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Alzaagi IA, Alshahrani KM, Abudalli AN, Surbaya S, Alnajrani R, Ali S. The Extent of Medication Errors During Hajj in the Kingdom of Saudi Arabia. Cureus 2023; 15:e41801. [PMID: 37575735 PMCID: PMC10422090 DOI: 10.7759/cureus.41801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Background Medication errors are frequently identified in healthcare institutions and pose a risk to patients. The mass gathering during Hajj may expose the pilgrims to numerous health risks. No study has reported the extent of medication errors during Hajj in Saudi Arabia. We investigated the rate, nature, reporting, severity, and causes of medication errors in Hajj pilgrims. Methodology A retrospective analysis of medication errors reported by healthcare professionals was conducted from July 5, 2022, to July 15, 2022, at Mina Al Wadi Hospital, Saudi Arabia. This study included all medication error report forms collected during the Hajj season. The National Coordinating Council for Medication Error Reporting and Prevention Index was used to classify the severity of medication errors. Results There were reports of 43 medication errors in 3,210 prescriptions. The medication error incidence rate was 1.5% (43/3,210). The highest proportion of medication errors (83.72%, 95% confidence interval (CI) = 72.69-94.75) occurred during the prescribing phase, and 97% (95% CI = 93.16-100.0) of medication errors were classified as near misses. Wrong drugs (23.25%) and frequency (18.60%) were responsible for nearly half of the medication errors. Lack of drug information was the leading cause of reported medication errors (58.14%), followed by environmental, personnel, and workload issues (23.25%), and look-alike/sound-alike medication issues (18.60%). Conclusions This study found that the incidence of medication errors was consistent with the global standard, and many of them did not reach pilgrims and were preventable. This highlights the importance of targeted interventions. Incorrect medication was the common type of medication error, highlighting a crucial area for intervention and improvement. Lack of drug information was the primary underlying factor in the occurrence of medication errors. Pharmacists were more likely than other healthcare professionals to report medication errors, highlighting the importance of their involvement in improving medication safety among pilgrims. Future research needs to focus on examining the effectiveness of interventions (e.g., provision of education regarding medicines and medication review) in reducing medicine-related events during Hajj.
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Affiliation(s)
- Ibrahim A Alzaagi
- Pharmaceutical Care Services, King Saud Medical City, Ministry of Health, Riyadh, SAU
| | - Khalid M Alshahrani
- Primary Health Care Center, Mina Al-Wadi Hospital, Ministry of Health, Makkah, SAU
| | - Abdulrahman N Abudalli
- General Directorate of Quality and Efficiency Medical Supply, Ministry of Health, Riyadh, SAU
| | - Saud Surbaya
- Primary Health Care Center, Mina Al-Wadi Hospital, Ministry of Health, Makkah, SAU
| | - Rashid Alnajrani
- Pharmaceutical Care Services, King Saud Medical City, Ministry of Health, Riyadh, SAU
| | - Sheraz Ali
- College of Health and Medicine, University of Tasmania, Hobart, AUS
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Lei KC, Loi CI, Cen Z, Li J, Liang Z, Hu H, Chan TF, Ung COL. Adopting an electronic medication administration system in long-term care facilities: a key stakeholder interview study in Macao. Inform Health Soc Care 2023:1-15. [PMID: 36650719 DOI: 10.1080/17538157.2023.2165084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To improve medication safety for residents in long-term care facilities (LTCFs), electronic medication administration records (eMARs) are widely adopted in Macao. This study aimed to (1) develop a logic model for adopting eMAR in LTCFs and (2) explore the contextual factors relevant to the implementation. Semi-structured interviews were conducted with key stakeholders (managers, doctors, nurses, pharmacy staff and other frontline workers) experienced with eMAR in LTCFs in Macao between February and March 2021. Purposive sampling was used for recruitment and thematic analysis followed the theoretical framework of the logic model. All 57 participants were positive about eMAR. Financial and nonfinancial resources were critical to adopting eMAR. eMAR was mostly used for its functions in documentation, e-prescribing and monitoring. Immediate output included simplified working process, reduced errors, closer monitoring of residents' conditions, and timely communication among staff. The outcomes mainly related to efficiency, safety and quality of care, workload redundancy, and data unification. Key influencing factors included eMAR flexibility, stability, and technical support. Adopting eMARs is highly consuming and the benefits in improving quality of care can only be realized with appropriate implementation, precise execution, regular evaluation and responsive adjustment. The proposed logic model framework serves as a roadmap for LTCFs, both current and future users of eMAR.
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Affiliation(s)
- Ka Cheng Lei
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Cheng I Loi
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Zhifeng Cen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Junlei Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Zuanji Liang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China.,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macao, SAR, China
| | - Tek Fai Chan
- Macao Society for Medicinal Administration, Macao, SAR, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China.,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macao, SAR, China
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Kadro ZO, Chilcoat A, Hill J, Kenney S, Nguyen C, Post E, Corbett AH, Asher GN, Faurot K. Healthcare Professionals' Perspectives on Improving Dietary Supplement Documentation in the Electronic Medical Record: Current Challenges and Opportunities to Enhance Quality of Care and Patient Safety. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2023; 12:27536130231215029. [PMID: 38130392 PMCID: PMC10734342 DOI: 10.1177/27536130231215029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/01/2023] [Accepted: 10/27/2023] [Indexed: 12/23/2023]
Abstract
Background Around half the US population uses dietary supplements (DS), and concomitant use with medications is common. Many DS include bioactive substances that can interact with medications; therefore, accurate tracking is critical for patient safety. Unfortunately, documentation of patients' DS use is often missing or incomplete in the electronic medical record (EMR), leaving patients susceptible to potential adverse events. Novel approaches to assist healthcare professionals (HCPs) in capturing patients' DS use are needed. Objective To assess HCPs' perspectives on challenges and facilitators of DS documentation in the EMR and their opinions on a proposed mHealth application (app) to aid in DS capture. Methods HCPs, recruited from professional networks, largely in North Carolina, using purposive sampling, took part in semi-structured interviews. We inquired about HCPs' experiences with DS documentation in the EMR and their opinions about our proposed mHealth app. Interviews were recorded, transcribed, and coded. Thematic analysis included deductive codes based on the interview guide, and inductive codes that emerged during transcript review. Results HCPs (N = 30) included 60% females, mean age 46 ± 10; 70% White. Pharmacists (20%), nurses (17%), and physicians (17%) were the most represented professions. Years in practice ranged from 3-35 years. Most HCPs were concerned about DS safety and potential supplement-drug interactions, and cited several barriers to accurate EMR DS documentation including time constraints, database inconsistencies, and poor patient-HCP communication about DS. HCPs' views on our proposed mHealth app were generally positive. They expressed that our proposed mHealth app could streamline documentation processes and enhance patient-provider communication. HCPs expressed desire for a high-quality mHealth app that includes access to evidence-based DS information, integrates with the EMR, and does not increase time burdens. Conclusion HCPs believe documentation of patients' DS use is important but not accurately captured in the EMR. Support was expressed for our proposed barcode-scanning DS mHealth app.
