Use of Medication Error Simulations in Continuing Professional Education to Effect Change To Practice

INTRODUCTION

A novel continuing professional education CPE training program and simulation were used to teach pharmacists and pharmacy technicians about continuous quality improvement and how to identify, report, and communicate information regarding medication related errors using root cause analysis.

METHODS

Pharmacists and pharmacy technicians attending a statewide pharmacy association meeting voluntary attended a CPE training program and simulation. During the simulation, learners investigated and identified medication related errors in three different pharmacy settings. A collection of items found at each pharmacy and audio recordings were used by learners to identify the medication related error. After each simulation, facilitators led a debriefing to discuss the learners' experiences. Data was collected using online surveys. Descriptive statistics and chi-square tests were used to analyze the data.

RESULTS

Fourteen months following the program, 15 of the 67 participants responded to an anonymous survey. Of the 15 responding participants, 73.3% (11/15) were confident or very confident they could establish or maintain a high-quality continuous quality improvement plan at their practice site. Sixty percent (9/15) felt the experience reinforced their current practices, 13.3% (2/15) had implemented changes to their practice, and 13.3% (2/15) felt they needed more information before considering changes to their practice. Reported barriers to establishing a continuous quality improvement program were time constraints, 40.0% (6/15), system constraints, 26.7% (4/15), or lack of staff 20.0% (3/15).

CONCLUSION

A CPE training program and simulation reinforced practice for pharmacy personnel, resulted in changes to practice, and positively increased participants' confidence in establishing a continuous quality improvement plan in the workplace.

Development of a safe drug administration assessment instrument for nursing students

OBJECTIVE

to determine the content and face validity of a safe drug administration assessment instrument for nursing students.

METHOD

quantitative, descriptive study. The literature on medication errors made by students was analyzed, and an instrument was developed using the Architecture of Integrated Information Systems and the Work Breakdown Structure. Face validity was analyzed using the nominal technique, with experts in education, management, research and/or clinical practice.

RESULTS

nine experts participated in the validation process, which resulted in an instrument containing 8 sub-processes and 58 items, adjusted to the simulation environment and to clinical practice.

CONCLUSION

the instrument may be used for the evaluation of safe drug administration by nursing students, especially in a simulation environment.

Registered Nurses' Experiences of Medication Errors-An Original Research Protocol: Methodology, Methods, and Ethics

BACKGROUND

The investigation of medication errors in nursing includes both methodological and ethical considerations because it is a sensitive field of research.

PURPOSE

To present an original research protocol for the investigation of nurses' experiences of medication errors with interpretative phenomenological analysis and the relevant methodological and ethical considerations.

METHODS

A discursive paper which presents an original research protocol about nurses' experiences of medication errors with interpretative phenomenological analysis followed by a literature review and personal reflections about the relevant methodological and ethical considerations. The review included papers published in English from 1990 to February 2019 on PubMed, BNI (British Nursing Index), CINAHL (Cumulative Index to Allied Health Literature), ScienceDirect, and Wiley Online Library.

RESULTS

The following methodological considerations were identified: recruitment of participants, data collection, and data analysis, and the ethical considerations included researcher's morality, ethics committees, sensitivity, phrasing of sentences and words, recruitment of participants, location of interviews, type of interviews, emotionality management, medication error incidents' management, researcher, or nurse?

CONCLUSION

By facing as many as possible methodological and ethical considerations and establishing solutions for them, the study's validity, reliability, and rigor are enhanced, and the study is ethically robust. Finally, their understanding enables researchers to uncover nurses' experiences and interpret the meanings they generate in depth.

Impact of an Antimicrobial Stewardship Team on Reducing Antiretroviral Medication Errors

Background: Numerous interventions have been used to reduce medication errors related to antiretroviral (ARV) therapy for hospitalized patients with HIV. Objective: This study assessed the impact of an antimicrobial stewardship (ASP) team intervention on reducing the rate of ARV therapy errors in patients admitted to an academic medical center. Methods: This observational, retrospective study included patients who received ARV therapy from June 2016 to December 2017. The primary outcome was evaluation of ASP team performance in detecting ARV medication errors in the inpatient setting. Errors were further categorized by type (interaction, dosing, regimen). The Mann-Whitney U test and χ² tests were utilized to analyze continuous and categorical data, respectively. Results: Medication errors occurred in 51% of patients in the preintervention group (n = 152) and 48% of patients in the postintervention group (n = 203; P = 0.43). The most frequent medication error type was drug interactions in both groups, involving integrase strand transfer inhibitors and polyvalent cations (64% vs 67%). There was a significant difference between preintervention and postintervention groups regarding number of errors detected (13 vs 106, P < 0.001), corrected (12 vs 86, P < 0.001), and persisting at discharge (106 vs 18, P < 0.001). Conclusion and Relevance: Review of ARV regimens by an ASP team significantly decreased medication errors. Drug interactions are the most common medication error found in HIV-positive patients admitted to our academic center.

