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

Frequency of Medication Administration Timing Error in Hospitals: A Systematic Review

BACKGROUND

Medication administration timing error (MATE) leads to poor medication efficacy, harm, and death. Frequency of MATE is understudied.

PURPOSE

To determine MATE frequency, and characteristics and quality of reporting studies.

METHODS

A systematic review of articles between 1999 and 2021 was conducted using the Cumulative Index of Nursing and Allied Health Literature, ProQuest, and PubMed databases. Articles were scored for quality using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist.

RESULTS

Initially, 494 articles were screened; 23 were included in this review. MATE was defined as administration beyond 60 minutes before or after the scheduled time in 13 (57%) of the included studies. Measurement procedures included data abstraction, self-report, and observation. Frequency of MATE was 1% to 72.6%. Moderate study quality was found in 78% of articles.

CONCLUSION

Research on MATE is characterized by inconsistent definitions, measurements procedures, and calculation techniques. High-quality studies are lacking. Many research improvement opportunities exist.

Evaluation of errors in preparation and administration of intravenous medications in critically ill patients

BACKGROUND

Intravenous medications have greater complexity and require multiple steps in their preparation and administration, which is considered a high risk for patients.

OBJECTIVE

To determine the incidence of intravenous medications preparation and administration errors in critically ill patients.

METHODS

This was an observational, cross-sectional, prospective study design. The study was performed in Wad Medani Emergency Hospital, Sudan .

RESULTS

All nurses working at the study setting were observed over nine days. During the study period, a total number of 236 drugs were observed and evaluated. The total error rate was 940 (33.4%), of which 136 (57.6%) errors with no harm, 93 (39.4%) errors with harm and 7 (3%) of errors associated with mortality. 17 different drug categories were involved, in which antibiotic was the highest error rate 104 (44.1%) and 39 different drugs were involved, in which metronidazole was the most drug involved 34 (14.4%). The total error rate was associated with nurse experience, OR (95% CI); 3.235 (1.834-5.706), and nurse education level, OR (95% CI); 0.125 (0.052-0.299).

CONCLUSION

The study reported high frequency of IV medications preparation and administration errors. Nurse education level, and experiences were influenced the total errors.

Impact of Clinical Pharmacist Intervention on Clinical Outcomes in the Critical Care Unit, Taif City, Saudi Arabia: A Retrospective Study

(1) Objectives: Clinical pharmacists are now playing a significant role in hospitals aiming to reduce medication errors, adverse drug reactions, and healthcare costs. Therefore, the main objective of this study was to assess the interventions provided by a clinical pharmacist in the intensive care unit at the King Faisal Hospital in Taif city. (2) Methods: For this single-center retrospective study, patients were included from December 2021 to May 2022. In the present study, all the interventions of clinical pharmacists made over six months were included. The Intensive care unit (ICU) ward was covered by three clinical pharmacists, and the interventions made were categorized into four groups: (1) interventions related to indications; (2) interventions regarding safety; (3) interventions regarding dosing, and (4) miscellaneous. Descriptive statistics was applied to evaluate the results in the form of frequencies and percentages. Analysis was performed using the statistical package SPSS 20.0. (3) Results: Overall, a total of 404 interventions were recommended for 165 patients during the six- month period of study. Among them, 370 interventions (91.5%) were accepted by physicians. Among all the interventions, the majority were suggested regarding ‘indication’ (45.7%), including the addition of drugs, drugs with no indications, and duplication. The acceptance rate of clinical pharmacist intervention was 98.5%. (4) Conclusions: This retrospective study shows that clinical pharmacists played a critical role in optimizing drug therapy which could subsequently help to prevent drug-related issues and lower drug costs. More research is needed to do a thorough cost-benefit analysis.

Drug administration errors in Latin America: A systematic review

Purpose

This study systematically reviewed studies to determine the frequency and nature of medication administration errors in Latin American hospitals.

Summary

We systematically searched the medical literature of seven electronic databases to identify studies on medication administration errors in Latin American hospitals using the direct observation method. Studies published in English, Spanish, or Portuguese between 1946 and March 2021 were included. A total of 10 studies conducted at 22 hospitals were included in the review. Nursing professionals were the most frequently observed during medication administration and were observers in four of the ten included studies. Total number of error opportunities was used as a parameter to calculate error rates. The administration error rate had a median of 32% (interquartile range 16%–35.8%) with high variability in the described frequencies (9%–64%). Excluding time errors, the median error rate was 9.7% (interquartile range 7.4%–29.5%). Four different definitions of medication errors were used in these studies. The most frequently observed errors were time, dose, and omission. Only four studies described the therapeutic classes or groups involved in the errors, with systemic anti-infectives being the most reported. None of the studies assessed the severity or outcome of the errors. The assessment of the overall risk bias revealed that one study had low risk, three had moderate risk, and three had high risk. In the assessment of the exploratory, observational, and before-after studies, two were classified as having fair quality and one as having poor quality.

Conclusion

The administration error rate in Latin America was high, even when time errors were excluded. The variation observed in the frequencies can be explained by the different contexts in which the study was conducted. Future research using direct observation techniques is necessary to more accurately estimate the nature and severity of medication administration errors.

Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Background Intravenous admixture preparation errors (IAPEs) may lead to patient harm. Insight into the prevalence as well as the determinants associated with these IAPEs is needed to elicit preventive measures. Aim The primary aim of this study was to assess the prevalence of IAPEs. Secondary aims were to identify the type, severity, and determinants of IAPEs. Method A prospective observational study was performed in a Dutch university hospital. IAPE data were collected by disguised observation. The primary outcome was the proportion of admixtures with one or more IAPEs. Descriptive statistics were used for the prevalence, type, and severity of IAPEs. Mixed-effects logistic regression analyses were used to estimate the determinants of IAPEs. Results A total of 533 IAPEs occurred in 367 of 614 admixtures (59.8%) prepared by nursing staff. The most prevalent errors were wrong preparation technique (n = 257) and wrong volume of infusion fluid (n = 107). Fifty-nine IAPEs (11.1%) were potentially harmful. The following variables were associated with IAPEs: multistep versus single-step preparations (adjusted odds ratio [OR_adj] 4.08, 95% confidence interval [CI] 2.27–7.35); interruption versus no interruption (OR_adj 2.32, CI 1.13–4.74); weekend versus weekdays (OR_adj 2.12, CI 1.14–3.95); time window 2 p.m.-6 p.m. versus 7 a.m.-10 a.m. (OR_adj 3.38, CI 1.60–7.15); and paediatric versus adult wards (OR_adj 0.14, CI 0.06–0.37). Conclusion IAPEs, including harmful IAPEs, occurred frequently. The determinants associated with IAPEs point to factors associated with preparation complexity and working conditions. Strategies to reduce the occurrence of IAPEs and therefore patient harm should target the identified determinants.

