ART-related medication errors in hospitalized people with HIV in the INSTI-era: analysis from 2 health systems in South Georgia, U.S

ABSTRACTART-related medication errors occur at high rates in hospitalized people with HIV (PWH), but few studies included modern regimens. As such, we evaluated ART-related medication errors in hospitalized PWH in an era where use of INSTI-based regimens dominate. This multi-center, retrospective cohort included PWH at least 18 years hospitalized in South Georgia, U.S. between March 2016 and March 2018. Of those eligible for inclusion, 400 were randomly selected and included. Three hundred sixty-three inpatient ART-related medication errors occurred in 203 patients during the study period due to incorrect scheduling (44%), an incorrect or incomplete regimen (27%), and drug-drug interactions (27%). Approximately 25% of errors persisted to discharge. Medication errors were more likely to occur in patients receiving NNRTI- or PI-containing multi-tablet regimens, whereas those receiving INSTI-containing multi-tablet regimens were less likely to experience a medication error. ART-related medication errors are less likely in patients receiving INSTI-containing multi-tablet regimens. Ensuring appropriate transition of ART throughout hospitalization remains an area in need of significant improvement.

Ratios d’incidents et d’accidents totaux et médicamenteux par 1000 jours-présence en établissement de santé au Québec: une étude exploratoire

Background

Since 2022, it has been mandatory in Québec to report all incidents and accidents (I&As) occurring in health-care facilities. Since 2011, a summary report of these I&As has been published each year. However, it is difficult to compare health facilities given that no denominator is specified and ratios are not calculated.

Objective

The primary objective was to calculate the ratios of total I&As and medication-related I&As per 1000 inpatient-days per type of facility for all health-care facilities in Québec.

Methods

This retrospective descriptive study was based on data from the period of April 1, 2016, to March 31, 2021. Data were extracted from the National Register of Incidents and Accidents Occurring during the Provision of Health Care and Social Services in Québec (Registre national des incidents et accidents survenus lors de la prestation des soins et services de santé au Québec) and financial reports. The ratios of total I&As/1000 inpatient-days and medication-related I&As/1000 inpatient-days, expressed as the mean ± standard deviation and median [minimum; maximum], were calculated.

Results

A total of 85 health-care facilities had usable data, specifically 33 acute-care facilities, 45 long-term care facilities, and 7 rehabilitation facilities. The mean ratio for total I&As/1000 inpatient-days varied from 33 ± 19 to 38 ± 22 in acute-care facilities, from 14 ± 5 to 16 ± 7 in long-term care facilities, and from 99 ± 39 to 147 ± 55 in rehabilitation facilities. The mean ratio for medication-related I&As/1000 inpatient-days varied from 11 ± 7 to 12 ± 7 in acute care facilities, from 3 ± 2 to 4 ± 3 in long-term care facilities, and from 24 ± 10 to 40 ± 21 in rehabilitation facilities.

Conclusions

This exploratory study demonstrated the feasibility of calculating I&A ratios from the National Register of Incidents and Accidents Occurring during the Provision of Health Care and Social Services in Québec. These ratios facilitate discussion of the reporting culture of I&As within the health-care system. It is hoped that these ratios will be added to future annual reports from the Québec I&A register.

An observational study of root-cause analysis of medication errors in elderly with methotrexate toxicity

INTRODUCTION

Medication errors are inherent in a healthcare system. This results in both time and cost burdens for both the patient and the health system. The aim of this study was to conduct a root-cause analysis of medication errors in elderly patients with methotrexate toxicity, analyze associated factors, and propose solutions.

METHODS

This single-center prospective study was designed to identify medication errors in cases of methotrexate toxicity between November 2022 to May 2023. Categorical data and free-text data are used to describe incidents. Harm assessment, factors related to medication errors, and preventability were evaluated for each case. Possible strategies to prevent similar occurrences are discussed.

RESULTS

Out of a total of 15 patients who presented during the study period, nine suffered from methotrexate toxicity due to medication errors. Most medication errors occurred during prescribing or dispensing (seven cases). Inadequate knowledge about medication and dosage, inadequate communication was identified as a contributing factor for all medication errors. Patients on long-term methotrexate treatment are at high risk of methotrexate toxicity.

CONCLUSION

This study highlights the challenges of health literacy and lacking communication between healthcare providers and patients that can be met through community pharmacy programs for the elderly in lower-middle-income countries.

One Year Evaluation of Pharmacist Medication Charting Service in a Principal Referral Women and Newborn Hospital

Background: Accuracy of medication charts on admission to hospital has previously shown that inadvertent omission of therapy was the most common discrepancy, accounting for 40% to 60% of errors. Partnered Pharmacist Medication Charting (PPMC) has shown to reduce medicationrelated problems. Objective: The aim of this study was to evaluate the implementation of Pharmacist Medication Charting (PMC), a derivative of PPMC, in a maternity and gynecological hospital. The occurrence of medication omission identified by the pharmacists was assessed and the pharmacist interventions involving PMC analyzed. Methods: The pharmacist interventions documented from 1st July 2022 to 30th June, 2023 were evaluated using PowerBI for data and trends on the Medication-Related Problems (MRPs) identified, occurrence of PMC, common medications charted by the pharmacists and the pharmacist recommendation and action following the identification of MRPs. Results: A total of 4898 pharmacy interventions was documented in the 12-month period. Of the total interventions documented, 1321 (26.97%) were related to pharmacist medication charting. Of all the interventions related to PMC, 53.29% involved pharmacists charting medications for the continuation or initiation of over-the-counter medications, 13.32% involved pharmacist partnered charting of Prescription Only Medications and Controlled Medications with medical staff, and 33.3% were referred to a credentialled pharmacist for PMC service. With regards to action taken following interventions involving PMC, 1065 (80.62%) were resolved following PMC. Common medications charted by the pharmacists include: macrogol and docusate laxatives (288), pregnancy multivitamin containing iron, iodine and folate (169), colecalciferol (133), iron (127), asthma inhaler (99), paracetamol and ibuprofen (88), nicotine (38), calcium (29), folic acid (26), and pantoprazole (15). Conclusion: Our study demonstrated that hospital pharmacists contribute to the reduction of MRPs, and PMC enables pharmacist to address prescribing omission and conditions untreated in the hospital. This study also reflects skills enhancement in practice for clinical pharmacists and resulted in successful implementation of PMC.

A Review of Medication Errors and the Second Victim in Pediatric Pharmacy

The concept of the second victim, described as the sense of victimization of health care professionals following the exposure to a traumatic, unanticipated medical error, was first introduced in 2000 by Albert W. Wu. Since then, the concept has gained immense traction and inspired the generation of assistance programs for second victims. With most second victim occurrences resulting from medication errors, pediatric pharmacists are at a high risk of experiencing second victim phenomenon. Second victims may experience both psychological and physical symptoms of distress often akin to post-traumatic stress disorder. Typical trajectories for second victims, as well as typical support needs, have been previously described, with several organizations responding by creating formal programs designed to support their staff in the events of traumatic workplace experiences. Most support programs involve peer-to-peer support, group sessions, and programs designed to increase coping skills. Additional resources are available for health care workers who do not have formalized support programs at their institution, although these are limited. Despite these resources, institutions across the country have room for additional growth in their support of employees who become second victims to tragedy.

An Assessment of Medication Errors Among Pediatric Patients in Three Hospitals in Freetown Sierra Leone: Findings and Implications for a Low-Income Country

Background

Pediatric patients are prone to medicine-related problems like medication errors (MEs), which can potentially cause harm. Yet, this has not been studied in this population in Sierra Leone. Therefore, this study investigated the prevalence and nature of MEs, including potential drug-drug interactions (pDDIs), in pediatric patients.

