Carers' Medication Administration Errors in the Domiciliary Setting: A Systematic Review

Parents' understanding of medication at discharge and potential harm in children with medical complexity

OBJECTIVE

Children with medical complexity (CMC) are among the most vulnerable patient groups. This study aimed to evaluate their prevalence and risk factors for medication misunderstanding and potential harm (PH) at discharge.

DESIGN AND SETTING

Cross-sectional study at a tertiary care centre.

STUDY POPULATION

CMC admitted at Medical University of Vienna between May 2018 and January 2019.

INTERVENTION

CMC and caregivers underwent a structured interview at discharge; medication understanding and PH for adverse events were assessed by a hybrid approach.

MAIN OUTCOME MEASURES

Medication misunderstanding rate; PH.

RESULTS

For 106 included children (median age 9.6 years), a median number of 5.0 (IQR 3.0-8.0) different medications were prescribed. 83 CMC (78.3%) demonstrated at least one misunderstanding, in 33 CMC (31.1%), potential harm was detected, 5 of them severe. Misunderstandings were associated with more medications (r=0.24, p=0.013), new prescriptions (r=0.23, p=0.019), quality of medication-related communication (r=-0.21, p=0.032), low level of education (p=0.013), low language skills (p=0.002) and migratory background (p=0.001). Relative risk of PH was 2.27 times increased (95% CI 1.23 to 4.22) with new medications, 2.14 times increased (95% CI 1.10 to 4.17) with migratory background.

CONCLUSION

Despite continuous care at a tertiary care centre and high level of subjective satisfaction, high prevalence of medication misunderstanding with relevant risk for PH was discovered in CMC and their caregivers. This demonstrates the need of interventions to improve patient safety, with stratification of medication-related communication for high-risk groups and a restructured discharge process focusing on detection of misunderstandings ('unknown unknowns').

Medication errors by caregivers in the homes of children discharged from a pediatric department in Ghana

Background

Medication errors (MEs) by caregivers at home are a cause of morbidity and mortality, shortly after discharge from the hospital.

Objectives

The objective of this study was to determine the rate and types of MEs at the homes of children discharged from a hospital in Ghana and to explore the factors associated with these errors.

Design

This was a cross-sectional study of infants and children discharged from the hospital to review medication administration practices.

Methods

Caregivers of children discharged from the hospital after at least 24 hours of admission were interviewed at their homes about medication administration practices. The study assessed potential harm associated with MEs made by caregivers using the Harm Associated with Medication Error Classification tool. The Least Absolute Shrinkage and Selection Operator regression were used to identify the variables associated with MEs.

Results

A total of 95 children (mean age: 28.6 months, 52.6% female) and their caregivers were included. Overall, 65 (68.4%) children experienced one or more MEs. Out of a total of 232 medications reviewed, 102 (44.0%) (95% CI: 37.6-50.4) were associated with a ME. The top two errors, wrong time errors and errors in the frequency of dosing were, 45.1% and 21.6%, respectively. Understanding the information on the disease condition being treated and the medicines dispensed was associated with committing fewer MEs. The number of medicines prescribed was associated with a higher likelihood of MEs. Out of 102 MEs, 48 (47.1%) were assessed as posing potentially no harm, 26 (25.5%) minor harm, 15 (14.7%) moderate harm, and 13 (12.8%) serious harm to the patients. Importantly, none of the MEs were assessed as posing potentially severe or life-threatening harm to the patients.

Conclusion

MEs in children following discharge are high, and systems should be developed to prevent these errors.

Medication risk checklist for older adults (LOTTA) - development and validation of a self-assessment tool

BACKGROUND

Patient safety strategies highlight patients' own active involvement in ensuring medication safety. A prerequisite for involving patients in their medication therapy is having tools that can assist them in ensuring safe medicine use. Older home-dwelling adults with multiple medications are at high risk for medication-related problems, yet only a few age-specific patient self-administered medication risk screening tools exist. This study aimed to develop, validate, and assess the feasibility of a self-administered medication risk checklist for home-dwelling older adults ≥65 years.

MATERIALS AND METHODS

The draft checklist was formed based on a validated practical nurse-administered Drug Related Problem Risk Assessment Tool supplemented with findings from two systematic literature reviews. The content validity of the draft checklist was determined by a three-round Delphi survey with a panel of 19 experts in geriatric care and pharmacotherapy. An agreement of ≥80% was required. A feasibility assessment (i.e. understandability of the items, fill-out time of the checklist) of the content-validated checklist was conducted among older adults ≥65 years (n = 87) visiting community pharmacies (n = 4). Data were analysed using qualitative content analysis.

