these hazards will increase.

OBJECTIVE

Over the last decade, unintended consequences have received great attention in the medical informatics literature, and this paper seeks to identify the major themes that have emerged.

RESULTS

Rich typologies of the causes of unintended consequences have been developed, along with a number of explanatory frameworks based on socio-technical systems theory. We however still have only limited data on the frequency and impact of these events, as most studies rely on data sets from incident reporting or patient chart reviews, rather than undertaking detailed observational studies. Such data are increasingly needed as more organizations implement health information technologies. When outcome studies have been done in different organizations, they reveal different outcomes for identical systems. From a theoretical perspective, recent advances in the emerging discipline of implementation science have much to offer in explaining the origin, and variability, of unintended consequences.

CONCLUSION

The dynamic nature of health care service organizations, and the rapid development and adoption of health information technologies means that unintended consequences are unlikely to disappear, and we therefore must commit to developing robust systems to detect and manage them.

Use of Text Searching for Trigger Words in Medical Records to Identify Adverse Drug Reactions within an Intensive Care Unit Discharge Summary

PURPOSE

To evaluate the performance of using trigger words (e.g. clues to an adverse drug reaction) in unstructured, narrative text to detect adverse drug reactions (ADRs) and compare the use of these trigger words to a targeted chart review for ADR detection within the intensive care unit (ICU) discharge summary note.

MATERIALS

A retrospective medical record review was conducted. Evaluation of ADRs occurred in two phases - targeted chart review of the ICU discharge summary notes in Phase 1 and targeted chart review using specific words and phrases as triggers for ADRs in Phase 2.

RESULTS

Four hundred ADRs were documented in 223 patients for Phase 1. For Phase 2, there were 219 ADRs identified in 120 patients. 138 real or accurate ADRs were identified from Phase 1 and 47 duplicate events. 34 ADRs from Phase 2 were not identified in Phase 1. Fifteen of the ADRs were inaccurately presumed in Phase 2. Fifty-eight of 127 text triggers identified at least one ADR. Low and moderate frequency trigger words were more likely to have PPVs > 5%.

CONCLUSIONS

Targeted chart review using specific words and phrases as triggers for ADRs is a reasonable approach to identify ADRs and may save time compared to other methods after further refinement leads to a more accurately performing trigger word list.

Automated detection of medication administration errors in neonatal intensive care

OBJECTIVE

To improve neonatal patient safety through automated detection of medication administration errors (MAEs) in high alert medications including narcotics, vasoactive medication, intravenous fluids, parenteral nutrition, and insulin using the electronic health record (EHR); to evaluate rates of MAEs in neonatal care; and to compare the performance of computerized algorithms to traditional incident reporting for error detection.

METHODS

We developed novel computerized algorithms to identify MAEs within the EHR of all neonatal patients treated in a level four neonatal intensive care unit (NICU) in 2011 and 2012. We evaluated the rates and types of MAEs identified by the automated algorithms and compared their performance to incident reporting. Performance was evaluated by physician chart review.

RESULTS

In the combined 2011 and 2012 NICU data sets, the automated algorithms identified MAEs at the following rates: fentanyl, 0.4% (4 errors/1005 fentanyl administration records); morphine, 0.3% (11/4009); dobutamine, 0 (0/10); and milrinone, 0.3% (5/1925). We found higher MAE rates for other vasoactive medications including: dopamine, 11.6% (5/43); epinephrine, 10.0% (289/2890); and vasopressin, 12.8% (54/421). Fluid administration error rates were similar: intravenous fluids, 3.2% (273/8567); parenteral nutrition, 3.2% (649/20124); and lipid administration, 1.3% (203/15227). We also found 13 insulin administration errors with a resulting rate of 2.9% (13/456). MAE rates were higher for medications that were adjusted frequently and fluids administered concurrently. The algorithms identified many previously unidentified errors, demonstrating significantly better sensitivity (82% vs. 5%) and precision (70% vs. 50%) than incident reporting for error recognition.

