Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model

Evaluating deviations and considerations in daily practice when double-checking high-risk medication administration: A qualitative study using the FRAM

Background

Double-check protocol compliance during administration is low. Regardless, most high-risk medication administrations are performed without incidents. The present study investigated the process of preparing and administrating high-risk medication and examined which variations occur in daily practice. Additionally, we investigated which considerations were taken into account when deviating from the guidelines.

Methods

Ten Dutch hospital wards participated. The Functional Resonance Analysis Method was applied to construct a model depicting the Dutch guidelines and a ward-overarching model visualizing daily practice. To create the ward-overarching model, eight semi-structured interviews were conducted per ward discussing the preparation and administration of high-risk medication. Work related Efficiency-Thoroughness Trade-Off rules were used to structure subconscious considerations.

Results

In total, 77 nurses were interviewed. Six model deviations were found between the guideline model and ward-overarching model. Notably, four variations in double-check procedures were found. Here, time pressure was an important factor. Nurses made a risk-assessment, considering for patient stability, and difficulty of calculations, to determine whether the double-check would be executed. Additionally, subconscious reasonings, such as trusting their own or colleagues expertise, weighed on the decision.

Conclusion

Time pressure is the most important factor that withholds nurses from performing the double-check. Nurses instead conduct a risk-assessment to decide if the double-check will be executed. The double-check can thus become habitual or unnecessary for certain medications. In future research, insights of the FRAM could be used to make ward-specific alterations for the double-check procedure of medications, that focus on feasibility in daily practice, while maintaining patient safety.

Nursing errors in intensive care unit and their association with burnout, anxiety, insomnia and working environment: a cross-sectional study

BACKGROUND

In intensive care units (ICU), commonly identified nursing errors may have a negative impact on short- and long-term patient outcomes. Current data is scarce regarding nurses' burnout, insomnia, and anxiety impact on medication and several other types of nursing errors. This study aimed to record the commonness of various nursing errors, including checking patient data, medication preparation and administration, and infection control measures. It also aimed to investigate if "nurse-related" or "ICU-related" features may be associated with nursing error occurrence.

MATERIAL-METHODS

A sample of nurses employed in four Greek ICUs was evaluated using the self-completed Athens Insomnia Scale, the State-Trait Anxiety Inventory Form Y, and the Maslach Burnout Inventory. Moreover, we also recorded the sociodemographic characteristics of the ICU nurses, data regarding nursing errors and common practices, and variables regarding the working environment. We conducted a multinominal regression analysis to identify the variables independently associated with each error/mistake.

RESULTS

Ninety ICU nurses from the 99 addressed returned the completed questionnaires. The most frequent mistakes referred to drug preparation and administration, with 43.3 % of nurses reporting being "always/very often" distracted when preparing a drug and 90 % that "half of the times" they administer medication at unscheduled hours, followed in frequency by errors regarding the proper use of antiseptic solutions. Medication errors were independently predicted by state anxiety, satisfaction regarding training, emotional exhaustion score, number of ICU beds, and weekdays off work per month. In contrast, errors regarding infection control were independently associated with weekdays off work per month.

CONCLUSION

Medication errors are the commonest type of nursing error. Although several risk factors have been identified, no universal "nurse-related" or "ICU-related" factor can predict all types of errors. HIPPOKRATIA 2022, 26 (3):110-117.

Developing the 'checking' discipline

We explore how engagement with checklists and adoption of a strict 'checking' discipline help avoid unintentional individual, team and systemic errors. Paradoxically, this is equally important when performing repetitive mundane tasks as well as during times of high-stress workload. In this article, we aim to discuss the different types of checklists and explain how deviations from a 'checking' discipline can lead to never events such as wrong side or site surgery. Well-designed checklists function as mental notes and prompts in clinical situations where the combination of fatigue and stress can contribute to a decline in cognitive performance. Furthermore, the need for proactive discussion by all members of the team during the implementation of the surgical checklist also reinforces the concept of teamwork and contributes towards effective communication. Patient safety is often a product of good communication, teamwork and anticipation: a 'checking' mentality remains the lynchpin which links these factors.

What do double-check routines actually detect? An observational assessment and qualitative analysis of identified inconsistencies

OBJECTIVES

Double checking is used in oncology to detect medication errors before administering chemotherapy. The objectives of the study were to determine the frequency of detected potential medication errors, i.e., mismatching information, and to better understand the nature of these inconsistencies.

DESIGN

In observing checking procedures, field noteswere taken of all inconsistencies that nurses identified during double checking the order against the prepared chemotherapy.

SETTING

Oncological wards and ambulatory infusion centres of three Swiss hospitals.

PARTICIPANTS

Nurses' double checking was observed.

OUTCOME MEASURES

In a qualitative analysis, (1) a category system for the inconsistencies was developed and (2) independently applied by two researchers.