Methods

The study was conducted in three hospitals among pediatric patients in Freetown and consisted of two phases. Phase one was a cross-sectional retrospective review of prescriptions for completeness and accuracy based on the global accuracy score against standard prescription writing guidelines. Phase two was a point prevalence inpatient chart review of MEs categorized into prescription, administration, and dispensing errors and pDDIs. Data was analyzed using frequency, percentages, median, and interquartile range. Kruskal-Wallis H and Mann-Whitney U-tests were used to compare the prescription accuracy between the hospitals, with p<0.05 considered statistically significant.

Results

Three hundred and sixty-six (366) pediatric prescriptions and 132 inpatient charts were reviewed in phases one and two of the study, respectively. In phase one, while no prescription attained the global accuracy score (GAS) gold standard of 100%, 106 (29.0%) achieved the 80-100% mark. The patient 63 (17.2%), treatment 228 (62.3%), and prescriber 33 (9.0%) identifiers achieved an overall GAS range of 80-100%. Although the total GAS was not statistically significant (p=0.065), the date (p=0.041), patient (p=<0.001), treatment (p=0.022), and prescriber (p=<0.001) identifiers were statistically significant across the different hospitals. For phase two, the prevalence of MEs was 74 (56.1%), while that of pDDIs was 54 (40.9%). There was a statistically positive correlation between the occurrence of pDDI and number of medicines prescribed (r=0.211, P=0.015).

Conclusion

A Low GAS indicates poor compliance with prescription writing guidelines and high prescription errors. Medication errors were observed at each phase of the medication use cycle, while clinically significant pDDIs were also reported. Thus, there is a need for training on prescription writing guidelines and medication errors.

Admission Medication Reconciliation Discrepancies in Trauma Patients: Consistent Nursing Care May Not Be the Answer

Inadvertent medication reconciliation discrepancies are common among trauma patient populations. We conducted a prospective study at a level 1 trauma center to assess incidence of inadvertent medication reconciliation discrepancies following decreased reliance on short-term nursing staff. Patients and independent sources were interviewed for home medication lists and compared to admission medication reconciliation (AMR) lists. Of the 108 patients included, 37 patients (34%) never received an AMR. Of the 71 patients that had a completed AMR, 42 patients (59%) had one or more errors, with total 154 errors across all patients, for a rate of 3.7 per patient with any discrepancy. Patients taking ≥ 5 medications were significantly more likely to have an incomplete or inaccurate AMR than those taking <5 medications (89% vs 41%, P < .0001). Decreased reliance on short-term nursing staff did not decrease inadvertent admission medication reconciliation discrepancies. Additional interventions to decrease risk of medication administration errors are needed.

Guidance on using Medicaid web portals and other electronic prescriptions claims data to improve admission medication reconciliation in critical access hospitals

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Analysis of pharmaceutical interventions in chemotherapy prescriptions of adult and pediatric patients at an oncology reference institute

Chemotherapy, one of the primary cancer treatments, has a high risk of causing significant harm in cases of its misuse. Pharmaceutical intervention is one of the strategies used to prevent medication errors from reaching the patient by identifying drug-related problems or other discrepancies related to patient data or medical progress. The primary objective of this study was to analyze the profile of the pharmaceutical intervention made in chemotherapy prescriptions for adult and pediatric patients in order to measure its impact on patient safety. A retrospective cross-sectional and observational study was conducted at a reference center for cancer treatment in Rio de Janeiro, Brazil. Pharmaceutical interventions performed in chemotherapy prescriptions from January to October 2022 were quantified, classified, and analyzed by their type, most common medicine, and acceptability. From the patients treated in the period, 220 (14.8%) adults and 64 (23.4%) children and teenagers received at least one pharmaceutical intervention. The most common types for adults were dose adjustments: overdose (22.5%) and underdose (22.5%). However, in pediatry, incompleteness of supporting drug protocol (22.1%) was the most registered. The most common medicines involved in pharmaceutical intervention were carboplatin (for adults) and electrolytes/hydration (for pediatric patients). Pharmaceutical intervention acceptability by prescriptors was very similar, reaching 80.4% for adults and 77.9% for pediatrics. The pharmaceutical intervention profile was quite distinct by virtue of the singularities of each population. The pharmacists' role was shown to be paramount in intercepting medication errors in the prescription of chemotherapy protocols, contributing to patient safety.

Labelling of intravenous drug delivery devices in critically ill patients: A scoping review

BACKGROUND

Labelling is a strategy that contributes to the correct and faster identification of drugs, minimizing misidentification. There is a gap in knowledge on optimal labelling standards for intravenous (IV) devices applied to the care of critically ill patients.

AIM

The goal of this article was to map existing knowledge on the labelling of IV drug delivery devices in critically ill patients for the prevention of medication errors.

STUDY DESIGN

This was a scoping review conducted according to the JBI methodology in the LILACS, MEDLINE, CINAHL, IBECS, Scopus, Embase and Web of Science databases, and on the websites of specialized institutions. Searches were conducted up to December 2022 for scientific articles and grey literature that addressed the labelling of IV devices in intensive care units, emergency departments, and anaesthesia units. The data were collected using a structured form and were later classified, summarized, and aggregated to map the knowledge related to the review question.

RESULTS

Twenty-one documents were included, which demonstrated variability in label use with IV drug delivery devices. The following features of structure and design stood out: printed format, colour coding, letter size differentiation, and the use of sturdy material. In terms of information, the name of the drug, dose, date and time of preparation, identification of the patient, and who prepared it were found.

CONCLUSIONS

The identified patterns contributed to the reduction of drug misidentification and the development of timelier drug labelling and administration.

RELEVANCE TO CLINICAL PRACTICE

The evidence supports the development of standardized labels for the prevention of medication errors.

Error reporting in a large animal veterinary teaching hospital identifies medication errors occur most often in the prescribing phase of therapy

OBJECTIVE

To identify the rate at which medication errors occurred over a 2-year period in a large animal veterinary teaching hospital and describe the types of errors that occurred.

SAMPLE

226 medication errors over 6,155 large animal visits occurred during the study period. Multiple errors may have affected the same patient.

METHODS

Medication error reports from March 1, 2021, to March 31, 2023, were reviewed retrospectively and classified by species, type of drug, and month and day of the week the error occurred. Errors were categorized according to multiple previously developed systems to allow for comparison to other studies.

RESULTS

226 medication errors occurred over 6,155 patient visits in a 2-year period: 57.5% (130/226) were identified by a dedicated large animal pharmacist, and 64.2% (145/226) of errors were identified and corrected before reaching the patient. Prescription/medication order errors (58.4% [132/226]) occurred significantly more often than errors in medication preparation (21.7% [49/226]; P < .001) and administration (19.6%; P < .001). Antibiotics (48.7% [110/226]) and NSAIDs (17.7% [40/226]) were the drug classes most involved in errors.

CLINICAL RELEVANCE

Most medication errors in this study occurred in the ordering/prescribing phase. This is similar to reports in human medicine, where standardized medication error reporting strategies exist. Developing and applying similar strategies in veterinary medicine may improve patient safety and outcome.

The Red Square: A Healthcare Sterile Cockpit to Reduce Medication Errors

Medication administration is one of many duties and responsibilities of school nurses and involves both scheduled and as-needed (prn) medications. When administering medications, school nurses also experience unscheduled student health room visits, as well as interruptions such as staff member inquiries, miscellaneous phone calls, and occasional safety drills, to name a few. These distractions, inherent to the school nursing position, can lead to medication errors and pose a risk to students. This article describes the concept of a health care sterile cockpit (red square) and a school district's use of innovation in the health room to improve medication safety and reduce errors. Other benefits of implementing the red square will be discussed.

Factors Influencing Medication Administration Errors as Perceived by Nurses in Pediatric Units in a Jordanian Tertiary Hospital: A Qualitative Descriptive Study

BACKGROUND

The World Health Organization declared that medication errors are the third largest global patient safety challenge. The medication administration stage is a common and susceptible stage for medical errors to occur.