CONCLUSIONS

Automated detection of medication administration errors through the EHR is feasible and performs better than currently used incident reporting systems. Automated algorithms may be useful for real-time error identification and mitigation.

Pediatric aspects of inpatient health information technology systems

In the past 3 years, the Health Information Technology for Economic and Clinical Health Act accelerated the adoption of electronic health records (EHRs) with providers and hospitals, who can claim incentive monies related to meaningful use. Despite the increase in adoption of commercial EHRs in pediatric settings, there has been little support for EHR tools and functionalities that promote pediatric quality improvement and patient safety, and children remain at higher risk than adults for medical errors in inpatient environments. Health information technology (HIT) tailored to the needs of pediatric health care providers can improve care by reducing the likelihood of errors through information assurance and minimizing the harm that results from errors. This technical report outlines pediatric-specific concepts, child health needs and their data elements, and required functionalities in inpatient clinical information systems that may be missing in adult-oriented HIT systems with negative consequences for pediatric inpatient care. It is imperative that inpatient (and outpatient) HIT systems be adapted to improve their ability to properly support safe health care delivery for children.

Medication errors in pediatric nursing: assessment of nurses' knowledge and analysis of the consequences of errors

AIM

The purposes of this study were (i) to evaluate pediatric nurses' knowledge of pharmacology, and (ii) to analyze known pediatric administration errors.

BACKGROUND

Medication errors occur frequently and ubiquitously, but medication errors involving pediatric patients attract special attention for their high incidence and injury rates.

METHODS

A cross-sectional study was conducted. A questionnaire with 20 true-false questions regarding pharmacology was used to evaluate nurses' knowledge, and the known pediatric administration errors were reported by nurses.

FINDINGS

The overall correct answer rate on the knowledge of pharmacology was 72.9% (n=262). Insufficient knowledge (61.5%) was the leading obstacle nurses encountered when administering medications. Of 141 pediatric medication errors, more than 60% (61.0%) of which were wrong doses, 9.2% of the children involved suffered serious consequences.

CONCLUSIONS

Evidence-based results demonstrate that pediatric nurses have insufficient knowledge of pharmacology. Such strategies as providing continuing education and double-checking dosages are suggested.

[Preparation and administration of injectable antibiotics: a tool for nurses]

Nurses, the main caregivers to administer medications, often find themselves lacking the information which is nevertheless essential for the preparation of injectable antibiotics. This problem, frequent in hospitals, impacts on patient safety. On the initiative of the pharmacy and nursing staff, a tool has been created in the Percy Army Teaching Hospital in Clamart.

Electronic prescribing in pediatrics: toward safer and more effective medication management

This policy statement identifies the potential value of electronic prescribing (e-prescribing) systems in improving quality and reducing harm in pediatric health care. On the basis of limited but positive pediatric data and on the basis of federal statutes that provide incentives for the use of e-prescribing systems, the American Academy of Pediatrics recommends the adoption of e-prescribing systems with pediatric functionality. The American Academy of Pediatrics also recommends a set of functions that technology vendors should provide when e-prescribing systems are used in environments in which children receive care.

Terms used in patient safety related to medication: a literature review

PURPOSE

There is a lack of homogeneity in the terminology used in the context of patient safety related to medication. The aim of this review was to identify the terms and definitions used in patient safety related to medication within the scientific literature.

METHODS

Original and review articles that were indexed between 1998 and 2008 in MEDLINE and EMBASE and contained terms used in patient safety related to medication were included. Terms and definitions were extracted and categorised according to whether its definition referred to the process of medication use, or to the clinical outcome of medication use, or both.