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Affiliation(s)
- Zachary O. Kadro
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Integrative Medicine Program, Division of Supportive Care, Fred Hutch Cancer Center, Seattle, WA, USA
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutch Cancer Center, Seattle, WA, USA
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Aisha Chilcoat
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacob Hill
- Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Stephanie Kenney
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Catharine Nguyen
- Janssen Pharmaceutical Companies of Johnson and Johnson, Titusville, NJ, USA
| | - Elana Post
- Clinical Pharmacologist, Vertex Pharmaceuticals Inc, Boston, MA, USA
| | - Amanda H. Corbett
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Gary N. Asher
- Department of Family Medicine, Director Integrative Medicine Services, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Keturah Faurot
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Pruitt ZM, Kazi S, Weir C, Taft T, Busog DN, Ratwani R, Hettinger AZ. A Systematic Review of Quantitative Methods for Evaluating Electronic Medication Administration Record and Bar-Coded Medication Administration Usability. Appl Clin Inform 2023; 14:185-198. [PMID: 36889339 PMCID: PMC9995218 DOI: 10.1055/s-0043-1761435] [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: 08/17/2022] [Accepted: 12/20/2022] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Although electronic medication administration records (eMARs) and bar-coded medication administration (BCMA) have improved medication safety, poor usability of these technologies can increase patient safety risks. OBJECTIVES The objective of our systematic review was to identify the impact of eMAR and BCMA design on usability, operationalized as efficiency, effectiveness, and satisfaction. METHODS We retrieved peer-reviewed journal articles on BCMA and eMAR quantitative usability measures from PsycInfo and MEDLINE (1946-August 20, 2019), and EMBASE (1976-October 23, 2019). Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we screened articles, extracted and categorized data into the usability categories of effectiveness, efficiency, and satisfaction, and evaluated article quality. RESULTS We identified 1,922 articles and extracted data from 41 articles. Twenty-four articles (58.5%) investigated BCMA only, 10 (24.4%) eMAR only, and seven (17.1%) both BCMA and eMAR. Twenty-four articles (58.5%) measured effectiveness, 8 (19.5%) efficiency, and 17 (41.5%) satisfaction. Study designs included randomized controlled trial (n = 1; 2.4%), interrupted time series (n = 1; 2.4%), pretest/posttest (n = 21; 51.2%), posttest only (n = 14; 34.1%), and pretest/posttest and posttest only for different dependent variables (n = 4; 9.8%). Data collection occurred through observations (n = 19, 46.3%), surveys (n = 17, 41.5%), patient safety event reports (n = 9, 22.0%), surveillance (n = 6, 14.6%), and audits (n = 3, 7.3%). CONCLUSION Of the 100 measures across the 41 articles, implementing BCMA and/or eMAR broadly resulted in an increase in measures of effectiveness (n = 23, 52.3%) and satisfaction (n = 28, 62.2%) compared to measures of efficiency (n = 3, 27.3%). Future research should focus on eMAR efficiency measures, utilize rigorous study designs, and generate specific design requirements.
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Affiliation(s)
- Zoe M. Pruitt
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
| | - Sadaf Kazi
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
| | - Teresa Taft
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
| | - Deanna-Nicole Busog
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
| | - Raj Ratwani
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Aaron Z. Hettinger
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
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Boehme S, Wohlt P, Valentine J, Ensign R. Sustained barcode medication administration rates less than 2 percent in a large healthcare system. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2022. [DOI: 10.1177/25160435221137145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Purpose Implementation of bar code medication administration (BCMA) technology is an effective strategy to decrease medication administration errors. Consistent use of BCMA technology within a hospital system should result in improved patient safety through the reduction of medication related administration errors. Based on this premise, a large health system established an annual goal to reduce BCMA override rates to less than 2%. Methods A large health system located in the Intermountain West developed a BCMA override reporting tool to assist with reducing BCMA override rates. An essential component of the reporting tool is the visual management strategy which allows caregivers to easily identify goal progress. The tool also includes information that managers can use to determine how often their direct reports override medications. Pharmacy caregivers can also use the data from the reporting tool to address specific issues related to medications that do not scan properly. Results Implementation of the tool and education on its use, resulted in individual follow up with nursing units and nurses, ultimately producing sustained barcode overrides less than 2%. Conclusion By implementing reporting systems that identifies specific opportunities for improvement, barcode override rates can be decreased to less than 2% in a large healthcare system.
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Affiliation(s)
- Sabrina Boehme
- Department of Pharmacy, Primary Children's Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Paul Wohlt
- Department of Pharmacy, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - John Valentine
- Enterprise Analytics, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Richard Ensign
- Enterprise Analytics, Intermountain Healthcare, Salt Lake City, Utah, USA
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Fuller AEC, Guirguis LM, Sadowski CA, Makowsky MJ. Evaluation of Medication Incidents in a Long-term Care Facility Using Electronic Medication Administration Records and Barcode Technology. Sr Care Pharm 2022; 37:421-447. [DOI: 10.4140/tcp.n.2022.421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains
analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Design
Retrospective incident report review. Setting A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. Participants 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. Interventions
None. Results Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%,
43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8%
(30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Conclusion Administration
and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.