OBJECTIVE

To explore the factors contributing to medication administration errors specifically in pediatric care units as perceived by nurses in a Jordanian hospital.

METHODS

A qualitative descriptive study was conducted involving face-to-face audio-recorded interviews with 9 nurses in a tertiary hospital located in the north of Jordan. A convenience sampling technique was used to select the participants of our study. Data were collected between October 2022 and November 2022. The data were analyzed using inductive thematic analysis.

RESULTS

Four themes emerged affecting medication administration errors in pediatric care units. These were environmental, staff, parents and patient, and medication-related factors.

CONCLUSION

The findings of this study raise awareness of the most frequent sources of medication errors in a Jordanian hospital. Holding training and supervision to raise awareness among nurses and the availability of equipment and supplies could improve medication safety practices.

Advanced prescription of injectable anticancer drugs: Safety assessment in a European Comprehensive Cancer Centre using the risk matrix approach

AIMS

The purpose of this work was to assess failures in the advanced prescription of parenteral anticancer agents in an adult day oncology care unit with more than 100 patients per day.

METHODS

An a priori descriptive analysis was carried out by using the risk matrix approach. After defining the scope in a multidisciplinary meeting, we determined at each step the failure modes (FMs), their effects (E) and their associated causes (C). A severity score (S) was assigned to all effects and a probability of occurrence (O) to all causes. These S and O indicators, were used to obtain a criticality index (CI) matrix. We assessed the risk control (RC) of each failure in order to define a residual criticality index (rCI) matrix.

RESULTS

During risk analysis, 14 FMs were detected, and 61 scenarios were identified considering all possible effects and causes. Nine situations (15%) were highlighted with the maximum CI, 18 (30%) with a medium CI, and 34 (55%) with a negligible CI. Nevertheless, among all these critical situations, only three (5%) had an rCI to process (i.e., missed dose adjustment, multiple prescriptions and abnormal biology data); the others required monitoring only. Clinicians' and pharmacists' knowledge of these critical situations enables them to manage the associated risks.

CONCLUSIONS

Advanced prescription of injectable anticancer drugs appears to be a safe practice for patients when combined with risk management. The major risks identified concerned missed dose adjustment, prescription duplication and lack of consideration for abnormal biology data.

Prevalence and underreporting of immunization errors in childhood vaccination: results of a household survey

OBJECTIVE

To investigate underreporting of immunization errors based on vaccination records from children under five years of age.

METHOD

An epidemiological, cross-sectional analytical study, carried out through a household survey with 453 children aged 6 months to 4 years in three municipalities in Minas Gerais in 2021. A descriptive analysis was carried out, and the prevalence of the error was calculated per 100 thousand doses applied between 2016 and 2021. The magnitude was estimated of the association between variables by prevalence and 95% Confidence Intervals (95%CI). To analyze underreporting, State reporting records were used.

RESULTS

A prevalence of immunization errors was found to be 41.9/100,000 doses applied (95%CI:32.2 - 51.6). The highest prevalence occurred between 2020 (50.0/100,000 doses applied) and 2021 (78.6/100,000 doses applied). The most frequent error was an inadequate interval between vaccines (47.2%) associated with adsorbed diphtheria, tetanus and pertussis (DTP) vaccine (13.7/100,000) administration. Vaccination delay was related to immunization errors (7.55 95% CI:2.30 - 24.80), and the errors found were underreported.

CONCLUSION

The high prevalence of underreported errors points to a worrying scenario, highlighting the importance of preventive measures.

How Intuitive Is the Administration of Pediatric Emergency Medication Devices for Parents? Objective Observation and Subjective Self-Assessment

BACKGROUND

to assess the intuitiveness of parents' administration of pediatric emergency devices (inhalation, rectal, buccal, nasal, and auto-injector).

METHODS

We invited parents without prior experience to administer the five devices to dummy dolls. We observed whether the parents chose the correct administration route and subsequently performed the correct administration procedures without clinically relevant errors. We interviewed parents for their self-assessment of their own administration performance and willingness to administer devices in actual emergencies.

RESULTS

The correct administration route was best for the inhalation device (81/84, 96% of parents) and worst for the intranasal device (25/126, 20%). The correct administration procedures were best for the buccal device (63/98, 64%) and worst for the auto-injector device (0/93, 0%). Their own administration performance was rated to be best by parents for the inhalation device (59/84, 70%) and worst for the auto-injector device (17/93, 18%). The self-assessment of the correct administration overestimated the correct administration procedures for all the devices except the buccal one. Most parents were willing to administer the inhalation device in an emergency (67/94, 79%), while the fewest were willing to administration procedures the auto-injector device (28/93, 30%).

CONCLUSIONS

Intuitiveness concerning the correct administration route and the subsequent correct administration procedures have to be improved for all the devices examined. The parents mostly overestimated their performance. Willingness to use a device in an actual emergency depended on the device.

Exploring the challenges faced by foundation doctors when prescribing high risk medicines safely during the on-call period: A qualitative study

AIMS

Errors with prescribing high-risk medicines (HRMs) have a greater propensity to cause harm than with non-HRMs. Prescribing errors arise due to multiple factors and it can be particularly challenging for junior doctors to prescribe safely during the on-call period. Knowledge regarding the challenges of prescribing HRM during the on-call period would be useful to target preventative interventions. The aim of this study was to explore the challenges encountered by foundation doctors (doctors who have graduated medical school within the last 2 years) when prescribing specific HRMs (anticoagulants, insulin and opioids) safely during the on-call period.

METHODS

Six focus groups exploring the challenges of prescribing HRMs safely during the on-call period were conducted, 3 with foundation year 1 and 3 with foundation year 2 doctors from across 3 different hospitals. A thematic framework analysis based on the London Protocol was conducted.

RESULTS

Doctors described multiple challenges to prescribing HRMs safely during the on-call period including a lack of prescribing support, nursing pressure, complex prescribing tasks, unknown patients as well as individual factors such as lack of knowledge and tiredness. Many of these factors exist to some extent during the day, yet the nature of the on-call period as a fast-paced environment heightened the challenges that prescribers faced.

CONCLUSION

There are multiple challenges experienced by foundation doctors when prescribing HRMs during the on-call period. The potentially devastating consequences of errors with HRMs means that closer attention and more concern from healthcare professionals, researchers and policymakers is required to improve safe prescribing of HRMs in hospitals.

Developing a Comprehensive Framework of Safeguarding Strategies to Address Anticipated Errors With Organizational High-Alert Medications

Purpose: To describe the development of a comprehensive framework of safeguarding strategies to address observed/anticipated errors with organizational high-alert medications. Methods: Observed/anticipated errors were identified for organizational high-alert medications and medication classes based on a review of external literature and alerts as well as internal voluntary error reporting. Anticipated or frequently reported errors were categorized into common cause error types. Error reduction strategies to address each common cause error were identified in collaboration with medication safety specialists and specialty practice pharmacists. Results: The review of externally and internally reported errors identified 101 observed/anticipated common cause errors across the 19 high-alert medication classes (median 5 error types per medication class, interquartile range 3-6). Safeguarding strategies specific to high-alert medications were identified in the following domains: separate or sequestered storage; restricted ordering; active alerts; dispensing in patient-specific dosing, unit of use, or unit-dose packaging; dispensing from pharmacy only; auxiliary labeling; level of care restriction; required monitoring; independent double checks; certification/privileging of staff; specific guidelines for use/monitoring; and other/miscellaneous. Identification of the observed/anticipated errors and the associated safeguarding strategies facilitated the development of a comprehensive tool and visual framework for addressing common cause errors associated with organizational high-alert medications. Conclusion: A comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications is proposed. Although individual safeguards are institution-specific, the framework can be leveraged by all hospitals in order to take inventory of error-reduction strategies and prospectively identify gaps to address common cause errors.