RESULTS

Of 2564 articles, 147 were included. Sixty terms used in patient safety related to medication with 189 different definitions were identified. Among terms that referred only to the process of medication use (n = 23), medication error provided the greatest number of definitions (n = 29). Among terms that referred only to the clinical outcome of medication use (n = 31), adverse drug event provided the greatest number of definitions (n = 15). Finally, among terms that referred both to the process of use and to the clinical outcome of medication use (n = 13), drug-related problem provided the greatest number of definitions (n = 7).

CONCLUSIONS

A multitude of terms and definitions are used in patient safety related to medication. This heterogeneity makes it difficult to compare the results among studies and to appreciate the true magnitude of the problem. Classifying and unifying the terminology is necessary to advance in patient safety strategies.

How should medication errors be defined? Development and test of a definition

Aims: Definitions of medication errors vary widely in the literature, and prevalence from 2–75% in part because of this lack of consensus. Thus, clarification of the concept is urgently needed. The objective was to develop a clear-cut definition of medication errors and specify relevant error types in the medication process. Methods: Based on existing taxonomy and through a modified Delphi-process consensus of definition and error types were reached among Danish experts appointed by 13 healthcare organisations and the project group. The experts prioritised five definitions of medication errors and score the relevance of 76 error types. Based on explicit criteria, the project group settled non-consensus cases. Results: The panel consisted of 12 physicians, seven pharmacists, and six nurses. Consensus was reached for the definition “An error in the stages of the medication process – ordering, dispensing, administering and monitoring the effect – causing harm or implying a risk of harming the patient”. Moreover, consensus for 60 of 76 error types was achieved. Applied to a historic dataset the definition reduced the number of medication errors from 34% to 7%. Conclusions: Experts deemed a definition using harm or risk of harm as cut-off point as the most appropriate in Danish hospital settings. In addition, they agreed on a list of 60 error types covering the medication process. Interestingly, a substantial lower occurrence of medication errors was found when applied to historic data. The definition is in accordance with international taxonomy, thus is assumed to be applicable to modern healthcare settings abroad.

Validating reasons for medication discontinuation in electronic patient records at hospital discharge

RATIONALE, AIMS AND OBJECTIVES

The accuracy of health care professionals in reporting safety events determines their usefulness for both system improvement and research. The study objectives were to: (1) validate (assess the accuracy of) the reasons recorded by doctors and pharmacists for discontinuing medication orders at discharge in a hospital's electronic patient records (EPR); (2) investigate the causes of any detected recording inaccuracy; and (3) collect preliminary data on the frequency and types of medication discontinuation.

METHODS

This was a validation study in one English hospital. The study comprised two steps: extraction of discontinued medication orders from the EPR followed by short structured interviews with doctors and pharmacists who made the discontinuation. A total of 104 discontinued orders were discussed during 15 face-to-face and six telephone interviews. The software package spss was used for data analysis.

RESULTS

Duplication of therapy (27, 25.2%), omission of drug (23, 21.5%) and dosage regimen change (19, 17.8%) were the three most frequent reasons given for discontinuing medications. The majority of recorded discontinuation reasons were correct (100, 96.2%) and complete (101, 97.1%), and hence were judged accurate (97, 93.3%). The difference in accurate recording between doctors (15, 88.2%) and pharmacists (82, 94.3%) was not statistically significant. Potential causes of recording inaccuracy included: slip or lapse, lack of training, carelessness and electronic system rigidity.

CONCLUSION

This study showed that doctors and pharmacists recorded accurate reasons for the majority of the discontinued medication orders. It also showed that utilizing pharmacists' recorded reasons during clinical interventions using EPR was beneficial in understanding and characterizing prescribing errors. Although they require further research, the reasons identified present preliminary data about the most prevalent types of pharmacists' interventions during hospital discharge.