Nurses' Perceptions on the Implementation of a Safe Drug Administration Protocol and Its Effect on Error Notification

Patient safety and quality of care are fundamental pillars in the health policies of various governments and international organizations. The purpose of this study is to evaluate nurses’ perceptions on the degree of implementation of a protocol for the standardization of care and to measure its influence on notification of adverse events related to the administration of medications. This comparative study used data obtained from questionnaires completed by 180 nurses from medical and surgical units. Our analyses included analysis of variance and regression models. We observe that the responses changed unevenly over time in each group, finding significant differences in all comparisons. The mean response rating was increased at 6 months in the intervention group, and this level was maintained at 12 months. With the new protocol, a total of 246 adverse events and 481 incidents without harm was reported. Thus, actions such as the use of protocols and event notification systems should be implemented to improve quality of care and patient safety.

Clinical Decision Support System-Assisted Pharmacy Intervention Reduces Feeding Tube-Related Medication Errors in Hospitalized Patients: A Focus on Medication Suitable for Feeding-Tube Administration

Background

Administering medication through an enteral feeding tube (FT) is a frequent cause of errors resulting in increased morbidity and cost. Studies on interventions to prevent these errors in hospitalized patients, however, are limited.

Objective

The objective was to study the effect of a clinical decision support system (CDSS)–assisted pharmacy intervention on the incidence of FT‐related medication errors (FTRMEs) in hospitalized patients.

Methods

A pre‐post intervention study was conducted between October 2014 and May 2015 in Catharina Hospital, the Netherlands. Patients who were admitted to the wards of bowel and liver disease, oncology, or neurology; using oral medication; and had an enteral FT were included. Preintervention patients were given care as usual. The intervention consisted of implementing a CDSS‐assisted pharmacy check while also implementing standard operating procedures and educating personnel. An FTRME was defined as the administration of inappropriate medication through an enteral FT. The incidence was expressed as the number of FTRMEs per medication administration. Multivariate Poisson regression was used to calculate the incidence ratio (IR) comparing both phases.

Results

Eighty‐one patients were included, 38 during preintervention and 43 during the intervention phase. Incidence of FTRMEs in the preintervention phase was 0.15 (95% CI, 0.07–0.23) vs 0.02 (95% CI, 0.00–0.04) in the intervention phase, resulting in an adjusted IR of 0.13 (95% CI, 0.10–0.18).

Discussion

Incidence of FTRMEs, as well as the IR, is comparable to previous studies.

Conclusion

The intervention resulted in a substantial reduction in the incidence of FTRMEs.

Prevalence and characteristics of medication errors at an emergency department of a teaching hospital in Malaysia

BACKGROUND

Medication use process in the emergency department (ED) can be challenging and the risk for medication error (ME) to occur is high. In Malaysia, several studies on ME have been conducted in various hospital settings. However, little is known about the prevalence of ME in emergency department (ED) in these hospitals. The objective of this study was to determine the prevalence and characteristics of ME at an ED of a teaching hospital in Malaysia.

METHODS

A cross-sectional study was conducted over the period of 9 weeks in patients who visited the ED of Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia. Data on patient medication orders and demographic information was collected from the doctor's clerking sheet. Observations were made on nursing activities and these were documented in the data collection form. Other information related to the administration of medications were obtained from the nursing care records.

RESULTS

Observations and data collections were made for 547 patients who fulfilled the study criteria. From these, 311 patient data were randomly selected for analysis. Ninety-five patients had at least one ME. The prevalence of ME was calculated to be 30.5%. The most common types of ME were wrong time error (46.9%), unauthorized drug error (25.4%), omission error (18.5%) and dose error (9.2%). The most frequently drug associated with ME was analgesics. No adverse event was observed.

CONCLUSIONS

The prevalence of ME in our ED setting was moderately high. However, the majority of them did not result in any adverse event. Intervention measures are needed to prevent further occurrence.

Educational Targets to Reduce Medication Errors by General Surgery Residents

OBJECTIVE

Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers.

DESIGN

This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018.

SETTING

A single large academic medical center located in the Midwest, United States.

PARTICIPANTS

General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders.

RESULTS

Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (n = 24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (n = 8703, 36.1%) or errors in renal dosing (n = 7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (n = 5280) and 13.5% (n = 3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (OR = 1.21, 95%CI = 1.14-1.29) and in August versus other months (OR = 1.09, 95%CI = 1.01-1.17), but were independent of other resident and order characteristics.

CONCLUSIONS

This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.

Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units

Purpose

To determine the type, frequency, and factors associated with medication preparation and administration errors in adult intensive care units (ICUs) and neonatal ICUs (NICUs)/pediatric ICUs (PICUs).

Patients and methods

We conducted a prospective direct observation study in an adult ICU and NICU/PICU in a tertiary university hospital. Between June 2012 and June 2013, a clinical pharmacist and medical student observed the nursing care staff on weekdays during the preparation and administration of intravenous drugs. We analyzed the frequency and type of preparation and administration errors and factors associated with errors.

Results

Six hundred and three preparations in the adult ICU and 281 in the NICU/PICU were observed. Three hundred and eighty-five errors occurred in the adult ICU and 38 in the NICU/PICU. There were 5,040 and 2,514 error opportunities, with overall error rates of 7.6% and 1.5%, respectively. The total opportunities for error meant each single step of preparation and administration that was relevant for the drug. Most errors applied to the category “uniform mixing” (adult ICU: n=227, 59%; NICU/PICU: n=14, 37%). The multivariate logistic regression results showed a significantly different influence of the “preparation type” for the adult ICU compared with the NICU/PICU with regard to the occurrence of an error. Preparations for adult patients of the LCD type (liquid concentrate with diluent into syringe or infusion bag) were more often associated with errors than the P (powder in a glass vial that must be reconstituted and diluted if necessary), P=0.012, and LC (liquid concentrate into syringe), P=0.002 type.

Conclusion

“Uniform mixing” was the most erroneous preparation step in intravenous drug preparations in two ICUs. Improvement of nurse training and the preparation of prefilled syringes in the pharmacy might reduce errors and improve the quality and safety of drug therapy.

Preparing Drugs for Infusion Via Syringe Pump: A Key Step to Ensure Homogeneous Concentration

OBJECTIVE

Preparation of drug solutions used with electronic syringe infusion pumps plays a crucial role in the delivery of an accurate drug concentration. Is there a correlation between drug concentrations during syringe pump infusion and preparation protocols?

