Drug administration errors in hospital inpatients: a systematic review

Medication incidents associated with the provision of medication assistance by non-medical care staff in residential care facilities

The shift towards community-based care in Japan has led to increased medication assistance for older people by non-medical care staff. These staff members help take pre-packaged medications, apply patches, and administer eye drops. This study assessed the risks associated with such assistance by reviewing medication-related incidents across 106 residential care facilities between April 1, 2015, and March 31, 2016. An analysis of incident reports showed that all incidents were minor, with no serious outcomes. The incidents were categorized into four types: dropped drugs, misdelivery/misuse of medicines, forgetting to take medicines, and loss of medicines, with dropped drugs being the most frequent. Most incidents occurred in the morning and primarily involved residents with intermediate nursing care needs. These findings indicate a low risk of serious incidents because of medication assistance from non-medical staff. However, the frequency and nature of the incidents were influenced by the timing of medication administration and the care needs of the residents. These insights highlight the need for customized approaches to medication assistance, considering the residents' care levels and potentially optimizing medication administration times to improve safety in residential care settings.

Risks in the analogue and digitally-supported medication process and potential solutions to increase patient safety in the hospital: A mixed methods study

BACKGROUND

In hospital medication errors are common. Our aim was to investigate risks of the analogue and digitally-supported medication process and any potential solutions.

METHODS

A mixed methods study including a structured literature search and online questionnaires based on the Delphi method was conducted. First, all risks were structured into main and sub-risks and second, risks were grouped into risk clusters. Third, healthcare experts assessed risk clusters regarding their likelihood of occurrence their possible impact on patient safety. Experts were also asked to estimate the potential for digital solutions and solutions that strengthen the competence of healthcare professionals.

RESULTS

Overall, 160 main risks and 542 sub-risks were identified. Main risks were grouped into 43 risk clusters. 33 healthcare experts (56% female, 50% with >20 years professional-experience) ranked the likelihood of occurrence and the impact on patient safety in the top 15 risk clusters regarding the process steps: admission (n = 4), prescribing (n = 3), verifying (n = 1), preparing/dispensing (n = 3), administering (n = 1), discharge (n = 1), healthcare professional competence (n = 1), and patient adherence (n = 1). 28 healthcare experts (64% female, 43% with >20 years professional-experience) mostly suggested awareness building and training, strengthened networking, and involvement of pharmacists at point-of-care as likely solutions to strengthen healthcare professional competence. For digital solutions they primarily suggested a digital medication list, digital warning systems, barcode-technology, and digital support in integrated care.

CONCLUSIONS

The medication process holds a multitude of potential risks, in both the analogue and the digital medication process. Different solutions to strengthen healthcare professional competence and in the area of digitalization were identified that could help increase patient safety and minimize possible errors.

Original Research: Exploring Medication Safety Practices from the Nurse's Perspective

BACKGROUND

Medication preparation and administration are complex tasks that nurses must perform daily within today's complicated health care environment. Despite more than two decades of efforts to reduce medication errors, it's well known that such errors remain prevalent. Obtaining insight from direct care nurses may clarify where opportunities for improvement exist and guide future efforts to do so.

PURPOSE

The study purpose was to explore direct care nurses' perspectives on and experiences with medication safety practices and errors.

METHODS

A qualitative descriptive study was conducted among direct care nurses employed across a large health care system. Data were collected using semistructured interview questions with participants in focus groups and one-on-one meetings and were analyzed using qualitative direct content analysis.

RESULTS

A total of 21 direct care nurses participated. Four major themes emerged that impact the medication safety practices of and errors by nurses: the care environment, nurse competency, system influences, and the error paradigm. These themes were often interrelated. Most participants depicted chaotic environments, heavy nursing workloads, and distractions and interruptions as increasing the risk of medication errors. Many seemed unsure about what an error was or could be.

CONCLUSIONS

The complexity of medication safety practices makes it difficult to implement improvement strategies. Understanding the perspectives and experiences of direct care nurses is imperative to implementing such strategies effectively. Based on the study findings, potential solutions should include actively addressing environmental barriers to safe medication practices, ensuring more robust medication management education and training (including guidance regarding the definition of medication errors and the importance of reporting), and revising policies and procedures with input from direct care nurses.

Identifying the data elements and functionalities of clinical decision support systems to administer medication for neonates and pediatrics: a systematic literature review

BACKGROUND

Patient safety is a central healthcare policy worldwide. Adverse drug events (ADE) are among the main threats to patient safety. Children are at a higher risk of ADE in each stage of medication management process. ADE rate is high in the administration stage, as the final stage of preventing medication errors in pediatrics and neonates. The most effective way to reduce ADE rate is using medication administration clinical decision support systems (MACDSSs). The present study reviewed the literature on MACDSS for neonates and pediatrics. It identified and classified the data elements that mapped onto the Fast Healthcare Interoperability Resources (FHIR) standard and the functionalities of these systems to guide future research.

METHODS

PubMed/ MEDLINE, Embase, CINAHL, and ProQuest databases were searched from 1995 to June 31, 2021. Studies that addressed developing or applying medication administration software for neonates and pediatrics were included. Two authors reviewed the titles, abstracts, and full texts. The quality of eligible studies was assessed based on the level of evidence. The extracted data elements were mapped onto the FHIR standard.

RESULTS

In the initial search, 4,856 papers were identified. After removing duplicates, 3,761 titles, and abstracts were screened. Finally, 56 full-text papers remained for evaluation. The full-text review of papers led to the retention of 10 papers which met the eligibility criteria. In addition, two papers from the reference lists were included. A total number of 12 papers were included for analysis. Six papers were categorized as high-level evidence. Only three papers evaluated their systems in a real environment. A variety of data elements and functionalities could be observed. Overall, 84 unique data elements were extracted from the included papers. The analysis of reported functionalities showed that 18 functionalities were implemented in these systems.

CONCLUSION

Identifying the data elements and functionalities as a roadmap by developers can significantly improve MACDSS performance. Though many CDSSs have been developed for different medication processes in neonates and pediatrics, few have actually evaluated MACDSSs in reality. Therefore, further research is needed on the application and evaluation of MACDSSs in the real environment.

PROTOCOL REGISTRATION

(dx.doi.org/10.17504/protocols.io.bwbwpape).

Assessing the severity of medication administration errors identified in an observational study using a valid and reliable method

BACKGROUND

Epidemiological data on medication errors severity are scarce. The assessment of the prevalence and severity of medication errors may be limited because of several reasons, including a lack of standardization in the method of identifying medication administration errors and little knowledge about the appropriate assessment tools to measure severity. Thus, in this study, we aim to assess the potential severity of errors identified by direct observation in a teaching hospital.

METHODS

We used a validated method for assessing the potential severity of medication administration errors. Responses are scored on a 10-point scale. The 203 errors identified in a previous study were organized per similarity, resulting in 67 errors. This list was assessed by a panel of a physician, a nurse, and two pharmacists. The average score for each of the 67 errors was estimated considering the scores given by the 4 judges. Errors with a severity index < 3, between 3 and 7, and > 7 were considered minor, moderate, and severe, respectively.

RESULTS

Professionals classified the potential clinical significance of the errors as minor, moderate, and severe in 8.8% (18/203), 82.8% (168/203), and 8.4% (17/203) of the cases, respectively. Most errors considered potentially serious (41%, 7/17) were technical errors. Most potentially serious errors involved insulin. Regarding the administration route, nine (53%) potentially serious errors involved medications administered intravenously.

CONCLUSIONS

Most of the errors were considered as potentially moderated by the expert panel; however, the frequency of potentially serious errors was higher than that in previous studies using the same methodology, which highlights the need for strategies to reduce their occurrence.

Meta-Analysis of Medication Administration Errors in African Hospitals

ABSTRACT

The incidence of medication administration errors (MAEs) and associated patient harm continue to plague hospitals worldwide. Moreover, there is a lack of evidence to address this problem, especially in Africa. This research synthesis was intended to provide current evidence to decrease the incidence of MAEs in Africa. Standardized search criteria were used to identify primary studies that reported the incidence and/or predictors of MAEs in Africa. Included studies met specifications and were validated with a quality-appraisal tool. The pooled incidence of MAEs in African hospitals was estimated to be 0.56 (CI: 0.4324-0.6770) with a 0.13-0.93 prediction interval. The primary estimates were highly heterogeneous. Most MAEs are explained by system failure and patient factors. The contribution of system factors can be minimized through adequate and ongoing training of nurses on the aspects of safe medication administration. In addition, ensuring the availability of drug use guidelines in hospitals, and minimizing disruptions during the medication process can decrease the incidence of MAEs in Africa.