A computerized system for reporting medication events in psychiatry: the first two years of operation

The aim of this paper is to describe the first 2 years of operation of an electronic system for reporting medication events in psychiatry (Medi-Event system). We have carried out a descriptive analysis of all medication events (errors, near misses and adverse drug reactions) reported between 1 March 2008 and 28 February 2010 at a large, specialist UK psychiatric hospital. A total of 406 medication errors, 40 near misses and no adverse drug reactions were reported in the study period, representing a very large increase in reporting frequency with respect to the previous paper system. The majority (88.8%) of incidents were medication administration errors. The most common error types were failure to sign for a drug and omission of a drug without valid clinical reason. Although most errors were of minor severity, 6.3% were rated as moderate or serious. Distraction was cited as the most common contributory factor, also poor communication and being unfamiliar with the ward. In conclusion, use of the Medi-Event system increased the reporting of medication errors. Analysis of the pattern of errors, as well as of contributory factors and suggestions for error prevention, may help reduce the frequency of medication events and hence improve patient care.

Secondary use of electronic health record data: spontaneous triggered adverse drug event reporting

PURPOSE

Physicians in the United States report fewer than 1% of adverse drug events (ADEs) to the Food and Drug Administration (FDA), but frequently document ADEs within electronic health records (EHRs). We developed and implemented a generalizable, scalable EHR-based system to automatically send electronic ADE reports to the FDA in real-time.

METHODS

Proof-of-concept study involving 26 clinicians given access to EHR-based ADE reporting functionality from December 2008 to May 2009.

MEASUREMENTS

Number and content of ADE reports; severity of adverse reactions (clinician and computer algorithm defined); clinician survey.

RESULTS

During the study period, 26 clinicians submitted 217 reports to the FDA. The clinicians defined 23% of the ADEs as serious and a computer algorithm defined 4% of the ADEs as serious. The most common drug classes were cardiovascular drugs (40%), central nervous system drugs (19%), analgesics (13%), and endocrine drugs (7%). The reports contained information, pre-filled from the EHR, about comorbid conditions (207 reports [95%] listed 1899 comorbid conditions), concurrent medications (193 reports [89%] listed 1687 concurrent medications), weight (209 reports [96%]), and laboratory data (215 reports [99%]). It took clinicians a mean of 53 seconds to complete and send the form. In the clinician survey, 21 of 23 respondents (91%) said they had submitted zero ADE reports to the FDA in the prior 12 months.

CONCLUSIONS

EHR-based, triggered ADE reporting is efficient and acceptable to clinicians, provides detailed clinical information, and has the potential to greatly increase the number and quality of spontaneous reports submitted to the FDA.

Twelve tips for implementing a patient safety curriculum in an undergraduate programme in medicine

Patient safety is a major priority for health services. It is a multi-disciplinary problem and requires a multi-disciplinary solution; any education should therefore be a multi-disciplinary endeavour, from conception to implementation. The starting point should be at undergraduate level and medical education should not be an exception. It is apparent that current educational provision in patient safety lacks a systematic approach, is not linked to formal assessment and is detached from the reality of practice. If patient safety education is to be fit for purpose, it should link theory and the reality of practice; a human factors approach offers a framework to create this linkage. Learning outcomes should be competency based and generic content explicitly linked to specific patient safety content. Students should ultimately be able to demonstrate the impact of what they learn in improving their clinical performance. It is essential that the patient safety curriculum spans the entire undergraduate programme; we argue here for a spiral model incorporating innovative, multi-method assessment which examines knowledge, skills, attitudes and values. Students are increasingly learning from patient experiences, we advocate learning directly from patients wherever possible. Undergraduate provision should provide a platform for continuing education in patient safety, all of which should be subject to periodic evaluation with a particular emphasis on practice impact.

Improving the quality of drug error reporting

BACKGROUND

Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections.

AIM

The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital.

METHODS

A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi-disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting.

RESULTS

The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems-based. Staff felt obliged to report but rarely received feedback. IMPLICATIONS AND CONCLUSION: Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi-centred evaluation.

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

OBJECTIVE

To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).

STUDY DESIGN

A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified chi(2) test was used for analysis.

