Drug-related problems in hospitalised patients

OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record

In studies on success and failure of ICT applications in health care, the 'context' is often used to explain the failure of a system and seldom to explain the success of a system. Science and Technology Studies (STS) have showed that for understanding success and failure of phenomena, one has to take a symmetrical approach and thus use the same concept for analyzing success and failure. In this article we analyze the success of OZIS, a communication protocol that makes it possible for pharmacists to exchange medication data by sharing a regionally accessible electronic medication record. Though OZIS serves a common goal - reducing medication errors - the stakeholders that are involved also have other, competing, interests. By focussing on the context and more specifically the interests of the stakeholders, we will show how the success of OZIS can be explained. By doing this, we will also show that this context is highly dynamic and that continuously changing incentives and constraints within the context lead to both facilitating and threatening the success of OZIS.

Prescribing errors resulting in adverse drug events: how can they be prevented?

As approximately 19% of medical errors occurring in hospitals are related to medication errors, reduction of these is one of the major goals to be achieved by healthcare providers. Medication errors may occur at different levels: i) prescribing; ii) transcription; iii) dispensing; and iv) administration. Whereas errors in transcription can be significantly reduced by computerised physician order systems, improvement of prescribing appears to be a much larger problem. Continuous support by ward pharmacists may be feasible in some hospitals, but not in the setting of ambulatory prescribing. Much hope relies on computerised physician order systems with a knowledge database for interactions, warnings on allergies and other intelligent alerts. However, these systems still have some shortcomings and it has not yet convincingly been shown that the use of this technology really improves patient safety.

Overriding of drug safety alerts in computerized physician order entry

Many computerized physician order entry (CPOE) systems have integrated drug safety alerts. The authors reviewed the literature on physician response to drug safety alerts and interpreted the results using Reason's framework of accident causation. In total, 17 papers met the inclusion criteria. Drug safety alerts are overridden by clinicians in 49% to 96% of cases. Alert overriding may often be justified and adverse drug events due to overridden alerts are not always preventable. A distinction between appropriate and useful alerts should be made. The alerting system may contain error-producing conditions like low specificity, low sensitivity, unclear information content, unnecessary workflow disruptions, and unsafe and inefficient handling. These may result in active failures of the physician, like ignoring alerts, misinterpretation, and incorrect handling. Efforts to improve patient safety by increasing correct handling of drug safety alerts should focus on the error-producing conditions in software and organization. Studies on cognitive processes playing a role in overriding drug safety alerts are lacking.

Medication management at home: medication-related risk factors associated with poor health outcomes

BACKGROUND

Some patients may have medication-related risk factors only identified by home visits, but the extent to which those risk factors are associated with poor health outcomes remains unclear.

OBJECTIVE

To determine the association between medication-related risk factors and poor patient health outcomes from observations in the patients' homes.

DESIGN

Cross-sectional study.

SETTING

Patients' homes.

SUBJECTS

204 general practice patients living in their own homes and at risk of medication-related poor health outcomes.

METHODS

Medications and medication-related risk factors were identified in the patients' homes by community pharmacists and general practitioners (GPs). The medication-related risk factors were examined as determinants of patients' self-reported health related quality of life (SF-36) and their medication use, as well as physicians' impression of patient adverse drug events and health status.

RESULTS

Key medication-related risk factors associated with poor health outcomes included: Lack of any medication administration routine, therapeutic duplication, hoarding, confusion between generic and trade names, multiple prescribers, discontinued medication repeats retained and multiple storage locations. Older age and female gender were associated with some poorer health outcomes. In addition, expired medication and poor adherence were also associated with poor health outcomes, however, not independently.

CONCLUSION

The findings support the theory that polypharmacy and medication-related risk factors as a result of polypharmacy are correlated to poor health outcomes.

Medication errors in anaesthesia and critical care

There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers. However, study of medication error is hampered by difficulty with definitions, research methods and study populations. Few doctors are as involved in the process of prescribing, selecting, preparing and giving drugs as anaesthetists, whether their practice is based in the operating theatre, critical care or pain management. Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. New technology, theories of human error and lessons learnt from the nuclear, petrochemical and aviation industries are being used to tackle the problem.

Influence of Computerised Medication Charts on Medication Errors in a Hospital

INTRODUCTION

In hospitals where computerised physician order entry systems will not be available in the near future, there is a need to explore other ways of reducing medication errors that occur in the drug ordering and delivery system. One of these ways is the use of a computerised medication chart that is updated daily. The aim of this study was to evaluate the frequency, types and potential clinical significance of drug prescription and administration errors by comparing a traditional medication distribution system (where the transcription of handwritten into printed medication orders takes 3-5 days and the transfer of medication orders was not complete) with the use of a computerised medication chart (which was updated daily by pharmacy assistants on the ward).