METHOD

Norepinephrine, insulin, and sufentanil were prepared in 3 different ways: (1) the drug was taken from the vial, then the solvent was added followed by an air bubble, and mixing was performed by turning the syringe top-to-bottom in a 180° shaking movement 5 consecutive times; (2) the drug was taken from the vial, then the solvent was added and not mixed; and (3) the solvent was taken from a stock solution, then the drug was added and not mixed. Concentrations of drugs were determined at different times during administration by reverse-phase high-performance liquid chromatography with ultraviolet detection. All analyses were performed in triplicate and were based on measurement of peak areas.

RESULTS

With no shaking of the syringe, the concentration of the injected drugs varies widely. In any case, mixing of the syringe contents by turning the syringe in a top-to-bottom 180° shaking movement 5 times with an air bubble would ensure administration of the drug at a constant concentration.

CONCLUSIONS

Without mixing, the concentrations of all drug solutions varied widely when administered via an electronic syringe infusion pump. Mixing syringe contents should be made part of the compulsory curriculum for administering medications at all levels of medical education. (Critical Care Nurse. 2016;36[4]:36-45).

A Review of Best Practices for Intravenous Push Medication Administration

In 2015, the Institute for Safe Medication Practices (ISMP) released safe practice guidelines for adult intravenous (IV) push medications. ISMP's most recent set of guidelines has added to a growing list of recommendations from professional groups on the safe use of IV medications. These recommendations and guidelines vary with regard to their audience, scope, and terminology. In some ways, these variations may contribute to confusion and delayed adoption of the standards. This report attempts to provide clarity about the rationale and background regarding the need for practice improvement, discussion of various guidelines, and practice mitigation strategies to improve patient safety.

Nurse compliance with a protocol for safe injectable medication administration: comparison of two multicentre observational studies

OBJECTIVES

Medication administration errors with injectable medication have a high risk of causing patient harm. To reduce this risk, all Dutch hospitals implemented a protocol for safe injectable medication administration. Nurse compliance with this protocol was evaluated as low as 19% in 2012. The aim of this second evaluation study was to determine whether nurse compliance had changed over a 4-year period, what factors were associated over time with protocol compliance and which strategies have been implemented by hospitals to increase protocol compliance.

METHODS

In this prospective observational study, conducted between November 2015 and September 2016, nurses from 16 Dutch hospitals were directly observed during intravenous medication administration. Protocol compliance was complete if nine protocol proceedings were conducted correctly. Protocol compliance was compared with results from the first evaluation. Multilevel logistic regression analyses were used to assess the associations over time between explanatory variables and complete protocol compliance. Implemented strategies were classified according to the five components of the Systems Engineering Initiative for Patient Safety (SEIPS) model.

RESULTS

A total of 372 intravenous medication administrations were observed. In comparison with 2012, more proceedings per administration were conducted (mean 7.6, 95% CI 7.5 to 7.7 vs mean 7.3, 95% CI 7.3 to 7.4). No significant change was seen in complete protocol compliance (22% in 2016); compliance with the proceedings 'hand hygiene' and 'check by a second nurse' remained low. In contrast to 2012, the majority of the variance was caused by differences between wards rather than between hospitals. Most implemented improvement strategies targeted the organisation component of the SEIPS model.

CONCLUSIONS

Compliance with 'hand hygiene' and 'check by a second nurse' needs to be further improved in order to increase complete protocol compliance. To do so, interventions focused on nurses and individually tailored to each ward are needed.

Knowledge, behaviours, training and attitudes of nurses during preparation and administration of intravenous medications in intensive care units (ICU). A multicenter Italian study

BACKGROUND

Medication errors can put at risk the life of patients hospitalized in the ICUs. These errors occur more frequently in the ICUs due to their peculiar medical framework. There is not much information about the knowledge, attitudes, behaviours and training needs of the nurses who work in ICUs towards the medication errors.

OBJECTIVE

This study aims at describing the knowledge, attitudes, behaviours and training needs of the Italian nurses who work in ICUs towards the use of IV drugs, and identifying the strategies that nurses can adopt to prevent the occurrence of medication errors.

MATERIALS AND METHODS

Cross-sectional study. The survey was carried out through a self-administrated questionnaire and it was addressed to 529 Italian nurses who work in the ICUs of Southern, Centre and Northern Italy hospitals (average age of the sample 39.9, SD=9.1, 68.1% females). The questionnaire, made of 36 items divided into 7 sections, was validated after the results of the pilot study.

RESULTS

The study highlighted the importance of the role, behaviours and knowledge of the nurses to prevent the medication errors. The results of the multivariate analysis of the multicentre study show a relation among correct behaviours and positive attitudes, even if it is not statistically significant. Worth mentioning is the fact that the achievement of a university degree affects negatively the correct behaviours (OR 0.56, 95% CI 0.34-0.95), as well as the years of work (OR 0.97, 95% CI 0.94-0.99).

CONCLUSIONS

The results of this multicentre study are encouraging. Nurses who have a good command of the English language (sufficient, good, and excellent) dedicate more than an hour per week to the bibliography update. Extending and deepening the knowledge of the nurses in a cyclical way might be an effective strategy to keep a high level of security of the drugs in the ICUs. The study highlighted that almost all the surveyed nurses (93%) are aware that an adequate knowledge of the drugs dosage calculation is essential to reduce the occurrence of medication errors in the drugs preparation phase.

Effects of multidisciplinary teams and an integrated follow-up electronic system on clinical pharmacist interventions in a cancer hospital

Background The aim of drug therapy is to attain distinct therapeutic effects that not only improve patient's quality of life but also reduce the inherent risks associated with the therapeutic use of drugs. Pharmacists play a key role in reducing these risks by developing appropriate interventions. Whether to accept or reject the intervention made by the pharmacist is a relevant consultant's decision. Objective To evaluate the impact of electronic prompts and follow-up of rejected pharmacy interventions by clinical pharmacists in an in-patient setting. Setting Shaukat Khanum Cancer Hospital & Research Center, Lahore, Pakistan. Method The study was conducted in two phases. Data for 3 months were collected for each phase of the study. Systematic and quantifiable consensus validity was developed for rejected interventions in phase 1, based on patient outcome analyses. Severity rating was assigned to assess the significance of interventions. Electronic prompts for follow-on interventions in phase 2 were then developed and implemented, including daily review via a multidisciplinary team (MDT) approach. Main outcome measure Validity of rejected interventions, acceptance of follow-on interventions before and after re-engineering the pharmacy processes, rejection rate and severity rating of follow-on interventions. Result Of a total of 2649 and 3064 interventions that were implemented during phase 1 and phase 2, 238 (9%) and 307 (10%) were rejected, respectively. Additionally, 133 (56%) were inappropriate rejections during phase 1. The estimated reliability between pharmacists regarding rejected interventions was 0.74 (95% CI of 0.69, 0.79, p 0.000). Prospective data were analysed after implementing electronic alerts and an MDT approach. The acceptance rate of follow-on interventions in phase 2 was 60% (184). Conclusion Electronic prompts for follow-on interventions together with an MDT approach enhance the optimization of pharmacotherapy, increase drug rationality and improve patient care.