RESULT

6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P=0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/delivery device failures were more likely to be harmful (P< or =0.05).

CONCLUSION

Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

Pediatric antidepressant medication errors in a national error reporting database

OBJECTIVE

To describe inpatient and outpatient pediatric antidepressant medication errors.

METHODS

We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years.

RESULTS

Of the 451 error reports identified, 95% reached the patient, 6.4% reached the patient and necessitated increased monitoring and/or treatment, and 77% involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30% cited dispensing, 28% cited transcribing, and 7.9% cited prescribing. The most commonly cited medications were sertraline (20%), bupropion (19%), fluoxetine (15%), and trazodone (11%). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59% vs 32%, p = .023), errors occurring in inpatient care (93% vs 68%, p = .012) and extra doses of medication (31% vs 10%, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p < .001) and more errors due to inaccurate or omitted transcription (p < .001), compared with inpatient errors. Family notification of medication errors was reported in only 12% of errors.

CONCLUSIONS

Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.

Evaluation of causes and frequency of medication errors during information technology downtime

PURPOSE

The causes and frequency of medication errors occurring during information technology downtime were evaluated.

METHODS

Individuals from a convenience sample of 78 hospitals who were directly responsible for supporting and maintaining clinical information systems (CISs) and automated dispensing systems (ADSs) were surveyed using an online tool between February 2007 and May 2007 to determine if medication errors were reported during periods of system downtime. The errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention severity scoring index. The percentage of respondents reporting downtime was estimated.

RESULTS

Of the 78 eligible hospitals, 32 respondents with CIS and ADS responsibilities completed the online survey for a response rate of 41%. For computerized prescriber order entry, patch installations and system upgrades caused an average downtime of 57% over a 12-month period. Lost interface and interface malfunction were reported for centralized and decentralized ADSs, with an average downtime response of 34% and 29%, respectively. The average downtime response was 31% for software malfunctions linked to clinical decision-support systems. Although patient harm did not result from 30 (54%) medication errors, the potential for harm was present for 9 (16%) of these errors.

CONCLUSION

Medication errors occurred during CIS and ADS downtime despite the availability of backup systems and standard protocols to handle periods of system downtime. Efforts should be directed to reduce the frequency and length of down-time in order to minimize medication errors during such downtime.

Medication errors: what they are, how they happen, and how to avoid them

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults--irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration). They can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors. Reporting of errors should be encouraged by creating a blame-free, non-punitive environment. Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. In balanced prescribing the mechanism of action of the drug should be married to the pathophysiology of the disease.

Cardiovascular medication errors in children

OBJECTIVES

We sought to describe pediatric cardiovascular medication errors and to determine patients and medications with more-frequently reported and/or more-harmful errors.

METHODS

We analyzed cardiovascular medication error reports from 2003-2004 for patients <18 years of age, from the US Pharmacopeia MEDMARX database. Reports were stratified according to harm score (A, near miss; B-D, error, no harm; E-I, harmful error). Proportions of harmful reports were determined according to drug class and age group. "High-risk" drugs were defined as antiarrhythmics, antihypertensives, digoxin, and calcium channel blockers.

RESULTS

A total of 147 facilities submitted 821 reports with community hospitals predominating (70%). Mean patient age was 4 years (median: 0.9 years). The most common error locations were NICUs, general care units, PICUs, pediatric units, and inpatient pharmacies. Drug administration, particularly improper dosing, was implicated most commonly. Severity analysis showed 5% "near misses," 91% errors without harm, and 4% harmful errors, with no reported fatalities. A total of 893 medications were cited in 821 reports. Diuretics were cited most frequently, followed by antihypertensives, angiotensin inhibitors, beta-adrenergic receptor blockers, digoxin, and calcium channel blockers. Calcium channel blockers, phosphodiesterase inhibitors, antiarrhythmics, and digoxin had the largest proportions of harmful events, although the values were not statistically significantly different from those for other drug classes. Infants <1 year of age accounted for 50% of reports. Proportions of harmful events did not differ according to age.