RESULTS

The final validated and feasibility-tested Medication Risk Checklist (LOTTA) for home-dwelling older adults consists of eight items screening the highest priority systemic risks (three items), potentially drug-induced symptoms (one item), adherence, and self-management problems (four items). The checklist proved feasible for self-administration, the mean fill-out time being 6.1 min.

CONCLUSIONS

A wide range of potential medication risks related to the medication use process can be identified by patient self-assessment. Screening tools such as LOTTA can enhance early detection of potential medication risks and risk communication between older adults and their healthcare providers. A wider and more integrated use of the checklist could be facilitated by making it electronically available as part of the patient information systems.

Reducing Medication Errors in Children's Hospitals

OBJECTIVES

Knowledge of the prevalence and characteristics of medication errors in pediatric and neonatal patients is limited. This study aimed to evaluate the incidence and medication error characteristics in a pediatric hospital over 5 years and to determine whether serial error prevention programs to optimize a computerized physician order entry (CPOE) system reduce error incidence.

METHODS

We retrospectively reviewed medication errors documented between January 2015 and December 2019.

RESULTS

A total of 2,591,596 prescriptions were checked, and 255 errors were identified. Wrong dose prescriptions constituted the most common errors (56.9%). Medications with the highest rate of errors were antibiotics/antiviral drugs (36.9%). Oral route medications comprised the highest portion (60.8%), followed by intravenous ones (28.6%). The most common stage for medication errors was physician ordering (93.3%). Junior residents were responsible for most errors (45.9%). Most errors occurred in the pediatric ward (53.7%). In total, 221 (86.7%) errors were near misses. Only 4 errors (1.6%) were considered significant and required active monitoring or intervention. Type of error, stage of error, staff composition, and severity level of errors were significantly related to the number of errors in different years. There was a statistically significant decrease in errors per 100,000 prescriptions across different years after optimizing the CPOE system.

CONCLUSIONS

The incidence of medication errors decreased with extensive use of the CPOE system. Continuous application of the CPOE optimization program can effectively reduce medication errors. Further incorporation of pediatric-specific decision-making and support tools and error prevention measures into CPOE systems is needed.

Medication-Related Outcomes and Health Equity: Evidence for Pharmaceutical Care

Marginalised people experience diminished access to pharmaceutical care and worse medication-related outcomes than the general population. Health equity is a global priority. This article explores the key evidence of health inequity and medication use, structures the causes and contributory factors and suggests opportunities that can be taken to advance the pharmaceutical care agenda so as to achieve health equity. The causes of, and contributors to, this inequity are multi-fold, with patient- and person-related factors being the most commonly reported. Limited evidence is available to identify risk factors related to other aspects of a personal medication use system, such as technology, tasks, tools and the internal and the external environments. Multiple opportunities exist to enhance equity in medication-related outcomes through pharmaceutical care research and practice. To optimise the effects and the sustainable implementation of these opportunities, it is important to (1) ensure the meaningful inclusion and engagement of members of marginalised groups, (2) use a person-centred approach and (3) apply a systems-based approach to address all of the necessary components of a system that interact and form a network as work processes that produce system outcomes.

The medication self-management work system of patients and informal carers from a human factors & ergonomics perspective: A scoping review protocol

Background: Healthcare is increasingly delivered closer to the patients' homes, which increases the level of responsibility that patients and informal carers take for managing their medication-taking, although this is associated with hazards. Medication self-management has been conceptualised as work taking place in non-formal settings ( e.g., households), which are complex systems. Human factors and ergonomics (HFE) models provide a framework for studying such systems. The Systems Engineering Initiative for Patient Safety (SEIPS) is one framework that considers work system elements and how they interact with each other to shape processes that lead to outcomes ( e.g., safety). Given the increasing amount of diverse research on patient and carer work and on system-shaping factors, the objectives of this review are to: (i) identify available evidence in a structured and systems-oriented way, (ii) explore approaches that have been applied and (iii) highlight research gaps. Methods: An evidence-informed patient, public and carer involvement (PPCI) approach will be implemented at all post-protocol stages to ensure the relevance, uptake and translation of the scoping review. The review will systematically search MEDLINE, Embase, PsycInfo, CINAHL and Web of Science to identify relevant qualitative studies. The methodological approach will be guided by Johanna Briggs Institute methodology and will be reported according to the PRISMA-ScR standards. Data charting and qualitative content analysis directed by SEIPS will explore how the work system and its constituting elements have been described in the literature and identify specific gaps and opportunities for future research. Borrowing from realist approaches, included studies will be assessed in terms of richness and relevance to our review question. Discussion: Strengths of this scoping review include PPCI and a converging focus on medication safety, medication self-management and HFE. Ultimately, this approach will advance our understanding of this complex system and guide opportunities to broaden and strengthen the evidence base.