Creating an evidence-based economic model for prefilled parenteral medication delivery in the hospital setting

OBJECTIVES

Prefilled syringes (PFS) may offer clinical and economic advantages over conventional parenteral medication delivery methods (vials and ampoules). The benefits of converting from vials and ampoules to PFS have been explained in previous drug-specific economic models; however, these models have limited generalisability to different drugs, healthcare settings and other countries. Our study aims to (1) present a comprehensive economic model to assess the impact of switching from vials to PFS delivery; and (2) illustrate through two case studies the model's utility by highlighting important features of shifting from vials to PFS.

METHODS

The economic model estimates the potential benefit of switching to PFS associated with four key outcomes: preventable adverse drug events (pADE), preparation time, unused drugs, and cost of supplies. Model reference values were derived from existing peer-reviewed literature sources. The user inputs specific information related to the department, drug, and dose of interest and can change reference values. Two hypothetical case studies are presented to showcase model utility. The first concerns a cardiac intensive care unit in the United Kingdom administering 30 doses of 1 mg/10 mL atropine/day. The second concerns a coronavirus (COVID-19) intensive care unit in France that administers 30 doses of 10 mg/25 mL ephedrine/day.

RESULTS

Total cost savings per hospital per year, associated with reductions in pADEs, unused drugs, drug cost and cost of supplies were £34 829 for the atropine example and €104 570 for the ephedrine example. Annual preparation time decreased by 371 and 234 hours in the atropine and ephedrine examples, respectively.

CONCLUSIONS

The model provides a generalisable framework with customisable inputs, giving hospitals a comprehensive view of the clinical and economic value of adopting PFS. Despite increased costs per dose with PFS, the hypothetical case studies showed notable reductions in medication preparation time and a net budget savings owing to fewer pADEs and reduced drug wastage.

Imaged capillary isoelectric focusing associated with multivariate analysis: A powerful tool for quality control of therapeutic monoclonal antibodies

Monoclonal antibodies are increasingly used in cancer therapy. To guarantee the quality of these mAbs from compounding to patient administration, characterization methods are required (e.g. identity). In a clinical setting, these methods must be fast and straightforward. For this reason, we investigated the potential of image capillary isoelectric focusing (icIEF) combined with Principal Component Analysis (PCA) and Partial least squares-discriminant analysis (PLS-DA). icIEF profiles obtained from monoclonals antibodies (mAbs) analysis have been pre-processed and the data submitted to principal component analysis (PCA). This pre-processing method has been designed to avoid the impact of concentration and formulation. Analysis of four commercialized mAbs (Infliximab, Nivolumab, Pertuzumab, and Adalimumab) by icIEF-PCA led to the formation of four clusters corresponding to each mAb. Partial least squares-discriminant analysis (PLS-DA) applied to these data allowed us to build models to predict which monoclonal antibody is analyzed. The validation of this model was obtained from k-fold cross-validation and prediction tests. The selectivity and the specificity of the model performance parameters were assessed by the excellent classification obtained. In conclusion, we established that the combination of icIEF and chemometric approaches is a reliable approach for unambiguously identifying compounded therapeutic monoclonal antibodies (mAbs) before patient administration.

Prevalence of medication administration errors in hospitalized adults: A systematic review and meta-analysis up to 2017 to explore sources of heterogeneity

Previous estimates to meta-analyze administration error rates were limited by the high statistical heterogeneity, restricting their use. This study aimed to investigate sources of heterogeneity in pooled administration error rates in hospitalized adults. We systematically searched scientific databases up to November 2017 for studies presenting error rates/relevant numerical data in hospitalized adults. We conducted separate meta-analyses for the numerators: One Medication Error (OME) (each dose can be correct or incorrect) and Total Number of Errors (TNE) (more than one error per dose could be counted), using the generic inverse variance with a 95% confidence interval. Heterogeneity was assessed using the I² and Cochran's Q test. We meta-analyzed 33 studies. The global pooled analyses based on the OME and TNE numerators showed very high heterogeneity (I²  = 100%; p < 0.00001). For each meta-analysis, subgroup analyses based on study characteristics (countries, wards, population, routes of administration, error detection methods, and medications) yielded results with consistently elevated heterogeneity. Beyond these characteristics, we stratified the studies according to the mean error prevalence level as the threshold. Based on the OME numerator, we identified two subgroups of low (0.15[0.13-0.17]; I²  = 0%; p = 0.43) and high (0.26[0.24-0.27]; I²  = 38%; p = 0.17) pooled prevalence rates, with controlled heterogeneity. Similarly, for the TNE numerator, we identified two subgroups of low (0.10[0.09-0.10]; I²  = 0%; p = 0.76) and high (0.28[0.27-0.29]; I²  = 0%; p = 0.89) pooled prevalence rates, with controlled heterogeneity. These subgroups differed regarding the denominators used: Total opportunities for errors versus others (doses, observations, administrations). Calculation methods, specifically the denominator, seem a primary factor in explaining heterogeneity in error rates. Standardizing numerators, denominators, and definitions is necessary.

Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study

AIMS AND OBJECTIVES

To identify the prevalence and determinants of medication administration errors (MAEs).

BACKGROUND

Insight into determinants of MAEs is necessary to identify interventions to prevent MAEs.

DESIGN

A prospective observational study in two Dutch hospitals, a university and teaching hospital.

METHODS

Data were collected by observation. The primary outcome was the proportion of administrations with one or more MAEs. Secondary outcomes were the type, severity and determinants of MAEs. Multivariable mixed-effects logistic regression analyses were used for determinant analysis. Reporting adheres to the STROBE guideline.

RESULTS

MAEs occurred in 352 of 2576 medication administrations (13.7%). Of all MAEs (n = 380), the most prevalent types were omission (n = 87) and wrong medication handling (n = 75). Forty-five MAEs (11.8%) were potentially harmful. The pharmaceutical forms oral liquid (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43-7.25), infusion (OR 1.73, CI 1.02-2.94), injection (OR 3.52, CI 2.00-6.21), ointment (OR 10.78, CI 2.10-55.26), suppository/enema (OR 6.39, CI 1.13-36.03) and miscellaneous (OR 6.17, CI 1.90-20.04) were more prone to MAEs compared to oral solid. MAEs were more likely to occur when medication was administered between 10 a.m.-2 p.m. (OR 1.91, CI 1.06-3.46) and 6 p.m.-7 a.m. (OR 1.88, CI 1.00-3.52) compared to 7 a.m.-10 a.m. and when administered by staff with higher professional education compared to staff with secondary vocational education (OR 1.68, CI 1.03-2.74). MAEs were less likely to occur in the teaching hospital (OR 0.17, CI 0.08-0.33). Day of the week, patient-to-nurse ratio, interruptions and other nurse characteristics (degree, experience, employment type) were not associated with MAEs.

CONCLUSIONS

This study identified a high MAE prevalence. Identified determinants suggest that focusing interventions on complex pharmaceutical forms and error-prone administration times may contribute to MAE reduction.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can be used to develop targeted interventions to improve patient safety.

A Novel Use of Bar Code Medication Administration Data to Assess Nurse Staffing and Workload

OBJECTIVE

The aim of the study is to introduce an innovative use of bar code medication administration (BCMA) data, medication pass analysis, that allows for the examination of nurse staffing and workload using data generated during regular nursing workflow.

METHODS

Using 1 year (October 1, 2014-September 30, 2015) of BCMA data for 11 acute care units in one Veterans Affairs Medical Center, we determined the peak time for scheduled medications and included medications scheduled for and administered within 2 hours of that time in analyses. We established for each staff member their daily peak-time medication pass characteristics (number of patients, number of peak-time scheduled medications, duration, start time), generated unit-level descriptive statistics, examined staffing trends, and estimated linear mixed-effects models of duration and start time.

RESULTS

As the most frequent (39.7%) scheduled medication time, 9:00 was the peak-time medication pass; 98.3% of patients (87.3% of patient-days) had a 9:00 medication. Use of nursing roles and number of patients per staff varied across units and over time. Number of patients, number of medications, and unit-level factors explained significant variability in registered nurse (RN) medication pass duration (conditional R2  = 0.237; marginal R2  = 0.199; intraclass correlation = 0.05). On average, an RN and a licensed practical nurse (LPN) with four patients, each with six medications, would be expected to take 70 and 74 minutes, respectively, to complete the medication pass. On a unit with median 10 patients per LPN, the median duration (127 minutes) represents untimely medication administration on more than half of staff days. With each additional patient assigned to a nurse, average start time was earlier by 4.2 minutes for RNs and 1.4 minutes for LPNs.