Clinical Practice Guideline: Safe Medication Use in the ICU

OBJECTIVE

To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill.

DATA SOURCES

PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015.

STUDY SELECTION

Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed.

DATA EXTRACTION

Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation.

DATA SYNTHESIS

The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations.

CONCLUSIONS

This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana

OBJECTIVES

This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana.

METHODS

This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes.

RESULTS

Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems.

CONCLUSIONS

This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Impact of the implementation of vasoactive drug protocols on safety and efficacy in the treatment of critically ill patients

WHAT IS KNOWN AND OBJECTIVE

The correct management of high-alert medications is a priority issue in expert recommendations for improving the clinical safety of patients. Objectives were to assess the impact of the implementation of vasoactive drug (VAD) protocols on safety and efficacy in the treatment of critically ill patients.

METHODS

A prospective before-and-after study on the implementation of different VAD protocols, comparing medication errors (MEs) rates, mean intensive care unit (ICU) stay, mean blood pressure (MAP), heart rate (HR) and oxygen saturation.

RESULTS AND DISCUSSION

The study included 432 patients. There was a statistically significant decrease in prescribing errors (55·9%), validation errors (68·1%) and medication administration records (MAR) errors (78·8%). No differences were found between the two phases in ICU stay, MAP, HR and oxygen saturation.

WHAT IS NEW AND CONCLUSION

Implementation of protocols decreases variability in clinical practice, reduces the incidence of MEs and maintains the effectiveness of VAD therapy in critically ill patients.

Medication safety in neonatal care: a review of medication errors among neonates

OBJECTIVE

The objective of this study was to describe the medication errors in hospitalized patients, comparing those in neonates with medication errors across the age spectrum.

METHOD

In tier 1, PubMed, Embase and Google Scholar were searched, using selected MeSH terms relating to hospitalized paediatric, adult and elderly populations. Tier 2 involved a search of the same electronic databases for literature relating to hospitalized neonatal patients.

RESULTS

A total of 58 articles were reviewed. Medication errors were well documented in each patient group. Overall, prescribing and administration errors were most commonly identified across each population, and mostly related to errors in dosing. Errors due to patient misidentification and overdosing were particularly prevalent in neonates, with 47% of administration errors involving at least tenfold overdoses. Unique errors were identified in elderly patients, comprising duplication of therapy and unnecessary prescribing of medicines. Overall, the medicines most frequently identified with error across each patient group included: heparin, antibiotics, insulin, morphine and parenteral nutrition. While neonatal patients experience the same types of medication errors as other hospitalized patients, the medication-use process within this group is more complex and has greater consequences resulting from error. Suggested strategies to help overcome medication error most commonly involved the integration of a clinical pharmacist into the treating team.

CONCLUSION

This review highlights that each step of the medication-use process is prone to error across the age spectrum. Further research is required to develop targeted strategies relevant to specific patient groups that integrate key pharmacy services into wards.

An integrative review of drug errors in critical care

Medication error is the commonest cause of medical error and the consequences can be grave. This integrative review was undertaken to critically appraise recent literature to further define prevalence, most frequently-implicated drugs and effects on patient morbidity and mortality in the critical care environment. Forty studies were compared revealing a markedly heterogeneous data set with significant variability in reported incidence. There is an important differentiation to be made between medication error (incidence 5.1-967 per 1000 patient days) and adverse drug event (incidence 1-96.5 per 1000 patient days) with significant ramifications for patient outcome and cost. The most commonly implicated drugs were cardiovascular, gastrointestinal, antimicrobial and hypoglycaemic agents. Beneficial interventions to reduce such errors include computerised prescribing, education and pharmacist input. The studies described provide insight into suboptimal management in the critical care environment and have implications for the development of specific improvement strategies and future training.

Medication Errors in Vietnamese Hospitals: Prevalence, Potential Outcome and Associated Factors

Background

Evidence from developed countries showed that medication errors are common and harmful. Little is known about medication errors in resource-restricted settings, including Vietnam.

Objectives

To determine the prevalence and potential clinical outcome of medication preparation and administration errors, and to identify factors associated with errors.

Methods

This was a prospective study conducted on six wards in two urban public hospitals in Vietnam. Data of preparation and administration errors of oral and intravenous medications was collected by direct observation, 12 hours per day on 7 consecutive days, on each ward. Multivariable logistic regression was applied to identify factors contributing to errors.

Results

In total, 2060 out of 5271 doses had at least one error. The error rate was 39.1% (95% confidence interval 37.8%- 40.4%). Experts judged potential clinical outcomes as minor, moderate, and severe in 72 (1.4%), 1806 (34.2%) and 182 (3.5%) doses. Factors associated with errors were drug characteristics (administration route, complexity of preparation, drug class; all p values < 0.001), and administration time (drug round, p = 0.023; day of the week, p = 0.024). Several interactions between these factors were also significant. Nurse experience was not significant. Higher error rates were observed for intravenous medications involving complex preparation procedures and for anti-infective drugs. Slightly lower medication error rates were observed during afternoon rounds compared to other rounds.

Conclusions

Potentially clinically relevant errors occurred in more than a third of all medications in this large study conducted in a resource-restricted setting. Educational interventions, focusing on intravenous medications with complex preparation procedure, particularly antibiotics, are likely to improve patient safety.

Intensive care unit capacity strain and adherence to prophylaxis guidelines

PURPOSE

The purpose of the study is to examine the relationship between different measures of capacity strain and adherence to prophylaxis guidelines in the intensive care unit (ICU).

MATERIALS AND METHODS

We conducted a retrospective cohort study within the Project IMPACT database. We used multivariable logistic regression to examine relationships between ICU capacity strain and appropriate usage of venous thromboembolism prophylaxis (VTEP) and stress ulcer prophylaxis (SUP).