Medication Errors and Blood Pressure Control Among Patients Managed for Hypertension in Public Ambulatory Care Clinics in Botswana

Background

The prevalence of hypertension in low‐ and middle‐income countries is rapidly increasing, with most cases undiagnosed and many poorly controlled among those diagnosed. Medication reconciliation studies from high‐income countries have demonstrated a high occurrence of antihypertensive medication errors and a strong association between medication errors and inadequate blood pressure control, but data from low‐ and middle‐income countries are lacking.

Methods and Results

We conducted a cross‐sectional study from April to October 2018 of adult patients on pharmacologic management for known hypertension at 7 public health facilities in Kweneng East District, Botswana. Our aims included to evaluate the frequency of uncontrolled hypertension, the frequency and type of medication errors causing discrepancies between patient‐reported and prescribed antihypertensive medications, and the association between medication errors and uncontrolled hypertension. Descriptive analyses and multivariable logistic regression were used. The prevalence of uncontrolled hypertension was 55% among 280 enrolled adult patients, and 95 (34%) had ≥1 medication error. The most common errors included patients taking medications incorrectly (11.1%; 31/280), patients omitting medications (7.9%; 22/280), and unfilled prescriptions caused by pharmacy stock outs (7.5%%; 21/280). Uncontrolled hypertension was significantly associated with having ≥1 medication error compared with no errors (adjusted odds ratio, 3.26; 95% CI, 1.75–6.06; P<0.001).

Conclusions

Medication errors are strongly associated with poor blood pressure control in this setting. Further research is warranted to assess whether medication reconciliation and other low‐cost interventions addressing root causes of medication errors can improve the control of hypertension and other chronic conditions in low‐ and middle‐income countries.

Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety

A failure modes, effects and criticality analysis was supported by an observational medication error rate study to analyze the impact of Phocus Rx^®, a new image-based workflow software system, on chemotherapy compounding error rates. Residual risks that should be a target for additional action were identified and prioritized and pharmacy staff satisfaction with the new system was evaluated. In total, 16 potential failure modes were recognized in the pre-implementation phase and 21 after Phocus Rx^® implementation. The total reduction of the criticality index was 67 percent, with a reduction of 46 percent in material preparation, 76 percent in drug production and 48 percent in quality control subprocesses. The relative risk reduction of compounding error rate was 63 percent after the implementation of Phocus Rx^®, from 0.045 to 0.017 percent. The high-priority recommendations defined were identification of the product with batch and expiration date from scanned bidimensional barcodes on drug vials and process improvements in image-based quality control. Overall satisfaction index was 8.30 (SD 1.06) for technicians and 8.56 (SD 1.42) for pharmacists (p = 0.655). The introduction of a new workflow management software system was an effective approach to increasing safety in the compounding procedures in the pharmacy department, according to the failure modes, effects and criticality analysis method.

The Patient-Held Active Record of Medication Status (PHARMS) study: a mixed-methods feasibility analysis

BACKGROUND

Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue.

AIM

To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge.

DESIGN AND SETTING

A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland.

METHOD

The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process.

RESULTS

In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders.

CONCLUSION

The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error.

Impact of pharmacist-led multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing home: a before-after study

Objectives: Adverse drug events (ADE) are a common cause of morbidity and mortality in elderly patients. In this study, we assessed the impact of multidisciplinary medication review (MMR) for nursing home residents on patient safety and costs incurred by the hospital and the national health service. Methods: Medical files of residents were retrospectively assessed for medications prescribed in the previous six months. A pharmacist reviewed the prescriptions and suggested modifications to the patient's medical team. Patients were followed for six months. Trivalle's ADE geriatric risk score was calculated before and after MMR, as were number of potentially inappropriate medications, and economic impact from the perspective of the health care system and the nursing home. Results: Forty-nine patients were recruited. ADE score dropped one risk level (median score of 4 before versus 1 after, p < 0.0001). The number of patients taking at least one potentially inappropriate medication decreased from 30.6% before to 6.1% after MMR (p = 0.005). A mean saving of €232 per patient was made from the nursing home perspective following MMR (p = 0.008). Conclusion: The MMR reduced the iatrogenic drug risk for elderly residents and costs from the nursing home perspective, particularly drug expenditure.