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Affiliation(s)
- Andrew E. C. Fuller
- University of Alberta, College of Health Sciences, Edmonton, Alberta, Canada
| | - Lisa M. Guirguis
- University of Alberta, College of Health Sciences, Edmonton, Alberta, Canada
| | - Cheryl A. Sadowski
- University of Alberta, College of Health Sciences, Edmonton, Alberta, Canada
| | - Mark J. Makowsky
- University of Alberta, College of Health Sciences, Edmonton, Alberta, Canada
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Ledlow JH, Judson T, Watts P, Vance DE, Moss J. Integrating a simulated electronic medical record system and barcode medication administration into a pre-licensure nursing program. J Prof Nurs 2022; 40:38-41. [DOI: 10.1016/j.profnurs.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 11/29/2022]
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Nurses' Perceptions of Using Personal Digital Assistants in Tertiary Hospitals. Comput Inform Nurs 2022; 40:682-690. [PMID: 35475919 DOI: 10.1097/cin.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Personal digital assistants can perform multiple functions such as Internet search, documentation, calculating, and barcode scanning. This study examined nurses' perceptions of personal digital assistants used as a barcode scanner for medication administration, blood transfusions, and blood collection. A total of 236 nurses participated in the survey using the instrument developed by the researchers. The data collected were analyzed using descriptive statistics, one-way analysis of variance, and the Scheffe test. Written responses to the advantages and drawbacks of using personal digital assistants were categorized by meaning. The results showed that the nurses perceived more drawbacks than advantages in using personal digital assistants because of nonworking barcodes, prescription practice requiring additional scanning, poor interfacing between personal digital assistants and the EMR, and frequent Wi-Fi disconnection. The drawbacks resulted in delays in nursing workflow for patient care. Therefore, increasing the availability of barcode scanning for all medications applicable to personal digital assistant use, redesigning the practice of current prescriptions to eliminate additional scanning, and seamless interfacing between personal digital assistants and EMRs should be considered. This enables the nurses to use personal digital assistants more efficiently and effectively for patient care.
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Interdisciplinary and Innovative: A Nursing and Computer Science Collaboration to Create a Barcode Medication Administration System. Nurs Educ Perspect 2022; 44:192-193. [PMID: 35420576 DOI: 10.1097/01.nep.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Preventing medication errors remains a priority in nursing education. The implementation of Barcode Medication Administration (BCMA) systems is one strategy that has been used to reduce medication errors. Practice using BCMA in simulated settings may enhance the transfer of these skills to the clinical practice setting. However, the purchase of BCMA educational products available for nursing students can be cost prohibitive for many nursing programs. To overcome the barrier of cost, an interdisciplinary and innovative collaborative approach was used to create a fully functional low-cost BCMA system.
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Pezzotti G, Boschetto F, Ohgitani E, Fujita Y, Shin‐Ya M, Adachi T, Yamamoto T, Kanamura N, Marin E, Zhu W, Nishimura I, Mazda O. Raman Molecular Fingerprints of SARS-CoV-2 British Variant and the Concept of Raman Barcode. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2103287. [PMID: 34877818 PMCID: PMC8787433 DOI: 10.1002/advs.202103287] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/04/2021] [Indexed: 06/12/2023]
Abstract
The multiple mutations of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus have created variants with structural differences in both their spike and nucleocapsid proteins. While the functional relevance of these mutations is under continuous scrutiny, current findings have documented their detrimental impact in terms of affinity with host receptors, antibody resistance, and diagnostic sensitivity. Raman spectra collected on two British variant sub-types found in Japan (QK002 and QHN001) are compared with that of the original Japanese isolate (JPN/TY/WK-521), and found bold vibrational differences. These included: i) fractions of sulfur-containing amino acid rotamers, ii) hydrophobic interactions of tyrosine phenol ring, iii) apparent fractions of RNA purines and pyrimidines, and iv) protein secondary structures. Building upon molecular scale results and their statistical validations, the authors propose to represent virus variants with a barcode specially tailored on Raman spectrum. Raman spectroscopy enables fast identification of virus variants, while the Raman barcode facilitates electronic recordkeeping and translates molecular characteristics into information rapidly accessible by users.
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Affiliation(s)
- Giuseppe Pezzotti
- Ceramic Physics LaboratoryKyoto Institute of TechnologySakyo‐ku, MatsugasakiKyoto606‐8585Japan
- Department of ImmunologyGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐ku, 465 Kajii‐choKyoto602‐8566Japan
- Department of Orthopedic SurgeryTokyo Medical University6‐7‐1 Nishi‐Shinjuku, Shinjuku‐kuTokyo160‐0023Japan
- The Center for Advanced Medical Engineering and InformaticsOsaka University2‐2 Yamadaoka, SuitaOsaka565‐0854Japan
- Institute of Biomaterials and BioengineeringTokyo Medical and Dental University2‐3‐10 Kanda‐Surugadai, Chiyoda‐kuTokyo101‐0062Japan
- Department of Dental MedicineGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐kuKyoto602‐8566Japan
| | - Francesco Boschetto
- Ceramic Physics LaboratoryKyoto Institute of TechnologySakyo‐ku, MatsugasakiKyoto606‐8585Japan
- Department of ImmunologyGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐ku, 465 Kajii‐choKyoto602‐8566Japan
| | - Eriko Ohgitani
- Department of ImmunologyGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐ku, 465 Kajii‐choKyoto602‐8566Japan
| | - Yuki Fujita
- Ceramic Physics LaboratoryKyoto Institute of TechnologySakyo‐ku, MatsugasakiKyoto606‐8585Japan
| | - Masaharu Shin‐Ya
- Department of ImmunologyGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐ku, 465 Kajii‐choKyoto602‐8566Japan
| | - Tetsuya Adachi
- Department of Dental MedicineGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐kuKyoto602‐8566Japan
| | - Toshiro Yamamoto
- Department of Dental MedicineGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐kuKyoto602‐8566Japan
| | - Narisato Kanamura
- Department of Dental MedicineGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐kuKyoto602‐8566Japan
| | - Elia Marin
- Ceramic Physics LaboratoryKyoto Institute of TechnologySakyo‐ku, MatsugasakiKyoto606‐8585Japan
- Department of Dental MedicineGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐kuKyoto602‐8566Japan
| | - Wenliang Zhu
- Ceramic Physics LaboratoryKyoto Institute of TechnologySakyo‐ku, MatsugasakiKyoto606‐8585Japan
| | - Ichiro Nishimura
- Division of Advanced ProsthodonticsThe Jane and Jerry Weintraub Center for Reconstructive BiotechnologyUCLA School of DentistryLos AngelesCA90095USA
| | - Osam Mazda
- Department of ImmunologyGraduate School of Medical ScienceKyoto Prefectural University of MedicineKamigyo‐ku, 465 Kajii‐choKyoto602‐8566Japan
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Revel E, Picard A, Malet L, Grenier B, Susong G, Gaillourdet P, Breant V, Dode X. [EASYSCAN: French pilot study for securing drug administration by barcode reading]. ANNALES PHARMACEUTIQUES FRANÇAISES 2021; 80:738-748. [PMID: 34968478 DOI: 10.1016/j.pharma.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Elsa Revel
- Service Pharmacie, Groupement Hospitalier Est, Hospices Civils de Lyon, France.