CONCLUSION

Medication pass analysis of BCMA data can provide health systems a means for assessing variations in staffing, workload, and nursing practice using data generated during routine patient care activities.

Effect of a Pharmacy-based Centralized Intravenous Admixture Service on the Prevalence of Medication Errors: A Before-and-After Study

OBJECTIVES

Intravenous admixture preparation errors (IAPEs) may lead to patient harm. The primary aim of this study was to assess the effect of a pharmacy-based centralized intravenous admixture service (CIVAS) on IAPEs.

METHODS

We conducted a before-and-after study in 3 clinical wards before CIVAS implementation and in the CIVAS unit 18 months after implementation. Intravenous admixture preparation error data were collected by disguised observation. The primary outcome was the proportion of admixtures with 1 or more IAPEs. Secondary outcomes were the type and potential severity of IAPEs, noncompliance to hygiene procedures, and nursing staff satisfaction with the CIVAS. The primary outcome was analyzed using a multivariable mixed-effects logistic regression model.

RESULTS

One or more IAPEs were identified in 14 of 543 admixtures (2.6%) in the CIVAS unit and in 148 of 282 admixtures (52.5%) in the clinical wards (odds ratio, 0.02; 95% confidence interval, 0.004-0.05). The most common IAPE types were wrong solvent or diluent (n = 95) and wrong volume of infusion fluid (n = 45). No potentially harmful IAPEs occurred in the CIVAS unit as opposed to 22 (7.8%) in the clinical wards. Disinfection procedures were better adhered to in the CIVAS unit. Overall nurse satisfaction with the CIVAS increased from a median of 70 (n = 166) 5 months after intervention to 77 (n = 115) 18 months after intervention ( P < 0.001) on a 100-point scale.

CONCLUSIONS

Centralized intravenous admixture service performed notably better than the clinical wards with regard to IAPEs and noncompliance to hygiene procedures. Nurses were satisfied with the CIVAS. Hence, the implementation of CIVAS is an important strategy to improve medication safety in hospitals.

Drug closed-loop management system using mobile technology

BACKGROUND

Drug closed-loop management reflects the level of hospital management and pharmacist service. It is a challenge for hospital pharmacists to realize the whole-process closed-loop management of drugs in hospital pharmacies. Therefore, this study aimed to evaluate the operational effect of using mobile technology to build a closed-loop drug management system.

METHODS

Using mobile technology, replacing the traditional paper dispensing model and constructing a multinode information collection system according to the Healthcare Information and Management Systems Society Standard, we reformed the hospital information system and inpatient pharmacy workflow and then evaluated the new approach using statistical methods.

RESULTS

After the transformation, the entire process of drug data can be traced. Closed-loop management, as well as real-time data verification and control, thereby improves the work efficiency and reduces the drug dispensing time. By reducing the work error rate, the number of dispensing errors decreased from 5 to 1 case/month. The comprehensive dispensing process can achieve the whole workflow of paperless operation and reduce the use of paper A4 by 180,000 pieces per year.

CONCLUSIONS

Mobile technology can improve the service level of pharmacies, enhance the level of drug management and hospital quality management, ensure the safety of medication for inpatients, and significantly reduce the amount of paper used.

Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta-Analysis

INTRODUCTION

Neonates are at greater risk of preventable adverse drug events as compared to children and adults.

OBJECTIVE

This study aimed to estimate and critically appraise the evidence on the prevalence, causes and severity of medication administration errors (MAEs) amongst neonates in Neonatal Intensive Care Units (NICUs).

METHODS

A systematic review and meta-analysis was conducted by searching nine electronic databases and the grey literature for studies, without language and publication date restrictions. The pooled prevalence of MAEs was estimated using a random-effects model. Data on error causation were synthesised using Reason's model of accident causation.

RESULTS

Twenty unique studies were included. Amongst direct observation studies reporting total opportunity for errors as the denominator for MAEs, the pooled prevalence was 59.3% (95% confidence interval [CI] 35.4-81.3, I² = 99.5%). Whereas, the non-direct observation studies reporting medication error reports as the denominator yielded a pooled prevalence of 64.8% (95% CI 46.6-81.1, I² = 98.2%). The common reported causes were error-provoking environments (five studies), while active failures were reported by three studies. Only three studies examined the severity of MAEs, and each utilised a different method of assessment.

CONCLUSIONS

This is the first comprehensive systematic review and meta-analysis estimating the prevalence, causes and severity of MAEs amongst neonates. There is a need to improve the quality and reporting of studies to produce a better estimate of the prevalence of MAEs amongst neonates. Important targets such as wrong administration-technique, wrong drug-preparation and wrong time errors have been identified to guide the implementation of remedial measures.

Observational study on medication administration errors at a University Hospital in Brazil: incidence, nature and associated factors

Background

Medication administration errors are frequent and cause significant harm globally. However, only a few data are available on their prevalence, nature, and severity in developing countries, particularly in Brazil. This study attempts to determine the incidence, nature, and factors associated with medication administration errors observed in a university hospital.

Methods

This was a prospective observational study, conducted in a clinical and surgical unit of a University Hospital in Brazil. Two previously trained professionals directly observed medication preparation and administration for 15 days, 24 h a day, in February 2020. The type of error, the category of the medication involved, according to the anatomical therapeutic chemical classification system, and associated risk factors were analyzed. Multivariate logistic regression was adopted to identify factors associated with errors.

Results

The administration of 561 drug doses was observed. The mean total medication administration error rate was 36.2% (95% confidence interval 32.3–40.2). The main factors associated with time errors were interruptions. Regarding technique errors, the primary factors observed were the route of administration, interruptions, and workload.

Conclusions

Here, we identified a high total medication administration error rate, the most frequent being technique, wrong time, dose, and omission errors. The factors associated with errors were interruptions, route of administration and workload, which agrees well with the results of other national and international studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-022-00443-x.

Drug administration errors in Latin America: A systematic review

Purpose

This study systematically reviewed studies to determine the frequency and nature of medication administration errors in Latin American hospitals.

Summary

We systematically searched the medical literature of seven electronic databases to identify studies on medication administration errors in Latin American hospitals using the direct observation method. Studies published in English, Spanish, or Portuguese between 1946 and March 2021 were included. A total of 10 studies conducted at 22 hospitals were included in the review. Nursing professionals were the most frequently observed during medication administration and were observers in four of the ten included studies. Total number of error opportunities was used as a parameter to calculate error rates. The administration error rate had a median of 32% (interquartile range 16%–35.8%) with high variability in the described frequencies (9%–64%). Excluding time errors, the median error rate was 9.7% (interquartile range 7.4%–29.5%). Four different definitions of medication errors were used in these studies. The most frequently observed errors were time, dose, and omission. Only four studies described the therapeutic classes or groups involved in the errors, with systemic anti-infectives being the most reported. None of the studies assessed the severity or outcome of the errors. The assessment of the overall risk bias revealed that one study had low risk, three had moderate risk, and three had high risk. In the assessment of the exploratory, observational, and before-after studies, two were classified as having fair quality and one as having poor quality.

Conclusion

The administration error rate in Latin America was high, even when time errors were excluded. The variation observed in the frequencies can be explained by the different contexts in which the study was conducted. Future research using direct observation techniques is necessary to more accurately estimate the nature and severity of medication administration errors.

Cost-effectiveness of central automated unit dose dispensing with barcode-assisted medication administration in a hospital setting

BACKGROUND

Central automated unit dose dispensing (cADD) with barcode-assisted medication administration (BCMA) has been shown to reduce medication administration errors (MAEs). Little is known about the cost-effectiveness of this intervention.

OBJECTIVE

To estimate the cost-effectiveness of cADD with BCMA compared to usual care.

METHODS

An economic evaluation was conducted alongside a prospective before-and-after effectiveness study in a Dutch university hospital. The primary effect measure was the difference between the rate of MAEs before and after implementation of cADD with BCMA, obtained by disguised observation in six clinical wards and subsequent extrapolation to the entire hospital. The cost-analysis was conducted from a hospital perspective with a 12-month incremental costing approach. The total costs covered the pharmaceutical service, nurse medication handling, wastage, and materials related to cADD. The primary outcome was the cost-effectiveness ratio expressed as costs per avoided MAE, obtained by dividing the annual incremental costs by the number of avoided MAEs. The secondary outcome was the cost-effectiveness ratio expressed as costs per avoided potentially harmful MAE (i.e. MAEs with the potential to cause harm).

RESULTS

The intervention was associated with an absolute MAE reduction of 4.5% and a reduction of 2.7% for potentially harmful MAEs. Based on 2,260,870 administered medications in the entire hospital annually, a total of 102,210 MAEs and 59,830 potentially harmful MAEs were estimated to be avoided. The intervention was associated with an increased incremental cost of €1,808,600 annually. The cost-effectiveness ratio was €17.69 per avoided MAE and €30.23 per avoided potentially harmful MAE.