Diseño, validación facial y de contenido del instrumento “rol del cuidador familiar en administración de medicamentos”

Objetivo: Diseñar un instrumento para medir la adopción del rol del cuidador familiar en la administración de medicamentos en personas con enfermedad crónica y establecer tanto su validez de contenido como facial. Método: Estudio metodológico que incluyó tres fases: diseño del instrumento, determinación de la validez de contenido con 9 expertos y determinación de la validez facial mediante entrevistas cognitivas a 14 cuidadores y juicios de 30 cuidadores de adultos con enfermedades crónicas. Resultados: Se obtuvo un cuestionario conformado por 32 ítems distribuidos en 3 dimensiones denominadas labores, organización y respuesta ante el rol. El instrumento presentó una adecuada validez de contenido dado que todos los ítems superaron el CVI mínimo de 0,58, mientras que para la escala total fue de 0,97. Por su parte, la validez facial mostró que la claridad fue del 99,6%, la comprensión fue del 98,4% y la precisión fue del 96,9%. Conclusión: El instrumento Adopción del rol en la administración de medicamentos mide de forma lógica el constructo y los ítems que lo conforman representan adecuadamente sus dominios.

A Cell-Phone Medication Error eHealth App for Managing Safety in Chronically Ill Young Patients at Home: A Prospective Study

Introduction: Whereas ample information describes medication errors (MEs) in children or in mixed pediatric and adult populations discharged with acute or chronic diseases from hospital to community settings, little is known about MEs in children and adolescents with chronic diseases discharged home, a major concern. To promote home medication safety, we trained parents of children discharged with chronic diseases to record ME with a tailored cell-phone eHealth app. Methods: In a 1-year prospective study, we used the app to monitor ME in patients with chronic diseases discharged home from a tertiary hospital in Rome, Italy. Univariate and multivariate analyses detected the ME incidence rate ratio (IRR). Results: Of the 310 parents enrolled, 194 used the app. The 41 MEs involved all drug management phases. The ME IRR was 0.46 errors per child. Children <1 year had the highest ME risk (1.69 vs. 0.35, p = 0.002). Children discharged from the cardiology unit had a statistically higher ME IRR than others (3.66, 95% confidence interval: 1.01-13.23%). Conclusions: The highest ME risk at home involves children with chronic diseases <1 year old. A significant ME IRR at home concerns children with heart diseases of any age. Parents find a tailored eHealth app for monitoring and reporting ME at home easy to use. At discharge, clinical teams need to identify age-related and disease-residual risks to target additional actions for monitoring ME, thus increasing medication safety at home.

Suicidal and accidental drug poisoning mortality among older adults and working-age individuals in Spain between 2000 and 2018

BACKGROUND

Although medication poisoning in older adults is considered an increasingly important, but preventable cause of death, it has received relatively little attention. We explored recent trends and correlates of suicidal and accidental fatal drug poisonings among older and working-age individuals using nationwide data from Spain.

METHODS

We identified all 15,353 fatal drug poisonings involving decedents aged ≥15 years in Spain between 2000 and 2018 and divided them by age into older adults (≥65 years) and working-age (15-64 years) individuals. For each age group, we analyzed time trends in suicidal and accidental fatal drug poisoning rates (overall and by ICD-10 drug categories) using joinpoint regressions. To understand the specific drugs classified as "Non-psychotropic/non-specified", we used 2018 data including substance-specific ICD-10 supplementary codes. We explored relevant sociodemographic correlates of suicidal and accidental fatal poisoning rates using multivariable negative binomial regressions.

RESULTS

Between 2000 and 2018, suicidal fatal poisonings increased faster among older (from 0.19 to 0.63 per 100,000 - average annual change: 7.7%) than working-age individuals (from 0.40 to 0.72 per 100,000 - average annual change: 3.8%). Accidental fatal poisonings increased among older adults (from 0.25 to 2.67 per 100,000 - average annual change: 16.2%) but decreased among working-age counterparts (from 2.38 to 1.42 per 100,000 - average annual change: - 1.9%). Anticoagulants and cardiac-stimulants glycosides accounted for 70% of the 223 accidental fatal poisonings due to non-psychotropic/non-specified drugs registered among older adults in 2018. Roles of gender and urban dwelling in suicidal and accidental poisonings were heterogeneous across age groups.