Integrating Patient Safety Discussions with First-Year Doctor of Pharmacy Students in a Skills Lab Course

The patient safety problem has been well established for over 20 years in the United States (U.S.), and there is a recognized focus on ensuring that health professions' trainees receive explicit education in various patient safety principles and practices. While the literature provides examples of different approaches towards patient safety education for pharmacy students, there are few that focus on first-year pharmacy students. This educational observational study describes the implementation and evaluation of two 20 min patient safety learning activities integrated into a required pharmacy skills lab course. The first learning activity utilized a mock prescription and patient safety checklist that had students identify patient safety problems on the prescription, followed by a group discussion of implications for the patient. The second learning activity used images of common safety problems with a facilitated group discussion to have students identify systems-based solutions to those problems. Our study's findings revealed that students were able to identify basic patient safety problems and safety solutions, although some additional foundational information may be needed, particularly for students who may not have pharmacy work experience. Additional research is needed to continue building a literature base on patient safety education approaches, particularly for first-year pharmacy students.

Medication errors by caregivers in the homes of children discharged from a pediatric department in Ghana

Background

Medication errors (MEs) by caregivers at home are a cause of morbidity and mortality, shortly after discharge from the hospital.

Objectives

The objective of this study was to determine the rate and types of MEs at the homes of children discharged from a hospital in Ghana and to explore the factors associated with these errors.

Design

This was a cross-sectional study of infants and children discharged from the hospital to review medication administration practices.

Methods

Caregivers of children discharged from the hospital after at least 24 hours of admission were interviewed at their homes about medication administration practices. The study assessed potential harm associated with MEs made by caregivers using the Harm Associated with Medication Error Classification tool. The Least Absolute Shrinkage and Selection Operator regression were used to identify the variables associated with MEs.

Results

A total of 95 children (mean age: 28.6 months, 52.6% female) and their caregivers were included. Overall, 65 (68.4%) children experienced one or more MEs. Out of a total of 232 medications reviewed, 102 (44.0%) (95% CI: 37.6-50.4) were associated with a ME. The top two errors, wrong time errors and errors in the frequency of dosing were, 45.1% and 21.6%, respectively. Understanding the information on the disease condition being treated and the medicines dispensed was associated with committing fewer MEs. The number of medicines prescribed was associated with a higher likelihood of MEs. Out of 102 MEs, 48 (47.1%) were assessed as posing potentially no harm, 26 (25.5%) minor harm, 15 (14.7%) moderate harm, and 13 (12.8%) serious harm to the patients. Importantly, none of the MEs were assessed as posing potentially severe or life-threatening harm to the patients.

Conclusion

MEs in children following discharge are high, and systems should be developed to prevent these errors.

Rule-Based Natural Language Processing Pipeline to Detect Medication-Related Named Entities: Insights for Transfer Learning

We document the procedure and performance of a rule-based NLP system that, using transfer learning, automatically extracts essential named entities related to drug errors from Japanese free-text incident reports. Subsequently, we used the rule-based annotated data to fine-tune a pre-trained BERT model and examined the performance of medication-related incident report prediction. The rule-based pipeline achieved a macro-F1-score of 0.81 in an internal dataset and the BERT model fine-tuned with rule-annotated data achieved a macro-F1-score of 0.97 and 0.75 for named entity recognition and relation extraction tasks, respectively. The model can be deployed to other, similar problems in medication-related clinical texts.

Frequency and influential factors on occurrence of medical errors: A three-year cross-sectional study

BACKGROUND

Despite efforts to improve patient safety, medical errors (MEs) continue to recur. Proper utilization of reported MEs can be effective in preventing their recurrence. This study investigated the errors reported in 3 years and examined the factors affecting them.

MATERIALS AND METHODS

This descriptive analytical study was conducted using the errors reported in 20 hospitals under the auspices of one of Iran's medical universities from 2018 to 2020. All reported errors were investigated by an expert panel.

RESULTS

In total, 6584 reported errors were grouped into four main categories based on the type of error. The highest reported errors were related to the management and treatment procedures. Analyses of the factors influencing medical errors revealed that 15 factors affected the occurrence of errors. An increasing trend of error was found in 9 of the 15 identified factors. Incorrect documenting of the physician's order in the nursing Kardex and noncompliance with the patient identification guide were the highest with 16.03 and 15.47%, respectively.

CONCLUSION

The most identified factor was the incorrect registration of the physician's prescription on the nursing card; therefore, it seems that the use of computerized physician order entry should be considered. Furthermore, the mere existence and training of patient safety guides cannot help prevent errors. Not only should the underlying causes of errors be carefully identified and investigated but it also requires serious determination to follow the patient's safety instructions from the highest to the lowest levels of the health system.

Standardization of the Verification Nurse Role in the Delivery of Chemotherapy and Biotherapy

After a chemotherapy overdose in 1994 resulted in the death of one patient and the permanent injury of another, the role of the verification nurse was created at a National Cancer Institute-designated comprehensive cancer c.

Council of Europe Resolution on the Implementation of Pharmaceutical Care-A Step Forward in Enhancing the Appropriate Use of Medicines and Patient-Centred Care

Pharmaceutical care was proposed to address morbidity and mortality associated with medicine-related problems. It utilises the pharmacist's expertise in medicines, their relationship with the patient and cooperation with other healthcare professionals to optimise the use of medicines. The European Directorate for the Quality of Medicines & HealthCare (EDQM), part of the Council of Europe, found significant variation in the acceptance of pharmaceutical care and in the implementation of pharmaceutical care in Europe. A multidisciplinary group was established to draft a statement of principles and recommendations concerning pharmaceutical care. Through face-to-face meetings, circulation of draft texts and informal consultation with stakeholders, the group produced a resolution. On 11 March 2020, the resolution was adopted by the Committee of Ministers of the Council of Europe. It explains pharmaceutical care and illustrates pharmacists' contribution to medicine optimisation in different care settings. Pharmaceutical care's value to health services and its place in health policy were emphasised by addressing the risks and harms from suboptimal use of medicines. Pharmaceutical care can improve medicine use, promote rational use of healthcare resources and reduce inequalities in healthcare by realigning the roles and responsibilities of pharmacists and healthcare professionals. EDQM will promote and advocate for the implementation of pharmaceutical care by enacting practice Resolution CM/Res(2020)3.

Perceptions and Practices of Saudi Hospital Pharmacists Towards Reporting Medication Errors Including Near Misses

OBJECTIVES

Medication errors (MEs) represent a patient safety concern that can have negative consequences on patients in the short and long term. Community pharmacists play an important role in the medication management process, which urges the need for their role in managing MEs. Therefore, this study aimed to investigate the perceptions and attitudes of Saudi pharmacists towards reporting MEs.

METHODOLOGY

A cross-sectional study was conducted using a semi-structured questionnaire that was distributed to Saudi pharmacists. The questionnaire was distributed to pharmacists via email after they had provided their consent to take part in the study. Data from the questionnaire were analysed using Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied.

RESULTS

The findings showed that most pharmacists appreciated the importance of reporting MEs and the role the reporting played in improving the quality of healthcare delivery. However, pharmacists raised many concerns regarding barriers to reporting. Such barriers to reporting included blaming patients or healthcare professionals, underdeveloped protocols, and the lack of standard procedures for ME reporting. Moreover, inadequate communication between healthcare professionals (for example, between pharmacists and doctors) represented an additional barrier to reporting MEs.

CONCLUSIONS

MEs and near misses are underreported among Saudi pharmacists due to many operational and communication challenges. These findings are useful for healthcare authorities involved in developing patient safety frameworks for reporting MEs and near misses. Future work can also determine the attitudes of other healthcare professionals involved in the medication management process.

Descriptive analysis on disproportionate medication errors and associated patient characteristics in the Food and Drug Administration's Adverse Event Reporting System

BACKGROUND

Medication errors (MEs) are a major public health concern which can cause harm and financial burden within the healthcare system. Characterizing MEs is crucial to develop strategies to mitigate MEs in the future.