RESULTS

Of 776,905 patient-days eligible for VTEP, appropriate therapy was provided on 68%. Strain as measured by proportion of new admissions (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.90-0.91) and census (OR, 0.97; 95% CI, 0.97-0.98) was associated with decreased odds of receiving VTEP. With increasing strain as measured by new admissions, the degradation of VTEP utilization was more severe in ICUs with closed (OR, 0.85; 95% CI, 0.83-0.88) than open (OR, 0.91; 95% CI, 0.91-0.92) staffing models (interaction P<.001). Of 185425 patient-days eligible for SUP, 48% received appropriate therapy. Administration of SUP was not significantly influenced by any measure of strain.

CONCLUSIONS

Rising capacity strain in the ICU reduces the odds that patients will receive appropriate VTEP but not SUP. The variability among different types of ICUs in the extent to which strain degraded VTEP use suggests opportunities for systems improvement.

An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit

Aim

To assess the impact of the implementation of a Computerized Physician Order Entry (CPOE) associated with a pharmaceutical checking of medication orders on medication errors in the 3 stages of drug management (i.e. prescription, dispensing and administration) in an orthopaedic surgery unit.

Methods

A before-after observational study was conducted in the 66-bed orthopaedic surgery unit of a teaching hospital (700 beds) in Paris France. Direct disguised observation was used to detect errors in prescription, dispensing and administration of drugs, before and after the introduction of computerized prescriptions. Compliance between dispensing and administration on the one hand and the medical prescription on the other hand was studied. The frequencies and types of errors in prescribing, dispensing and administration were investigated.

Results

During the pre and post-CPOE period (two days for each period) 111 and 86 patients were observed, respectively, with corresponding 1,593 and 1,388 prescribed drugs. The use of electronic prescribing led to a significant 92% decrease in prescribing errors (479/1593 prescribed drugs (30.1%) vs 33/1388 (2.4%), p < 0.0001) and to a 17.5% significant decrease in administration errors (209/1222 opportunities (17.1%) vs 200/1413 (14.2%), p < 0.05). No significant difference was found in regards to dispensing errors (430/1219 opportunities (35.3%) vs 449/1407 (31.9%), p = 0.07).

Conclusion

The use of CPOE and a pharmacist checking medication orders in an orthopaedic surgery unit reduced the incidence of medication errors in the prescribing and administration stages. The study results suggest that CPOE is a convenient system for improving the quality and safety of drug management.

Incidence of Intravenous Medication Errors in a Chinese Hospital

OBJECTIVES

The purpose of this study was to explore intravenous (IV) medication errors in a Chinese hospital. The specific objectives were to 1) explore and measure the frequency of IV medication errors by direct observation and identify clues to their causes in Chinese hospital inpatient wards and 2) identify the clinical importance of the errors and find the potential risks in the preparation and administration processes of IV medications.

METHODS

A prospective study was conducted by using the direct observational method to describe IV medication errors on two general surgery patient wards in a large teaching hospital in Beijing, China. A trained observer accompanied nurses during IV preparation rounds to detect medication errors. The difference in mean error rates between total parenteral nutrition (TPN) and non-TPN medications was tested by using the Mann-Whitney U test.

RESULTS

A final total of 589 ordered IV doses plus 4 unordered IV doses as prepared and administered to the patients was observed from August 3, 2010, to August 13, 2010. The overall error rate detected on the study ward was 12.8%. The most frequent errors by category were wrong dose (5.4%), wrong time (3.7%), omission (2.7%), unordered dose (0.7%), and extra dose (0.3%). Excluding wrong time errors, the error rate was 9.1%. Non-TPN medications had significantly higher error rates than did TPN medications including wrong time errors (P = 0.0162).

CONCLUSIONS

A typical inpatient in a Chinese hospital was subject to about one IV error every day. Pharmacists had a very limited role in ensuring the accuracy of IV medication preparation and administration processes.

More than just crushing: a prospective pre-post intervention study to reduce drug preparation errors in patients with feeding tubes

WHAT IS KNOWN AND OBJECTIVES

Incorrect drug preparation for patients with feeding tubes can result in harm for the patient and the preparing person. Combined intervention programs are effective tools to reduce such preparation errors. However, to date, intervention programs have been mostly tested in hospitals with computerized physician order entry (CPOE), unit-dose systems, or ward-based clinical pharmacists. Hence, the primary objective of this study was to develop and evaluate an intervention program tailored to hospitals without such preconditions.

METHODS

We conducted a prospective pre-/post-intervention study on a gastroenterological intensive care unit (ICU) and a surgical ward for oral, dental and maxillofacial diseases (surgical ward). During the study periods, observers documented and evaluated drug preparation processes of all peroral drugs for patients with feeding tubes. The primary endpoint was the rate of inappropriately crushed and/or suspended solid peroral drugs in regards to all solid peroral drugs.

RESULTS AND DISCUSSION

Altogether, we evaluated 775 drug preparation processes of solid peroral drugs on the ICU and 975 on the surgical ward. The intervention program significantly reduced incorrect crushing and/or suspending of solid peroral drugs for administration to patients with feeding tubes from 9·8% to 4·2% (P < 0·01) on the ICU and from 5·7% to 1·4% (P < 0·01) on the surgical ward.

WHAT IS NEW AND CONCLUSION

The implementation of the newly developed intervention program significantly reduced the rate of inappropriately prepared solid peroral drugs, suggesting that it is an effective measure to enable safe drug administration for inpatients with feeding tubes.

Protocol compliance of administering parenteral medication in Dutch hospitals: an evaluation and cost estimation of the implementation

OBJECTIVES

Preventable adverse drug events (ADEs) are closely related to administration processes of parenteral medication. The Dutch Patient Safety Program provided a protocol for administering parenteral medication to reduce the amount of ADEs. The execution of the protocol was evaluated and a cost estimation was performed to provide insight in the associated costs of protocol compliance.

METHODS

A longitudinal evaluation study was performed in secondary care. A total of 2154 observations of the administration process of parenteral medication were carried out within 10 measurements in 19 hospitals between November 2011 and December 2012. The total time needed for the process was measured in a sample of five hospitals. Multilevel linear and logistic regression analyses were used to analyse the trend over time of the implementation and to assess the association between hospital and administration characteristics, and compliance of the protocol. A cost estimation provided insight into the costs of performing a complete administration process and the costs at department level for 1 year.

RESULTS

The complete protocol was performed in 19% of the observations. The proceeding 'check by a second nurse' was least performed. Large differences were found between individual hospitals in performing the administration protocol. The compliance of the protocol was negatively influenced in case of disturbance of the administrator. The overall trend over time of completion of the protocol fluctuated during the study period. On average, 3 min 26 s were needed to perform the complete protocol, which costs €2.42. Extrapolating the costs to department level, including cost for clinical lessons, the difference in costs in performing the complete protocol and an incomplete protocol was €7.891 for 1 year.