CONCLUSIONS

The implementation of cADD with BCMA was associated with a reduced rate of medication errors, including harmful ones, at higher overall costs. The costs per avoided error are relatively low, and therefore, this intervention could be an important strategy to improve patient safety in hospitals.

Exploring Nurses' Attitudes, Skills, and Beliefs of Medication Safety Practices

BACKGROUND

Medication errors exist within health care systems despite efforts to reduce their incidence. These errors may result in patient harm including morbidity, mortality, and increased health care costs.

PURPOSE

The purpose of this study was to explore direct care nurses' attitudes, skills, and beliefs about medication safety practice.

METHODS

Researchers conducted a descriptive exploratory study using the Nurses' Attitudes and Skills around Updated Safety Concepts (NASUS) scale and the Nurse Beliefs about Errors Questionnaire (NBEQ).

RESULTS

Responses from 191 surveys were analyzed. Of the participants, 70% were bachelor's prepared registered nurses and 88% were female. Results of the NASUS scale revealed the median of means of the Perceived Skills subscale was 79.2 out of 100 and the Attitudes subscale was 65.8 out of 100. The mean of the belief questions related to severity of error was 7.66 out of 10; most participants agreed with reporting of severe errors, reporting errors with moderate or major adverse events, and reporting of incorrect intravenous fluids.

CONCLUSIONS

Understanding direct care nurses' attitudes, skills, and beliefs about medication safety practices provides a foundation for development of improvement strategies.

In vitro assessment of the direct hemolytic effect of the volatile halogenated anesthetics sevoflurane, isoflurane, and desflurane

Sevoflurane is being repurposed as a topical analgesic for painful wounds. Providing pre-charged sevoflurane syringes to irrigate wounds implies a potential risk of accidental intravenous injections. We assessed the potential of two concentrations (33% and 50% v/v) of three anesthetics, isoflurane, desflurane and sevoflurane, to produce hemolysis in vitro. Spectrophotometric absorbance was read at 576 nm. For both concentrations, the percentage of hemolysis (mean ± SD) was higher for isoflurane (29.7 ± 3.4% and 39.5 ± 5.3%), mild for desflurane (8.0 ± 0.5% and 6.5 ± 0.9%) and negligible for sevoflurane (0.7 ± 0.0% and 0.6 ± 0.1%), respectively. In conclusion, in contrast to isoflurane and desflurane, sevoflurane did not display hemolytic potential in vitro. However, the use of syringes preloaded with sevoflurane may still be problematic if it increases the possibility of inadvertent intravenous administration through increased risk of gas embolism and severe central nervous system depression.

Assessing the impact of a mixed intervention model on the reduction of medication administration errors in an Australian hospital

BACKGROUND

Medication errors remain one of the most common types of incidents reported in Australian hospitals. Studies have reported that for every 10 medication administrations, a medication administration error is likely to occur and reach the patient, potentially contributing to a preventable patient harm.

OBJECTIVE

To assess the impact of a mixed intervention model on medication administration errors in an Australian hospital.

METHODS

Two types of intervention model (human and system orientated) were implemented through collaboration with key stakeholders (nurses, educators, and policy makers) to reduce medication administration errors across this 650-bed multisite Australian hospital from August 2018 to June 2019. To assess the impact of the mixed intervention model, the total number of reported medication errors and the number of medication administration errors were retrieved from the hospital electronic medication management system for 12 months before (from June 2017 to July 2018) and after (from July 2019 to June 2020) implementation of all interventions.

RESULTS

Implementation of a mixed intervention model through collaboration with stakeholders resulted in significant reduction in the number of medication administration errors, and those with harm (from 68 to 55%, P < 0.0001 and from 12 to 8%, P = 0.0001 respectively). Additionally, the severity of medication administration errors was also reduced (HR 0.562, 95% CI (0.298-1.062)) in the post-intervention phase.

CONCLUSION

Introducing a mixed intervention model reduces medication administration errors across health settings and has the potential to drive excellence in healthcare.

Effect of automated unit dose dispensing with barcode scanning on medication administration errors: an uncontrolled before-and-after study

BACKGROUND

Medication administration errors (MAEs) occur frequently in hospitals and may compromise patient safety. Preventive strategies are needed to reduce the risk of MAEs.

OBJECTIVE

The primary aim of this study was to assess the effect of central automated unit dose dispensing with barcode-assisted medication administration on the prevalence of MAEs. Secondary aims were to assess the effect on the type and potential severity of MAEs. Furthermore, compliance with procedures regarding scanning of patient and medication barcodes and nursing staff satisfaction with the medication administration system were assessed.

METHODS

We performed a prospective uncontrolled before-and-after study in six clinical wards in a Dutch university hospital from 2018 to 2020. MAE data were collected by observation. The primary outcome was the proportion of medication administrations with one or more MAEs. Secondary outcomes were the type and potential severity of MAEs, rates of compliance with patient identification and signing of administered medication by scanning and nursing staff satisfaction with the medication administration system. Multivariable mixed-effects logistic regression analyses were used for the primary outcome to adjust for confounding and for clustering on nurse and patient level.

RESULTS

One or more MAEs occurred in 291 of 1490 administrations (19.5%) pre-intervention and in 258 of 1630 administrations (15.8%) post-intervention (adjusted odds ratio 0.70, 95% confidence interval 0.51-0.96). The rate of omission fell from 4.6% to 2.0% and of wrong dose from 3.8% to 2.1%, whereas rates of other MAE types were similar. The rate of potentially harmful MAEs fell from 3.0% (n = 44) to 0.3% (n = 5). The rates of compliance with scanning of patient and medication barcode post-intervention were 13.6% and 55.9%, respectively.The median overall satisfaction score of the nurses with the medication administration system on a 100-point scale was 70 (interquartile range 63-75, n = 193) pre-intervention and 70 (interquartile range 60-78, n = 145) post-intervention (P = 0.626, Mann-Whitney U test).

CONCLUSION

The implementation of central automated unit dose dispensing with barcode-assisted medication administration was associated with a lower probability of MAEs, including potentially harmful errors, but more compliance with scanning procedures is needed. Nurses were moderately satisfied with the medication administration system, both before and after implementation. In conclusion, despite low compliance with scanning procedures, this study shows that this intervention contributes to the improvement of medication safety in hospitals.

Effectiveness of a 'do not interrupt' vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial

Background

The use of a ‘do not interrupt’ vest during medication administration rounds is recommended but there have been no controlled randomized studies to evaluate its impact on reducing administration errors. We aimed to evaluate the impact of wearing such a vest on reducing such errors. The secondary objectives were to evaluate the types and potential clinical impact of errors, the association between errors and several risk factors (such as interruptions), and nurses’ experiences.

Methods

This was a multicenter, cluster, controlled, randomized study (March–July 2017) in 29 adult units (4 hospitals). Data were collected by direct observation by trained observers. All nurses from selected units were informed. A ‘Do not interrupt’ vest was implemented in all units of the experimental group. A poster was placed at the entrance of these units to inform patients and relatives. The main outcome was the administration error rate (number of Opportunities for Error (OE), calculated as one or more errors divided by the Total Opportunities for Error (TOE) and multiplied by 100).

Results

We enrolled 178 nurses and 1346 patients during 383 medication rounds in 14 units in the experimental group and 15 units in the control group. During the intervention period, the administration error rates were 7.09% (188 OE with at least one error/2653 TOE) for the experimental group and 6.23% (210 OE with at least one error/3373 TOE) for the control group (p = 0.192). Identified risk factors (patient age, nurses’ experience, nurses’ workload, unit exposition, and interruption) were not associated with the error rate. The main error type observed for both groups was wrong dosage-form. Most errors had no clinical impact for the patient and the interruption rates were 15.04% for the experimental group and 20.75% for the control group.

Conclusions

The intervention vest had no impact on medication administration error or interruption rates. Further studies need to be performed taking into consideration the limitations of our study and other risk factors associated with other interventions, such as nurse’s training and/or a barcode system.

Trial registration

The PERMIS study protocol (V2–1, 11/04/2017) was approved by institutional review boards and ethics committees (CPP Ile de France number 2016-A00211–50, CNIL 21/03/2017, CCTIRS 11/04/2016). It is registered at ClinicalTrials.gov (registration number: NCT03062852, date of first registration: 23/02/2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00671-7.

Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Background Intravenous admixture preparation errors (IAPEs) may lead to patient harm. Insight into the prevalence as well as the determinants associated with these IAPEs is needed to elicit preventive measures. Aim The primary aim of this study was to assess the prevalence of IAPEs. Secondary aims were to identify the type, severity, and determinants of IAPEs. Method A prospective observational study was performed in a Dutch university hospital. IAPE data were collected by disguised observation. The primary outcome was the proportion of admixtures with one or more IAPEs. Descriptive statistics were used for the prevalence, type, and severity of IAPEs. Mixed-effects logistic regression analyses were used to estimate the determinants of IAPEs. Results A total of 533 IAPEs occurred in 367 of 614 admixtures (59.8%) prepared by nursing staff. The most prevalent errors were wrong preparation technique (n = 257) and wrong volume of infusion fluid (n = 107). Fifty-nine IAPEs (11.1%) were potentially harmful. The following variables were associated with IAPEs: multistep versus single-step preparations (adjusted odds ratio [OR_adj] 4.08, 95% confidence interval [CI] 2.27–7.35); interruption versus no interruption (OR_adj 2.32, CI 1.13–4.74); weekend versus weekdays (OR_adj 2.12, CI 1.14–3.95); time window 2 p.m.-6 p.m. versus 7 a.m.-10 a.m. (OR_adj 3.38, CI 1.60–7.15); and paediatric versus adult wards (OR_adj 0.14, CI 0.06–0.37). Conclusion IAPEs, including harmful IAPEs, occurred frequently. The determinants associated with IAPEs point to factors associated with preparation complexity and working conditions. Strategies to reduce the occurrence of IAPEs and therefore patient harm should target the identified determinants.

Investigation of interventions to reduce nurses' medication errors in adult intensive care units: A systematic review

BACKGROUND

Medication errors in adult intensive care units (ICUs) are both frequent and harmful. For nurses, these errors may be multifactorial and multidisciplinary, extending from prescription stage to monitoring of patient response to medication. Therefore, diverse interventions have been developed to optimise the medication process to prevent such errors.

OBJECTIVES

The objective of this systematic review was to identify research investigating interventions that may be effective in reducing the rate of nurses' medication errors in adult ICUs.

METHODS

A systematic search was undertaken of three databases: Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online, and EMCARE using a combination of key terms related to "medication errors", "nurses", "interventions", and "intensive care units". The search was limited to studies published in English between 2009 and 2019. Independent screening, quality appraisal, and data extraction were undertaken by two reviewers.

RESULTS

A total of 464 records were identified from database searches. Eleven studies met inclusion criteria: ten were quasi-experimental designs and one was a randomised controlled trial. Studies examined six types of interventions: prefilled syringes, barcode-assisted medication administration, an automated dispensing system, nursing education programs, a protocolised program logic form, and a preventive interventions program with protocols and pharmacist-supported supervision and monitoring. Findings revealed that a prefilled syringe, nurses' education programs, and the protocolised program logic form were most effective in reducing medication errors. For the barcode-assisted medication administration, automated dispensing systems, and a preventive interventions program with protocols and pharmacist-supported supervision and monitoring, results showed wide variability in effectiveness.

CONCLUSION

This review found that the evidence for effective interventions to reduce nurses' medication errors in adult ICUs is limited, due largely to inconsistencies in research design and methods. Therefore, further studies such as randomised controlled trials focusing on a single intervention are required to provide robust evidence of the effectiveness of interventions.

Using risk analysis to ensure patients' medication safety during hospital relocations and evacuations

OBJECTIVES

To ensure patient safety and the preparedness of medication processes during hospital relocations and evacuations by using Failure Modes, Effects, and Criticality Analysis (FMECA).

METHODS

The relocation of six regional hospitals to a single building, resulting in 400 beds being moved, could be compared with an emergency evacuation. An FMECA was performed on the hospital group's internal medicine and intensive care units (IMU and ICU), examining how medication processes would be affected by a hospital relocation or evacuation.

RESULTS

We identified 59 hospital relocation and 68 evacuation failure modes. Failure modes were ranked based on their criticality index (CI; range 1-810). The higher the CI, the greater the patient-related risk. Average initial IMU and ICU hospital relocation CI scores were 160 (range 105-294) and 201 (range 125-343), respectively, subsequently reduced to 32 (-80%) and 49 (-76%) after mitigation measures. Average initial IMU and ICU evacuation CI scores were 319 (range 245-504) and 592 (range 441-810), respectively, subsequently reduced to 194 (-39%) and 282 (-52%). Most mitigation measures (17/22), such as for example checklists, could be implemented in both situations. Due to their unpredictable nature, five measures were specific to evacuation situations.

CONCLUSIONS

This study highlights the value of using an FMECA on medication processes to anticipate potential negative impacts on patient safety during hospital relocations or evacuations. Preparation for a hospital relocation can provide useful knowledge and an opportunity to test mitigation measures that might prove useful in evacuations.

Evaluation of medication error rates in Saudi Arabia: A protocol for systematic review and meta-analysis

INTRODUCTION

Due to the diversity of reports and on the rates of medications errors (MEs) in Saudi Arabia, we performed the first meta-analysis to determine the rate of medications errors in Saudi Arabia using meta-analysis in the hospital settings.

METHODS

We conducted a systematic literature search through August 2019 using PubMed, EMBASE, CINAHL, PsycINFO, and Google Scholar to identify all observational studies conducted in hospital settings in Saudi Arabia that reported the rate of MEs. A random-effects models were used to calculate overall MEs, as well as prescribing, dispensing, and administration error rates. The I2 statistics were used to analyze heterogeneity.

RESULTS

Sixteen articles were included in this search. The total incidence of MEs in Saudi Arabia hospitals was estimated at 44.4%. Prescribing errors, dispensing errors, and adminstration errors incidents represent 40.2%, 28.2%, and 34.5% out of the total number of reported MEs, respectively. However, between-study heterogeneity was also generally found to be >90% (I-squared statistic).

CONCLUSIONS

This study demonstrates the MEs common in health facilities. Additional efforts in the field are needed to improve medication management systems in order to prevent patient harm incidents.

Automation of in-hospital pharmacy dispensing: a systematic review

OBJECTIVES

The current systematic review (SR) was undertaken to identify and summarise the published literature reporting on the clinical and economic value of automated in-hospital pharmacy services with a primary focus on systems supporting the dispensing of medicines.

METHODS

Literature searches were conducted in MEDLINE, Embase and the Cochrane Library on 17 December 2017 to identify English-language publications investigating any automated dispensing systems (ADSs) in the inpatient setting to include central pharmacy and ward-based systems.

RESULTS

4320 publications were screened by title and abstract and 45 of 175 full publications screened were included. Grey literature searching identified an additional three publications. Therefore, 48 publications relating to ADSs were eligible for inclusion. Although a relatively large evidence base was identified as part of the current SR, the eligible studies were inconsistent in terms of their design and the format of reporting of outcomes. The studies demonstrate that both pharmacy and ward-based ADSs offer benefits over traditional manual dispensing methods in terms of clinical and economic outcomes. The primary benefits following implementation of an ADS include reductions in medication errors, medication administration time and costs. Studies examining optimisation/inventory management strategies/refill programmes for these systems suggest that optimal implementation of the ADS is required to ensure that clinical success and economic benefits are maximised.

CONCLUSIONS

The published evidence suggests positive impacts of ADS and should encourage hospitals to invest in automation, with a global strategy to improve the reliability and the efficiency of the medication process. However, one of the key findings of the current SR is the need for further data from adequately powered studies reporting clinically relevant outcomes which would allow for robust, evidence-based recommendations on the return on investment of the technologies. These studies would probably contribute to a larger adoption of these technologies by European hospitals.

Harm Prevalence Due to Medication Errors Involving High-Alert Medications: A Systematic Review

OBJECTIVE

The aim of the study was to determine the prevalence and main types of harm caused by high-alert medication after medication errors (MEs) in hospitals.

METHOD

A literature systematic review was conducted on PubMed, Scopus, Web of Science, and Lilacs. Eligible studies published until June 2017 were included.

RESULT

Of 6244 studies identified through searching four electronic databases, five studies meeting the selection criteria of this study were analyzed. There was wide variation in the overall prevalence of harm due to MEs involving HAM, from 3.8% to 100%, whereas the pooled prevalence was 16.3%. Overall, 0.01% of harm caused by MEs involving HAM resulted in death. The severity of errors ranged from 0.1% to 19.2% for moderate errors, 0.2% to 15.4% for serious errors, and 1.9% lethal to the patients. The highest prevalences of harm occurred after errors involving potassium chloride 15%, insulin, and epoprostenol. The lowest prevalence of harm was related to errors of anticoagulants administration. The methodological heterogeneity limited direct comparisons among the studies.