OBJECTIVES

To characterize ME-associated reports, and investigate signals of disproportionate reporting (SDRs) on MEs in the Food and Drug Administration's Adverse Event Reporting System (FAERS).

METHODS

FAERS data from 2004 to 2020 was used. ME reports were identified with the narrow Standardised Medical Dictionary for Regulatory Activities® (MedDRA®) Query (SMQ) for MEs. Drug names were converted to the Anatomical Therapeutic Chemical (ATC) classification. SDRs were investigated using the reporting odds ratio (ROR).

RESULTS

In total 488 470 ME reports were identified, mostly (59%) submitted by consumers and mainly (55%) associated with females. Median age at time of ME was 57 years (interquartile range: 37-70 years). Approximately 1 out of 3 reports stated a serious health outcome. The most prevalent reported drug class was "antineoplastic and immunomodulating agents" (25%). The most common ME type was "incorrect dose administered" (9%). Of the 1659 SDRs obtained, adalimumab was the most common drug associated with MEs, noting a ROR of 1.22 (95% confidence interval: 1.21-1.24).

CONCLUSION

This study offers a first of its kind characterization of MEs as reported to FAERS. Reported MEs are frequent and may be associated with serious health outcomes. This FAERS data provides insights on ME prevention and offers possibilities for additional in-depth analyses.

A medication reconciliation failure: A case report and incident analysis

BACKGROUND

Medication reconciliation is advocated to ensure the continuity, safety, and effective use of medicines across transitions of care.

CASE REPORT

In this report, we describe the case of a 90-year-old female with previous diagnoses of atrial fibrillation and cutaneous metastatic breast cancer presenting with bilateral ulcerative lesions on the chest wall. The patient was diagnosed with Deep Vein Thrombosis at the Emergency Department and started on rivaroxaban, although the patient was already taking edoxaban. This therapeutic duplication was noticed only one week later, even though she was already experiencing significant bleeding managed through a prescribing cascade. Despite the technical error (action-based), it is possible to identify several weaknesses in the organisation's structure, which provided a trajectory of accident opportunity.

CONCLUSION

Anticoagulants are ranked first for the highest priority to receive a medication reconciliation. To achieve an optimal level of medication reconciliation, we ought to recognise and correct latent failures.

Does circle priming improve smart infusion pump and electronic health record interoperability for chemotherapy in a pediatric hematology/oncology setting?

INTRODUCTION

The objective of this project was to assess the percentage of interoperability compliance within our pediatric hematology/oncology patient care areas for intravenous chemotherapy medications before and after the implementation of circle priming.

METHODS

We conducted a retrospective quality improvement project at an inpatient pediatric hematology/oncology floor and outpatient pediatric infusion center before and after implementation of circle priming.

RESULTS

There was a statistically significant increase in percent interoperability compliance for the inpatient pediatric hematology/oncology floor from 4.1% prior to implementation of circle priming to 35.6% after (odds ratio 13.1 (95% CI, 3.96-43.1), p < 0.001), as well as for the outpatient pediatric infusion center from 18.5% to 47.3%, respectively (odds ratio 3.9 (95% CI, 2.7-5.9), p < 0.001).

CONCLUSION

Implementation of circle priming has significantly increased the percentage of interoperability compliance for intravenous chemotherapy medications in our pediatric hematology/oncology patient care areas.

Medication Prescribing Errors on a Surgery Service - Addressing the Gap with a Curriculum for Surgery Residents: A Prospective Observational Study

OBJECTIVES

Educational interventions with proven effectiveness to reduce medication prescribing errors are currently lacking. Our objective was to implement and assess the effectiveness of a curriculum to reduce medication prescribing errors on a surgery service.

METHODS

This was a prospective observational cohort study at a Canadian academic hospital without an electronic order entry system. A pharmacist-led medication prescribing curriculum for surgery residents was developed and implemented over 2 days (2 h/day) in July 2019. Thirteen (76%) out of 17 surgery residents contributed pre-implementation data, while 13 (81%) out of 16 surgery residents contributed post-implementation data. Medication prescribing errors were tracked for 12 months pre-implementation and 6 months post-implementation. Errors were classified as prescription writing (PW) or decision making (DM).

RESULTS

There were a total of 1050 medication prescribing errors made in the pre-implementation period with 615 (59%) PW errors and 435 (41%) DM. There were a mean of 87.5 (SD  =  14.6) total medication prescribing errors per month in the pre-implementation period with 51.3 (11.9) PW and 36.3 (6.0) DM errors. There were a total of 472 medication prescribing errors made in the post-implementation period with 260 (55%) PW and 212 (45%) DM errors. There were a mean of 78.7 (10.3) total medication prescribing errors per month in the post-implementation period with 43.3 (9.5) PW and 35.3 (4.2) DM errors. In the first quarter of the academic year, there were significantly fewer mean total errors per month post-implementation versus pre-implementation (77.7(12.7) versus 107.3(8.1); P  =  .035), with significantly fewer PW errors per month (40.7(13.2) versus 68.7(9.3); P  =  .046) and no difference in DM errors per month (37.0(2.0) versus 38.7(5.7);P  =  .671). There were no differences noted in the second quarter of the academic year.

CONCLUSION

Medication prescribing errors occurred from PW and DM. Medication prescribing curriculum decreased PW errors; however, a continued education program is warranted as the effect diminished over time.

Designing Human-Centered AI to Prevent Medication Dispensing Errors: Focus Group Study With Pharmacists

BACKGROUND

Medication errors, including dispensing errors, represent a substantial worldwide health risk with significant implications in terms of morbidity, mortality, and financial costs. Although pharmacists use methods like barcode scanning and double-checking for dispensing verification, these measures exhibit limitations. The application of artificial intelligence (AI) in pharmacy verification emerges as a potential solution, offering precision, rapid data analysis, and the ability to recognize medications through computer vision. For AI to be embraced, it must be designed with the end user in mind, fostering trust, clear communication, and seamless collaboration between AI and pharmacists.

OBJECTIVE

This study aimed to gather pharmacists' feedback in a focus group setting to help inform the initial design of the user interface and iterative designs of the AI prototype.

METHODS

A multidisciplinary research team engaged pharmacists in a 3-stage process to develop a human-centered AI system for medication dispensing verification. To design the AI model, we used a Bayesian neural network that predicts the dispensed pills' National Drug Code (NDC). Discussion scripts regarding how to design the system and feedback in focus groups were collected through audio recordings and professionally transcribed, followed by a content analysis guided by the Systems Engineering Initiative for Patient Safety and Human-Machine Teaming theoretical frameworks.

RESULTS

A total of 8 pharmacists participated in 3 rounds of focus groups to identify current challenges in medication dispensing verification, brainstorm solutions, and provide feedback on our AI prototype. Participants considered several teaming scenarios, generally favoring a hybrid teaming model where the AI assists in the verification process and a pharmacist intervenes based on medication risk level and the AI's confidence level. Pharmacists highlighted the need for improving the interpretability of AI systems, such as adding stepwise checkmarks, probability scores, and details about drugs the AI model frequently confuses with the target drug. Pharmacists emphasized the need for simplicity and accessibility. They favored displaying only essential information to prevent overwhelming users with excessive data. Specific design features, such as juxtaposing pill images with their packaging for quick comparisons, were requested. Pharmacists preferred accept, reject, or unsure options. The final prototype interface included (1) checkmarks to compare pill characteristics between the AI-predicted NDC and the prescription's expected NDC, (2) a histogram showing predicted probabilities for the AI-identified NDC, (3) an image of an AI-provided "confused" pill, and (4) an NDC match status (ie, match, unmatched, or unsure).