CONCLUSION

Increases in suicidal drug poisonings were faster among older than working-age individuals. Accidental fatal poisonings increased only among older adults. Our findings that (i) sociodemographic correlates were heterogeneous across age groups and (ii) anticoagulant and cardiac-stimulant glycosides were particularly salient drivers of accidental poisonings among older adults have implications for prevention.

Going home after a child's cardiac surgery: education for safe care

OBJECTIVES

to validate the content and appearance of the booklet "Going home after a child's cardiac surgery" and assess family members' cognitive learning regarding its use.

METHODS

a methodological and quasi-experimental study of before and after type, with semi-structured interview, pre-test and reading of the booklet in a hospital; post-test and validation occurred after hospital discharge. Wilcoxon non-parametric statistics were used.

RESULTS

nineteen family members of children with heart disease participated. The average of correct answers increased 14 percentage points from pre- to post-test; most were medication errors. There was a significant difference (p <0.0001) in the comparison between cognitive knowledge prior to using the booklet and learning acquired from its use. All items received a positive rating, except font size.

CONCLUSIONS

the booklet helps family members to understand a child's needs after cardiac surgery, and can be used to prevent unwanted occurrences and enable safe care at home.

Medication errors in homecare setting: An Italian validation study

OBJECTIVE

Medication errors are a concern in overall the world. Although there are studies that investigate what may be the main causes that lead to the genesis of the medication error in the home care setting, there is no tool that correlates knowledge, attitudes, and behavior to medication errors in the context of home care. This study aimed to psychometrically test to the questionnaire on knowledge, attitudes, and behaviors in the administration of medication in the new setting: home care setting.

DESIGN

This observational study was reported according to the STROBE checklist.

SAMPLE

Sixty two nurses working in home care setting responded to the online survey.

MEASUREMENT

The face and content validity of the items generated was assessed. An Exploratory Factorial Analysis descriptive statistical analysis was conducted. The final questionnaire is composed of 20 items.

RESULTS

The results of the statistical analyses allowed to validate the questionnaire, ensuring good internal consistency and reliability. Most of the sample pointed out that the use of electronic health record, medication reconciliation and the pharmacist's figure are all useful strategies for reducing the risk of medication errors.

CONCLUSION

The questionnaire is reliable to measure knowledge, attitude, and behavior about medication errors prevention in home care settings.

Patterns of medication errors involving pediatric population reported to the French Medication Error Guichet

Background

Medication error is a global threat to patient safety, particularly in pediatrics. Yet, this issue remains understudied in this population, in both hospital and community settings.

Objectives

To characterize medication errors involving pediatrics reported to the French Medication Error Guichet, and compare them with medication errors in adults, in each of the hospital and community settings.

Methods

This was a retrospective secondary data analysis of medication errors reported throughout 2013-2017. Descriptive and multivariate analyses were performed to compare actual and potential medication error reports between pediatrics (aged <18 years) and adults (aged >18 and <60 years). Two subanalyses of actual medication errors with adverse drug reaction (ADR), and serious ADR were conducted.

Results

We analyzed 4,718 medication error reports. In pediatrics, both in hospital (n=791) and community (n=1,541) settings, antibacterials for systemic use (n=121, 15.7%; n=157, 10.4%, respectively) and wrong dose error type (n=391, 49.6%; n=549, 35.7%, respectively) were frequently reported in medication errors. These characteristics were also significantly more likely to be associated with reported errors in pediatrics compared with adults. In the hospital setting, analgesics (adjusted odds ratio (aOR)=1.59; 95% confidence interval (CI) 1.03:2.45), and blood substitutes and perfusion solutions (aOR=3.74; 95%CI 2.24:6.25) were more likely to be associated with reported medication errors in pediatrics; the latter drug class (aOR=3.02; 95%CI 1.59:5.72) along with wrong technique (aOR=2.28; 95%CI 1.01:5.19) and wrong route (aOR=2.74; 95%CI 1.22:6.15) error types related more to reported medication errors with serious ADR in pediatrics. In the community setting, the most frequently reported pediatric medication errors involved vaccines (n=389, 25.7%). Psycholeptics (aOR=2.42; 95%CI 1.36:4.31) were more likely to be associated with reported medication errors with serious ADR in pediatrics. Wrong technique error type (aOR=2.71; 95%CI 1.47:5.00) related more to reported medication errors with ADR in pediatrics.

Conclusions

We identified pediatric-specific medication error patterns in the hospital and community settings. Our findings inform focused error prevention measures, and pave the way for interventional research targeting the needs of this population.