Rosuvastatin-induced rhabdomyolysis due to medication errors

Case (description): A 74 years old Caucasian suffering from chronic kidney disease presented with progressive asthenia and diffuse myalgia. It was revealed that the patient used three different rosuvastatin-containing preparations in a total daily dose of 120 mg for 76 days. Laboratory investigations revealed a marked elevation of serum urea, creatinine, myoglobin, creatine kinase (CK) and transaminases. Two serious medication errors have been identified as possible major factors that synergistically contributed to the development of rosuvastatin-induced rhabdomyolysis. First, 40 mg of rosuvastatin dose was prescribed to the patient, although the estimation of glomerular filtration rate (eGFR) declined below 40 ml/min/1.73 m2. Moreover, the patient used 3 different rosuvastatin formulations simultaneously in a total dose of 120 mg/day. The heterozygous CYP2C9*1/*3 genotype and warfarin co-administration could further contribute to the development of rhabdomyolysis. A number of preventive measures, notably in drug policy, are suggested to overcome unintended intoxications. Conclusion: Rosuvastatin-induced myopathy is a rare, but serious adverse effect. This case report highlights the need for a proper treatment and dose adjustment during chronic medical therapy, the need for adequate patient education and application of adequate drug policy measures in the era of fragmented health care delivery and polypragmasia.

The role of organizational and professional cultures in medication safety: a scoping review of the literature

PURPOSE

This scoping review explores what is known about the role of organizational and professional cultures in medication safety. The aim is to increase our understanding of 'cultures' within medication safety and provide an evidence base to shape governance arrangements.

DATA SOURCES

Databases searched are ASSIA, CINAHL, EMBASE, HMIC, IPA, MEDLINE, PsycINFO and SCOPUS.

STUDY SELECTION

Inclusion criteria were original research and grey literature articles written in English and reporting the role of culture in medication safety on either organizational or professional levels, with a focus on nursing, medical and pharmacy professions. Articles were excluded if they did not conceptualize what was meant by 'culture' or its impact was not discussed.

DATA EXTRACTION

Data were extracted for the following characteristics: author(s), title, location, methods, medication safety focus, professional group and role of culture in medication safety.

RESULTS OF DATA SYNTHESIS

A total of 1272 citations were reviewed, of which, 42 full-text articles were included in the synthesis. Four key themes were identified which influenced medication safety: professional identity, fear of litigation and punishment, hierarchy and pressure to conform to established culture. At times, the term 'culture' was used in a non-specific and arbitrary way, for example, as a metaphor for improving medication safety, but with little focus on what this meant in practice.

CONCLUSIONS

Organizational and professional cultures influence aspects of medication safety. Understanding the role these cultures play can help shape both local governance arrangements and the development of interventions which take into account the impact of these aspects of culture.

The development of a test battery to assess the hand-eye functions relevant in predicting easy and accurate tablet subdivision in older people: A pilot study

AIMS

Tablets may be subdivided for dose adaptations or to ease swallowing. The handling is common in older patients but can be difficult and inaccurate. Currently, it is not known which hand-eye functions determine the ability of older people to break tablets by hand and to do so with acceptable ease and accuracy. The aim of this study was to develop a test battery to assess the hand-eye functions relevant in predicting easy and accurate tablet subdivision in older people.

METHODS

A mixed methods study was conducted including literature reviews and a pilot experiment. The reviews were conducted in Pubmed, Google Scholar, Dutch journals and professional standards. The first review tried to identify the hand-eye functions relevant to tablet subdivision and the second the associated measuring instruments, testing protocols and normative data. A test battery was empanelled. A pilot experiment was conducted in 30 adult volunteers to optimize and evaluate the test battery.

RESULTS

Five domains were considered relevant: hand size, hand strength, flexibility/manual dexterity, vision and coordination. Hand size could best be measured by finger circumference, hand strength by pinch- and grip strength, flexibility by active range of joint motion, manual dexterity (and flexibility, coordination, cognition, vision) by pegboard function, vision by near visual acuity. Older people preferred the use of tablet splitters over hand breaking.

CONCLUSION

Easy and accurate tablet subdivision is essential to the good use of medicines. We developed a test battery for older people, but probably of value to all age groups.

Hospitalization as an opportunity to correct errors in anticoagulant treatment in patients with atrial fibrillation

AIMS

To assess whether hospitalization may assist in correcting errors in anticoagulant therapy among patients with atrial fibrillation (AF).