CONCLUSIONS

In partnership with pharmacists, we developed a human-centered AI prototype designed to enhance AI interpretability and foster trust. This initiative emphasized human-machine collaboration and positioned AI as an augmentative tool rather than a replacement. This study highlights the process of designing a human-centered AI for dispensing verification, emphasizing its interpretability, confidence visualization, and collaborative human-machine teaming styles.

Adverse event following immunization or vaccination in children in Minas Gerais: 2015 to 2020

OBJECTIVE

To describe adverse event following immunization or vaccination in children in Minas Gerais: 2015 to 2020, resulting from immunization errors in children from zero to nine years old.

METHODS

An ecological, descriptive study with a quantitative approach, based on event notifications available in the National Immunization Program Information System.

RESULTS

Among the 39,903,277 doses of immunobiologicals in children aged zero to nine, administered in the state of MG, 3,259 events of types of immunization errors were recorded, around 0.008% of the total and, of these, 91.86% did not result in adverse events and 56.02% were children under one year of age. The most frequent diagnosis was application outside the recommended age (29.12%). Among the manifestations, 71.91% were local and systemic, with fever being the most common (40.85%).

CONCLUSION

The study demonstrated that immunization errors were rare and that most of them were not associated with adverse events, which reinforces the safety of the immunization process. This undoubtedly raises reflection on the need and relevance of continuing education for health professionals.

Enhancing Patient Safety: A Cross-Sectional Study to Assess Medical Interns' Attitude and Knowledge About Medication Safety in Saudi Arabia

Introduction and aim Medication errors (MEs) pose a severe threat in the medical field. Since such errors are preventable, it is paramount for all healthcare workers to be educated on the matter. This study aimed to assess medical interns' attitudes and knowledge of medication safety and errors. We also aimed to validate current university programs to educate students about medication safety and errors. Methods A cross-sectional study that utilized a self-administered online questionnaire comprised 31 questions. The questionnaire was distributed via social media networks, such as WhatsApp, Twitter, email, Instagram, and Snapchat among 100 medical, pharmacy, and nursing interns in Saudi Arabia. The study population included both Saudi and non-Saudi interns. Results The majority of participants, comprising 92% (n=92), indicated that they were familiar with the definition of medication errors (ME). Additionally, 85% (n=85) expressed their willingness to report instances of MEs when medications were not prescribed but required. Moreover, 90% (n=90) of the surveyed individuals expressed their willingness to report MEs in situations where patients did not receive medications as prescribed. In cases where patients experienced harm and required treatment due to an ME, 91% (n=91) of respondents committed to reporting such incidents. A total of 52 (52%) respondents stated that they would report MEs regardless of whether they reached/harmed the patient. A good ME knowledge level was observed in 48% of respondents. A higher likelihood of good ME knowledge was significantly associated with safety reporting system (SRS) awareness and reporting MEs regardless of whether they reached/harmed the patient (p<0.05). College, awareness/attitude, or other demographic factors were not significantly related to ME knowledge (p>0.05). Conclusion This study showed that although interns in the healthcare field do have some knowledge about MEs, there is still a significant need to improve their knowledge. This can be achieved through various ways, one of which is by implementing this topic into the university curricula.

National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system

BACKGROUND

Parenteral nutrition (PN)-related patient safety incidents have been associated with harm. Large-scale studies are scarce, and little is known about contributory factors. This study evaluated PN-related incident reports that described harm using a national database.

MATERIALS AND METHODS

A retrospective evaluation of incident reports involving PN in England and Wales reported to the National Reporting and Learning System between 2015 and 2020. We described frequency by degree of reported harm and incident characteristics. Content analysis was undertaken to understand contributory factors for reports related to moderate/severe harm or death.

RESULTS

12,907 incident reports were identified. After screening, 2242 were evaluated; 1879 (83.8%) reported no harm, 309 (13.8%) low harm, 47 (0.02%) moderate harm, 4 (0.002%) severe harm, 3 (0.001%) deaths. The most reported age group, medication process, and error category were neonates (<28 days) (n = 570/1923, 29.6%), administration (n = 1126/2242, 50%), and omitted medication/ingredient (n = 291/2242, 13%), respectively. Content analysis of reports related to moderate/severe harm and death revealed patient age of <1 year, dependence on home PN (HPN), comorbidities, and staff errors as contributory factors.

CONCLUSIONS

This is the first evaluation of PN-related incident reports in England and Wales to our knowledge. We demonstrated a low frequency of reports related to moderate or severe harm or death. More incidents were reported for neonates and during the administration processes. To reduce harm, systems/procedures that reduce errors in high-risk patients (eg, neonates, patients receiving HPN) need to be established within organizations. Database limitations of voluntary reporting systems were recognized.

Analysis of anaesthesia incidents during caesarean section reported to webAIRS between 2009 and 2022

Anaesthesia for caesarean section occurs commonly and places specific demands on anaesthetists. We analysed 469 narratives concerning anaesthesia for caesarean section, entered by Australian and New Zealand anaesthetists into the webAIRS incident reporting system between 2009 and 2022. As expected, compared with the remaining 8978 database entries, the 469 incidents were more likely to be emergency cases (relative risk (RR) 1.95), more likely to occur between 18:00 and 22:00 hours (RR 1.81) and between 22:00 and 07:59 hours (RR 4.40) and more likely to be undertaken using neuraxial anaesthesia (RR 9.18). Most incidents involved more than one event. The most commonly reported incidents included intraoperative neuraxial anaesthesia complications (180, 38%), medication errors or issues (136, 29%), equipment issues (49, 10%), obstetric haemorrhage (38, 8%), maternal cardiac arrests (28, 6%), endotracheal tube issues (28, 6%) and neonatal resuscitation (24, 5%). Inadequate neuraxial block, reported in 95 incidents, was the most common intraoperative neuraxial complication. Allergic reactions, reported in 30 incidents, were the most common medication issue, followed by 17 associated with oxytocin and 16 syringe swaps. Thirty-eight reports included significant maternal haemorrhage, with eight of those incidents including maternal cardiac arrest. There was one maternal death and eight incidents with neonatal deaths reported, affecting nine neonates. Problems with intraoperative neuraxial anaesthesia were the most commonly reported events. Implementation of specific strategies are encouraged to enhance preparation for conversion to general anaesthesia and to mitigate medication errors, particularly those relating to oxytocic use and neuraxial anaesthesia medications.

Knowledge, Attitudes, and Behavior in the administration of medication in the home care setting: Cross-cultural Spanish adaptation

OBJECTIVE

The aim of the study is to validate and adapt the "Knowledge Attitute and Behaviour in the administration of medication in the home care setting questionnaire" in the home care setting in Cordoba, Spain, through a cross-validation process.

DESIGN

Cross-sectional study SAMPLE: 106 community nurses provide home care in Cordoba, and are involved in the management of the medication process in the patient's home.

MEASUREMENTS

Community nurses' knowledge, attitudes, and behaviors toward medication error prevention strategies in-home care.

RESULTS

For the evaluation of psychometric properties, Cronbach's α was calculated, which returned a value of 0.639, showing good internal consistency. Most participants agreed that the home care setting increases the risk of medication errors.

CONCLUSION

The study, underscores the importance of analyzing the phenomenon of medication errors in the home care setting. The characteristics and peculiarities of a home care setting are different from a hospital setting, which means that factors such as the environment, the figures involved in the care process (caregivers and/or family members), and the way in which they communicate with the rest of the multi-professional team can influence both the type of errors and the likelihood of their occurrence.

Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey

BACKGROUND

Medication errors are common in residential aged care facilities (RACFs) due to several factors. Effective medication management is essential to prevent medication errors among older people particularly due to the complexity of co-morbidities they can experience.

OBJECTIVES

This study aimed to examine and quantify the contributing factors of medication errors from nurses' perspectives and the prevention strategies to reduce medication errors among older adults living in RACFs.

METHODS

A survey with 140 completed responses from registered nurses (RNs) and endorsed enrolled nurses (EENs) working in RACFs across Australia were included in the study. The survey had 24 items, related to contributing factors of medication errors, and the prevention strategies. Descriptive statistics and exploratory factor analysis were used in the data analysis process.