RESULTS

In 22 (3.2%) of 690 observed double checks, 28 chemotherapy-related inconsistencies were detected. Half of them related to non-matching information between order and drug label, while the other half was identified because the nurses used their own knowledge. 75% of the inconsistencies could be traced back to inappropriate orders, and the inconsistencies led to 33 subsequent or corrective actions.

CONCLUSIONS

In double check situations, the plausibility of the medication is often reviewed. Additionally, they serve as a correction for errors and that are made much earlier in the medication process, during order. Both results open up new opportunities for improving the medication process.

Effectiveness of double checking to reduce medication administration errors: a systematic review

Background

Double checking medication administration in hospitals is often standard practice, particularly for high-risk drugs, yet its effectiveness in reducing medication administration errors (MAEs) and improving patient outcomes remains unclear. We conducted a systematic review of studies evaluating evidence of the effectiveness of double checking to reduce MAEs.

Methods

Five databases (PubMed, Embase, CINAHL, Ovid@Journals, OpenGrey) were searched for studies evaluating the use and effectiveness of double checking on reducing medication administration errors in a hospital setting. Included studies were required to report any of three outcome measures: an effect estimate such as a risk ratio or risk difference representing the association between double checking and MAEs, or between double checking and patient harm; or a rate representing adherence to the hospital’s double checking policy.

Results

Thirteen studies were identified, including 10 studies using an observational study design, two randomised controlled trials and one randomised trial in a simulated setting. Studies included both paediatric and adult inpatient populations and varied considerably in quality. Among three good quality studies, only one showed a significant association between double checking and a reduction in MAEs, another showed no association, and the third study reported only adherence rates. No studies investigated changes in medication-related harm associated with double checking. Reported double checking adherence rates ranged from 52% to 97% of administrations. Only three studies reported if and how independent and primed double checking were differentiated.

Conclusion

There is insufficient evidence that double versus single checking of medication administration is associated with lower rates of MAEs or reduced harm. Most comparative studies fail to define or investigate the level of adherence to independent double checking, further limiting conclusions regarding effectiveness in error prevention. Higher-quality studies are needed to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required.

CRD42018103436.

Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study

Purpose:

Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards.

Methods:

Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent.

Results:

Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed.

Conclusion:

We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.

Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences

BACKGROUND

Double-checking is widely recommended as an essential method to prevent medication errors. However, prior research has shown that the concept of double-checking is not clearly defined, and that little is known about actual practice in oncology, for example, what kind of checking procedures are applied.

OBJECTIVE

To study the practice of different double-checking procedures in chemotherapy administration and to explore nurses' experiences, for example, how often they actually find errors using a certain procedure. General evaluations regarding double-checking, for example, frequency of interruptions during and caused by a check, or what is regarded as its essential feature was assessed.

METHODS

In a cross-sectional survey, qualified nurses working in oncology departments of 3 hospitals were asked to rate 5 different scenarios of double-checking procedures regarding dimensions such as frequency of use in practice and appropriateness to prevent medication errors; they were also asked general questions about double-checking.

RESULTS

Overall, 274 nurses (70% response rate) participated in the survey. The procedure of jointly double-checking (read-read back) was most commonly used (69% of respondents) and rated as very appropriate to prevent medication errors. Jointly checking medication was seen as the essential characteristic of double-checking-more frequently than 'carrying out checks independently' (54% vs 24%). Most nurses (78%) found the frequency of double-checking in their department appropriate. Being interrupted in one's own current activity for supporting a double-check was reported to occur frequently. Regression analysis revealed a strong preference towards checks that are currently implemented at the responders' workplace.

CONCLUSIONS

Double-checking is well regarded by oncology nurses as a procedure to help prevent errors, with jointly checking being used most frequently. Our results show that the notion of independent checking needs to be transferred more actively into clinical practice. The high frequency of reported interruptions during and caused by double-checks is of concern.

Outbreak column 17: Situational Awareness for healthcare outbreaks

Outbreak column 17 introduces the utility of Situation Awareness (SA) for outbreak management. For any given time period, an individual or team's SA involves a perception of what is going on, meaning derived from the perception and a prediction of what is likely to happen next. The individual or team's SA informs, but is separate to, both the decisions and actions that follow. The accuracy and completeness of an individual or team's SA will therefore impact on the effectiveness of decisions and actions taken. SA was developed by the aviation industry and is utilised in situations which, like outbreaks, have dynamic, i.e. continuously changing problem spaces, and wherein a loss of SA is likely to lead to both poor decision-making and actions with potentially fatal consequences. The potential benefits of using SA for outbreaks are discussed and include: (1) retrospectively to identify if poor decision-making was a result of a poor SA; (2) prospectively to identify where the system is weakest; and (3) as a teaching tool to improve the skills of individuals and teams in developing a shared understanding of the here and now.