METHODS

Data were collected during two 3-week periods, from a 32-bed internal medicine unit, before and after the introduction of the computerised medication charts. Prescribing errors were observed by evaluation of all new and changed medication orders and administration errors were detected by using the disguised-observation technique.

RESULTS

For prescribing errors, a total of 611 prescriptions before and 598 prescriptions after the intervention were evaluated. The total prescription error rate (of medication orders with >or=1 error) was found to be significantly higher with the computerised charts when compared with the old system (50.0% [299 of 598] vs 20.3% [124 of 611], odds ratio [OR] 3.80 [95% CI 2.94, 4.90]). This increase was caused by an increase in administrative prescription errors with a low potential clinical significance (mainly omission of the prescriber's name and the prescription date). The error rate for errors with a potential clinical significance was found to be significantly lower because the prescription error 'duplicate therapy' was eliminated (3.4% with the traditional medication chart vs 0% with the computerised chart). For administration errors, a total of 1122 drugs before the intervention and 1175 drugs after the intervention was observed to be administered. The total administration error rate was found to be significantly lower after the intervention (6.1% [72 of 1175] vs 10.5% [118 of 1122], OR 0.61 [95% CI 0.45, 0.84]), as was the error rate with a potential clinical significance. The contribution of handwritten medication orders to the total amount of medication orders was significantly decreased after the intervention (12.8% vs 20.6% [95% CI 4.6, 11.0]) and the administration of a drug ordered by a handwritten medication order resulted in a significantly higher administration rate than with administration of a drug ordered by a printed medication order (before the intervention 20.7% vs 8.0%, OR 2.99 [95% CI 1.96, 4.56], after the intervention 11.4% vs 5.6%, OR 2.18 [95% CI 1.16, 4.11]).

CONCLUSION

This observational study shows a significant reduction in clinically relevant, administration and (therapeutic) prescription error rates when applying a system using computerised and daily updated medication charts compared with a system using traditional medication charts. Therefore, the use of computerised and daily updated medication charts has the potential to improve the quality of the medication distribution process in hospitals waiting for the implementation of a computerised physician order entry system.

Administração de medicamentos: aquisição de conhecimentos e habilidades requeridas por um grupo de enfermeiros

Atualmente, sabe-se que o processo da administração de medicamentos é multidisciplinar e exige atualização constante. Escassez de conhecimento, falta de reciclagem e de educação em serviço permeiam a temática da administração de medicamentos. Objetivos: analisar as necessidades educacionais de enfermeiros atuantes em uma instituição hospitalar universitária do interior do Estado de São Paulo, no que concerne à administração de medicamentos e discutir sobre necessidade da aquisição de conhecimentos e habilidades requeridos pelo grupo de enfermeiros em questão. Utilizou-se da Técnica do Grupo Nominal por meio da seguinte questão: "O que você necessita saber mais para complementar seu conhecimento sobre a administração de medicamentos?" Destacaram-se oito categorias de necessidades educacionais: mecanismos de ação dos medicamentos, preparo e administração de medicamentos, obtenção de informações e conhecimento, interações medicamentosas, estabilidade do medicamento, medicamentos específicos e quimioterápicos, efeitos colaterais dos medicamentos e outros aspectos da administração de medicamentos. Propõem-se um curso de atualização, baseado nas necessidades educacionais identificadas.

[Incidence and prevention of lethal undesirable drug effects]

About every second decision of a medical doctor concerns drug therapy. On the basis of a representative Norwegian study, which analyzed fatal drug reactions in stationary patients of internal medicine wards by autopsy and plasma drug concentrations, in Germany 58,000 fatalities are occurring in this patient population. The treating physicians classified only 6% of drug induced fatalities as such. Therefore, the risk of drug therapy is grossly underestimated. In half of the cases medication errors were causative and therefore these could potentially all be avoided. In addition to improved pre- and postgraduate education in clinical pharmacology the use of computer-based expert systems would be a decisive step to optimize drug therapy.

Identification and verification of critical performance dimensions. Phase 1 of the systematic process redesign of drug distribution

BACKGROUND

Worldwide patient safety has become a major social policy problem for healthcare organisations. As in other organisations, the patients in our hospital also suffer from an inadequate distribution process, as becomes clear from incident reports involving medication errors. Medisch Spectrum Twente is a top primary-care, clinical, teaching hospital. The hospital pharmacy takes care of 1070 internal beds and 1120 beds in an affiliated psychiatric hospital and nursing homes.

OBJECTIVE

In the beginning of 1999, our pharmacy group started a large interdisciplinary research project to develop a safe, effective and efficient drug distribution system by using systematic process redesign. The process redesign includes both organisational and technological components. This article describes the identification and verification of critical performance dimensions for the design of drug distribution processes in hospitals (phase 1 of the systematic process redesign of drug distribution).