CONCLUSIONS

Infants <1 year of age were most frequently reported in cardiovascular medication errors reaching inpatients, in a national, voluntary, error-reporting database. Proportions of harmful errors were not significantly different by age or cardiovascular medication. Most errors were related to medication administration, largely due to improper dosing.

Medication errors in neonates

Prevention of harm from medication errors has become a national priority. Medication errors in the neonatal intensive care unit are common, and most can be avoided. This article reviews the prevalence and types of medication errors affecting the care of the neonate and summarizes approaches that have been used to reduce these errors. Safety initiatives applicable to minimizing medication errors also are discussed.

Using snowball sampling method with nurses to understand medication administration errors

AIMS AND OBJECTIVES

We aimed to encourage nurses to release information about drug administration errors to increase understanding of error-related circumstances and to identify high-alert situations.

BACKGROUND

Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors.

METHODS

Snowball sampling was conducted to recruit participants. A semi-structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates.

RESULTS

Eighty-five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one-third of total errors. Among 259 actual errors, 83.8% resulted in no adverse effects; among remaining 16.2%, 6.6% had mild consequences and 9.6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double-check procedures by colleagues and nurses responsible for errors; reporting rates were 62.5% (162/259) vs. 50.7% (35/69) and only 3.5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High-alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR).

CONCLUSIONS

Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high-alert situations. Strategies for reducing drug administration errors by nurses are suggested.

RELEVANCE TO CLINICAL PRACTICE

Survey results suggest that nurses should double check medication administration in known high-alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non-reprimanding atmosphere, helping to establish standard operational procedures for known high-alert situations.

Raising the awareness of inpatient nursing staff about medication errors

OBJECTIVE

The study objective was to design and implement an educational programme to raise the awareness of in-patient nursing staff about medication errors and other medication-related safety issues.

METHOD

A sample of in-patient nursing staff in Al Ain hospital (n = 370) was included in the study and completed a self-reported questionnaire about medication errors. A structured program was developed and used by the clinical pharmacists to identify the nursing knowledge on medication errors and other medication-related safety issues. The program consisted of a pre/post self-reported questionnaire, a training service, educational material, successive presentations and handouts. The self-reported questionnaire included twenty closed questions asking nurses opinions about medication errors. A training program on medication safety (Med Safe tool) was carried out by [clinical pharmacy team (n = 2) and quality coordinator nurse (n = 1)], for each group of 10 nurses. Main outcome measure The study outcomes were the change in mean scores pre and post intervention.

RESULTS

Findings revealed differences in the knowledge of nurses about the causes and reporting of medication errors. There were statistically significant differences in responses across the participant's years of experience and the current clinical working area. The participant's responses improved significantly [57.4% +/- 8.2, (95%CI: 56.6-58.2) vs. 68.9 +/- 10.3, (95%CI: 67.8-69.9); P < 0.05] pre and post questionnaire respectively.

CONCLUSIONS

The clinical pharmacist's structured program has improved knowledge of the in-patient nursing staff in terms of raising their awareness about medication errors.

Internal reporting system to improve a pharmacy's medication distribution process

PURPOSE

The current pharmacy occurrence-reporting system in an institution was reviewed, and an internal procedure that would provide data to improve the medication-use process was developed.

SUMMARY

In a rural, 353-bed, tertiary care academic center, the effectiveness of a departmental occurrence-reporting system was determined over a nine-month period to increase occurrence reporting within the pharmacy and allow administrators to identify specific areas for improvement within the medication distribution process. These events were identified according to the number and type of near misses documented by pharmacy staff. The pharmacy staff was asked to complete a survey about the department's current reporting process and what the staff desired in a new occurrence-reporting system. The staff was also surveyed on which steps of the pharmacy's medication distribution process could contribute to the most errors. Initially, a paper-based error-reporting form was developed for all steps of the pharmacy distribution process except pharmacist order entry. Once the paper-based error-reporting form was introduced, the pharmacist order-entry phase of the project was begun. During the evaluation period, 203 pharmacy-dispensing errors were reported to the hospital's error-reporting system. In contrast, 1385 total pharmacy events were documented using the pharmacy's internal occurrence-reporting system. At least 204 of those reported events involved high-alert medications according to the institution's high-alert medications policy.