CONCLUSIONS

Of the 15 drugs on the list of Institute for Safe Medication Practices HAMs in the United States and Brazil, nine did not present scientific evidence of the potential for harm. In general, few studies, characterized by methodological and conceptual heterogeneity, were performed to determine the harm prevalence resulting from errors involving these drugs.

What should patients do if they miss a dose? A systematic review of patient information leaflets and summaries of product characteristics

Purpose

Medicines regulatory authorities advise that patient information leaflets (PILs) should provide specific advice on what actions to take if one or more doses are missed. We aimed to assess the content in this regard, of PILs and Summaries of Product Characteristics (SmPCs) of prescription only medicines (POMs) marketed in the UK.

Methods

PILs and SmPCs were accessed via the electronic Medicines Compendium. The following terms were used in the advanced search facility: miss(ed), omit(ted), adhere(d), delay(ed), forgot, forget, lapse. Identified documents were screened for instructions on missed doses which were categorised according to level of specificity, and cross-referenced to the National Patient Safety Agency (NPSA) grading of risk of harm from omitted and delayed medicines. Any supporting clinical or pharmacological evidence was identified from SmPCs.

Results

Two thousand two hundred eighty-four documents were identified from 7248 PILs and SmPCs relating to 1501 POMs. Seven hundred eighty-three (52%) POMs had SmPCs or PILs with no instructions on missed doses; 487 POMs (32%) included non-specific advice (e.g. “take as soon as possible”); 138 (9%) provided specific instructions; and 93 (6%) referred patients to seek medical advice. SmPCs for only 13/138 (9%) of those which included specific instructions provided any supporting clinical or pharmacological evidence. Instructions were absent for several medicines where the NPSA assessed that dose omissions may result in significant risk of harm.

Conclusions

Advice on missed doses is generally inadequate. Pharmaceutical companies and regulatory authorities should produce clear and concise instructions on what patients should do if they miss doses, with supporting evidence where necessary.

Self-administration of medication during hospitalization-a randomized pilot study

Background

Self-administration of medication (SAM) during hospitalization is a complex intervention where patients are involved in their course of treatment. The study aim was to pilot test the SAM intervention. The objectives were to assess the feasibility of conducting a randomized controlled trial on the safety and cost-consequences of SAM during hospitalization.

Methods

The study was performed in a Danish cardiology unit.

Patients ≥ 18 years capable of self-administering medication during hospitalization were eligible. Patients were excluded if they did not self-administer medication at home, were incapable of self-administering medication, were not prescribed medication suitable for self-administration, did not bring their medication, or were unable to speak Danish.

Feasibility was assessed as part of the pilot study. A future randomized controlled trial was considered feasible if it was possible to recruit 60 patients within 3 months, if outcome measurement method was capable of detecting dispensing errors in both groups, and if patients in the intervention group were more satisfied with the medication management during hospitalization compared to the control group.

Forty patients were recruited to gain experience about the intervention (self-administration). Additionally, 20 patients were randomized to the intervention or control group (nurse-led dispensing) to gain experience about the randomization procedure.

Dispensing error proportions were based on data collected through disguised observation of patients and nurses during dispensing. The error proportion in the control group was used for the sample size calculation. Patient acceptability was assessed through telephone calls.

Results

Of the 60 patients recruited, one withdrew and 11 were discharged before observation resulting in analysis of 39 patients in the intervention group and nine in the control group. A dispensing error proportion of 3.4% was found in the intervention group and 16.1% in the control group. A total of 91.7% of patients in the intervention group and 66.7% in the control group were highly satisfied with the medication management during hospitalization. The overall protocol worked as planned. Minor changes in exclusion criteria, intervention, and outcome measures were considered.

Conclusions

It may be feasible to perform a pragmatic randomized controlled trial of the safety and cost-consequences of self-administration of medication during hospitalization.

Trial registration

ClinicalTrials.gov, NCT03541421, retrospectively registered on 30 May 2018.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

An analysis of fatal iatrogenic therapeutic errors reported to United States poison centers

OBJECTIVE

This is a descriptive study evaluating fatal iatrogenic and in-hospital medication errors reported to United States poison centers.

METHODS

A retrospective evaluation of the National Poison Data System from 2000-2017 of all therapeutic errors with a scenario coded as iatrogenic/healthcare professional or occurring in a healthcare facility. Death abstracts were reviewed for details of the exposure and therapeutic error scenarios were recoded or added to the case as appropriate. Cases, where death was considered not related to the exposure, were excluded. Additionally, we created one additional scenario (rate-related) and one additional route of administration (intrathecal) to better describe the cases.

RESULTS

A total of 172 cases were evaluated. The majority of the patients were female (52.3%) with a median age of 58.5 years (range: 2 days to 96 years). The most commonly reported medication error was "other incorrect dose" (22.7%) followed by other/unknown error (15.1%). The route of exposure was primarily parenteral (54.9%), followed by ingestion (30.2%), then intrathecal (7.0%). The most common medications were cardiac drugs, chemotherapeutics, opioids, anticoagulants, and sedative-hypnotic/antipsychotics.

CONCLUSIONS

Iatrogenic and in-hospital medication errors have been studied extensively with goals to reduce their occurrence. Specific controls to prevent incorrect dosing routes, 10-fold overdoses, and incorrect intrathecal administration have been instituted. Despite interventions, all three of these therapeutic errors continued to occur in 2017, suggesting that more preventive controls should be instituted.

Self-administration of medication: a pragmatic randomized controlled trial of the impact on dispensing errors, perceptions, and satisfaction

BACKGROUND

Our aim was to investigate whether self-administration of medication (SAM) during hospitalization affects the number of dispensing errors, perceptions regarding medication, and participant satisfaction when compared with nurse-led medication dispensing.

METHODS

A pragmatic randomized controlled trial was performed in a Danish cardiology unit. Patients aged ⩾ 18 years capable of SAM were eligible for inclusion. Patients were excluded if they did not self-administer medication at home, were not prescribed medication suitable for self-administration, or did not speak Danish.Intervention group participants self-administered their medication. In the control group, medication was dispensed and administered by nurses.The primary outcome was the proportion of dispensing errors collected through modified disguised observation of participants and nurses. Dispensing errors were divided into clinical and procedural errors.Secondary outcomes were explored through telephone calls to determine participant perceptions regarding medication and satisfaction, and finally, deviations in their medication list two weeks after discharge.

RESULTS

Significantly fewer dispensing errors were observed in the intervention group, with 100 errors/1033 opportunities for error (9.7%), compared with 132 errors/1028 opportunities for error (12.8%) in the control group. The number of clinical errors was significantly reduced, whereas no difference in procedural errors was observed. At follow up, those who were self-administering medication had fewer concerns regarding their medication, found medication to be less harmful, were more satisfied, preferred this opportunity in the future, and had fewer deviations in their medication list after discharge compared with the control group.

CONCLUSION

In conclusion, the reduced number of dispensing errors in the intervention group, indicate that SAM is safe. In addition, SAM had a positive impact on (a) perceptions regarding medication, thus suggesting increased medication adherence, (b) deviations in medication list after discharge, and (c) participant satisfaction related to medication management at the hospital.

Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC)

Classifying harm associated with a medication error can be time consuming and labour intensive and limited studies undertake this step. There is no standardised process, and few studies that report harm assessment provide adequate methods to allow for study replication. Studies typically mention that a clinical review panel classified patient harm and provide a reference to a classification tool. Moreover, in many studies it is unclear whether potential or actual harm was classified as studies refer only to ‘error severity’. The tools used to categorise the severity of patient harm vary widely across studies and few have been assessed for inter-rater reliability and criterion validity. In this paper, we describe the systematic process we undertook to synthesise the defining elements and strengths, while mitigating the limitations, of existing harm classification tools to derive the Harm Associated with Medication Error Classification (HAMEC). This new tool provides a harm classification for use across clinical and research settings. The provision of an explicit process for its application and guiding category descriptors are designed to reduce the risk of misclassification and produce results that are comparable across studies. As the World Health Organisation embarks on its international safety challenge of reducing medication-related harm by 50%, accompanying methodological advances are required to measure progress.

