Comparison of the validity, perceived usefulness, and usability of I-MeDeSA and TEMAS, two tools to evaluate alert system usability

OBJECTIVE

Two tools are currently available in the literature to evaluate the usability of medication alert systems, the instrument for evaluating human factors principles in medication-related decision support alerts (I-MeDeSA) and the tool for evaluating medication alerting systems (TEMAS). This study aimed to compare their convergent validity, perceived usability, usefulness, strengths, and weaknesses, as well as users' preferences.

METHOD

To evaluate convergent validity, two experts mapped TEMAS' items against I-MeDeSA's items with respect to the usability dimensions they target. To assess perceived usability, usefulness, strengths, and weaknesses of both tools, staff with expertise in their medication alerting system were asked to use French versions of the TEMAS and I-MeDeSA. After the use of each tool, participants were asked to complete the System Usability Scale (SUS) and answer questions about the understandability and usefulness of each tool. Finally, participants were asked to name their preferred tool. Numeric scores were statistically compared. Free-text responses were analyzed using an inductive approach.

RESULTS

Forty-five participants from 10 hospitals took part in the study. In terms of convergent validity, I-MeDeSA focuses more on the usability of the graphical user interface while TEMAS considers a wider range of usability principles. Both tools have a fair level of perceived usability (I-MeDeSA' SUS score = 61.85 and TEMAS' SUS score = 62.87), but results highlight that revisions are necessary to both tools to improve their usability. Participants found TEMAS more useful than I-MeDeSA (t = -3.63, p =.005) and had a clear preference for TEMAS to identify problems in formative evaluation (39 of 45; 0.867, p <.001) and to compare the usability of alert systems during the procurement process (36 of 45; 0.8, p <.001).

CONCLUSIONS

The TEMAS is perceived as more useful and is preferred by participants. The I-MeDeSA seems more relevant for quick evaluations that focus on the graphical user interface. The TEMAS seems to be more suitable for in-depth usability evaluations of alert systems. Even if both tools are perceived to be equally usable, they suffer from wording, instructional, and organizational problems that hinder their use. The results of this study will be used to improve the design of I-MeDeSA and TEMAS.

Association Between Exposure to Effervescent Paracetamol and Hospitalization for Acute Heart Failure: A Case-Crossover Study

We investigated whether effervescent paracetamol, as an important source of non-dietary sodium and fluid load, is associated with a transient increase in the risk of hospitalization for acute heart failure (AHF). We conducted a unidirectional case-crossover study using data from the 1/97^th representative sample from the French healthcare database. Subjects aged 18 years or more, hospitalized for AHF during the 2014-2016 period were included. Exposure to effervescent paracetamol was compared between a risk period (i.e. 15 days immediately prior to admission for AHF) and three earlier 15-day control periods, to test a possible trigger effect of effervescent paracetamol intake on AHF. Adjusted odds ratios (aOR) were estimated with a conditional logistic regression. We identified 4,301 patients hospitalized for AHF. We found that 5.7% of AHF subjects were exposed to effervescent paracetamol during the risk period, as compared with 4.1% during the control periods (aOR 1.56 [CI_95% : 1.27 - 1.90], p < 0.001). This association was also found in the subgroup of subjects with hypertension (aOR 1.45 [CI_95% : 1.13 - 1.87], p = 0.004, n = 2,648) and in the subgroup of subjects aged 83 years or more (aOR 1.70 [CI_95% : 1.28 - 2.24], p < 0.001, n = 2,238). A similar analysis, considering exposure to non-effervescent paracetamol, did not support the existence of an indication bias likely to explain the association observed for effervescent paracetamol. This study suggests an association between effervescent paracetamol and admission for AHF and should be confirmed with other complementary study designs. This article is protected by copyright. All rights reserved.

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.

Effects of a multifaceted intervention to promote the use of intravenous iron sucrose complex instead of ferric carboxymaltose in patients admitted for more than 24 h

PURPOSE

Although more practical for use, the impact of ferric carboxymaltose (FCM) on the hospital budget is considerable, and intravenous iron sucrose complex (ISC) represents a cost-saving alternative for the management of iron deficiency anemia in patients during hospitalization. The Drug Committee decided to reserve FCM for day hospitalizations and contraindications to ISC, especially allergy. ISC was available for prescription for all other situations.

METHODS

The impact of a multifaceted intervention promoting a switch from FCM to ISC was evaluated using an interrupted time series model with segmented regression analysis. The standardized rate of the dispensing of FCM, ISC, and oral iron by the hospital pharmacy, as well as the rate of the dispensing of packed red blood cells and the number of biological iron status measurements, was analyzed before and after the intervention.

RESULTS

There was an immediate decrease in FCM consumption following the intervention, with a reduction of 88% (RR: 0.12 [CI_95% 0.10 to 0.15]). Conversely, there was a large increase in ISC use (RR: 5.1 [CI_95% 4.4 to 5.9]). We did not observe a prescription shift to packed red blood cells or oral iron after the intervention. The time series analysis showed the frequency of iron status testing to remain stable before and after. The direct savings for intravenous iron for 8 months were 187,417.54 €.