RESULTS

The study identified medication errors are caused by contributing factors such as use of agency staffing (70.4%) and delays in receipt of laboratory results (94.3%). However, it also identified suggestions to reduce medication errors in RACFs, for example use of electronic alerts (88.3%), and efficient laboratory communication (91.8%). Our results revealed three key factors for causes (workload, interprofessional involvement and interruptions) and suggestions (medication safety alerts, medication process improvement and effective reporting).

CONCLUSION

Medication errors in RACFs are a global problem being one of the leading causes of morbidity and mortality. The knowledge and awareness of the factors associated with medication errors and the prevention strategies can guide potential quality improvement plans and contribute to minimisation of risk associated with medication safety in RACFs.

IMPLICATIONS FOR PRACTICE

The study recommends strategies for best practices in medication management such as interprofessional collaboration, implementing standardised policies and electronic alerts to reduce medication errors in RACFs.

Barriers and enablers for safe medication administration in adult and neonatal intensive care units mapped to the behaviour change wheel

BACKGROUND

Intensive care settings have high rates of medication administration errors. Medications are often administered by nurses and midwives using a specified process (the '5 rights'). Understanding where medication errors occur, the contributing factors and how best practice is delivered may assist in developing interventions to improve medication safety.

AIMS

To identify medication administration errors and context specific barriers and enablers for best practice in an adult and a neonatal intensive care unit. Secondary aims were to identify intervention functions (through the Behaviour Change Wheel).

STUDY DESIGN

A dual methods exploratory descriptive study was conducted (May to June 2021) in a mixed 56-bedded adult intensive care unit and a 6-bedded neonatal intensive care unit in Sydney, Australia. Incident monitoring data were examined. Direct semi-covert observational medication administration audits using the 5 rights (n = 39) were conducted. Brief interviews with patients, parents and nurses were conducted. Data were mapped to the Behaviour Change Wheel.

RESULTS

No medication administration incidents were recorded. Audits (n = 3) for the neonatal intensive care unit revealed no areas for improvement. Adult intensive care unit nurses (n = 36) performed checks for the right medication 35 times (97%) and patient identity 25 times (69%). Sixteen administrations (44%) were interrupted. Four themes were synthesized from the interview data: Trust in the nursing profession; Availability of policies and procedures; Adherence to the '5 rights' and departmental culture; and Adequate staffing. The interventional functions most likely to bring about behaviour change were environmental restructuring, enablement, restrictions, education, persuasion and modelling.

CONCLUSIONS

This study reveals insights about the medication administration practices of nurses in intensive care. Although there were areas for improvement there was widespread awareness among nurses regarding their responsibilities to safely administer medications. Interview data indicated high levels of trust among patients and parents in the nurses.

RELEVANCE TO CLINICAL PRACTICE

This novel study indicated that nurses in intensive care are aware of their responsibilities to safely administer medications. Mapping of contextual data to the Behaviour Change Wheel resulted in the identification of Intervention functions most likely to change medication administration practices in the adult intensive care setting that is environmental restructuring, enablement, restrictions, education, persuasion and modelling.

Accuracy of drawing up liquid medications by veterinary anaesthetists and nurses

OBJECTIVE

To evaluate the accuracy with which veterinary anaesthetists and nurses of different experience draw up small volumes of liquid.

STUDY DESIGN

Prospective blinded randomized study.

METHODS

A group of seven European College of Veterinary Anaesthesia and Analgesia (ECVAA) diplomates, six ECVAA residents and six anaesthesia nurses participated in the study. For each participant, five target volumes between 0.01 and 1.0 mL were randomly allocated. They were drawn up 20 times in random order using a 1 mL syringe attached to a 23 gauge needle. A total of 1900 measurements were analysed. An investigator filled the syringe and needle dead space with water for injection before each experiment. The change in mass of the syringe once filled to the target volume was used to calculate the actual volume of liquid drawn up.

RESULTS

Large errors were made with measurements < 0.04 mL, so they were excluded from the statistical analysis. There was a significant effect of the target volume (p < 0.001) and of the order (p < 0.01). For each mL increase in the target volume, the absolute error decreased by 4% and from the first to the hundredth withdrawal each participant's absolute error decreased by 1%. The target volume was underestimated in 52.3% of measurements, 42% were overestimated and 5.7% were on target. None of the between-subject predictor variables approached significance.

CONCLUSIONS AND CLINICAL RELEVANCE

Accuracy of veterinary anaesthetists and nurses in drawing up medications decreases as the target volume becomes smaller. Small veterinary patients receive small volumes of anaesthetic drugs with higher risks of overdosing compared with larger dogs. Years of experience and staff grade are not associated with greater accuracy. Large percentage errors may be seen with target volumes less than 0.04 mL. Dilutions are recommended for volumes > 0.19 mL in 1 mL syringe.

EPERCAS study (Strategies for Preventing Medication Administration Errors in Nursing Homes). Preparation of a list of strategies to prevent the most frequent medication administration errors in the residential care environment

Medication administration errors are one of the most frequent types of errors. There are different safety guides and recommendations to prevent medication errors generally directed to the hospital environment. However, specific recommendations for the management process in the residential care environment are lacking. The main objective of this study was to develop a list of recommendations to aid in preventing the most important medication errors that occur during the administration process in nursing homes (NHs), such as not administering doses or administering medication to the wrong patient. The effectiveness and feasibility of the strategies proposed were evaluated by a panel of experts. The conventional Delphi method was applied. The first round in our study was a face-to-face questionnaire; the second round included an online questionnaire based on the results of the first round. Finally, eight strategies were included in the EPERCAS List: one professional in charge per shift; one professional commissioned by the residential unit; avoid interruptions; avoid medication outside of meal times; personalized medication drawer for each resident including oral medication from a bag and laxatives, inhalers, syrups, eye drops, etc.; identification of the resident and their medication; visual check that everything has been administered; and signature to verify medication administration. The great continual challenge for NH is to define safe and affordable procedures. Minimum safety recommendations for administering the medications, such as those included in this study, should be employed. Our next stage is to implement these strategies in one of our NH and subsequently, evaluate its effectiveness and consider expanding it to the rest of the NH.

Automated search methods for identifying wrong patient order entry-a scoping review

Objective

To investigate: (1) what automated search methods are used to identify wrong-patient order entry (WPOE), (2) what data are being captured and how they are being used, (3) the causes of WPOE, and (4) how providers identify their own errors.

Materials and Methods

A systematic scoping review of the empirical literature was performed using the databases CINAHL, Embase, and MEDLINE, covering the period from database inception until 2021. Search terms were related to the use of automated searches for WPOE when using an electronic prescribing system. Data were extracted and thematic analysis was performed to identify patterns or themes within the data.

Results

Fifteen papers were included in the review. Several automated search methods were identified, with the retract-and-reorder (RAR) method and the Void Alert Tool (VAT) the most prevalent. Included studies used automated search methods to identify background error rates in isolation, or in the context of an intervention. Risk factors for WPOE were identified, with technological factors and interruptions deemed the biggest risks. Minimal data on how providers identify their own errors were identified.

Discussion

RAR is the most widely used method to identify WPOE, with a good positive predictive value (PPV) of 76.2%. However, it will not currently identify other error types. The VAT is nonspecific for WPOE, with a mean PPV of 78%-93.1%, but the voiding reason accuracy varies considerably.

Conclusion

Automated search methods are powerful tools to identify WPOE that would otherwise go unnoticed. Further research is required around self-identification of errors.