Medication-related knowledge, administration practice and adherence among caregivers of chronically ill children in Malaysia

Background

Caregivers’ knowledge, practice and adherence in medication administration who care for children with chronic illness requiring long-term pharmacological treatments are factors associating with children medication safety at home. This study aimed to determine the medication-related knowledge, administration practice and adherence among caregivers of chronically ill children in Malaysia. This cross-sectional study was conducted at the paediatric outpatient clinic of a tertiary public hospital. Caregivers of chronically ill children, who engaged in medication administration at home for at least 3 months, were conveniently recruited. Their medication-related knowledge and administration practice were evaluated based on a checklist, while their adherence to medication administration was assessed using a validated 5-point scale. The associated factors were also explored.

Results

Of the 141 participants, most were mothers (90.8%) and had a full-time job (55.3%). Most of them had adequate medication-related knowledge (71.6%) and an appropriate administration practice (83.0%). The majority of them (83.0%) also rated themselves as adherent to medication administration. The participants with a child above 5 years of age (91.2%) were found to have a better practice than those with younger children (75.3%) in medication administration (p = 0.012). However, those with a child taking two (adjusted OR: 12.53) or three (adjusted OR: 8.29) medications, getting their refills from private health institutions apart from this hospital (adjusted OR = 7.06) and having multiple illnesses (adjusted OR = 21.25) were more likely to be not adherent to medication administration.

Conclusion

Caregivers of chronically ill children in Malaysia generally have sufficient knowledge and an appropriate practice of medication administration at home. Yet, strategies to improve the adherence to medication administration, particularly in those who care for children with complicated health conditions, are warranted.

Interventions to Reduce Pediatric Prescribing Errors in Professional Healthcare Settings: A Systematic Review of the Last Decade

INTRODUCTION

Pediatric medication therapy is prone to errors due to the need for pharmacokinetic and pharmacodynamic individualization and the diverse settings in which pediatric patients are treated. Prescribing errors have been reported as the most common medication error.

OBJECTIVES

The aim of this review was to systematically identify interventions to reduce prescribing errors and corresponding patient harm in pediatric healthcare settings and to evaluate their impact.

METHODS

Four databases were systematically screened (time range November 2011 to December 2019), and experimental studies were included. Interventions to reduce prescribing errors were extracted and classified according to a 'hierarchy of controls' model.

RESULTS

Forty-five studies were included, and 70 individual interventions were identified. A bundle of interventions was more likely to reduce prescribing errors than a single intervention. Interventions classified as 'substitution or engineering controls' were more likely to reduce errors in comparison with 'administrative controls', as is expected from the hierarchy of controls model. Fourteen interventions were classified as substitution or engineering controls, including computerized physician order entry (CPOE) and clinical decision support (CDS) systems. Administrative controls, including education, expert consultations, and guidelines, were more commonly identified than higher level controls, although they may be less likely to reduce errors. Of the administrative controls, expert consultations were most likely to reduce errors.

CONCLUSIONS

Interventions to reduce pediatric prescribing errors are more likely to be successful when implemented as part of a bundle of interventions. Interventions including CPOE and CDS that substitute risks or provide engineering controls should be prioritized and implemented with appropriate administrative controls including expert consultation.

Interventions to Reduce Medication Dispensing, Administration, and Monitoring Errors in Pediatric Professional Healthcare Settings: A Systematic Review

Introduction: Pediatric patients cared for in professional healthcare settings are at high risk of medication errors. Interventions to improve patient safety often focus on prescribing; however, the subsequent stages in the medication use process (dispensing, drug administration, and monitoring) are also error-prone. This systematic review aims to identify and analyze interventions to reduce dispensing, drug administration, and monitoring errors in professional pediatric healthcare settings. Methods: Four databases were searched for experimental studies with separate control and intervention groups, published in English between 2011 and 2019. Interventions were classified for the first time in pediatric medication safety according to the "hierarchy of controls" model, which predicts that interventions at higher levels are more likely to bring about change. Higher-level interventions aim to reduce risks through elimination, substitution, or engineering controls. Examples of these include the introduction of smart pumps instead of standard pumps (a substitution control) and the introduction of mandatory barcode scanning for drug administration (an engineering control). Administrative controls such as guidelines, warning signs, and educational approaches are lower on the hierarchy and therefore predicted by this model to be less likely to be successful. Results: Twenty studies met the inclusion criteria, including 1 study of dispensing errors, 7 studies of drug administration errors, and 12 studies targeting multiple steps of the medication use process. A total of 44 interventions were identified. Eleven of these were considered higher-level controls (four substitution and seven engineering controls). The majority of interventions (n = 33) were considered "administrative controls" indicating a potential reliance on these measures. Studies that implemented higher-level controls were observed to be more likely to reduce errors, confirming that the hierarchy of controls model may be useful in this setting. Heterogeneous study methods, definitions, and outcome measures meant that a meta-analysis was not appropriate. Conclusions: When designing interventions to reduce pediatric dispensing, drug administration, and monitoring errors, the hierarchy of controls model should be considered, with a focus placed on the introduction of higher-level controls, which may be more likely to reduce errors than the administrative controls often seen in practice. Trial Registration Prospero Identifier: CRD42016047127.