METHODS

Our cohort included patients admitted to our institution with a history of AF between 2016 and 2018. We categorized patient's treatment upon admission and discharge as lacking (no treatment despite indication), inadequate (according to individual characteristics) or adequate. We assessed adequacy of treatment upon discharge and determined factors associated with correcting admission errors.

RESULTS

Of 4427 patients admitted with a history of AF, the categorization to lacking, inadequate and adequate treatment was 1746 (39.4%), 1237 (27.9%) and 1444 (32.6%) patients, respectively. Of those with inadequate treatment, the most common types of errors were direct oral anticoagulant (DOAC) underdosing (n = 578; 46.7%), vitamin-K antagonists when DOAC was indicated (n = 258; 20.9%), DOAC despite contraindication to DOAC (n = 166; 13.4%) and DOAC overdosing (n = 124; 10%). Upon discharge 688 (18.6%, out of n = 3694) corrections but also 316 (8.6%) new mistakes were found. On multivariate logistic regression, the factors associated with correction of an error on admission were hospitalization due to AF (odds ratio [OR] 2.94 [2.39-3.61]), hospitalization in the neurologic or geriatric wards (OR 2.79 [2.04-3.80]), female sex (OR 1.34 [1.10-1.63]) and a history of stroke (OR 1.47 [1.17-1.86]), while the presence of a contraindication to DOAC decreased the chance of correction (OR 0.10 [0.06-0.18]).

CONCLUSION

Hospitalization for any reason may contribute to correction of errors in AC treatment in patients with AF. Unfortunately, a significant portion of patients remains inadequately treated by both outpatient and inpatient providers.

Medication-rights detection using incident reports: A natural language processing and deep neural network approach

Medication errors often occurred due to the breach of medication rights that are the right patient, the right drug, the right time, the right dose and the right route. The aim of this study was to develop a medication-rights detection system using natural language processing and deep neural networks to automate medication-incident identification using free-text incident reports. We assessed the performance of deep neural network models in classifying the Advanced Incident Reporting System reports and compared the models' performance with that of other common classification methods (including logistic regression, support vector machines and the decision-tree method). We also evaluated the effects on prediction outcomes of several deep neural network model settings, including number of layers, number of neurons and activation regularisation functions. The accuracy of the models was measured at 0.9 or above across model settings and algorithms. The average values obtained for accuracy and area under the curve were 0.940 (standard deviation: 0.011) and 0.911 (standard deviation: 0.019), respectively. It is shown that deep neural network models were more accurate than the other classifiers across all of the tested class labels (including wrong patient, wrong drug, wrong time, wrong dose and wrong route). The deep neural network method outperformed other binary classifiers and our default base case model, and parameter arguments setting generally performed well for the five medication-rights datasets. The medication-rights detection system developed in this study successfully uses a natural language processing and deep-learning approach to classify patient-safety incidents using the Advanced Incident Reporting System reports, which may be transferable to other mandatory and voluntary incident reporting systems worldwide.

An Evaluation of Pharmacist-Led Interventions for Inpatient HIV-Related Medication Errors

Background: Inpatient HIV-related medication errors occur in up to 86% of patients. Objective: To evaluate the number of antiretroviral therapy (ART)- and opportunistic infection (OI)-related medication errors following the implementation of pharmacist-directed interventions. Methods: This quasi-experiment assessed adult patients with HIV who received ART, OI prophylaxis, or both from December 1, 2014, to February 28, 2017 (pre-intervention) or December 1, 2017, to February 28, 2018 (post-intervention). Pre-intervention patients were assessed retrospectively; verbal and written education were provided (intervention); prospective audit and feedback was conducted for post-intervention patients. The primary outcome was rate of ART errors between groups. Secondary outcomes included rate of OI errors, time to resolution of ART and OI errors, types of errors, and rate of recommendation acceptance. Results: Sixty-seven patients were included in each group. ART errors occurred in 44.8% and 32.8% (P = .156), respectively. OI prophylaxis errors occurred in 11.9% versus 9% (P = .572), respectively. Medication omission decreased significantly in the post-intervention group (31.3% vs 11.9%; P = .006). Pharmacist-based interventions increased in the post-intervention group (6.3% vs 52.9%; P = .001). No statistical difference was found in time to error resolution (72 vs 48 hours; P = .123), but errors resolved during admission significantly increased (50% vs 86.8%; P < .001). No difference was found in rate of intervention acceptance (100% vs 97%). Conclusion and Relevance: ART and OI prophylaxis errors resolved a day faster in the pharmacist-led, post-intervention period, and there was a trend toward error reduction. Future interventions should target prescribing errors on admission using follow-up education and evaluation of medication reconciliation practices in HIV-infected patients.