CONCLUSIONS

The protocol for administering parenteral medication is still not implemented completely, therefore an investment in time and Euros is needed.

Understanding the nature of medication errors in an ICU with a computerized physician order entry system

Objectives

We investigated incidence rates to understand the nature of medication errors potentially introduced by utilizing a computerized physician order entry (CPOE) system in the three clinical phases of the medication process: prescription, administration, and documentation.

Methods

Overt observations and chart reviews were employed at two surgical intensive care units of a 950-bed tertiary teaching hospital. Ten categories of high-risk drugs prescribed over a four-month period were noted and reviewed. Error definition and classifications were adapted from previous studies for use in the present research. Incidences of medication errors in the three phases of the medication process were analyzed. In addition, nurses' responses to prescription errors were also assessed.

Results

Of the 534 prescriptions issued, 286 (53.6%) included at least one error. The proportion of errors was 19.0% (58) of the 306 drug administrations, of which two-thirds were verbal orders classified as errors due to incorrectly entered prescriptions. Documentation errors occurred in 205 (82.7%) of 248 correctly performed administrations. When tracking incorrectly entered prescriptions, 93% of the errors were intercepted by nurses, but two-thirds of them were recorded as prescribed rather than administered.

Conclusion

The number of errors occurring at each phase of the medication process was relatively high, despite long experience with a CPOE system. The main causes of administration errors and documentation errors were prescription errors and verbal order processes. To reduce these errors, hospital-level and unit-level efforts toward a better system are needed.

Estimated cost savings from reducing errors in the preparation of sterile doses of medications

BACKGROUND

Preventing intravenous (IV) preparation errors will improve patient safety and reduce costs by an unknown amount.

OBJECTIVE

To estimate the financial benefit of robotic preparation of sterile medication doses compared to traditional manual preparation techniques.

METHODS

A probability pathway model based on published rates of errors in the preparation of sterile doses of medications was developed. Literature reports of adverse events were used to project the array of medical outcomes that might result from these errors. These parameters were used as inputs to a customized simulation model that generated a distribution of possible outcomes, their probability, and associated costs.

RESULTS

By varying the important parameters across ranges found in published studies, the simulation model produced a range of outcomes for all likely possibilities. Thus it provided a reliable projection of the errors avoided and the cost savings of an automated sterile preparation technology. The average of 1,000 simulations resulted in the prevention of 5,420 medication errors and associated savings of $288,350 per year. The simulation results can be narrowed to specific scenarios by fixing model parameters that are known and allowing the unknown parameters to range across values found in previously published studies.

CONCLUSIONS

The use of a robotic device can reduce health care costs by preventing errors that can cause adverse drug events.

Clinical relevance of and risk factors associated with medication administration time errors

PURPOSE

The clinical relevance of and risk factors associated with errors related to medication administration time were studied.

METHODS

In this explorative study, 66 medication administration rounds were studied on two wards (surgery and neurology) of a hospital. Data on medication errors were collected using the blister collection method. The emptied packaging material of medication was collected after each round and compared with each patient's medication orders. Administration time errors were defined as medication administration (actual intake) occurring more than one hour before or after the prescribed time. Generalized estimating equations analysis was performed to study the correlation between medication administration errors and risk factors.

RESULTS

Data from 129 patients were included in the study. Among these 129 patients, 2874 opportunities for error were recorded. The majority of opportunities for error occurred during the 7 a.m. round. Within the 2874 opportunities for errors, 10 administration time errors occurred for medications that might interact with food or another medication. Time of administration (noon and 3 p.m.), route of administration (injection or infusion), and frequency of administration (if necessary) had significant protective effects against the occurrence of administration time errors. The rectal route of administration was associated with a significant increase in the frequency of administration time errors compared with the oral route. A clinically relevant administration time error occurred in 2 cases (0.07%).

CONCLUSION

Analysis of medication administration rounds found time errors to be the most common medication error.

The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan canadian study

Paediatric medication administration errors (PMAEs) occur frequently, with devastating consequences for children and their families. This study explored the relationship between the nursing work environment and the occurrence of reported PMAEs. In total, 127 potential and 245 actual PMAEs were reported. Workload, distraction, and ineffective communication were identified as significant contributors to the occurrence of PMAEs. Medical/surgical units reported more errors than critical care environments (p=.000) and a 2.9% increase in the frequency of reported PMAEs was noted for each additional bed on units (p=.001). This study supports the awareness that a systems reform is required to reduce PMAEs.

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.

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings

OBJECTIVE

To compare the distribution, causes, and consequences of medication errors in the ICU with those in non-ICU settings.

DESIGN

: A cross-sectional study of all hospital ICU and non-ICU medication errors reported to the MEDMARX system between 1999 and 2005. Adjusted odds ratios are presented.

SETTING

Hospitals participating in the MEDMARX reporting system.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

MEDMARX is an anonymous, self-reported, confidential, deidentified, internet-accessible medication error reporting program that allows hospitals to report, track, and share medication error data. There were 839,553 errors reported from 537 hospitals. ICUs accounted for 55,767 (6.6%) errors, of which 2,045 (3.7%) were considered harmful. Non-ICUs accounted for 783,800 (93.4%) errors, of which 14,471 (1.9%) were harmful. Errors most often originated in the administration phase (ICU 44% vs. non-ICU 33%; odds ratio 1.63 [1.43-1.86]). The most common error type was omission (ICU 26% vs. non-ICU 28%; odds ratio 1.00 [0.91-1.10]). Among harmful errors, dispensing devices (ICU 14% vs. non-ICU 7.1%; odds ratio 2.09 [1.69-2.59]) and calculation mistakes (ICU 9.8% vs. non-ICU 5.3%; odds ratio 1.82 [1.48-2.24]) were more commonly identified to be the cause in the ICU compared to the non-ICU setting. ICU errors were more likely to be associated with any harm (odds ratio 1.89 [1.62-2.17]), permanent harm (odds ratio 2.45 [1.17-5.13]), harm requiring life-sustaining intervention (odds ratio 2.91 [1.86-4.56]), or death (odds ratio 2.48 [1.18-5.19]). When an error did occur, patients and their caregivers were rarely informed (ICU 1.5% vs. non-ICU 2.1%; odds ratio 0.63 [0.48-0.84]) by the time of reporting.