Household medication safety practices during the COVID-19 pandemic: a descriptive qualitative study protocol

INTRODUCTION

Those who are staying at home and reducing contact with other people during the COVID-19 pandemic are likely to be at greater risk of medication-related problems than the general population. This study aims to explore household medication practices by and for this population, identify practices that benefit or jeopardise medication safety and develop best practice guidance about household medication safety practices during a pandemic, grounded in individual experiences.

METHODS AND ANALYSIS

This is a descriptive qualitative study using semistructured interviews, by telephone or video call. People who have been advised to 'cocoon'/'shield' and/or are aged 70 years or over and using at least one long-term medication, or their caregivers, will be eligible for inclusion. We will recruit 100 patient/carer participants: 50 from the UK and 50 from Ireland. Recruitment will be supported by our patient and public involvement (PPI) partners, personal networks and social media. Individual participant consent will be sought, and interviews audio/video recorded and/or detailed notes made. A constructivist interpretivist approach to data analysis will involve use of the constant comparative method to organise the data, along with inductive analysis. From this, we will iteratively develop best practice guidance about household medication safety practices during a pandemic from the patient's/carer's perspective.

ETHICS AND DISSEMINATION

This study has Trinity College Dublin, University of Limerick and University College London ethics approvals. We plan to disseminate our findings via presentations at relevant patient/public, professional, academic and scientific meetings, and for publication in peer-reviewed journals. We will create a list of helpful strategies that participants have reported and share this with participants, PPI partners and on social media.

Factors contributing to reported medication administration incidents in patients' homes - A text mining analysis

AIMS

To describe the characteristics of medication administration (MA) incidents reported to have occurred in patients' own homes (reporters' profession, incident types, contributing factors, patient consequence, and most common medications involved) and to identify the connection terms related to the most common contributing factors based on free text descriptions.

DESIGN

A retrospective study using descriptive statistical analysis and text mining.

METHODS

Medication administration incidents (N = 19,725) reported to have occurred in patients' homes between 2013-2018 in one district in Finland were analysed, describing the data by the reporters' occupation, incident type, contributing factors, and patient consequence. SAS® Text Miner was used to analyse free text descriptions of the MA incidents to understand contributing factors, using concept linking.

RESULTS

Most MA incidents were reported by practical (lower level) nurses (77.8%, N = 15,349). The most common category of harm was 'mild harm' (40.1%, N = 7,915) and the most common error type was omissions of drug doses (47.4%, N = 9,343). The medications most commonly described were Marevan [warfarin] (N = 2,668), insulin (N = 811), Furesis [furosemide] (N = 590), antibiotic (N = 446), and Panadol [paracetamol] (N = 416). The contributing factors most commonly reported were 'communication and flow of information' (25.5%, N = 5,038), 'patient and relatives' (22.6%, N = 4,451), 'practices' (9.9%, N = 1,959), 'education and training' (4.8%, N = 949), and 'work environment and resources' (3.0%, N = 598).

CONCLUSION

There is need for effective communication and clear responsibilities between home care patients and their relatives and health providers, about MA and its challenges in home environments. Knowledge and skills relating to safe MA are also essential.

IMPACT

These findings about MA incidents that have occurred in patients' homes and have been reported by home care professionals demonstrate the need for medication safety improvement in home care.

Simplifying Medication Regimens for People Receiving Community-Based Home Care Services: Outcomes of a Non-Randomized Pilot and Feasibility Study

Purpose

Being able to manage a complex medication regimen is key to older people continuing to live at home. This study determined the feasibility of a multi-component intervention to simplify medication regimens for people receiving community-based home care services.