The Magnitude of Medication Administration Errors among Nurses in Ethiopia: a Systematic Review and Meta-analysis

Introduction: Nurses are the final safety check in the process of medication administration process to prevent errors that adversely affect life; yet death of comprehensive evidences in Ethiopia. The present study aimed to assess the pooled magnitude of MAEs (Medication Administration Errors) in Ethiopia. Methods: Systematic literature search in the databases of Pub-Med, Cochrane, and Google Scholar for gray literature were performed until December 3, 2018. The quality of study was assessed using criteria adopted from similar studies. Heterogeneity test and evidence of publication bias were assessed. Moreover, sensitivity analysis was also performed. Pooled prevalence of MAE was calculated using the random effects model. Results: A total of 2142 medication administrations were from observational and 681from self-reported studies were included in this systematic review and meta-analysis. The most prevalent and frequently reported type of MAEs was documentation error (52% to 87.5%) and time error (25.5% to 58.5%) respectively. Overall, the pooled magnitude of MAE was found to be 39.3% (95% CI, 29.1%-49.5%).It has no evidence of significant heterogeneity (I2 = 0%, P = 0.57) and publication bias Egger's test (P = 0.40). Conclusion: Overall, more than one in four observed/perceived medication administrations had errors. Documentation error is the most prevalent type of error. Nurses are suggested to strengthen their focus on the rights of medication administration guide particularly, documentation of their activities need special attention.

Challenges in making standardisation work in healthcare: lessons from a qualitative interview study of a line-labelling policy in a UK region

OBJECTIVE

To identify and learn from efforts to design and implement a standardised policy for labelling of invasive tubing and lines across a regional health system.

DESIGN

Single case study involving qualitative interviews and documentary analysis.

SETTING

A devolved health system in the UK National Health Service (NHS).

PARTICIPANTS

NHS staff (n=10) and policy-makers (n=8) who were involved in the design and/or implementation of the standardised policy.

RESULTS

Though standardising labelling of invasive tubing and lines was initially seen as a common-sense technical change, challenges during the process of developing and implementing the policy were multiple and sociotechnical in nature. Major challenges related to defining the problem and the solution, limited sustained engagement with stakeholders and users, prototyping/piloting of the solution, and planning for implementation. Some frontline staff remained unconvinced of the need for or value of the policy, since they either did not believe that there was a problem or did not agree that standardised labelling was the right solution. Mundane practical issues such authorisation and resourcing, supply chains for labels, the need to restructure work practices to accommodate the new standard, and the physical features of the labels in specific clinical settings all had important impacts.

CONCLUSIONS

Newly standardised tools and practices have to fit within a system of pre-existing norms, practices and procedures. We identified a number of practical, social and cultural challenges when designing and implementing a standardised policy in a regional healthcare system. Taking account of both sociocultural and technical aspects of standardisation, combined with systems thinking, could lead to more effective implementation and increase acceptability and usability of new standards.

A systems-centred approach to reducing medication error: Should pre-hospital providers and emergency departments dose children by age during resuscitation?

The high-risk, high-stress and high-stakes environment of out-of-hospital or emergency department paediatric resuscitation is prone to human error, and medication errors are common. This could be contributing to the difference in survival rate of resuscitation in the out-of-hospital versus inpatient setting. Medication for children during resuscitation requires estimation of the child's weight and calculation of the corresponding drug dose. Whilst both of these steps can lead to error, calculation errors (including 10-fold errors) are much more common and harmful than weight errors. Previous solutions aim to optimise each stage of the medication dosing process. Currently, Australian guidelines suggest using the highly inaccurate original advanced paediatric life support formula, weight = 2 × (age + 4), to dose medications in these settings. This means age is converted to weight, which is then converted to dose. There is no evidence that this is causing harm to patients. Therefore, it could be suggested that age could safely be converted straight to dose according to preset doses. This eliminates the need for any weight estimation or dose calculation, thus reducing the potential for error and harm.

Integration of a Commercial Barcode-Assisted Medication Dispensing System in a Teaching Hospital

OBJECTIVES

A commercial barcode-assisted medication administration (BCMA) system was integrated to secure the medication process and particularly the dispensing stage by technicians and the administration stage with nurses. We aimed to assess the impact of this system on medication dispensing errors and barriers encountered during integration process.

METHODS

We conducted a controlled randomized study in a teaching hospital, during dispensing process at the pharmacy department. Four wards were randomized in the experimental group and control group, with two wards using the system during 3 days with dedicated pharmacy technicians. The system was a closed loop system without information return to the computerized physician order entry system. The two dedicated technicians had a 1-week training session. Observations were performed by one observer among the four potential observers previously trained. The main outcomes assessed were dispensing error rates and the identification of barriers encountered to expose lessons learned from this study.

RESULTS

There was no difference between the dispensing error rate of the control and experimental groups (7.9% for both, p = 0.927). We identified 10 barriers to pharmacy barcode-assisted system technology deployment. They concerned technical (problems with semantic interoperability interfaces, bad user interface, false errors generated, lack of barcodes), structural (poor integration with local information technology), work force (short staff training period, insufficient workforce), and strategic issues (system performance problems, insufficient budget).

CONCLUSION

This study highlights the difficulties encountered in integrating a commercial system in current hospital information systems. Several issues need to be taken into consideration before the integration of a commercial barcode-assisted system in a teaching hospital. In our experience, interoperability of this system with the electronic health record is the key for the success of this process with an entire closed loop system from prescription to administration. BCMA system at the dispensing process remains essential to purchase securing medication administration process.

Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study

BACKGROUND

Of the various types of medication administration error that occur in hospitals, dose omissions are consistently reported as among the most common. It has been suggested that greater involvement from pharmacy teams could help address this problem. A pilot service, called pharmacy TECHnician supported MEDicines administration (TECHMED), was introduced in an English NHS hospital for a four-week period in order to reduce preventable medication dose omissions. The objective of this study was to evaluate the implementation, delivery and impact of the pilot TECHMED service using qualitative methods.

METHODS

Semi-structured interviews with pharmacy technicians, nursing staff and senior management involved with the pilot service were undertaken to evaluate TECHMED. Interviews were transcribed verbatim and analysed using the framework approach, guided by Weiss's Theory Based Evaluation model.

RESULTS

Twenty-two stakeholder interviews were conducted with 10 ward-based pharmacy technicians, nine nurses and three members of senior management. Most technicians performed a range of activities in line with the service specification, including locating drugs from a variety of sources, and identified situations where they had prevented missing doses. Nurses reported positive impacts of TECHMED on workload. However, not all technicians fully adhered to the service specification in regard to directly following nursing staff during each medication round, citing reasons related to productivity or perceived intrusiveness towards nursing staff. Some participants also reported a perceived lack of impact of TECHMED on medicine omissions. Seventeen of the 22 interviewees supported an extension of the service. There were however, concerns about the impact on technician workload and some participants advocated support for targeted service extension to wards/rounds with high schedule dose volumes and omitted dose rates.

CONCLUSIONS

The findings of this study suggest that the implementation of a pharmacy technician-supported medicines administration scheme to reduce omitted doses may be acceptable to staff in an NHS hospital, and that issues with service fidelity, staff resource/capacity and perceived interventions to avoid dose omissions have important implications for the feasibility of extending the service. The study has identified targets for future development in relation to individual and system factors to improve operationalisation of technician-led initiatives to reduce medicines omissions.

A Cost Minimization Analysis of Ready-to-Administer Prefilled Sterilized Syringes in a Dutch Hospital

PURPOSE

Preparation errors occur frequently during conventional preparation of parenteral medication in the clinical environment, causing patient harm and costs for the national health care system. The use of ready-to-administer prefilled sterilized syringes (PFSSs) produced by the hospital pharmacy can reduce preparation errors and the risk of bacteremia from contamination of the intravenous medication. The aim of this research is to compare the total costs of the conventional preparation method (CPM) with the PFSS method.

METHODS

In this cost-minimization analysis, costs related to the preparation of the medication, bacteremia from contamination, adverse drug events as a result of preparation medication errors, and wastage of syringes were taken into account. Annual costs in a general Dutch hospital were consistently calculated. Three scenarios were analyzed: (1) all preparations as CPM (864,246 administrations per year), (2) all preparations as PFSSs, and (3) 50% as PFSSs and 50% as CPM. Deterministic and probabilistic sensitivity analyses were performed.

FINDINGS

The first scenario found higher annual costs at €14.0 million (US$16.0 million) compared with the second scenario (€4.1 million, US$4.7 million). The most realistic situation (third scenario) found savings of €4.9 million (US$5.6 million) compared with the first scenario. Sensitivity analyses revealed that cost savings of PFSSs were strongly influenced by decreased risk of medication errors and contamination of intravenous medication. Extrapolating these results nationwide indicated potential savings of >€300 million (US$342 million) if only PFSSs were used.

IMPLICATIONS

The use of PFSSs prepared in the hospital pharmacy yielded cost savings compared with the CPM on the ward in the Dutch hospital.