Parent Dosing Tool Use, Beliefs, and Access: A Health Literacy Perspective

OBJECTIVES

To assess parent decision-making regarding dosing tools, a known contributor to medication dosing errors, by evaluating parent dosing tool use, beliefs, and access, and the role of health literacy, with a focus on dosing cups, which are associated with an increased risk of multifold overdose.

STUDY DESIGN

Cross-sectional analysis of data collected for randomized controlled study in 3 urban pediatric clinics. English/Spanish-speaking parents (n = 493) of children ≤8 years of age enrolled.

OUTCOMES

reported tool use, beliefs, and access. Predictor variable: health literacy (Newest Vital Sign; limited [0-3], adequate [4-6]). Multiple logistic regression analyses conducted.

RESULTS

Over two-thirds of parents had limited health literacy. Oral syringes (62%) and dosing cups (22%) were most commonly used. Overall, 24% believed dosing cups were the best tool type for dosing accuracy; 99% reported having access to ≥1 dosing tools with standard measurement markings. Parents with limited health literacy had greater odds of dosing cup use (limited vs adequate: aOR = 2.4 [1.2-4.6]). Parents who believed that dosing cups are best for accuracy had greater odds of dosing cup use (aOR = 16.3 [9.0-29.3]); this belief mediated health literacy-effects on dosing cup use.

CONCLUSIONS

Factors associated with dosing tool choice, including parent health literacy and beliefs are important to consider in the design of interventions to reduce dosing errors; future larger-scale studies addressing this issue are needed.

Voluntary and anonymous reporting of medication errors in patients admitted to the Department of Pediatrics

OBJECTIVE

To assess reports of medication errors in hospitalized children to establish their frequency, causes, and adverse events(AEs).

METHODS

Prospective study of medication errors reported at the Neonatal Intensive Care Unit (NICU), Pediatric Clinic (PC), and Pediatric intensive Care Unit (PICU). Ambulatory Pediatrics reports and incomplete data were excluded. Related variables were evaluated.

RESULTS

Out of 989 errors reported in Department of Pediatrics, 401 (41 %) corresponded to medication errors. Of these, 353 (88 %) reached patients and 48 (12 %) were quasi-errors; 42 % occurred in the morning; 24 %, in the afternoon; 17 %, in the morning and afternoon, and 17 %, in the night; differences were not significant (p = 0.18). Dosing errors were the most common ones, 118 (33.4 %). In total, 160 reports (45 %) corresponded to prescription errors; 149 (42 %), to administration errors; and 44 (2.5 %), to dispensing errors. Dosing errors were more common in prescriptions (p < 0.05). The highest number of errors was reported at the NICU, 179 (50 %); compared to 91 (25.5 %) at the PC and 83 (24.5 %) at the PICU. A total of 91 AEs were reported (22.5 %); most were mild, 53 (58 %), or moderate, 31 (34 %). The NICU reported 53 AEs (58 %); the PICU, 25 (27 %); and the DCP, 18 (19.7 %). No deaths occurred.

CONCLUSION

The rate of medication errors reported in hospitalized children was 41 %. Dosing errors were the most common ones. A total of 91 AEs were reported; most were mild (58 %); the highest number was reported at the NICU (58 %).

Factors Associated With Medication Errors at a Teaching Hospital in Malaysia

Background: Medication errors (MEs) continue to pose a significant problem to health care systems across the world, not only causing harm and death in patients but also consuming approximately $42 billion annually in health care expenditure. The emergency department (ED) is considered a high-risk area of having MEs to occur. Little is known about the associated factors of ME in the ED of hospitals in Malaysia. Objective: The objective of this study was to determine the factors associated with ME in an ED of a teaching hospital. Methods: A cross-sectional study was conducted on patients who visited the ED of Hospital Universiti Sains Malaysia over 9 weeks during normal working hours (ie, 8:00 am-5:00 pm). A total of 547 patients who satisfied the inclusion criteria were enrolled for the study. Patient demographic information, clinical characteristics, and medication orders and procedures were observed and recorded. The required number of patient data (n = 311) were selected randomly for analysis. Multiple logistic regression method was employed to determine factors associated with ME. Results: Of the 311 patient data, 95 (30.5%) patients had at least 1 ME. The factors found to be associated with ME were number of medications (adjusted odds ratio [OR], 1.91; 95% confidence interval [CI], 1.51-2.41), triage (adjusted OR, 0.11; 95% CI, 0.04-0.27), gender (adjusted OR, 0.50; 95% CI, 0.26-0.93), and time of patient visit (adjusted OR, 0.34; 95% CI, 0.52-0.75). Conclusion: Medication error was not uncommon in our ED setting. Patients with a higher number of medications prescribed during visit to the ED were found to be particularly at risk. Identification of such factors may guide intervention measures to prevent MEs in this setting.