METHODS

Based on reported errors and related causes, we suggested six generic performance domains. To assess the role of the performance dimensions, we used three approaches: flowcharts, interviews with stakeholders and review of the existing performance using time studies and medication error studies.

CONCLUSIONS

We were able to set targets for costs, quality of information, responsiveness, employee satisfaction, and degree of innovation. We still have to establish what drug distribution system, in respect of quality and cost-effectiveness, represents the best and most cost-effective way of preventing medication errors. We intend to develop an evaluation model, using the critical performance dimensions as a starting point. This model can be used as a simulation template to compare different drug distribution concepts in order to define the differences in quality and cost-effectiveness.

Assessing the economic impact of adverse drug effects

Although most commonly used drugs cause adverse effects, some of them with potentially serious consequences, relatively little is known about their economic impact. The purpose of this review is to summarise information describing the cost of treatment of drug-induced adverse effects as an additional cost of pharmaceutical treatment. The focus of this study was limited to the overall economic impact of drug-related morbidity and to the economic analysis of a single class of drugs with different safety profiles. Several studies carried out in the US have investigated adverse drug effects experienced by hospitalised patients and their impact on hospital costs. Patients who developed adverse effects were hospitalised an average of 1.2-3.8 days longer than patients who did not, with additional hospital costs of $US2284-5640 per patient (2000 values). Other research studies in different countries have quantified the incidence and economic consequences of adverse drug effects that occur in the ambulatory setting and that generate hospital admission and emergency department visits. They have shown that preventable adverse effects constitute between 43.3% and 80% of all adverse outcomes leading to emergency visits and hospital admissions, and disproportionately increase healthcare costs. Finally, a recent estimation revealed that in the US the cost of problems linked to drug use in the ambulatory setting exceeded $US177 billion in the year 2000.NSAIDs constitute a widely used class of drugs and they are one of the leading drug classes in causing adverse effects. The acquisition costs of the drugs, as well as the costs for prevention and treatment of adverse effects, determine their cost-effectiveness ratio. Depending on the incidence and severity of adverse effects, the cost per adverse effect avoided ranges from $US215 to $US35 459 (2000 values). According to the contingent valuation methodology, willingness to pay to avoid or reduce the incidence of adverse effects is an indicator of the value individuals associate with the impact of such effects on their well-being. Individuals are willing to pay annually an average of $US240 and $US350, respectively, to avoid vomiting and gastrointestinal distress induced by NSAIDs. Although the results of the different studies reviewed are not strictly comparable because of differences in the severity of adverse effects, the perspective of the analysis, the cost data included and the cost component considered, the data show that, apart from the implications for health, a substantial quantity of resources are used to treat adverse effects.

Cost-benefit analysis of the detection of prescribing errors by hospital pharmacy staff

OBJECTIVE

Prescribing errors are a major cause of iatrogenic patient morbidity and therefore interventions aimed at preventing the adverse outcomes of these errors are likely to result in cost reduction. However, it is unclear whether the costs associated with these preventive measures are outweighed by the cost reductions (benefits). Therefore, a study was set up to analyse costs and benefits of detecting prescribing errors by hospital pharmacy staff.

DESIGN

During 5 consecutive days in two Dutch hospitals in February 2000 all medication orders, in which prescribing errors were detected, were analysed. A cost-benefit analysis was performed, based on direct medical costs only. The benefit-to-cost ratio was calculated by taking into account the net time hospital pharmacy staff needed for the prevention of the error (this included potential time saving for nursing staff, when an error was prevented by hospital pharmacy staff instead of nursing staff), as well as taking into account the possible consequences of the prescribing error (were the error not prevented).

RESULTS

A total of 3540 orders, of which 351 contained prescribing errors (9.9%), were analysed. During the 1-week period investigated, time-investment of the pharmacy staff had net costs of EUR285 (2000 values). During the same period estimated benefits related to this investment were EUR9867. The finding of higher benefits than costs was robust in sensitivity analysis.

CONCLUSIONS

From this study it can be concluded that prevention of prescribing errors by hospital pharmacy staff results in higher benefits than the costs related to the net time investment.

Medication misadventure in cancer care

OBJECTIVES

To describe the nature and scope of the problem of medication errors in health care, with specific implications for error reduction and prevention.

DATA SOURCES

Articles and research studies.

CONCLUSIONS

Because of the complexity of chemotherapeutic regimens, requirements for supportive care drugs, and the physiologic vulnerability of patients due to their malignancies and intensive therapies, patients with cancer should be the focus of interdisciplinary medication error prevention programs.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a critical role in patient safety and the implementation of preventive and risk-reducing interventions to improve the drug delivery process.