CONCLUSION

A pharmacy internal occurrence-reporting system increased staff reporting and identified areas for improvement within the medication distribution process that may not have been recorded by a hospital-based reporting system.

Characteristics of pediatric chemotherapy medication errors in a national error reporting database

BACKGROUND

Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors.

METHODS

The authors queried the United States Pharmacopeia MEDMARX database, a national, voluntary, Internet-accessible error reporting system, for all error reports from 1999 through 2004 that involved chemotherapy medications and patients aged <18 years.

RESULTS

Of the 310 pediatric chemotherapy error reports, 85% reached the patient, and 15.6% required additional patient monitoring or therapeutic intervention. Forty-eight percent of errors originated in the administering phase of medication delivery, and 30% originated in the drug-dispensing phase. Of the 387 medications cited, 39.5% were antimetabolites, 14.0% were alkylating agents, 9.3% were anthracyclines, and 9.3% were topoisomerase inhibitors. The most commonly involved chemotherapeutic agents were methotrexate (15.3%), cytarabine (12.1%), and etoposide (8.3%). The most common error types were improper dose/quantity (22.9% of 327 cited error types), wrong time (22.6%), omission error (14.1%), and wrong administration technique/wrong route (12.2%). The most common error causes were performance deficit (41.3% of 547 cited error causes), equipment and medication delivery devices (12.4%), communication (8.8%), knowledge deficit (6.8%), and written order errors (5.5%). Four of the 5 most serious errors occurred at community hospitals.

CONCLUSIONS

Pediatric chemotherapy errors often reached the patient, potentially were harmful, and differed in quality between outpatient and inpatient areas. This study indicated which chemotherapeutic agents most often were involved in errors and that administering errors were common. Investigation is needed regarding targeted medication administration safeguards for these high-risk medications.

Retrospective analysis of medication incidents reported using an on-line reporting system

OBJECTIVE

To examine the types of prescribing, administration and dispensing incidents reported to an on-line incident-reporting scheme and determine the types of healthcare professionals responsible for reporting such incidents.

METHOD

Retrospective analysis of medication-related incidents reported to an on-line incident-reporting scheme in a large (1000-bed) teaching hospital in the UK.

MAIN OUTCOME MEASURES

Frequency and type of incidents, the discipline of the health care professional who reported the incident and the stage in the medication use process (prescribing, dispensing, or administration) at which the incident occurred.

RESULTS

Over a 26-month study period, there were 495 medication-related incidents reported, of which 38.6% (191) were classified to be a "near miss". Medication-related incidents were reported most often at the stages of administration (230, 46.5%) and prescribing (192, 38.8%), whilst incidents involving dispensing or supply of medication were reported less often (73, 14.7%). Of all the incidents, pharmacists reported 51.9% (257), nursing staff reported 37.6% (186), and doctors reported 9.1% (45). Cardiovascular (149, 30.1%), central nervous system (106, 21.4%), and antibiotic/anti-infective medication (71, 14.3%) were the most common therapeutic categories associated with reports of medication-related incidents.

CONCLUSION

An on-line reporting scheme can be used to monitor medication-related incidents at key stages in the medication-use process in secondary care. The types of incidents reported by health care professionals differ markedly, with fewer medication-related incidents being reported by doctors. Future research should explore the prevailing safety culture amongst the different health care disciplines, and examine the impact that information technology has on the willingness of health care professionals to report adverse incidents.