Utilization of neonatal medication error prevention strategies: a clinical practice survey of Australian and New Zealand neonatal units

Medication safety strategies in European adult, paediatric, and neonatal intensive care units: a cross-sectional survey

OBJECTIVES

Patients in intensive care units (ICUs) are potentially more vulnerable to medication errors than patients admitted to general wards. However, little is known about medication safety strategies used in European ICUs. Our objectives were to explore the strategies being used and being planned within European ICUs, to identify areas of variation, and to inform recommendations to improve medication safety in this patient group.

METHODS

We distributed an online survey, in seven European languages, via professional networks and social media. The survey explored a range of medication safety strategies and whether they were in use (and if so, whether fully or partially implemented) or being planned. Demographic information about respondents and their ICUs was also captured. A descriptive analysis was conducted, which included exploring geographical variation.

RESULTS

We obtained 587 valid responses from 32 different countries, with 317 (54%) completed by pharmacy staff. Medication safety practices most commonly implemented were patients' allergies being visible for all staff involved in their care (fully implemented in 382 (65%) of respondents' ICUs), standardised emergency medication stored in a fixed place (337, 57%), and use of standardised medication concentrations for commonly used intravenous infusions (330, 56%). Electronic prescribing systems were fully implemented in 310 (53%). A pharmacist was reported to be fully implemented in 181 (31%) of ICUs, of which there was 126 (70%) where there was a pharmacist review of all ordered medication five days per week. Critical care pharmacists were most common in Northern European ICUs (fully implemented to ICUs in 102, 50%) and electronic prescribing in Western Europe (108, 65%).

CONCLUSIONS

There is considerable variation in medication safety strategies used within European ICUs, both between and within geographical areas. Our findings may be helpful to ICU staff in identifying strategies that should be considered for implementation.

Cross-sectional survey of Australian and New Zealand clinical staff to explore attitudes regarding medication prescription and administration during neonatal emergencies

AIM

To survey Australasian neonatal medical and nursing staff to determine confidence regarding medication use, prior experience with medication errors and common resources utilised in neonatal emergencies.

METHODS

Data were collected through a cross-sectional online survey distributed to clinical staff affiliated with the Australian and New Zealand Neonatal Network. Information collected included: demographics, confidence in medication use, medication errors and resources used to assist with medication administration. Outcomes were compared between medical staff and nursing staff, and between clinical staff with differing levels of clinical experience (<5 years, 5-10 years and >10 years).

RESULTS

Respondents (n = 133) were most confident in calculating medication doses (89%, n = 119), but least confident in prescribing medication (50%, n = 67). Nurses were more likely to be confident than doctors with respect to appropriately diluting and drawing up medication (88% nurses vs. 28% doctors, P < 0.0001), and administering intravenous medications to critically ill neonates (97% nurses vs. 82% doctors, P < 0.01). Over half of respondents reported being personally involved in a medication error in the last 12 months: 33% had been involved in an error related to delayed administration, 18% related to incorrect documentation and 17% related to an incorrect dose. Free-text responses highlighted issues relating to adrenaline (epinephrine) administration and difficulties with equipment (syringe drivers and/or infusion pumps).

CONCLUSIONS

Medication errors in neonatal emergencies are common. Strategies to reduce such errors should be implemented in settings where neonates may require emergency care or resuscitation.

Priorities in the Prevention Strategies for Medication Error Using the Analytical Hierarchy Process Method

As medication error is inherently “preventable”, we should try to minimize errors to improve patient safety and quality of care. The aim of this study was to prioritize strategies to prevent medication errors using the analytic hierarchy process (AHP) method. The hierarchy structure consisted of three stages: goal of the decision, decision criteria, and alternatives. Ten experts of patient safety research or clinical pharmacology compared each pair of criteria and alternatives and assigned a nine-point numerical scale. We used the eigenvector method to aggregate the pairwise comparisons obtained from experts and to estimate the weights of each criterion and alternative. Among the decision criteria, system improvement in reporting was the most preferred criterion, followed by cultural improvement and system improvement in the counterplan. The preferred alternative was a counterplan by healthcare institutions, followed by a change from a blame culture to safety culture and the building of a reporting system. A sensitivity analysis indicated that priorities were generally robust in the methods used for calculating the integrated matrices. We have suggested the priority of preventive strategies against medication errors using the AHP method. The prioritization of preventive strategies could help policymakers understand current needs and therefore develop evidence-based policies on patient safety.