| | - Alexandre Picard
- Service Pharmacie, Groupement Hospitalier Est, Hospices Civils de Lyon, France
| | - Louise Malet
- Service Pharmacie, Groupement Hospitalier Est, Hospices Civils de Lyon, France
| | - Benjamin Grenier
- Service Pharmacie, Groupement Hospitalier Est, Hospices Civils de Lyon, France
| | - Gabriel Susong
- Direction des Systèmes d'Information et Informatique, Hospices Civils de Lyon, France
| | | | - Valentine Breant
- Service Pharmacie, Groupement Hospitalier Est, Hospices Civils de Lyon, France
| | - Xavier Dode
- Service Pharmacie, Groupement Hospitalier Est, Hospices Civils de Lyon, France; Centre National Hospitalier d'Information sur le Médicament (CNHIM), France
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12
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Adams KT, Pruitt Z, Kazi S, Hettinger AZ, Howe JL, Fong A, Ratwani RM. Identifying Health Information Technology Usability Issues Contributing to Medication Errors Across Medication Process Stages. J Patient Saf 2021; 17:e988-e994. [PMID: 34009868 DOI: 10.1097/pts.0000000000000868] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Different health information technology (health IT) systems are intended to support medication ordering, reviewing, and administration. We sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors. METHODS Patient safety event reports from more than 595 healthcare facilities entered between January 2013 and September 2018 were analyzed. We computationally identified reports associated with health IT intended to support the medication process, including computerized provider order entry, electronic medication administration record, and barcode medication administration. From these, 2700 reports were manually reviewed to determine the type of medication error, medication process stage, and health IT usability issue. RESULTS Of the 2700 manually reviewed reports, 1508 (55.9%) described a medication error that was associated with health IT use and 750 (49.7%) reached the patient. Improper dose errors were frequent (1214 of 1508, 80.5%) with most errors during ordering (673 of 1508, 44.6%) and reviewing medications (639 of 1508, 42.4%). Most health IT-associated medication error reports described usability issues (n = 1468 of 1508, 97.3%) including data entry, workflow support, and alerting. Data entry usability issues impacted few medication process stages, whereas workflow support and alerting impacted several stages. CONCLUSIONS Health IT usability issues are a prevalent contributing factor to medication errors, many of which reach the patient. Data entry, workflow support, and alerting should be prioritized during usability and safety optimization efforts.
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Affiliation(s)
- Katharine T Adams
- From the MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Hyattsville, MD
| | - Zoe Pruitt
- From the MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Hyattsville, MD
| | | | | | - Jessica L Howe
- From the MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Hyattsville, MD
| | - Allan Fong
- From the MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Hyattsville, MD
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Human-Based Errors Involving Smart Infusion Pumps: A Catalog of Error Types and Prevention Strategies. Drug Saf 2021; 43:1073-1087. [PMID: 32797355 DOI: 10.1007/s40264-020-00986-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Over 4000 preventable injuries due to medication errors occur each year in any given hospital. Smart pumps have been widely introduced as one means to prevent these errors. Although smart pumps have been implemented to prevent errors, they fail to prevent specific types of errors in the medication administration process and may introduce new errors themselves. As a result, unique prevention strategies have been implemented by providers. No catalog of smart pump error types and prevention strategies currently exists. The aim of this study is to review and catalog the types of human-based errors related to smart pump use identified in the literature and to summarize the associated error-prevention strategies. We searched MEDLINE, PubMed, PubMed Central, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for literature pertaining to human-based errors associated with smart pumps. Studies related to smart pump implementation, other types of pumps, and mechanical failures were excluded. Final selections were mapped for error types and associated prevention strategies. A total of 1177 articles were initially identified, and 105 articles were included in the final review. Extraction of error types and prevention strategies resulted in the identification of 18 error types and ten prevention strategies. Through a comprehensive literature review, we compiled a catalog of smart pump-related errors and associated prevention strategies. Strategies were mapped to error types to provide an initial framework for others to use as a resource in their error reviews and improvement work. Future research should assess the application of the resources provided by this review.