Drug shortages. Part 1. Definitions and harms

Drug shortages are repeatedly in the news. The earliest drug shortages were reported during the First World War, but the numbers of shortages have increased in recent years. In the first part of this two-part review, we discuss definitions of drug shortages and so-called stockouts, which are localized shortages, and the harms that they can cause. Drug shortages make it difficult or impossible to meet the therapeutic needs of individual patients or populations, but we lack an adequate definition. The problems are too complicated to be encompassed in a brief intensional dictionary-style definition, and that is reflected in the many different attempts at definition that have been proposed. We therefore propose an extensional operational definition that incorporates the processes by which products are manufactured, the causes of shortages and the contributory factors. A definition of this sort allows one to identify the main causes of a particular drug shortage and therefore the remedies that might prevent, mitigate or manage it. In the second part of the review we discuss the causes and solutions in more detail. Adverse drug reactions and medication errors attributable to shortages occur but are not often reported. Adverse reactions to substitute medicines are possible, and errors can occur because of unfamiliarity or unnecessary treatment with replacement medicines. Other harmful outcomes include withdrawal reactions, undertreatment, treatment delays and cancellations, failure of alternatives and disruption of clinical trials.

Drug shortages. Part 2: Trends, causes and solutions

Drug shortages make it difficult or impossible to meet the therapeutic needs of individual patients or populations. In the first part of this review we proposed an operational definition that incorporates the processes by which products are manufactured, the causes of shortages and stock-outs (local shortages), and the contributory factors. Here we discuss causes and possible solutions. Drug shortages have complex causes, and a single cause cannot always be identified. Reasons include lack or shortage of raw materials, manufacturing difficulties, regulatory and political actions, voluntary recalls, just-in-time inventory systems, halts in production for financial or other business reasons, low demand (eg, orphan products, reduced usage), mergers, market shifts (eg, diversion to home markets) and unexpected increases in demand (eg, improved diagnosis, new trial information, epidemics and pandemics, inappropriate use, off-label use). Potential solutions are as diverse as the potential causes. Prevention is hard, because shortages are not easily predicted. Everyone in the supply chain is involved in anticipating and managing shortages, with responsibilities for preventing them or at least trying to mitigate their effects. This includes manufacturers and suppliers, particularly of generic formulations, pharmacists, prescribers, patients and governments. Solutions can therefore be linked to the causes and classified according to where the responsibility for implementing them lies.

Recurrence of medical errors despite years of preventive measures: A grounded theory study

BACKGROUND

Despite great efforts to improve patient safety, serious preventable medical errors continue to occur. Accurate rooting causes of error recurrence are essential for reviewing methods to prevent them. This study aimed to identify the main causes of the recurrence of medical errors despite their previous occurrence.

MATERIALS AND METHODS

This qualitative study was performed using the grounded theory method, with theoretical sampling from April to July 2021, through semi-structured interviews with 25 experts and treatment staff of hospitals under the auspices of four universities of medical sciences in Iran.

RESULTS

Four main parts were identified: 1) primary and secondary factors leading to the occurrence of errors, 2) error prevention policies, 3) causes of error repetition, and 4) contextual factors.

CONCLUSION

The attention, seriousness, and commitment of health system managers, from top to bottom, to patient safety are essential for preventing error recurrence. The institutionalization of patient safety education from universities and attention to individual, social, and cultural factors should also be given serious attention.

Pharmacologic Stewardship in a Rural Community Pharmacy

BACKGROUND

Pharmacotherapy is an essential part of patient care. In order to achieve optimal health outcomes, safe and effective prescribing and administering of medications is crucial, especially since the process of pharmacotherapy can cause serious problems, mainly adverse events and/or interactions, that often pass undetected.

OBJECTIVE(S)

To investigate the feasibility of using community pharmacies as checkpoints to detect errors and failures in prescribing, as well as patients' compliance with pharmacotherapy. To this end, analysis and recording of the prescribing process was carried out and error-prone points were identified.

METHODS

Patients and caregivers filling prescriptions during the first 4 weeks of November 2017 and February 2018 answered questions in order to evaluate their attendance of regular checkups and their compliance with prescribing instructions. All prescriptions filled at the pharmacy were examined for detection of prescription errors and drug-drug interactions. Statistical analyses, including calculations of the correlation coefficient phi (φ), chi-square, and confidence intervals, were carried out. Detected errors and failures were evaluated by application of the Health Failure Mode Effect Analysis (HFMEA) quality tool.

RESULTS

A significant number of patients (16.7%) failed to regularly attend checkups regarding known health problems (95% CI: 10.6-22.7%), a corresponding percentage (16%, 95% CI: 10.1-21.9%) did not comply with prescribed pharmacotherapy, and a significant proportion of patients self-medicated regularly (32%, 95% CI: 24.5-39.5%). A total of 8.6% of prescriptions included medication combinations with a potential for severe drug-drug interactions (95% CI: 7.1-10.2%) while 58.7% of the prescriptions included combinations that could lead to moderate ones (95% CI: 56.1-61.4). The HFMEA indicated that all problems recorded required immediate interventions, except for prescribing errors.

CONCLUSIONS

Community pharmacies can be potential checkpoints for the detection and evaluation of prescribing errors and pharmacotherapy failures.

Evaluation of medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals: a cross-sectional study in Iran

Introduction

Medication errors in nursing negatively affect the quality of the provided health-treatment services and society's mentality about the health system, threatening the patient's life. Therefore, this study evaluates medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals.

Materials and methods

All the nurses working at teaching hospitals affiliated with Ahvaz Jundishapur University of Medical Sciences (southwest of Iran) comprised the statistical population of this research (260 participants). Data were collected using three questionnaires: a demographic characteristics questionnaire, a medication error questionnaire, and the standard Circadian Type Inventory (CTI) for a normal physiological cycle.

Results

At least one medication error was observed in 83.1% of nurses during their work span. A medication error was found in 36.2% of nurses during the COVID-19 pandemic (over the past year). Most medication errors (65.8%) occurred during the night shift. A significant relationship was detected between medication errors and shift work. Medicating one patient's drug to another (28.84%) and giving the wrong dose of drugs (27.69) were the most common types of medication errors. The utmost medication error was reported in emergency wards. The fear of reporting (with an average of 33.06) was the most important reason for not reporting medication errors (p < 0.01).

Discussion and conclusion

Most nurses experienced a history of medication errors, which were increased by shift work and the COVID-19 pandemic. Necessary plans are recommended to reduce the fatigue and anxiety of nurses and prevent their burnout, particularly in critical situations. Efforts to identify risky areas, setting up reporting systems and error reduction strategies can help to develop preventive medicine. On the other hand, since the quality of people's lives is considered the standard of countries' superiority, by clarifying medical errors, a higher level of health, satisfaction and safety of patients will be provided.

Minimizing prescribing errors: A phenomenological exploration of the views and experiences of independent prescribing pharmacists

AIMS

This study aims to explore the views and experiences of independent prescribing (IP) pharmacists regarding prescribing errors and strategies to mitigate errors in practice.

METHODS

One-to-one online semi-structured interviews were conducted with IP pharmacists across the United Kingdom. Verbatim transcripts of the interview were generated and coded using NVivo® 12 software for thematic analysis. A mixed inductive and deductive approach was used to generate themes and sub-themes which were then mapped onto the framework of factors that influence clinical practice proposed by Vincent et al. RESULTS: A total of 14 interviews were conducted. Participants linked the risk-averse nature of a pharmacist, self-perception of their roles as medicines experts, and previous experience of keeping checks on doctors' prescriptions as a dispenser often made them feel confident in prescribing. However, lacking adequate diagnostic skills, inadequate prescribing training programmes, and dealing with complex patients often made them feel vulnerable to committing errors. Organizational and system-related factors such as work interruptions and increased workload were identified as other factors linked to prescribing errors.

CONCLUSIONS

Independent prescribing pharmacists use a variety of strategies to reduce the risk of prescribing errors. Promoting diagnostic competency in their area of practice, strengthening undergraduate and prescribing curricula, and addressing known organizational and system-related factors linked to prescribing errors can minimize errors and promote patient safety.