Integrating mHealth in Oncology: Experience in the Province of Trento

BACKGROUND

The potential benefits of the introduction of electronic and mobile health (mHealth) information technologies, to support the safe delivery of intravenous chemotherapy or oral anticancer therapies, could be exponential in the context of a highly integrated computerized system.

OBJECTIVE

Here we describe a safe therapy mobile (STM) system for the safe delivery of intravenous chemotherapy, and a home monitoring system for monitoring and managing toxicity and improving adherence in patients receiving oral anticancer therapies at home.

METHODS

The STM system is fully integrated with the electronic oncological patient record. After the prescription of chemotherapy, specific barcodes are automatically associated with the patient and each drug, and a bedside barcode reader checks the patient, nurse, infusion bag, and drug sequence in order to trace the entire administration process, which is then entered in the patient's record. The usability and acceptability of the system was investigated by means of a modified questionnaire administered to nurses. The home monitoring system consists of a mobile phone or tablet diary app, which allows patients to record their state of health, the medications taken, their side effects, and a Web dashboard that allows health professionals to check the patient data and monitor toxicity and treatment adherence. A built-in rule-based alarm module notifies health care professionals of critical conditions. Initially developed for chronic patients, the system has been subsequently customized in order to monitor home treatments with capecitabine or sunitinib in cancer patients (Onco-TreC).

RESULTS

The STM system never failed to match the patient/nurse/drug sequence association correctly, and proved to be accurate and reliable in tracing and recording the entire administration process. The questionnaires revealed that the users were generally satisfied and had a positive perception of the system's usefulness and ease of use, and the quality of their working lives. The pilot studies with the home monitoring system with 43 chronic patients have shown that the approach is reliable and useful for clinicians and patients, but it is also necessary to pay attention to the expectations that mHealth solutions may raise in users. The Onco-TreC version has been successfully laboratory tested, and is now ready for validation.

CONCLUSIONS

The STM and Onco-TreC systems are fully integrated with our complex and composite information system, which guarantees privacy, security, interoperability, and real-time communications between patients and health professionals. They need to be validated in order to confirm their positive contribution to the safer administration of anticancer drugs.

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting

BACKGROUND

Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood.

OBJECTIVE

The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors.

METHODS

The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment.

RESULTS

Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks.

CONCLUSIONS

Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required.

Developing checklists to prevent diagnostic error in Emergency Room settings

BACKGROUND

Checklists have been shown to improve performance of complex, error-prone processes. To develop a checklist with potential to reduce the likelihood of diagnostic error for patients presenting to the Emergency Room (ER) with undiagnosed conditions.

METHODS

Participants included 15 staff ER physicians working in two large academic centers. A rapid cycle design and evaluation process was used to develop a general checklist for high-risk situations vulnerable to diagnostic error. Physicians used the general checklists and a set of symptom-specific checklists for a period of 2 months. We conducted a mixed methods evaluation that included interviews regarding user perceptions and quantitative assessment of resource utilization before and after checklist use.

RESULTS

A general checklist was developed iteratively by obtaining feedback from users and subject matter experts, and was trialed along with a set of specific checklists in the ER. Both the general and the symptom-specific checklists were judged to be helpful, with a slight preference for using symptom-specific lists. Checklist use commonly prompted consideration of additional diagnostic possibilities, changed the working diagnosis in approximately 10% of cases, and anecdotally was thought to be helpful in avoiding diagnostic errors. Checklist use was prompted by a variety of different factors, not just diagnostic uncertainty. None of the physicians used the checklists in collaboration with the patient, despite being encouraged to do so. Checklist use did not prompt large changes in test ordering or consultation.

CONCLUSIONS

In the ER setting, checklists for diagnosis are helpful in considering additional diagnostic possibilities, thus having potential to prevent diagnostic errors. Inconsistent usage and using the checklists privately, instead of with the patient, are factors that may detract from obtaining maximum benefit. Further research is needed to optimize checklists for use in the ER, determine how to increase usage, to evaluate the impact of checklist utilization on error rates and patient outcomes, to determine how checklist usage affects test ordering and consultation, and to compare checklists generally with other approaches to reduce diagnostic error.

'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns

OBJECTIVES

To explore the experiences of oncology staff with communicating safety concerns and to examine situational factors and motivations surrounding the decision whether and how to speak up using semistructured interviews.

SETTING

7 oncology departments of six hospitals in Switzerland.

PARTICIPANTS

Diverse sample of 32 experienced oncology healthcare professionals.