Patients and Methods

Research nurses recruited people receiving community-based home care services to participate in this non-randomized pilot and feasibility study (Australian New Zealand Clinical Trials Registry ACTRN12618001130257). Participants received a one-off clinical pharmacist intervention comprising medication reconciliation, assessment of capacity to self-manage medications, and application of a structured 5-step tool to identify medication simplification opportunities. A mixed-methods feasibility assessment with an explanatory design was undertaken to assess recruitment, protocol adherence and stakeholder acceptability. Data from interviews with 12 stakeholders were thematically analyzed. Secondary outcome measures, including medication discrepancies, and changes in number of medication administration times per day, quality of life, medication adherence and health service utilization, were determined over a 4-month follow-up.

Results

Twenty-five out of the target 50 participants were recruited. Initial recruitment was impacted by apparent uncertain role responsibilities in medication management, with some clients who declined to participate perceiving they would be unlikely to benefit or being reluctant to change regimens. However, with few exceptions, participants who received intervention did so with a high degree of protocol adherence and acceptability. Stakeholders valued the intervention and supported wider implementation. Discrepancies between the baseline medication history from the general medical practitioner and the pharmacist-compiled “best possible medication history” were identified for all participants’ regimens (median of 6 per participant), with one-third resolved at follow-up. Simplification was possible for 14 participants (56%) and implemented for 7 (50%) at follow-up. No significant changes in other secondary outcomes were observed.

Conclusion

The intervention was delivered as planned, and valued by stakeholders. Recruitment barriers should be addressed before wider implementation.

Medication Safety at Home: A Qualitative Study on Caregivers of Chronically Ill Children in Malaysia

Introduction: Medication errors are more likely to occur in chronically ill children, who are highly dependent on caregivers for medication administration. This study aimed to explore the issues related to medication safety among pediatric outpatients in Malaysia from the caregivers' perspective. Methods: This was a qualitative study conducted between May and June 2018 at a pediatric clinic of a regional referral hospital. Caregivers of children who (1) were under 6 years of age and (2) had hypothyroidism, epilepsy, thalassemia, asthma, or other chronic diseases were recruited via purposive sampling. Each selected disease was represented by at least 3 caregivers, who were identified from the medical records of their children. Face-to-face interviews were conducted with each of them, facilitated by a semi-structured interview guide. All the interviews were audio-recorded, transcribed verbatim, and analyzed using the thematic analysis approach. Results: A total of 15 mothers with a median age of 34 years were interviewed. Three themes emerged from the interviews: (I) actual experiences with medication errors, (II) underlying risk factors for medication errors, and (III) recommendations to improve medication safety. Several cases of administration errors, including missed doses and self-decided dose adjustment, were detected. Furthermore, the caregivers were found to have inadequate understanding of the medications in general. Conclusions: While children were shown to be consistently exposed to medication errors at home in Malaysia, the recommendations of the caregivers, including the use of written instructions and a diary, could be effective strategies to improve the out-of-hospital medication safety in children.

Reporting adverse events-Swedish Registered Nurses experience in a municipal home care context

AIM

To describe how Registered Nurses in a municipal home care context experience adverse event reports.

DESIGN

A qualitative design was used.

METHOD

Twelve semistructured individual interviews with Registered Nurses in a municipal home care context were collected on two occasions and analysed with qualitative content analysis.

RESULTS

The results show that conflicts exist between being able to trust the managers and their feedback, being loyal to colleagues and retaining professional pride. These are described in the theme "Contradiction" and the three categories: "Awareness"; "Uncertainty"; and "Concealment."

Support for Australian carers from community pharmacy: Insight into carer perspectives of a novel service

The feasibility of an individualised carer support service delivered in community pharmacies was assessed from the perspective of carer participants using a pre-post questionnaire and semistructured interviews. Eligible pharmacies were required to offer a medication management service relevant to carers and have a semiprivate space for conversations. Carers were required to self-identify as an unpaid support person for someone with a chronic condition or disability. Between September 2016 and March 2017, staff from 11 community pharmacies in South-East Queensland, Australia were trained, and provided with ongoing mentoring from a pharmacist and carer to support service implementation. Identification of carers and support to achieve a personal and care-giving goal were key features of the service. Questionnaires included the EQ-5D-3L, the Bakas Caregiving Outcomes Scale, and questions relating to goal achievement, carer roles, and responsibilities. Seven follow-up carer interviews were undertaken between March and May 2017 and analysed thematically. Pre-post questionnaires were available for 17 carers (one withdrew, two incomplete). Of the 29 goals set, 10 were achieved and 14 partially achieved. EQ-5D-3L scores were unchanged, while 7 of the 15 items comprising the Bakas score improved (p < 0.05). Carer service evaluation was generally favourable, and these two main interview themes were the impact of caring and pharmacy experience. The impact of caring, while variable, was significant. Pharmacy experiences were mostly positive and the opportunity for carers to further engage with pharmacy staff was appreciated. The service was feasible and initial reported benefits to carers may support further research potentially in terms of a larger controlled trial.