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Regier BA, Meyer TA, McAllister RK. Propofol 2%: understanding a new concentration of a well-known medication. Proc AMIA Symp 2021; 34:642-643. [PMID: 34456502 DOI: 10.1080/08998280.2021.1937009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Betsy A Regier
- Department of Anesthesiology, Baylor Scott & White Medical Center - Temple, Temple, Texas.,Department of Anesthesiology, Texas A&M College of Medicine, Temple, Texas
| | - Tricia A Meyer
- Department of Anesthesiology, Texas A&M College of Medicine, Temple, Texas.,Department of Pharmacy, Baylor Scott & White Medical Center - Temple, Temple, Texas
| | - Russell K McAllister
- Department of Anesthesiology, Baylor Scott & White Medical Center - Temple, Temple, Texas.,Department of Anesthesiology, Texas A&M College of Medicine, Temple, Texas
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Dose Verification Errors in Hospitals: Literature Review of the eMAR-based Systems Used by Nurses. J Nurs Care Qual 2021; 36:182-187. [PMID: 32541426 DOI: 10.1097/ncq.0000000000000491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effectiveness of the dose verification features of the electronic medication administration record (eMAR) and complementary systems in the hospital setting is not well understood. PURPOSE The authors completed a narrative synthesis of literature findings on the effectiveness of eMAR-based systems in the hospital setting. METHODS A literature review was carried out across 5 bibliographic databases to evaluate the safety features of current eMAR-based systems in preventing dosing errors and design issues that impede their usability. RESULTS While eMAR-based systems are beneficial to reducing order and drug cross-checking errors, safe dose verification features are sporadically available for targeted tasks. Overall, the eMAR had little impact on preventing low to moderate dosing errors. Dosing errors may occur because of error-prone activities that result from system design and work process issues during medication administration.
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Maximous R, Wong J, Chung F, Abrishami A. Interventions to reduce medication errors in anesthesia: a systematic review. Can J Anaesth 2021; 68:880-893. [PMID: 33709263 DOI: 10.1007/s12630-021-01959-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/03/2021] [Accepted: 02/18/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The objective of this study was to provide a synthesis of the interventions designed to reduce medication errors in anesthetized patients. METHODS We electronically searched major databases using index and free-text keywords related to anesthesia and medication errors. We included cohort studies exploring interventions to reduce anesthetic medication errors in both adult and pediatric patients. The risk of bias for each study was assessed using the Newcastle-Ottawa Scale. RESULTS One thousand five-hundred and fifty-eight titles or abstracts were screened, and 56 full-text studies were assessed for eligibility; eight studies were included in the final analysis. Case reports and retrospective studies were excluded. The quality of most studies (n = 6) was graded as "low". There were three categories of interventions: I) multimodal interventions (6 studies, n = 900,170 medication administrations) showed a reduction in rates of errors of 21-35% per administration and 37-41% per anesthetic; II) improved labels (1 study, n = 55,426 medication administrations) resulted in a 37% reduction in rates of errors per anesthetic; and III) the effect of education was assessed in one study and showed no effect. CONCLUSION Multimodal interventions and improved labelling reduce medication errors in anesthetized patients.
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Affiliation(s)
- Ramez Maximous
- Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Symth Road #2044, Ottawa, ON, K1H 8M5, Canada.
| | - Jean Wong
- Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada
| | - Frances Chung
- Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada
| | - Amir Abrishami
- Niagara Health, St. Catharines, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Cairns Family Health and Bioscience, Niagara Regional Campus, St. Catharines, ON, Canada
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17
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Joseph R, Lee SW, Anderson SV, Morrisette MJ. Impact of interoperability of smart infusion pumps and an electronic medical record in critical care. Am J Health Syst Pharm 2021; 77:1231-1236. [PMID: 32620966 DOI: 10.1093/ajhp/zxaa164] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To describe the benefits of smart infusion pump interoperability with an electronic medical record (EMR) system in an adult intensive care unit (ICU) setting. SUMMARY In order to assess the impact of smart infusion pump and EMR interoperability, we observed whether there were changes in the frequency of electronic medication administration record (eMAR) documentation of dose titrations in epinephrine and norepinephrine infusions in the ICU setting. As a secondary endpoint, we examined whether smart pump/EMR interoperability had any impact on the rate of alerts triggered by the dose-error reduction software. Pharmacist satisfaction was measured to determine the impact of smart pump/EMR interoperability on pharmacist workflow. In the preimplementation phase, there were a total of 2,503 administrations of epinephrine and norepinephrine; 13,299 rate changes were documented, for an average of 5.31 documented rate changes per administration. With smart pump interoperability, a total of 13,024 rate changes were documented in association with 1,401 administrations, for an average of 9.29 documented rate changes per administration (a 74.9% increase). A total of 1,526 dose alerts were triggered in association with 76,145 infusions in the preimplementation phase; there were 820 dose alerts associated with 48,758 autoprogammed infusions in the postimplementation phase (absolute difference, -0.32%). ICU pharmacists largely agreed (75% of survey respondents) that the technology provided incremental value in providing patient care. CONCLUSION Interoperability between the smart pump and EMR systems proved beneficial in the administration and monitoring of continuous infusions in the ICU setting. Additionally, ICU pharmacists may be positively impacted by improved clinical data accuracy and operational efficiency.
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Affiliation(s)
- Roy Joseph
- Rady Children's Hospital - San Diego, San Diego, CA
| | - Sang Weon Lee
- University of Virginia Health System, Charlottesville, VA
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18
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Perrier Q, Lavallard V, Pernin N, Wassmer CH, Cottet-Dumoulin D, Lebreton F, Bellofatto K, Andres A, Berishvili E, Bosco D, Berney T, Parnaud G. Failure mode and effect analysis in human islet isolation: from the theoretical to the practical risk. Islets 2021; 13:1-9. [PMID: 33616002 PMCID: PMC8018422 DOI: 10.1080/19382014.2020.1856618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
This study aimed to assess the global mapping risk of human islet isolation, using a failure mode and effect analysis (FMEA), and highlight the impact of quality assurance procedures on the risk level of criticality. Risks were scored using the risk priority number (RPN) scoring method. The risk level of criticality was made based on RPN and led to risk classification (low to critical). A raw risk analysis and a risk control analysis (with control means and quality assurance performance) were undertaken. The process of human islet isolation was divided into 11 steps, and 230 risks were identified. Analysis of the highest RPN of each of the 11 steps showed that the 4 highest risks were related to the pancreas digestion and islet purification stages. After implementation of reduction measures and controls, critical and severe risks were reduced by 3-fold and by 2-fold, respectively, so that 90% of risks could be considered as low to moderate. FMEA has proven to be a powerful approach for the identification of weaknesses in the islet isolation processes. The results demonstrated the importance of staff qualification and continuous training and supported the contribution of the quality assurance system to risk reduction.