CONCLUSION

Our intervention to lower the impact of intravenous iron therapy on the hospital budget was effective.

Consequences of the new zolpidem prescription regulations: a cohort study from the French national healthcare database

PURPOSE

To determine changes in the prevalence of zolpidem consumption since the change in the regulations of prescription. Formulations containing zolpidem were subject to the regulations of narcotics by the French decree of April 7, 2017.

METHODS

Longitudinal cohort study using data from the representative French healthcare database. The main outcome was the prevalence of oral hypnotic drug reimbursement before and after April 2017. The secondary outcome was the change in prescription habits for zolpidem since the decree in long-term users and excessive users.

RESULTS

A total of 81,174 individuals had at least one hypnotic drug reimbursement; among, whom 2143 had at least one reimbursement of zolpidem. Before the decree, 26% had at least one reimbursement of zolpidem, whereas it dropped to 18.4% after the decree. Among the 545 long-term users, the reimbursement of zolpidem was discontinued after the decree for 60.4% and 24.2% retained zolpidem as a treatment. The main replacement drug was zopiclone for 6.4% of them. Among the 1598 excessive users, the reimbursement of zolpidem was stopped after the decree for 16.5% and 56.3% retained zolpidem as a treatment. The main replacement drug was zopiclone for 12.1% of them.

CONCLUSIONS

The French decree had a major impact on the reimbursement of oral zolpidem. Indeed, prescription of the hypnotic was discontinued for half of the long-term users of zolpidem, and just over one-sixth of the excessive users discontinued the prescription of zolpidem after the decree.

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.

The impact of interventions by pharmacists collected in a computerised physician order entry context: a prospective observational study with a 10-year reassessment

AIMS OF THE STUDY

This study assesses clinical interventions by pharmacists prospectively collected from medical and surgical wards, notably the acceptance of interventions, computerised physician order entry (CPOE)related problems, the potential impact of interventions on patient safety evaluated by a multidisciplinary committee, and their evolution over the 10 years since a first assessment.

METHODS

A prospective observational study covering 13 months was conducted in a French teaching hospital with a patient information system that integrates an electronic health record (EHR) with a CPOE. Interventions by pharmacists were prospectively recorded using CPOE. All interventions were reviewed by two pharmacists. We assessed the interventions, the possible implications of the CPOE in prescribing errors, and the acceptance of interventions by physicians. A committee reviewed the potential clinical impact for patients. The results were compared with the same outcomes collected 10 years ago in the same hospital.

RESULTS

A total of 2141 interventions by pharmacists were reviewed. Among them, 1589 (74.1%) were accepted by physicians. Regarding the potential clinical impact, a total of 1136 (53%) interventions concerned prescriptions that were potentially significant or serious for patients and 42 (2%) of them were potentially life-threatening. Ten years earlier, the acceptance rate was 23%. Moreover, 14.7% of errors were attributed to the use of the software, whereas 10 years earlier the rate of errors was 49%.

CONCLUSIONS

The acceptance rate and frequency of CPOE-related errors were better than 10 years before, which is encouraging and shows the importance of regular training and collaboration with healthcare givers to reduce errors. The routine analysis of interventions by pharmacists with medical staff feedback should continue to improve their relevance and effectiveness.

Evaluation of exposure to effervescent drugs in a large health check-up population in France: a cross-sectional study

OBJECTIVES

The relationship between high dietary sodium intake and hypertension is well established. Some drugs are associated with high-sodium content, particularly effervescent tablets (ETs). Despite a possible cardiovascular risk associated with the use of such drugs, observational data describing exposure to ETs in ambulatory subjects are lacking.This study aims to estimate the prevalence of exposure to ETs and to highlight factors associated with this exposure in a large French health check-up population.

DESIGN

This was a cross-sectional study.

SETTING AND PARTICIPANTS

Participants were French individuals who underwent medical check-ups at the Investigations Préventives et Cliniques centre between April and June 2017.

RESULTS

In total, 1043 subjects were included in the study. The prevalence of exposure to ETs in the last 30 days was 26.9% (95% CI 24.2% to 29.6%). Exposure was frequent (ie, two ETs per week or more in the last 30 days) for 7.3% of subjects. Self-medication was the major source of exposure (93.8%). Paracetamol, aspirin, vitamins and betaine accounted for 95.3% of the ETs used. The factors associated with this exposure by multivariate analysis were: male gender, Overseas French origin, depression and body mass index ≥25 kg/m². A diagnosis of hypertension or treatment with diuretics were not protective factors against exposure to ETs.

CONCLUSION

Exposure to ETs is frequent in the general population, particularly through self-medication. Clinical conditions associated with low-salt requirements were not associated with lower exposure to ETs, suggesting a lack of awareness by practitioners and patients about this iatrogenic issue.