Use of patient-held information about medication (PHIMed) to support medicines optimisation: protocol for a mixed-methods descriptive study

INTRODUCTION

Risks of poor information transfer across health settings are well documented, particularly for medication. There is also increasing awareness of the importance of greater patient activation. Patients may use various types of patient-held information about medication (PHIMed) to facilitate medication transfer, which may be paper or electronic. However, it is not known how PHIMed should best be used, whether it improves patient outcomes, nor is its key 'active ingredients' known. Discussion with patients and carers has highlighted this as a priority for research. We aim to identify how PHIMed is used in practice, barriers and facilitators to its use and key features of PHIMed that support medicines optimisation in practice.

METHODS AND ANALYSIS

This study will take place in Greater London, England. We will include patients with long-term conditions, carers and healthcare professionals. The study has four work packages (WPs). WP1 involves qualitative interviews with healthcare professionals (n=16) and focus groups with patients and carers (n=20), including users and non-users of PHIMed, to study perceptions around its role, key features, barriers and facilitators, and any unintended consequences. WP2 will involve documentary analysis of how PHIMed is used, what is documented and read, and by whom, in a stratified sample of 60 PHIMed users. In WP3, we will carry out a descriptive analysis of PHIMed tools used/available, both electronic and paper, and categorise their design and key features based on those identified in WP1/2. Finally, in WP4, findings from WPs 1-3 will be integrated and analysed using distributed cognition as a theoretical framework to explore how information is recorded, transformed and propagated among different people and artefacts.

ETHICS AND DISSEMINATION

The study has National Health Service ethics approval. It will provide initial recommendations around the present use of PHIMed to optimise patient care for patients, carers and healthcare professionals.

Intravenous Lipid Emulsion Overdose in Infancy: A Case Report and Overview of Opportunities, Challenges and Prevention

Medication errors remain among the major problems seen in hospitals. Such errors can relate to the prescription, dispensation, or administration of drugs. Human factors account for most of these mistakes, but other factors such as infusion pump programming defects should always be considered. Worldwide, medication errors have been reported to affect 2-30% of patients, depending on the institution. Intravenous lipid emulsion (ILE) infusion is frequently used as part of total parenteral nutrition in patients of all ages with feeding and gastrointestinal issues. ILE overdose has been previously reported, with variable clinical outcomes. We report a case of accidental ILE (Intralipid) overdose in a 3-month-old male infant who fully recovered after single-volume blood exchange transfusion. We also review reported cases and summarize potential solutions for ILE overdose. Our review indicates that ILE infusion is a high-risk medication, and opportunities for errors remain even in the best hospital set-ups. Attention should be directed towards proper prescription, dosing, dispensation, and administration. Most of the cases indicate the safety breach was at the nursing drug-administration level, with improper pump use or programming, together with other fluid infusion rate switching, being the main possible defects. Strategies targeting the areas of weakness in the drug-delivery pathway are needed. Special attention should be paid towards nursing duties and working hours. In addition, nursing staff should receive frequent education sessions and should be required to pass competency modules regularly. An error-prevention plan should be established and implemented. This plan needs full collaboration between physicians, pharmacists, and nursing staff.

A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting

Increasingly, medication is being administered at home by family and friends of the care-recipient. This study aims to identify and analyse risks associated with potential drug administration errors made by informal carers at home. We mapped medication administration at home with a multidisciplinary team that included carers, health care professionals and patients. Evidence-based risk-analysis methodologies were applied: Healthcare Failure Modes and Effect Analysis (HFMEA), Systematic Human Error Reduction and Prediction Analysis (SHERPA) and Systems-Theoretic Accident Model and Processes (STAMP). The process of administration comprises seven sub-processes. Thirty-four possible failure modes were identified and six of these were rated as high risk. These highlighted that medications may be given with a wrong dose, stored incorrectly, not discontinued as instructed, not recorded, or not ordered on time, and often caused by communication and support problems. Combined risk analyses contributed unique information helpful to better understand the medication administration risks and causes within homecare. Practitioner Summary: Increasingly, medication is being administered at home by family and friends of the care-recipient. This study identifies risks associated with potential drug administration errors made by informal carers at home through consensus-based quantitative techniques. The different analyses contribute unique information helpful to better understand the administration risks and causes.