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Affiliation(s)
- Quentin Perrier
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
- Clinical Pharmacy Department , Grenoble Alpes University, Grenoble, France
- CONTACT Quentin Perrier Centre Médical Universitaire de Genève Laboratoire de Transplantation Cellulaire, 1 Rue Michel Servet, Genève1211, Switzerland
| | - Vanessa Lavallard
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Nadine Pernin
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Charles-Henri Wassmer
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - David Cottet-Dumoulin
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Fanny Lebreton
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Kevin Bellofatto
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Axel Andres
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Ekaterine Berishvili
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Domenico Bosco
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Thierry Berney
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Géraldine Parnaud
- Cell Isolation and Transplantation Center, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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Batista A, Polidori P, Kohl S. Position paper on patient safety. Eur J Hosp Pharm 2020; 28:ejhpharm-2019-001924. [PMID: 33355293 PMCID: PMC8077631 DOI: 10.1136/ejhpharm-2019-001924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Aida Batista
- Pharmacy, Centro Hospitalar Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal
| | | | - Stephanie Kohl
- Policy & Advocacy, European Association of Hospital Pharmacists, Brussels, Belgium
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20
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Nurses' Compliance With Bar-code Medication Administration Technology: Results of Direct Observation of Jordanian Nurses' Practice. Comput Inform Nurs 2020; 38:256-262. [PMID: 32015260 DOI: 10.1097/cin.0000000000000591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Medication administration using bar-code medication administration technology enhances the verification of medication administration rights. Nurses' compliance with bar-code medication administration procedure is essential to maximize the benefits. This study evaluated the current rate of nurses' compliance with bar-code medication administration use through direct observation. A descriptive design was used and 134 RNs were recruited from two public hospitals located in the middle region of Jordan. Compliance with bar-code medication administration was evaluated using an evidence-based checklist of 17 items. Participants' compliance with the bar-code medication administration was 55%, which had a significant positive correlation with their level of comfort using bar-code medication administration, usefulness, and ease of use, perceived job productivity, and overall rating of bar-code medication administration. Stakeholders can benefit from assessing end-user acceptance and perceptions regarding the bar-code medication administration technology to promote acceptance and compliance.
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21
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Barakat S, Franklin BD. An Evaluation of the Impact of Barcode Patient and Medication Scanning on Nursing Workflow at a UK Teaching Hospital. PHARMACY 2020; 8:E148. [PMID: 32824909 PMCID: PMC7560167 DOI: 10.3390/pharmacy8030148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/10/2020] [Accepted: 08/15/2020] [Indexed: 11/16/2022] Open
Abstract
Barcode medication administration (BCMA) is advocated as a technology that reduces medication errors relating to incorrect patient identity, drug or dose. Little is known, however, about the impact it has on nursing workflow. Our aim was to investigate the impact of BCMA on nursing activity and workflow. A comparative study was conducted on two similar surgical wards within an acute UK hospital. We observed nurses during drug rounds on a non-BCMA ward and a BCMA ward. Data were collected on drug round duration, timeliness of medication administration, patient identification, medication verification and general workflow patterns. BCMA appears not to alter drug round duration, although it may reduce the administration time per dose. Workflow was more streamlined, with less use of the medicines room. The rate of patient identification increased from 74% (of 47) patients to 100% (of 43), with 95% of 255 scannable medication doses verified using the system. This study suggests that BCMA does not affect drug round duration; further research is required to determine the impact it has on timeliness of medication administration. There was reduced variability in the medication administration workflow of nurses, along with an increased patient identification rate and high medication scan rate, representing potential benefits to patient safety.
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Affiliation(s)
- Sara Barakat
- Department of Practice and Policy, UCL School of Pharmacy, University College London, London WC1N 1AX, UK;
| | - Bryony Dean Franklin
- Department of Practice and Policy, UCL School of Pharmacy, University College London, London WC1N 1AX, UK;
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London W6 8RF, UK
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22
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Leonard JB, McFadden C, Feemster AA, Klein-Schwartz W. Analysis of iatrogenic and in-hospital medication errors reported to United States poison centers: a retrospective observational study. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00723-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Chan R, Booth R, Strudwick G, Sinclair B. Nursing Students' Perceived Self-Efficacy and the Generation of Medication Errors with the Use of an Electronic Medication Administration Record (eMAR) in Clinical Simulation. Int J Nurs Educ Scholarsh 2019; 16:ijnes-2019-0014. [PMID: 31539361 DOI: 10.1515/ijnes-2019-0014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/30/2019] [Indexed: 11/15/2022]
Abstract
Medication errors continue to be a significant issue, posing substantial threats to the safety and well-being of patients. Through Bandura's theory of self-efficacy, nursing students' self-efficacy (confidence) related to medication administration was examined to investigate its influence on the generation of medication errors with the use of an Electronic Medication Administration Record (eMAR) in clinical simulation. This study examined the generation of medication errors and the differences that may exist based on nursing students' perceived confidence. The findings of this study demonstrated that nursing students continue to generate medication errors within clinical simulation. No differences in the generation of medication errors were found between nursing students with perceived high levels of confidence and those with perceived low levels of confidence (one exception noted). Further examination of the variables and contextual factors related to safe medication administration practices is required to inform nursing education and practice.
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Affiliation(s)
- Ryan Chan
- Arthur Labatt Family School of Nursing, Western University, N6A5B9London, Ontario, Canada
| | - Richard Booth
- Arthur Labatt Family School of Nursing, Western University, N6A5B9London, Ontario, Canada
| | | | - Barbara Sinclair
- Arthur Labatt Family School of Nursing, Western University, N6A5B9London, Ontario, Canada
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24
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Morelock SG, Kirk JD. An urban medical system's exploratory study of medication errors. Nurs Open 2019; 6:1197-1204. [PMID: 31367446 PMCID: PMC6650646 DOI: 10.1002/nop2.319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 03/21/2019] [Accepted: 05/21/2019] [Indexed: 11/06/2022] Open
Abstract
AIMS This study sought to identify patterns of medication errors with respect to shifts, day of week, unit involved, severity, medication class and cause of errors and to propose possible solutions. DESIGN This was a retrospective explorative study using a database containing 605 medication events from two medical centres. Variables assessed include medication type, the error severity, and time the medication was ordered, the unit that the error occurred on and the day of the week of the errors. METHODS Simple percentages were used to report the results, and point-biserial correlation was employed to test for significant differences between the day and night shifts. RESULTS There were no statistically significant findings when comparing event severity against the a.m. or p.m. shifts. The medication classes with the most errors were antibiotics, and the most common reason cited for errors was dose omission. The most commonly reported severity level was a 2 which requires increased patient monitoring.