CONCLUSIONS

More harmful errors are reported in ICU than non-ICU settings. Medication errors occur frequently in the administration phase in the ICU. When errors occur, patients and their caregivers are rarely informed. Consideration should be given to developing additional safeguards against ICU errors, particularly during drug administration, and eliminating barriers to error disclosures.

Prevalence and Nature of Medication Administration Errors in Health Care Settings: A Systematic Review of Direct Observational Evidence

OBJECTIVE:

To systematically review empirical evidence on the prevalence and nature of medication administration errors (MAEs) in health care settings.

DATA SOURCES:

Ten electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, Scopus, Applied Social Sciences Index and Abstracts, PsycINFO, Cochrane Reviews and Trials, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, and Health Management Information Consortium) were searched (1985-May 2012).

STUDY SELECTION AND DATA EXTRACTION:

English-language publications reporting MAE data using the direct observation method were included, providing an error rate could be determined. Reference lists of all included articles were screened for additional studies.

DATA SYNTHESIS:

In all, 91 unique studies were included. The median error rate (interquartile range) was 19.6% (8.6–28.3%) of total opportunities for error including wrong-time errors and 8.0% (5.1–10.9%) without timing errors, when each dose could be considered only correct or incorrect. The median rate of error when more than 1 error could be counted per dose was 25.6% (20.8–41.7%) and 20.7% (9.7–30.3%), excluding wrong-time errors. A higher median MAE rate was observed for the intravenous route (53.3% excluding timing errors (IQR 26.6–57.9%)) compared to when all administration routes were studied (20.1%; 9.0–24.6%), where each dose could accumulate more than one error. Studies consistently reported wrong time, omission, and wrong dosage among the 3 most common MAE subtypes. Common medication groups associated with MAEs were those affecting nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antiinfectives. Medication administration error rates varied greatly as a product of differing medication error definitions, data collection methods, and settings of included studies. Although MAEs remained a common occurrence in health care settings throughout the time covered by this review, potential targets for intervention to minimize MAEs were identified.

CONCLUSIONS:

Future research should attend to the wide methodological inconsistencies between studies to gain a greater measure of comparability to help guide any forthcoming interventions.

Effects of the implementation of a preventive interventions program on the reduction of medication errors in critically ill adult patients

PURPOSE

Medication errors (MEs) are a major factor limiting the effectiveness and safety of pharmacological therapies in critically ill patients. The purpose was to determine if a preventive interventions program (PIP) is associated with a significant reduction on prevalence of patients with MEs in intensive care unit (ICU).

METHODS

A prospective before-after study was conducted in a random sample of adult patients in a medical-surgical ICU. Between 2 observational phases, a PIP (bundle of interventions to reduce MEs) was implemented by a multidisciplinary team. Direct observation was used to detect MEs at baseline and postintervention. Each medication process, that is, prescription, transcription, dispensing, preparation, and administration, was compared with what the prescriber ordered; if there was a difference, the error was described and categorized. Medication errors were defined according to the National Coordinating Council for Medication Error Reporting and Prevention.

RESULTS

A total of 410 medications for 278 patients were evaluated. A 31.7% decrease on the prevalence of patients with MEs (41.9%-28.6%; P < .05) was seen. Main variations occurred in anti-infectives for systemic use and prescription and administration stage.

CONCLUSIONS

The implementation of PIP by a multidisciplinary team resulted in a significant reduction on the prevalence of patients with ME at an adult ICU.

[Medication errors in Spanish intensive care units]

OBJECTIVE

To estimate the incidence of medication errors in Spanish intensive care units.

DESIGN

Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU.

SETTING

Spanish intensive care units.

PATIENTS

Patients admitted to the intensive care unit participating in the SYREC during the period of study.

MAIN VARIABLES OF INTEREST

Risk, individual risk, and rate of medication errors.

RESULTS

The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable".

CONCLUSIONS

Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable.

Pharmaceutical and safety considerations of tablet crushing in patients undergoing enteral intubation

Medication in patients undergoing enteral intubation addresses various challenging issues considering safety and treatment efficiency. Ideally, other routes of administration (i.e. intravenous or intramuscular routes) or especially dedicated formulations should be used. However, in absence of liquid dosage form, tablets or pills must be crushed and suspended in a vehicle before administration. The administration of oral dosage forms by enteral tube is usually performed by the nursing staff facing (i) pharmaceutical relevance of crushing, (ii) loss and concomitant aero-contamination of drug substance, (iii) drug-nutriment interactions and (iv) enteral feeding tube clogging. In the present study, different combinations of either open or confined crushing and suspending protocols were compared by taking into account the crushing yield, the stability and granulometry of the solid oral form suspension and finally the extend of aerosol contamination during crushing and suspending. All protocols exhibited comparable crushing efficiency and suspending properties, but significantly higher aerosolisation of tablet particles was observed in both open crushing and suspending protocol. Therefore, both confined crushing and suspending protocol constitutes an efficient, time saving and safe alternative to the absence of available liquid dosage form for intubated patients.

Adverse event reporting in adult intensive care units and the impact of a multifaceted intervention on drug-related adverse events

Background

Adverse events (AEs) frequently occur in intensive care units (ICUs) and affect negatively patient outcomes. Targeted improvement strategies for patient safety are difficult to evaluate because of the intrinsic limitations of reporting crude AE rates. Single interventions influence positively the quality of care, but a multifaceted approach has been tested only in selected cases. The present study was designed to evaluate the rate, types, and contributing factors of emerging AEs and test the hypothesis that a multifaceted intervention on medication might reduce drug-related AEs.

Methods

This is a prospective, multicenter, before-and-after study of adult patients admitted to four ICUs during a 24-month period. Voluntary, anonymous, self-reporting of AEs was performed using a detailed, locally designed questionnaire. The temporal impact of a multifaceted implementation strategy to reduce drug-related AEs was evaluated using the risk-index scores methodology.

Results

A total of 2,047 AEs were reported (32 events per 100 ICU patient admissions and 117.4 events per 1,000 ICU patient days) from 6,404 patients, totaling 17,434 patient days. Nurses submitted the majority of questionnaires (n = 1,781, 87%). AEs were eye-witnessed in 49% (n = 1,003) of cases and occurred preferentially during an elective procedure (n = 1,597, 78%) and on morning shifts (n = 1,003, 49%), with a peak rate occurring around 10 a.m. Drug-related AEs were the most prevalent (n = 984, 48%), mainly as a consequence of incorrect prescriptions. Poor communication among caregivers (n = 776) and noncompliance with internal guidelines (n = 525) were the most prevalent contributing factors for AE occurrence. The majority of AEs (n = 1155, 56.4%) was associated with minimal, temporary harm. Risk-index scores for drug-related AEs decreased from 10.01 ± 2.7 to 8.72 ± 3.52 (absolute risk difference 1.29; 95% confidence interval, 0.88-1.7; p < 0.01) following the introduction of the intervention.