Analysis of standard concentrations of continuous infusions in nine Spanish neonatal intensive care units

OBJECTIVES

The aim of this study was to describe the use of standard concentrations for continuous infusion drugs in Spanish neonatal intensive care units (NICUs).

METHODS

We conducted an observational multicentre study based on a survey sent by email to 9 Spanish NICUs during January and February 2018. We collected data on intravenous drugs frequently used in neonates, and their preparation. Continuous infusion drugs with a standard concentration implemented in ≥2 NICUs were selected. An analysis of the concentrations reported was performed, and the rate of adherence to international recommendations of the Institute of Safe Medication Practice (ISMP) and Vermont Oxford Network (VON) was calculated.

RESULTS

From 69 drugs mentioned in the survey, 14 were included in the study, with all but one (furosemide) being considered high-alert medications by the ISMP. From the 9 participating NICUs, 3 had no established standard concentrations for any of the 14 drugs selected. In the other participating NICUs, dexmedetomidine was used with a standard concentration in the 3 NICUs which used the drug, whereas furosemide showed the lowest implementation rate (a standard concentration was implemented in 2 of the 7 NICUs which used the drug). In regard to concentrations adopted in the different NICUs, 80 variations were identified for the 14 drugs. The mean number of different standard concentrations for each drug per NICU was 2 (range 1-5). Adherence to ISMP/VON recommendations varied considerably depending on the drugs, from high adherence for heparin (2/3) and fentanyl (2/3) to low adherence for norepinephrine (0/4).

CONCLUSIONS

The establishment of standard concentrations is highly recommended for continuous infusion medications as an effective error-prevention strategy. Nevertheless, we detected a low implementation rate in our NICUs and a lack of consistency in the concentrations selected.

Association between neonatal intensive care unit medication safety practices, adverse events, and death

OBJECTIVE

Determine the associations between neonatal intensive care unit (NICU) medication safety practices, laboratory-based adverse events (lab-AEs), and death.

STUDY DESIGN

We combined data from a 2016 survey of Pediatrix NICUs on use of medication safety practices with 2014-2016 infant data. We grouped NICUs based on the number of safety practices used (≤5, 6-7, and 8-10) and evaluated the association between the number of safety practices used and lab-AEs and deaths using logistic regressions.

RESULTS

Of the 94 NICUs included, 17% used ≤5 medication safety practices, 51% used 6-7, and 32% used 8-10. NICUs with more safety practices did not have a difference in lab-AEs or death.

CONCLUSION

In this cohort, the use of more medication safety practices was not associated with fewer lab-AEs or decreased death.

Prevalence and Nature of Medication Errors and Preventable Adverse Drug Events in Paediatric and Neonatal Intensive Care Settings: A Systematic Review

INTRODUCTION

Children admitted to paediatric and neonatal intensive care units may be at high risk from medication errors and preventable adverse drug events.

OBJECTIVE

The objective of this systematic review was to review empirical studies examining the prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care units.

DATA SOURCES

Seven electronic databases were searched between January 2000 and March 2019.

STUDY SELECTION

Quantitative studies that examined medication errors/preventable adverse drug events using direct observation, medication chart review, or a mixture of methods in children ≤ 18 years of age admitted to paediatric or neonatal intensive care units were included.

DATA EXTRACTION

Data on study design, detection method used, rates and types of medication errors/preventable adverse drug events, and medication classes involved were extracted.

RESULTS

Thirty-five unique studies were identified for inclusion. In paediatric intensive care units, the median rate of medication errors was 14.6 per 100 medication orders (interquartile range 5.7-48.8%, n = 3) and between 6.4 and 9.1 per 1000 patient-days (n = 2). In neonatal intensive care units, medication error rates ranged from 4 to 35.1 per 1000 patient-days (n = 2) and from 5.5 to 77.9 per 100 medication orders (n = 2). In both settings, prescribing and medication administration errors were found to be the most common medication errors, with dosing errors the most frequently reported error subtype. Preventable adverse drug event rates were reported in three paediatric intensive care unit studies as 2.3 per 100 patients (n = 1) and 21-29 per 1000 patient-days (n = 2). In neonatal intensive care units, preventable adverse drug event rates from three studies were 0.86 per 1000 doses (n = 1) and 0.47-14.38 per 1000 patient-days (n = 2). Anti-infective agents were commonly involved with medication errors/preventable adverse drug events in both settings.

CONCLUSIONS

Medication errors occur frequently in critically ill children admitted to paediatric and neonatal intensive care units and may lead to patient harm. Important targets such as dosing errors and anti-infective medications were identified to guide the development of remedial interventions.