Frequency, Timing, and Types of Medication Ordering Errors Made by Residents in the Electronic Medical Records Era

Medication administration behaviors in prelicensure nursing students: A longitudinal, cohort study

AIM

This longitudinal study identified changes in safe medication administration behaviors in a single cohort of students followed over four semesters of nursing school.

BACKGROUND

Over 40% of a nurse's shift is dedicated to the processes of medication administration, placing them in a position to interrupt costly medication errors. Yet, despite efforts to decrease medication errors, including electronic medical records, smart pumps, and standardized processes, 5% of hospitalized patients experience adverse drug events and the sequela costs billions of dollars annually. One cognitive aid first introduced in nursing school to help nurses administer medications safely is the rights method, including the foundational five (patient, medication, dose, route, and time). However, facility restrictions, complicated electronic health records, and high faculty-to-student ratios are limiting opportunities to apply these rights and develop safe medication administration competency. Although nursing faculty and clinical partners expect competency when initially licensed as professionals, graduating nursing students are not competent and new graduates feel ill prepared to deliver medications safely. Previous studies report findings on safe medication administration in different cohorts of nursing students, but none has followed the same cohort of students throughout nursing school.

DESIGN

Using a non-experimental design, the same cohort of nursing students was followed over four semesters and observed independently administering medications in simulation scenarios.

METHODS

Each semester, this cohort of students self-selected into 10-12 simulation groups. One student from each group was randomized to the role of primary nurse. Guided by the NLN/Jeffries simulation theory and the International Nursing Association for Clinical Simulation and Learning's Standards of Best Practice: Simulation^SM, students participated in four simulations that required the primary nurse to deliver medications as part of clinical care. A single investigator completed an observational checklist during the simulations on verification of the foundational five rights in these students.

RESULTS

Verification of most rights varied each semester, but students consistently did poorly verifying right dose. One hundred percent of students observed in the first semester did not verify all five rights. At the time of graduation, 80% of students observed did not verify all five rights prior to medication administration.

CONCLUSIONS

These concerning findings align with previous research showing that students are not safely administering medications in patient care settings. Educators, administrators, and healthcare systems need to ensure that students receive consistent, high-quality experiences vital to training future nurses for competency in safe medication administration.

An Analysis of the Safety of Medication Ordering Using Typo Correction within an Academic Medical System

OBJECTIVES

Spelling during medication ordering is prone to error, which can contribute to frustration, confusion, and, ultimately, errors. Typo correction can be utilized in an effort to mitigate the effects of misspellings by providing results even when no exact matches can be found. Although, typo correction can be beneficial in some scenarios, safety concerns have been raised when utilizing the functionality for medication ordering. Our primary objective was to analyze the effects of typo correction technology on medication errors within an academic medical system after implementation of the technology. Our secondary objective was to identify and provide additional recommendations to further improve the safety of the functionality.

METHODS

We analyzed 8 months of post-implementation data obtained from staff-reported medication errors and search query information obtained from the electronic health record. The reports were analyzed by two pharmacists in two phases: retrospective identification of errors occurring as a result of typo correction and prospective identification of potential errors with continued use of the functionality.

RESULTS

In retrospective review of 2,603 reported medication-related errors, 26 were identified as potentially involving typo correction as a contributing factor. Six of these orders invoked typo correction, but none of the errors could be attributed to typo correction. In prospective review, a list of 40 error-prone words and terms were identified to be added as stop words and 407 medication synonyms were identified for removal from their associated medication records.

CONCLUSION

Our results indicate, when properly implemented, typo correction does not cause additional medication errors. However, there may be benefit in implementing further precautions for preventing future errors.

Pharmacist intervention on prescribing errors: Use of a standardized approach in the inpatient setting

Purpose

The objective of this study was to implement a standardized process across health systems to determine the prevalence and clinical relevance of prescribing errors intercepted by pharmacists.

Methods

This prospective, multicenter, observational study was conducted across 11 hospitals. Pharmacist-intercepted prescribing errors were collected during inpatient order verification over 6 consecutive weeks utilizing a standardized documentation process. The potential harm of each error was evaluated using a modified National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) index with physician validation, and errors were stratified into those with potentially low, serious, or life-threatening harm. Endpoints included the median error rate per 1,000 patient days, error type, and potential harm with correlating cost avoidance.

Results

Pharmacists intervened on 7,187 errors, resulting in a mean error rate of 39 errors per 1,000 patient days. Among the errors, 46.6% (n = 3,349) were determined to have potentially serious consequences and 2.4% (n = 175) could have been life-threatening if not intercepted. This equates to $874,000 in avoided cost. The top 3 error types occurring with the highest frequency were “wrong dose/rate/frequency” (n = 2,298, 32.0%), “duplicate therapy” (n = 1,431, 19.9%), and “wrong timing” (n = 960, 13.4%). “Wrong dose/rate/frequency” (n = 49, 28%), “duplicate therapy” (n = 26, 14.9%), and “drug-disease interaction” (n = 24, 13.7%) errors occurred with the highest frequency among errors with potential for life-threatening harm. “Wrong dose/rate/frequency” (n = 1,028, 30.7%), “wrong timing” (n = 573, 17.1%), and “duplicate therapy” (n = 482, 14.4%) errors occurred with the highest frequency among errors with potentially serious harm.