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25
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Darawad MW, Othman EH, Alosta MR. Nurses' satisfaction with barcode medication‐administration technology: Results of a cross‐sectional study. Nurs Health Sci 2019; 21:461-469. [DOI: 10.1111/nhs.12620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 04/14/2019] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
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26
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Wallis J, Fletcher D, Bentley A, Ludders J. Medical Errors Cause Harm in Veterinary Hospitals. Front Vet Sci 2019; 6:12. [PMID: 30805349 PMCID: PMC6370638 DOI: 10.3389/fvets.2019.00012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/15/2019] [Indexed: 11/17/2022] Open
Abstract
Medical errors are a leading cause of mortality in human medicine. In contrast, errors in veterinary medicine are rarely discussed, and there is little known about their nature and frequency. This study aimed to evaluate the type and severity of medical errors reported in three veterinary hospitals. The voluntary online incident reporting systems of a small animal teaching hospital, large animal teaching hospital, and small animal multi-specialty practice were reviewed. Reports were included if they were entered between February 2015 and March 2018, and involved an incident pertaining to patient safety. The reporting systems classified errors into the following categories: drug, iatrogenic, system, communication, lab, oversight, staff, or equipment errors. In addition, all incidents were classified as resulting in either a near miss, harmless hit, adverse incident, or unsafe condition. Adverse incidents were further evaluated retrospectively for error severity. A total of 560 incident reports were included for analysis. Drug errors were the most frequently reported in all three hospitals, followed by failures of communication. Errors most commonly reached patients without causing harm (45%); however, 15% of all incidents resulted in patient harm. Eight percent of patients harmed suffered permanent morbidity or death. A higher proportion of adverse incidents were reported in the small animal teaching hospital than in the other two practice settings. This study demonstrates that medical errors have a substantial impact on veterinary patients. Establishing that drug and communication errors are most frequent in a variety of hospitals is the first step toward interventions to improve patient safety and outcomes in veterinary medicine.
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Affiliation(s)
- Jessica Wallis
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Daniel Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Adrienne Bentley
- Cornell University Veterinary Specialists, Stamford, CT, United States
| | - John Ludders
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
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Abstract
When a medication administration error occurs, patient safety is endangered. Barcode medication administration system usage has been implemented to reduce medication errors. The purpose of this study was to evaluate barcode medication administration system usage outcomes. A survey based on DeLone and McLean's model of information systems success was utilized. The questionnaire, composed of 27 items, explored system quality, information quality, service quality, user satisfaction, and usage benefits. It was completed by 232 nurses. User satisfaction received the highest average score, and quality of information was the most critical factor related to this result (r = 0.83, P < .01). Medication errors occurring before and after barcode medication administration use were collected, and the reasons for errors related to work process were explored. Medication errors decreased from 405 at preimplementation to 314 at postimplementation (t = 77.62, P < .001). The main reason for medication errors related to work process was "not following the standard procedure," followed by "other factors." While technology is deployed to support individual practice, organizational elements also remain important to technology adoption.
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28
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Thompson KM, Swanson KM, Cox DL, Kirchner RB, Russell JJ, Wermers RA, Storlie CB, Johnson MG, Naessens JM. Implementation of Bar-Code Medication Administration to Reduce Patient Harm. Mayo Clin Proc Innov Qual Outcomes 2018; 2:342-351. [PMID: 30560236 PMCID: PMC6257885 DOI: 10.1016/j.mayocpiqo.2018.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/12/2018] [Accepted: 09/04/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To assess the impact of implementing bar-code medication administration (BCMA) technology on the rate of medication administration errors in the inpatient setting, specifically those that affect the patient and result in harm. Patients and Methods Implementation of the new technology began in September 2008 in a staged rollout of 4 or 5 units at a time in 11 separate waves. All corresponding medication administrations and voluntarily reported medication-related adverse events from March 1, 2007, through September 30, 2013, were included for analyses. Adherence to the use of BCMA technology and the number of adverse events were tracked and compared across the preimplementation period through follow-up. Actual errors, not potential errors, were included in the analysis. Results After the BCMA technology was introduced, reported medication administration errors decreased by 43.5%. More importantly, the rate of harmful medication errors decreased from 0.65 per 100,000 medications preintervention to 0.29 per 100,000 medications postintervention. This resulted in a 55.4% decrease in actual patient harm events. None of the errors at category E or higher was caused by BCMA factors. Conclusion Consistent use of BCMA technology improves patient safety by decreasing the number of patients harmed by medication administration errors.
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Affiliation(s)
| | - Kristi M Swanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Debra L Cox
- Department of Nursing, Mayo Clinic, Rochester, MN
| | | | | | - Robert A Wermers
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Curtis B Storlie
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Matthew G Johnson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - James M Naessens
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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29
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Courter JD, Parker SK, Thurm C, Kronman MP, Weissman SJ, Shah SS, Hersh AL, Brogan TV, Patel SJ, Smith MJ, Lee BR, Newland JG, Gerber JS. Accuracy of Administrative Data for Antimicrobial Administration in Hospitalized Children. J Pediatric Infect Dis Soc 2018; 7:261-263. [PMID: 28992185 DOI: 10.1093/jpids/pix064] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 07/12/2017] [Indexed: 12/26/2022]
Abstract
Administrative data are often used as a proxy for medication-administration record (MAR) data. Multicenter MAR data were compared retrospectively with administrative data from January 2010 through June 2013 from the Pediatric Health Information Systems database. We found that administrative data were more concordant with bill-upon-administration than bill-upon-dispense data.