Frequency and determinants of drug administration errors in the intensive care unit

OBJECTIVE

The study aimed to identify both the frequency and the determinants of drug administration errors in the intensive care unit.

DESIGN

Administration errors were detected by using the disguised-observation technique (observation of medication administrations by nurses, without revealing the aim of this observation to the nurses).

SETTING

Two Dutch hospitals.

PATIENTS

The drug administrations to patients in the intensive care units of two Dutch hospitals were observed during five consecutive days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 233 medications for 24 patients were observed to be administered (whether ordered or not) or were observed to be omitted. When wrong time errors were included, 104 administrations with at least one error were observed (frequency, 44.6%), and when they were excluded, 77 administrations with at least one error were observed (frequency, 33.0%). When we included wrong time errors, day of the week (Monday, odds ratio [OR] 2.69, confidence interval [CI] 1.42-5.10), time of day (6-10 pm, OR 0.28, CI 0.10-0.78), and drug class (gastrointestinal, OR 2.94, CI 1.48-5.85; blood, OR 0.12, CI 0.03-0.54; and cardiovascular, OR 0.38, CI,0.16-0.90) were associated with the occurrence of errors. When we excluded wrong time errors, day of the week (Monday, OR 3.14, CI 1.66-5.94), drug class (gastrointestinal, OR 3.47, CI 1.76-6.82; blood, OR 0.21, CI 0.05-0.91; and respiratory, OR 0.22, CI 0.08-0.60), and route of administration (oral by gastric tube, OR 5.60, CI 1.70-18.49) were associated with the occurrence of errors. In the hospital without full-time specialized intensive care physicians (which also lacks pharmacy-provided protocols for the preparation of parenteral drugs), more administration errors occurred, both when we included (OR 5.45, CI 3.04-9.78) and excluded wrong time errors (OR 4.22, CI 2.36-7.54).

CONCLUSIONS

Efforts to reduce drug administration errors in the intensive care unit should be aimed at the risk factors we identified in this study. Especially, focusing on system differences between the two intensive care units (e.g., presence or absence of full-time specialized intensive care physicians, presence or absence of protocols for the preparation of all parenteral drugs) may help reduce suboptimal drug administration.

Hospital prescribing errors: epidemiological assessment of predictors

AIMS

To demonstrate an epidemiological method to assess predictors of prescribing errors.

METHODS

A retrospective case-control study, comparing prescriptions with and without errors.

RESULTS

Only prescriber and drug characteristics were associated with errors. Prescriber characteristics were medical specialty (e.g. orthopaedics: OR: 3.4, 95% CI 2.1, 5.4) and prescriber status (e.g. verbal orders transcribed by nursing staff: OR: 2.5, 95% CI 1.8, 3.6). Drug characteristics were dosage form (e.g. inhalation devices: OR: 4.1, 95% CI 2.6, 6.6), therapeutic area (e.g. gastrointestinal tract: OR: 1.7, 95% CI 1.2, 2.4) and continuation of preadmission treatment (Yes: OR: 1.7, 95% CI 1.3, 2.3).

CONCLUSIONS

Other hospitals could use our epidemiological framework to identify their own error predictors. Our findings suggest a focus on specific prescribers, dosage forms and therapeutic areas. We also found that prescriptions originating from general practitioners involved errors and therefore, these should be checked when patients are hospitalized.

Analysis of Medication Incidents and Development of a Medication Incident Rate Clinical Indicator

Most health service organisations depend solely upon spontaneous voluntary reporting of medication incidents and a wide variety of available denominators are used in order to calculate the Medication Incident Rate (MIR). This paper describes how nursing staff and clinical pharmacists reviewed medication incident data, revised and established new systems of reporting and developed a clinically useful, rate-based MIR Clinical Indicator. In order to make the MIR more meaningful, the frequency of occurrence of incidents was considered within the context of the total number of medications given to patients. This was achieved by undertaking a point prevalence audit of all inpatient medication charts (n=372) to determine the total number of doses of medication given to patients during a 24 hour period (n=3211). This value was then used as the denominator for the MIR indicator. During 1998, a total of 475 medication incidents were reported; the average number of incidents was 1.3 per 24 hours. The MIR per 1000 doses was calculated to be 0.4. In most cases (77%) the incident caused no harm to the patient and no change in treatment was required, and the most 'severe' category for any incident was that active treatment was required (3% of reported incidents). The most common type of incident was the omission of a dose of medication (50%). A wide range of drugs were involved in the incidents, most commonly morphine (3.4%). The authors consider that the development and use of the MIR Clinical Indicator has positively influenced clinical practice in some areas at the authors' hospital.