Conclusion

Documentation of pharmacist intervention on prescribing errors via a standardized process creates a platform for multicenter analysis of prescribing error trends and an opportunity for development of system-wide solutions to reduce potential harm from prescribing errors.

A Methodological Assessment of Pharmacist Therapeutic Intervention Documentation (TID) in a Single Tertiary Care Hospital in Jeddah, Kingdom of Saudi Arabia

Pharmacist intervention has valuable input to the healthcare system by reducing medication errors, costs of treatment and improving therapeutic outcomes. This study aimed to analyze pharmacists’ interventions during the verification of computerized physician order entry and to determine the association between prescribers’ level and type of prescribing errors. In this cross-sectional, observational study, data collection was carried out over three months starting from 1 January 2020 to 31 March 2020. Included were 2405 interventions documented by 52 different pharmacists. The prevalence of prescribing order entry errors was 9.1%. The most identifiable type of intervention was incorrect dilution (40.2%) followed by dose substitution (27.7%). The drug category associated with a high percentage of interventions was perfusion solutions (41%), followed by antibacterial (35%). The number of junior physician orders that required pharmacist intervention was higher than other prescribers (45.2%), followed by specialist and senior physicians, (31.4% and 15.5%, respectively). Prescriber ordering time and types of prescribing errors were shown to have a significant (p < 0.05) association. Internal medicine physicians entered the highest percentage of prescribing errors, representing 22.7%. The current study concluded that TID has significant potential to reduce drug-related problems; TID fatigue is a real problem that might be under-reported and addressing this point in future studies would be of great value.

Antibiotic dosing adjustments in patients with declined kidney function at a tertiary hospital in Jordan

BACKGROUND

Estimating kidney function is essential to consider in drug dosing for renally eliminated drugs. It has been estimated that more than half of medications' adverse effects are caused by the inappropriate dosing. Limited data are available on drug dosing adjustment, particularly the antibiotics, among Jordanian patients with declined kidney function.

AIM

The aim of this study was to evaluate the extent of antibiotics' dose adjustment according to the recent guidelines of drugs' renal dose adjustment.

METHOD

The present study utilised data from a previous retrospective study, which recruited inpatients who were clinically stable and received IV antibiotics for more than 24 hours at King Abdullah University Hospital. Sociodemographic and clinical data were collected by referring to information technology departments at KAUH. The percentage of antibiotics which were inappropriately adjusted based on creatinine clearance was evaluated using Lexicomp-Clinical Drug information website.

RESULTS

A total of 110 antibiotics were dispensed for 80 patients. Results showed that (36.25%) of patients were given antibiotics without renal dose adjustments based on their creatinine clearance. Urinary tract infections followed by respiratory tract infections were the most common among the study participants. The most commonly prescribed antibiotic was Imipenem/cilastatin (41.25%). Among antibiotics prescribed without renal dose adjustment, Imipenem/cilastatin was the most common and represented 62% of the cases while vancomycin was the least and represented only 3.45% of the non-renally adjusted doses.

CONCLUSIONS

The current study clearly demonstrates the lack of adherence to recent guidelines of renal dose adjustment for renally excreted antibiotics. Such findings shed the light on the necessity of considering antibiotics dose adjustment in patients with declined kidney function with the aim of ensuring medication safety and improve health outcomes.

Explicating practice norms and tensions between values in resident training in family medicine

Background

Residency programs have the intricate and complex role of training health care providers. But little is known about what residents and attendings consider norms of practice or the tensions among different values residents are expected to uphold. Thus, dialogical and reflective frameworks are being explored for resident learning.

Methods

This study examined the use of facilitated conversations with groups of residents and attending physicians while reviewing video-recorded resident–patient interactions. The conversations were recorded, transcribed, and qualitatively analyzed.

Results

A total of 24 residents and 10 attendings participated in conversations while separately and in parallel groups reviewing 15 resident sessions. Residents explicated the norms of practice and evaluated their performance, which often agreed with those of attending physicians in calling out important learning opportunities. When disagreement occurred, residents’ explications of their reasoning were often relevant and, via reflection and dialogue, helped clarify intentions that were not apparent in the videos. Residents and attendings often judged actions on more than one domain of value. For instance, if a resident addressed problems, built relationships in a timely manner, and acted autonomously without jeopardizing the quality of care, she satisfactorily performed her duty.

Conclusions

Practice norms and value struggles were addressed by participants during reviews, which provided a promising framework for learning and assessment. Also, the non-hierarchical structure opened space to acknowledge a diversity of positions and for tensions among values to be explicated.