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Affiliation(s)
- Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical, Ohio
| | - Sarah K Parker
- Department of Pediatrics, Children's Hospital Colorado/University of Colorado, Aurora
| | - Cary Thurm
- Children's Hospital Association, Overland Park, Kansas
| | - Matthew P Kronman
- Division of Infectious Diseases, University of Washington School of Medicine
| | - Scott J Weissman
- Division of Infectious Diseases, University of Washington School of Medicine
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Ohio
| | - Adam L Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
| | - Thomas V Brogan
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine
| | - Sameer J Patel
- Division of Pediatric Infectious Disease Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Michael J Smith
- Division of Pediatric Infectious Diseases, University of Louisville School of Medicine, Kentucky
| | - Brian R Lee
- Division of Infectious Diseases, Children's Mercy Hospital-Kansas City
| | - Jason G Newland
- Division of Pediatric Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
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30
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Fuller AEC, Guirguis LM, Sadowski CA, Makowsky MJ. Electronic Medication Administration Records in Long-Term Care Facilities: A Scoping Review. J Am Geriatr Soc 2018; 66:1428-1436. [PMID: 29684250 DOI: 10.1111/jgs.15384] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To map the extent, range, and nature of research on the effectiveness, level of use, and perceptions about electronic medication administration records (eMARs) in long-term care facilities (LTCFs) and identify gaps in current knowledge and priority areas for future research. DESIGN Scoping review of quantitative and qualitative literature. SETTING Literature review. PARTICIPANTS Original research relating to eMAR in LTCF was eligible for inclusion. MEASUREMENTS We systematically searched MEDLINE, CINAHL, Scopus, ProQuest, and the Cochrane Library and performed general and advanced searches of Google to identify grey literature. Two authors independently screened for eligibility of studies. Independent reviewers extracted data regarding country of origin, design, study methods, outcomes studied, and main results in duplicate. RESULTS We identified 694 articles, of which 34 met inclusion criteria. Studies were published between 2006 and 2016 and were mostly from the United States (n=25). Twenty studies (59%) used quantitative methods, including surveys and analysis of eMAR data; 7 (21%) used qualitative methods, including interviews, focus groups, document review, and observation; and 7 (21%) used mixed methods. Three major research areas were explored: medication and medication administration error rates (n=11), eMAR benefits and challenges (n=19), and eMAR prevalence and uptake (n=15). Evidence linking eMAR use and reductions in medication errors is weak because of suboptimal study design and reporting. The majority of studies were descriptive and documented inconsistent benefits and challenges and low levels of eMAR implementation. CONCLUSION Further investigation is required to rigorously evaluate the effect of standalone eMAR systems on medication administration errors and patient safety, the extent of eMAR implementation, pharmacists' perceptions, and cost effectiveness of eMAR systems in LTCF.
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Affiliation(s)
- Andrew E C Fuller
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa M Guirguis
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Mark J Makowsky
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
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Abstract
OBJECTIVES To describe the clinical decision support tools and advancements in health information technology currently utilized at a National Cancer Institute designated cancer center to aid in achieving the Institute for Healthcare Improvement Triple Aim project. DATA SOURCES Published literature, Web sites. CONCLUSION Advances in health information technology facilitate increasing quality and satisfaction with care, improving the health of populations, and reducing the cost of care. New technology includes integration of the oncology electronic medical record (EMR), smart IV pumps, EMR after-hours nurse triage protocols, and bio-repository data warehouses. IMPLICATIONS FOR NURSING PRACTICE Cancer patients, oncology nurses, and oncologists have an increasing amount of clinical decision support tools available to help achieve the Institute for Healthcare Improvement's Triple Aim.
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Risør BW, Lisby M, Sørensen J. Comparative Cost-Effectiveness Analysis of Three Different Automated Medication Systems Implemented in a Danish Hospital Setting. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:91-106. [PMID: 29119475 DOI: 10.1007/s40258-017-0360-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice. METHODS The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period. RESULTS With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation. CONCLUSION The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.
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Affiliation(s)
- Bettina Wulff Risør
- Department of Public Health, Centre for Health Economic Research (COHERE), University of Southern Denmark, J.B. Winsløwsvej 9B, 5000, Odense C, Denmark.
- Hospital Pharmacy, Central Denmark Region, Nørrebrogade 44, 8000, Aarhus C, Denmark.
| | - Marianne Lisby
- Research Center of Emergency Medicine, Aarhus University Hospital, Building 1B, Nørrebrogade 44, 8000, Aarhus C, Denmark
| | - Jan Sørensen
- Department of Public Health, Centre for Health Economic Research (COHERE), University of Southern Denmark, J.B. Winsløwsvej 9B, 5000, Odense C, Denmark
- Healthcare Outcome Research Centre, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland
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Hawkins SF, Nickman NA, Morse JM. The Paradox of Safety in Medication Management. QUALITATIVE HEALTH RESEARCH 2017; 27:1910-1923. [PMID: 28992756 DOI: 10.1177/1049732317732968] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The reduction of medication errors is largely dependent upon the structure of the medication management system and the role of the pharmacist in the acute care setting. The significance of this claim became evident in an ethnographic study of nurses' work in which data were generated from extensive observations, formal interviews, and document reviews. Each step of medication management-from ordering to administering-was microanalyzed, and spaces and places for error emerged. Results revealed medication errors defined by proximity to the patient. Pharmacists became a surprising "stop-gap" between the physicians and patients in the recognition and interception of medication errors occurring far removed from the bedside and did not formally support the reporting of these errors. Understanding the complexity of this process and the roles of involved personnel reminds us that there is presently no fool-proof plan for the reduction of medication errors and implies a culture of safety remains elusive.
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Affiliation(s)
- Sara F Hawkins
- 1 The University of Utah, Salt Lake City, Utah, USA
- 2 Brigham Young University-Idaho, Rexburg, Idaho, USA
| | - Nancy A Nickman
- 1 The University of Utah, Salt Lake City, Utah, USA
- 3 University of Utah Health, Salt Lake City, Utah, USA
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