Medication safety problems priorities in community pharmacy in Saudi Arabia: a multi-stakeholder Delphi study using the human factors framework

AIM

To achieve multi-stakeholder consensus and prioritisation of medication safety problems in community pharmacies in Saudi Arabia.

DESIGN AND INTERVENTION

A theoretically-underpinned, three-round Delphi study.

SETTING

Saudi Arabia.

PARTICIPANTS

Patients and public (pharmacy users), pharmacy-related professionals (policymakers, academics, medication safety officers and pharmacy owners) and community pharmacists.

METHODS

Round 1 comprised 84 statements derived from a qualitative study. The items were grouped according to the Human Factors Framework (HFF). Rounds 1 and 2 aimed to achieve consensus, 6-point Likert response scale (agreement/disagreement) was used. Round 3 aimed to prioritise the items for which consensus was achieved in Rounds 1 and 2 indicated on a 5-point scale (very important to unimportant). Consensus was predefined as any item that achieved ≥70%.

RESULTS

The number of respondents in Rounds 1, 2 and 3 was 161, 120 and 112, respectively. In all three rounds, the majority of respondents were pharmacy users (Round 1 77% (n=124), Round 2 74% (n=89), Round 3 72% (n=81)). Consensus was achieved with 28/84 items. The top five medication safety priorities were: lack of pharmacy facilities such as counselling area, lack of communication between pharmacists and physicians, lack of patient databases, lack of post-registration pharmacist education and pharmacists' long working hours. The professional and pharmacy user groups achieved consensus on similar items through different categories of the HFFs. Community pharmacists had the highest percentage of consensus among the three groups for factors related to work, such as high workload and low salaries.

CONCLUSION

This multi-stakeholder study used the HFF to identify and prioritise the main medication safety challenges facing community pharmacy in Saudi Arabia. It indicates the need for changes to practice and policy and further research to address these priorities and promote medication safety at an individual, pharmacy and population level.

Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study

OBJECTIVES

Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, we evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.

DESIGN

We conducted a cross-sectional observational study using a web survey (contextual factors) and a national hospital database (hospital characteristics).

SETTING

Hospitals participating in the second Multi-Centre Medication Reconciliation Quality Improvement Study (MARQUIS2).

PARTICIPANTS

Implementation team members of 18 participating MARQUIS2 hospitals.

OUTCOMES

Primary outcome: contextual factor ratings (ie, organisational capacity, leadership support, goal alignment, staff involvement, patient safety climate and team cohesion). Secondary outcome: differences in contextual factors by hospital characteristics.

RESULTS

Fifty-five team members from the 18 participating hospitals completed the survey. Ratings of contextual factors differed significantly by domain (p<0.001), with organisational capacity scoring the lowest (mean=4.0 out of 7.0) and perceived team cohesion and goal alignment scoring the highest (mean~6.0 out of 7.0). No statistically significant differences were observed in contextual factors by hospital characteristics (p>0.05). Respondents in the pharmacy profession gave lower ratings of leadership support than did those in the nursing or other professions group (p=0.01).

CONCLUSIONS

Hospital size, type and location did not drive differences in contextual factors, suggesting that tailoring MedRec QI implementation to hospital characteristics may not be necessary. Strong team cohesion suggests the use of interdisciplinary teams does not detract from cohesion when conducting mentored QI projects. Organisational leaders should particularly focus on supporting pharmacy services and addressing their concerns during MedRec QI initiatives. Future research should correlate contextual factors with implementation success to inform how best to prepare sites to implement complex QI interventions such as MedRec.

Discharge Instruction Comprehension and Adherence Errors: Interrelationship Between Plan Complexity and Parent Health Literacy

OBJECTIVE

To examine associations between parent health literacy, discharge plan complexity, and parent comprehension of and adherence to inpatient discharge instructions.

STUDY DESIGN

This was a prospective cohort study of English/Spanish-speaking parents (n = 165) of children ≤12 years discharged on ≥1 daily medication from an urban, public hospital. Outcome variables were parent comprehension (survey) of and adherence (survey, in-person dosing assessment, chart review) to discharge instructions. Predictor variables included low parent health literacy (Newest Vital Sign score 0-3) and plan complexity. Generalized estimating equations were used to account for the assessment of multiple types of comprehension and adherence errors for each subject, adjusting for ethnicity, language, child age, length of stay, and chronic disease status. Similar analyses were performed to assess for mediation and moderation.