Successful use of "Choice Architecture" and "Nudge Theory" in a quality improvement initiative of analgesia administration after Caesarean section

BACKGROUND

Regular, routine, multimodal analgesia provides better pain relief following Caesarean section than reliance on "as required" opiate dosing. This quality improvement report describes the effective use of an education programme coupled with a highlighted, preprinted medication chart, employing "Nudge Theory" principles to achieve significant improvements in the administration of analgesic medications to patients after Caesarean section operations.

PROBLEM

An acute pain service audit identified a serious deficiency with delivery of regular postoperative analgesic medications to patients following Caesarean section operations.

METHODS

An audit of pain medication delivery to patients following Caesarean section demonstrated that postoperative analgesia was not being administered in line with local prescribing guidelines. Two interventions were planned: Education sessions for anaesthetic recovery and ward staff. Introduction of a new preprinted and highlighted medication chart. A postintervention audit was then conducted.

RESULTS

There were statistically significant improvements in all medications administered to patients following the two interventions. For analgesic medications, the rate of administration of drugs in compliance with guidelines rose from 39.6% to 89.9% (P < 0.001 using 2-sample z test). Each subgroup of medications also showed statistically significant improvements in administration compliance.

CONCLUSION

A combined approach, including application of "Nudge Theory" to the administration of analgesic medication after Caesarean section, considerably improved delivery of medications prescribed for postoperative analgesia.

A systematic literature review on strategies to avoid look-alike errors of labels

PURPOSE

Unclear labeling has been recognized as an important cause of look-alike medication errors. The aim of this literature review is to systematically evaluate the current evidence on strategies to minimize medication errors due to look-alike labels.

METHODS

A literature search of PubMed and EMBASE for all available years was performed independently by two reviewers. Original studies assessing strategies to minimize medication errors due to look-alike labels focusing on readability of labels by health professionals or consumers were included. Data were analyzed descriptively due to the variability of study methods.

RESULTS

Sixteen studies were included. Thirteen studies were performed in a laboratory and three in a healthcare setting. Eleven studies evaluated Tall Man lettering, i.e., capitalizing parts of the drug name, two color-coding, and three studies other strategies. In six studies, lower error rates were found for the Tall Man letter strategy; one showed significantly higher error rates. Effects of Tall Man lettering on response time were more varied. A study in the hospital setting did not show an effect on the potential look-alike sound-alike error rate by introducing Tall Man lettering. Color-coding had no effect on the prevention of syringe-swaps in one study.

CONCLUSIONS

Studies performed in laboratory settings showed that Tall Man lettering contributed to a better readability of medication labels. Only few studies evaluated other strategies such as color-coding. More evidence, especially from real-life setting is needed to support safe labeling strategies.

Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review

Background

Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear.

Objective

The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals.

Methods

We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented.

Results

Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5–20.1%), while adverse drug events causing admission were reported in 2.8% (0.7–6.4%) of patients but it was reported that a median of 43.5% (20.0–47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0–0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8–72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5–50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge/training) and environmental factors, such as workplace distraction and high workload.

Conclusion

Medication errors in the African healthcare setting are relatively common, and the impact of adverse drug events is substantial but many are preventable. This review supports the design and implementation of preventative strategies targeting the most likely contributing factors.

Electronic supplementary material

The online version of this article (10.1007/s40801-017-0125-6) contains supplementary material, which is available to authorized users.

Impact assessment of an automated drug-dispensing system in a tertiary hospital

OBJECTIVE

To evaluate the costs and patient safety of a pilot implementation of an automated dispensing cabinet in a critical care unit of a private tertiary hospital in São Paulo/Brazil.

METHODS

This study considered pre- (January-August 2013) and post- (October 2013-October 2014) intervention periods. We considered the time and cost of personnel, number of adverse events, audit adjustments to patient bills, and urgent requests and returns of medications to the central pharmacy. Costs were evaluated based on a 5-year analytical horizon and are reported in Brazilian Reals (R$) and US dollars (USD).

RESULTS

The observed decrease in the mean number of events reported with regard to the automated drug-dispensing system between pre- and post-implementation periods was not significant. Importantly, the numbers are small, which limits the power of the mean comparative analysis between the two periods. A reduction in work time was observed among the nurses and administrative assistants, whereas pharmacist assistants showed an increased work load that resulted in an overall 6.5 hours of work saved/day and a reduction of R$ 33,598 (USD 14,444) during the first year. The initial investment (R$ 206,065; USD 88,592) would have been paid off in 5 years considering only personnel savings. Other findings included significant reductions of audit adjustments to patient hospital bills and urgent requests and returns of medications to the central pharmacy.

CONCLUSIONS

Evidence of the positive impact of this technology on personnel time and costs and on other outcomes of interest is important for decision making by health managers.

Medication incidents in primary care medicine: a prospective study in the Swiss Sentinel Surveillance Network (Sentinella)

OBJECTIVES

To describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents.

DESIGN

Prospective surveillance study.

SETTING

Swiss primary healthcare, Swiss Sentinel Surveillance Network.

PARTICIPANTS

Patients with drug treatment who experienced any erroneous event related to the medication process and interfering with normal treatment course, as judged by their physician. The 180 physicians in the study were general practitioners or paediatricians participating in the Swiss Federal Sentinel reporting system in 2015.

OUTCOMES

Primary: medication incidents; secondary: potential risk factors like age, gender, polymedication, morbidity, care-dependency, previous hospitalisation.

RESULTS

The mean rates of detected medication incidents were 2.07 per general practitioner per year (46.5 per 1 00 000 contacts) and 0.15 per paediatrician per year (2.8 per 1 00 000 contacts), respectively. The following factors were associated with medication incidents (OR, 95% CI): higher age 1.004 per year (1.001; 1.006), care by community nurse 1.458 (1.025; 2.073) and care by an institution 1.802 (1.399; 2.323), chronic conditions 1.052 (1.029; 1.075) per condition, medications 1.052 (1.030; 1.074) per medication, as well as Thurgau Morbidity Index for stage 4: 1.292 (1.004; 1.662), stage 5: 1.420 (1.078; 1.868) and stage 6: 1.680 (1.178; 2.396), respectively. Most cases were linked to an incorrect dosage for a given patient, while prescription of an erroneous medication was the second most common error.

CONCLUSIONS

Medication incidents are common in adult primary care, whereas they rarely occur in paediatrics. Older and multimorbid patients are at a particularly high risk for medication incidents. Reasons for medication incidents are diverse but often seem to be linked to communication problems.

Association Between Workarounds and Medication Administration Errors in Bar Code-Assisted Medication Administration: Protocol of a Multicenter Study

Background

Information technology-based methods such as bar code-assisted medication administration (BCMA) systems have the potential to reduce medication administration errors (MAEs) in hospitalized patients. In practice, however, systems are often not used as intended, leading to workarounds. Workarounds may result in MAEs that may harm patients.

Objective

The primary aim is to study the association of workarounds with MAEs in the BCMA process. Second, we will determine the frequency and type of workarounds and MAEs and explore the potential risk factors (determinants) for workarounds.

Methods

This is a multicenter prospective study on internal medicine and surgical wards of 4 Dutch hospitals using BCMA systems to administer medication. We will include a total of 6000 individual drug administrations using direct observation to collect data.

Results

The project was funded in 2014 and enrollment was completed at the end of 2016. Data analysis is under way and the first results are expected to be submitted for publication at the end of 2017.

Conclusions

If an association between workarounds and MAEs is established, this information can be used to reduce the frequency of MAEs. Information on determinants of workarounds can aid in a focused approach to reduce workarounds and thus increase patient safety.

Trial Registration

Netherlands Trial Register NTR4355; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4355 (Archived by WebCite at http://www.webcitation.org/6pqTLxc6i).

The Impact of Information Culture on Patient Safety Outcomes. Development of a Structural Equation Model

Background

An organization’s information culture and information management practices create conditions for processing patient information in hospitals. Information management incidents are failures that could lead to adverse events for the patient if they are not detected.

Objectives

To test a theoretical model that links information culture in acute care hospitals to information management incidents and patient safety outcomes.

Methods

Reason’s model for the stages of development of organizational accidents was applied. Study data were collected from a cross-sectional survey of 909 RNs who work in medical or surgical units at 32 acute care hospitals in Finland. Structural equation modeling was used to assess how well the hypothesized model fit the study data.

Results

Fit indices indicated a good fit for the model. In total, 18 of the 32 paths tested were statistically significant. Documentation errors had the strongest total effect on patient safety outcomes. Organizational guidance positively affected information availability and utilization of electronic patient records, whereas the latter had the strongest total effect on the reduction of information delays.

Conclusions

Patient safety outcomes are associated with information management incidents and information culture. Further, the dimensions of the information culture create work conditions that generate errors in hospitals.