Conclusions

AEs occurred in the ICU with a typical diurnal frequency distribution. Medication-related AEs were the most prevalent. By applying the risk-index scores methodology, we were able to demonstrate that our multifaceted implementation strategy focused on medication-related adverse events allowed to decrease drug related incidents.

Errors Associated with IV Infusions in Critical Care

BACKGROUND

All medication errors are serious, but those associated with the IV route of administration often result in the most severe outcomes. According to the literature, IV medications are associated with 54% of potential adverse events, and 56% of medication errors.

OBJECTIVES

To determine the type and frequency of errors associated with prescribing, documenting, and administering IV infusions, and to also determine if a correlation exists between the incidence of errors and either the time of day (day versus night) or the day of the week (weekday versus weekend) in an academic medicosurgical intensive care unit without computerized order entry or documentation.

METHODS

As part of a quality improvement initiative, a prospective, observational audit was conducted for all IV infusions administered to critically ill patients during 40 randomly selected shifts over a 7-month period in 2007. For each IV infusion, data were collected from 3 sources: direct observation of administration of the medication to the patient, the medication administration record, and the patient's medical chart. The primary outcome was the occurrence of any infusion-related errors, defined as any errors of omission or commission in the context of IV medication therapy that harmed or could have harmed the patient.

RESULTS

It was determined that up to 21 separate errors might occur in association with a single dose of an IV medication. In total, 1882 IV infusions were evaluated, and 5641 errors were identified. Omissions or discrepancies related to documentation accounted for 92.7% of all errors. The most common errors identified via each of the 3 data sources were incomplete labelling of IV tubing (1779 or 31.5% of all errors), omission of infusion diluent from the medication administration record (474 or 8.4% of all errors), and discrepancy between the medication order as recorded in the patient's chart and the IV medication that was being infused (105 or 1.9% of all errors).

CONCLUSIONS

Strict definitions of errors and direct observation methods allowed identification of errors at every step of the medication administration process that was evaluated. Documentation discrepancies were the most prevalent type of errors in this paper-based system.

Streamlining the medication process improves safety in the intensive care unit

BACKGROUND

Multiple interventions were made to optimize the medication process in our intensive care unit (ICU). 1 Transcriptions from the medical order form to the administration plan were eliminated by merging both into a single document; 2 the new form was built in a logical sequence and was highly structured to promote completeness and standardization of information; 3 frequently used drug names, approved units, and fixed routes were pre-printed; 4 physicians and nurses were trained with regard to the correct use of the new form. This study was aimed at evaluating the impact of these interventions on clinically significant types of medication errors.

METHODS

Eight types of medication errors were measured by a prospective chart review before and after the interventions in the ICU of a public tertiary care hospital. We used an interrupted time-series design to control the secular trends.

RESULTS

Over 85 days, 9298 lines of drug prescription and/or administration to 294 patients, corresponding to 754 patient-days were collected and analysed for the three series before and three series following the intervention. Global error rate decreased from 4.95 to 2.14% (-56.8%, P < 0.001).

CONCLUSIONS

The safety of the medication process in our ICU was improved by simple and inexpensive interventions. In addition to the optimization of the prescription writing process, the documentation of intravenous preparation, and the scheduling of administration, the elimination of the transcription in combination with the training of users contributed to reducing errors and carried an interesting potential to increase safety.

[Medication errors in neonatal medicine: from prescription to administration]

Neonatal units have the highest incidence of medication errors (approximately 5%) compared to adult and pediatric wards. Medication errors include prescribing errors, transcription errors, dispensing errors, medication administration errors, and monitoring. Dosing error is the most common prescribing error. Prevention of medication error must be global. The implementation of a computerized physician order entry significantly reduces prescribing errors but other preventive measures remain necessary.

Identifying the latent failures underpinning medication administration errors: an exploratory study

OBJECTIVES

The primary aim of this article was to identify the latent failures that are perceived to underpin medication errors.

STUDY SETTING

The study was conducted within three medical wards in a hospital in the United Kingdom.

STUDY DESIGN

The study employed a cross-sectional qualitative design.

DATA COLLECTION METHODS

Interviews were conducted with 12 nurses and eight managers. Interviews were transcribed and subject to thematic content analysis. A two-step inter-rater comparison tested the reliability of the themes.

PRINCIPAL FINDINGS

Ten latent failures were identified based on the analysis of the interviews. These were ward climate, local working environment, workload, human resources, team communication, routine procedures, bed management, written policies and procedures, supervision and leadership, and training. The discussion focuses on ward climate, the most prevalent theme, which is conceptualized here as interacting with failures in the nine other organizational structures and processes.

CONCLUSIONS

This study is the first of its kind to identify the latent failures perceived to underpin medication errors in a systematic way. The findings can be used as a platform for researchers to test the impact of organization-level patient safety interventions and to design proactive error management tools and incident reporting systems in hospitals.

Standardised drug labelling in intensive care: results of an international survey among ESICM members

PURPOSE

Standardised coloured drug labels may increase patient safety in the intensive care unit (ICU). The rates of adherence to standardised drug syringe labelling (DSL) in European and non-European ICUs, and the standards applied are not known. The aim of this survey among ESICM members was to assess if and what standardised drug syringe labelling is used, if the standards for drug syringe labelling are similar internationally and if intensivists expect that standardised DSL should be delivered by the pharmaceutical industry.

METHODS

A structured, web-based, anonymised survey on standardised DSL, performed among ESICM members (March-May 2011; Clinicaltrials.gov NCT01232088). Descriptive data analysis was performed and Fisher's exact test was applied where applicable.

RESULTS

Four hundred eighty-two submissions were analysed (20 % non-European). Thirty-five percent of the respondents reported that standardised drug labelling was used hospital-wide, and 39 % reported that standardised DSL was used in their ICU (Europe: Northern 53 %, Western 52 %, Eastern 17 %, Southern 22 %). The International Organization of Standardization (ISO) 26825 norm in its original form was used by 30 %, an adapted version by 19 % and local versions by 45 %; 6 % used labels that were included in the drug's packaging. Eighty percent wished that the pharmaceutical industry supplied ISO 26825 norm labelling together with the drugs.

CONCLUSIONS

Standardised DSL is not widely applied in European and non-European ICUs and mostly does not adhere strictly to the ISO norm. The frequency and quality of DSL differs to a great extent among European regions. This leaves much room for improvement.