RESULTS

Error rates were highest for comprehension of medication side effects (50%), adherence to medication dose (34%), and return precaution (78%) instructions. Comprehension errors were associated with adherence errors (aOR, 8.7; 95% CI, 5.9-12.9). Discharge plan complexity was associated with comprehension (aOR, 7.0; 95% CI, 5.4-9.1) and adherence (aOR, 5.5; 95% CI, 4.0-7.6) errors. Low health literacy was indirectly associated with adherence errors through comprehension errors. The association between plan complexity and comprehension errors was greater in parents with low (aOR, 8.3; 95% CI, 6.2-11.2) compared with adequate (aOR, 3.8; 95% CI, 2.2-6.5) health literacy (interaction term P = .004).

CONCLUSIONS

Parent health literacy and discharge plan complexity play key roles in comprehension and adherence errors. Future work will focus on the development of health literacy-informed interventions to promote discharge plan comprehension.

Heuristics for designing user-centric drug products: Lessons learned from Human Factors and Ergonomics

Even the most effective drug product may be used improperly and thus ultimately prove ineffective if it does not meet the perceptual, motor and cognitive capacities of its target users. Currently, no comprehensive guideline for systematically designing user‐centric drug products that would help prevent such limitations exists. We have compiled a list of approximate but nonetheless useful strategies—heuristics—for implementing a user‐centric design of drug products and drug product portfolios. First, we present a general heuristic for user‐centric design based on the framework of Human Factors and Ergonomics (HF/E). Then we demonstrate how to implement this general heuristic for older drug users (i.e., patients and caregivers aged 65 years and older) and with respect to three specific challenges (use‐cases) of medication management: (A) knowing what drug product to take/administer, (B) knowing how and when to take/administer it, and (C) actually taking/administering it. The presented heuristics can be applied prospectively to include existing knowledge about user‐centric design at every step during drug discovery, pharmaceutical drug development, and pre‐clinical and clinical trials. After a product has been released to the market, the heuristics may guide a retrospective analysis of medication errors and barriers to product usage as a basis for iteratively optimizing both the drug product and its portfolio over their life cycle.

Effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units

BACKGROUND

The safety of hospitalized patients in the intensive care units (ICUs) is threatened due to incidents and adverse events, including medication errors. Medication error refers to any preventable event at different stage of medication process, such as prescription, transcription, distributing medication, and administration, which can lead to incorrect use of medicines or damage to the patient. This study aimed at investigating the effect of the interprofessional education of medication safety program on medication errors of physicians and nurses in the ICUs.

MATERIALS AND METHODS

The study was conducted using a quasi-experimental method (single group, before and after) in 2017. The setting of the study included one ICU of selected teaching hospital affiliated to Isfahan University of Medical Sciences located in the Central Iran with a total of 23 beds. Participants included 50 members of the health-care team (physician, nurse, and clinical pharmacist) with at least 1 year of work experience in the ICUs. Participants were selected using censuses sampling method. Data were collected using a two-section self-made questionnaire. Data were analyzed through descriptive, analytical statistics, and version 16 of the SPSS software (P < 0.05).

RESULTS

According to reporting of physicians, nurses, and clinical pharmacist, the medication error 1 month after implementation, the interprofessional education of medication safety program was significantly lower than before the implementation of it (P < 0.001).

CONCLUSIONS

Interprofessional education helps to improve interprofessional collaboration and patient care through the promotion of various professions of health to increase interprofessional collaboration compared to single profession education, which individuals learn in isolation and merely in their profession. Therefore, interprofessional education of medication safety program can reduce medication error and promote patient safety in the ICUs.

Existence of Notoriety Bias in FDA Adverse Event Reporting System Database and Its Impact on Signal Strength