Validity of a clinical decision rule-based alert system for drug dose adjustment in patients with renal failure intended to improve pharmacists' analysis of medication orders in hospitals

OBJECTIVE

The main objective of this study was to assess the diagnostic performances of an alert system integrated into the CPOE/EMR system for renally cleared drug dosing control. The generated alerts were compared with the daily routine practice of pharmacists as part of the analysis of medication orders.

MATERIALS AND METHODS

The pharmacists performed their analysis of medication orders as usual and were not aware of the alert system interventions that were not displayed for the purpose of the study neither to the physician nor to the pharmacist but kept with associate recommendations in a log file. A senior pharmacist analyzed the results of medication order analysis with and without the alert system. The unit of analysis was the drug prescription line. The primary study endpoints were the detection of drug dose prescription errors and inter-rater reliability (Kappa coefficient) between the alert system and the pharmacists in the detection of drug dose error.

RESULTS

The alert system fired alerts in 8.41% (421/5006) of cases: 5.65% (283/5006) "exceeds max daily dose" alerts and 2.76% (138/5006) "under-dose" alerts. The alert system and the pharmacists showed a relatively poor concordance: 0.106 (CI 95% [0.068-0.144]). According to the senior pharmacist review, the alert system fired more appropriate alerts than pharmacists, and made fewer errors than pharmacists in analyzing drug dose prescriptions: 143 for the alert system and 261 for the pharmacists. Unlike the alert system, most diagnostic errors made by the pharmacists were 'false negatives'. The pharmacists were not able to analyze a significant number (2097; 25.42%) of drug prescription lines because understaffing.

CONCLUSION

This study strongly suggests that an alert system would be complementary to the pharmacists' activity and contribute to drug prescription safety.

Drug administration errors in hospital inpatients: a systematic review

CONTEXT

Drug administration in the hospital setting is the last barrier before a possible error reaches the patient.

OBJECTIVES

We aimed to analyze the prevalence and nature of administration error rate detected by the observation method.

DATA SOURCES

Embase, MEDLINE, Cochrane Library from 1966 to December 2011 and reference lists of included studies.

STUDY SELECTION

Observational studies, cross-sectional studies, before-and-after studies, and randomized controlled trials that measured the rate of administration errors in inpatients were included.

DATA EXTRACTION

Two reviewers (senior pharmacists) independently identified studies for inclusion. One reviewer extracted the data; the second reviewer checked the data. The main outcome was the error rate calculated as being the number of errors without wrong time errors divided by the Total Opportunity for Errors (TOE, sum of the total number of doses ordered plus the unordered doses given), and multiplied by 100. For studies that reported it, clinical impact was reclassified into four categories from fatal to minor or no impact. Due to a large heterogeneity, results were expressed as median values (interquartile range, IQR), according to their study design.

RESULTS

Among 2088 studies, a total of 52 reported TOE. Most of the studies were cross-sectional studies (N=46). The median error rate without wrong time errors for the cross-sectional studies using TOE was 10.5% [IQR: 7.3%-21.7%]. No fatal error was observed and most errors were classified as minor in the 18 studies in which clinical impact was analyzed. We did not find any evidence of publication bias.

CONCLUSIONS

Administration errors are frequent among inpatients. The median error rate without wrong time errors for the cross-sectional studies using TOE was about 10%. A standardization of administration error rate using the same denominator (TOE), numerator and types of errors is essential for further publications.

Evaluation of drug administration errors in a teaching hospital

Background

Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors.

Methods

Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects.

Results

Twenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors were detected (27.6%). There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501). The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%). The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission). In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC) and the number of patient under the nurse's care.

Conclusion

Medication administration errors are frequent. The identification of its determinants helps to undertake designed interventions.

[Use of moxifloxacin in tuberculosis regimen in a French teaching hospital]

OBJECTIVE

To evaluate retrospectively indications of moxifloxacin prescriptions in inpatients with tuberculosis in a referent teaching hospital.

DESIGN

All patients hospitalized at Bichat-Claude Bernard hospital and who had an active tuberculosis disease with a tuberculosis regimen including moxifloxacin were included. Medical charts were retrospectively reviewed for all these patients over 21 months. Data collected were reasons for introduction of moxifloxacin in regimen.

RESULTS

Out of the 23 patients included in the study, 13 of them had a recurrence of tuberculosis. Several reasons for introduction of moxifloxacin were recorded and one prescription can be associated with one or more reasons: an extra pulmonary tuberculosis or disseminated tuberculosis (16 cases), an intolerance to other anti-tuberculosis drugs (13 cases), a medical history of therapeutic failure or a proved or suspected drug-resistant Mycobacterium tuberculosis (12 cases) or to avoid drug interactions (two cases).

CONCLUSIONS

This retrospective study in our hospital highlights that drug-resistance was not the first reason for introduction of moxifloxacin in anti-tuberculosis regimen. One major indication was bad tolerance to other first-line regimen drugs. A better supervision of the moxifloxacin prescription in tuberculosis regimen is needed in order to limit its ecological impact.