RESULTS

Nurses and doctors commonly experience situations which raise their concerns and require questioning, clarifying and correcting. Participants often used non-verbal communication to signal safety concerns. Speaking-up behaviour was strongly related to a clinical safety issue. Most episodes of 'silence' were connected to hygiene, isolation and invasive procedures. In contrast, there seemed to exist a strong culture to communicate questions, doubts and concerns relating to medication. Nearly all interviewees were concerned with 'how' to say it and in particular those of lower hierarchical status reflected on deliberate 'voicing tactics'.

CONCLUSIONS

Our results indicate a widely accepted culture to discuss any concerns relating to medication safety while other issues are more difficult to voice. Clinicians devote considerable efforts to evaluate the situation and sensitively decide whether and how to speak up. Our results can serve as a starting point to develop a shared understanding of risks and appropriate communication of safety concerns among staff in oncology.

Using simulation to assess chemotherapy competency

Simulation with lifelike mannequins is used in schools of nursing and hospital-based education as a method of teaching clinical content, enhancing clinical skills, applying theory to practice, and validating competency. It provides a safe learning environment to enhance nurses' clinical judgment and critical thinking skills in an increasingly complex care environment. Simulation can be used in the practice setting with experienced nurses to teach or reinforce complex information and allow the learner to practice without devastating consequences. Medical-surgical units in some institutions have dedicated beds for patients with cancer but may not be a full oncology unit. Evaluating chemotherapy and biotherapy competency is difficult when extensive time periods exist between chemotherapy administrations. One method for assessing annual chemotherapy competency is to use simulation.

The use of a checklist in a pediatric oncology clinic

BACKGROUND

Errors and near misses are common in medicine. Checklists and similar interventions are feasible and can reduce the incidence of errors and improve patient outcomes. This study assessed the feasibility and efficacy of a checklist in a pediatric oncology clinic.

PROCEDURE

Errors and near misses of all types were systematically tracked for 1 month in a pediatric oncology clinic. Following the initial 1 month time period (baseline), a 10-item checklist was implemented for each patient encounter during a 4-month period. During month 5 of the study while the checklist was being used, errors and near misses were again systematically tracked for 1 month.

RESULTS

The use of a checklist was associated with a significant reduction of errors in our clinic. The total number of errors (including documentation errors) decreased from 133 in month 1 to 39 in month 5 (P < 0.0001). In addition, checklist use decreased the rate of encounters with at least one error from 34% to 15% (P < 0.001). The reduction in errors occurred despite the checklist not being used for each encounter. The majority of practitioners were satisfied with the use of a checklist and think that the use of a checklist is a good way to reduce errors.

CONCLUSIONS

A checklist is potentially a feasible, safe, inexpensive, and simple method to lower the rate of medical errors in a pediatric oncology clinic.

Safeguarding the process of drug administration with an emphasis on electronic support tools

AIMS

The aim of this work is to understand the process of drug administration and identify points in the workflow that resulted in interventions by clinical information systems in order to improve patient safety.

METHODS

To identify a generic way to structure the drug administration process we performed peer-group discussions and supplemented these discussions with a literature search for studies reporting errors in drug administration and strategies for their prevention.

RESULTS

We concluded that the drug administration process might consist of up to 11 sub-steps, which can be grouped into the four sub-processes of preparation, personalization, application and follow-up. Errors in drug handling and administration are diverse and frequent and in many cases not caused by the patient him/herself, but by family members or nurses. Accordingly, different prevention strategies have been set in place with relatively few approaches involving e-health technology.

CONCLUSIONS

A generic structuring of the administration process and particular error-prone sub-steps may facilitate the allocation of prevention strategies and help to identify research gaps.

'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care - a review of the literature

PURPOSE

Approximately 10% of all patients is in some way harmed by the health care system. Risk factors have been identified and patients with cancer are at high risk due to the seriousness of the disease, co-morbidity, often old age, high risk treatments such as chemo and radiotherapy. Therefore, a closer look on safety for patients undergoing chemotherapy is needed. The aim of this study was to identify and evaluate interventions for improved patient safety in chemotherapy care.

METHOD

We undertook a review of the available evidence regarding interventions to improve patient safety in relation to chemotherapy care.

RESULTS

We found 12 studies describing the following interventions; 1) Computerized Prescription Order Entry (CPOE), 2) Failure Mode and Effect Analysis (FMEA) and Lean Sigma, 3) Error reporting and surveillance systems, 4) Administration Checklist and 5) Education for nurses. Even if all five interventions showed positive effects in patient safety, the evidence level is rather weak due to design, sample size and the difficulties involved measuring patient safety issues.

CONCLUSIONS

Three studies with fairly high evidence level showed that computerized chemotherapy prescriptions were significantly safer than manual prescriptions and could therefore be recommended. For the other remaining interventions, more research is needed to assess the effect on improved patient safety in chemotherapy care. There is a need for more rigorous studies with sophisticated design for generating evidence in the field.