Background: Notoriety bias is defined as "a selection bias in which a case has a greater chance of being reported if the subject is exposed to the studied factor known to cause, thought to cause, or likely to cause the event of interest." This study aimed to determine the existence of notoriety bias in the FDA Adverse Event Reporting System (FAERS) database and estimate the impact of potential notoriety bias induced by safety alerts on signal estimation using disproportionality analysis. Methods: Publicly available FAERS data were downloaded and used for analysis. Thirty-one drugs which had label change/safety alert issued by FDA from 2009 to 2013 were considered. These drugs were reviewed 4 quarters before and after the safety alert notification for the existence of notoriety bias. The impact of notoriety bias induced by safety alerts was analyzed by comparing the signal strength using reporting odds ratio (ROR) and proportional reporting ratio (PRR), 2 years before and after the safety alert. Wilcoxon signed rank test was used to determine whether there were a statistically significant difference before and after the safety alert. Results: There was increased reporting for 11 drugs after the safety alert/label change by the FDA. The reporting of 20 drugs decreased or remained unchanged after the safety alert/label change by the FDA. Wilcoxon signed rank test showed that there is no statistically significant difference with respect to the number of reports before and after the safety alert (P = .330, Z = -0.974). Fourteen (45.16%) drugs had an increase in ROR, while 17 (54.83%) drugs had a decrease in ROR after safety alert issued by FDA (P = .953, Z = -0.059). Fourteen (45.16%) drugs had an increase in PRR, while 17 (54.83%) drugs had a decrease in PRR after safety alert issued by the FDA (P = .914, Z = -0.108). Conclusion: Although few FDA safety alert/warnings had a strong and immediate impact, many had no impact on reporting of AE and signal strength. This study found that overreporting due to notoriety bias does not exist in the FAERS database and the overall disproportionality in signal estimates is not altered by the safety alert.

Opiate Intoxication Caused by Epidural Infusion of Morphine: A Case Report of a Near Fatal Medication Error

INTRODUCTION

Epidural infusion of local anesthetics with opioids is widely used for pain control during the perioperative-and peripartum-periods. Selection of the opioid, appropriate dosing, and follow-up by the acute pain service are critical in providing safe postoperative epidural analgesia.

CASE REPORT SUMMARY

A 71-year-old man was scheduled for a parastomal hernia repair with midline laparotomy. The parastomal hernia was a complication from a previously performed colectomy for ulcerative colitis. Preoperatively, the patient received a lower thoracic epidural catheter. The epidural infusate (0.2% ropivacaine with 0.5 µg/mL sufentanil) was prepared and double-checked by holding area nurses. The fact that the right prescription medication label partially covered a morphine label went unnoticed. The intraoperative phase was characterized by stable parameters. Postoperatively, it was not possible to demonstrate an epidural nerve block. No pain was reported, and the patient could be transferred to the ward. The patient developed coma and delayed respiratory depression after discharge to the surgical ward, requiring intensive care unit admission and naloxone administration. Analysis of the syringe content revealed the presence of morphine (1 mg/mL).

DISCUSSION

Color-coded prefilled syringes combined with the use of an epidural specific syringe connector to prevent cross-connections should become standard practice. In addition, delayed respiratory depression should be considered after epidural administration of morphine.

Improving Transplant Medication Safety Through a Technology and Pharmacist Intervention (ISTEP): Protocol for a Cluster Randomized Controlled Trial

Background

Medication errors, adverse drug events, and nonadherence lead to increased health care utilization and increased risk of adverse clinical outcomes, including graft loss, in solid organ transplant recipients. Veterans living with organ transplants represent a population that is at substantial risk for medication safety events and fragmented care coordination issues. To improve medication safety and long-term clinical outcomes in veteran transplant patients, interventions should address interorganizational system failures and provider-level and patient-level factors.

Objective

This study aims to measure the clinical and economic effectiveness of a pharmacist-led, technology-enabled intervention, compared with usual care, in veteran organ transplant recipients.

Methods

This is a 24-month prospective, parallel-arm, cluster-randomized, controlled multicenter study. The pharmacist-led intervention uses an innovative dashboard system to improve medication safety and health outcomes, compared with usual posttransplant care. Pharmacists at 10 study sites will be consented into this study before undergoing randomization, and 5 sites will then be randomized to each study arm. Approximately, 1600 veteran transplant patients will be included in the assessment of the primary outcome across the 10 sites.

Results

This study is ongoing. Institutional review board approval was received in October 2018 and the study opened in March 2019. To date there are no findings from this study, as the delivery of the intervention is scheduled to occur over a 24-month period. The first results are expected to be submitted for publication in August 2021.

Conclusions

With this report, we describe the study design, methods, and outcome measures that will be used in this ongoing clinical trial. Successful completion of the Improving Transplant Medication Safety through a Technology and Pharmacist Intervention study will provide empirical evidence of the effectiveness of a feasible and scalable technology-enabled intervention on improving medication safety and costs.

Clinical Trial

ClinicalTrials.gov NCT03860818; https://clinicaltrials.gov/ct2/show/NCT03860818

International Registered Report Identifier (IRRID)

PRR1-10.2196/13821