Development and Interrater Agreement of a Novel Classification System Combining Medical and Surgical Adverse Event Reporting

Importance

Categorization systems for adverse events are not standardized across care settings and specialties and do not always include near miss events (events where there was potential for patient harm, but where no actual harm occurred), making it difficult to effectively assess patient safety for quality improvement.

Objective

To develop and assess interrater agreement on a classification system for adverse events reporting that incorporates events in both inpatient and outpatient settings across medical and surgical subspecialties including near miss events.

Design, Setting, and Participants

A cross-sectional study in a tertiary care center including 174 patient cases occurring from 2018 to 2020 was carried out. Data were abstracted from a Department of Otorhinolaryngology-Head and Neck Surgery Quality Assurance database. The cases were comprised of near miss and adverse events occurring in adult and pediatric patients in inpatient, outpatient, and emergency department settings. The ratings took place in March and April of 2022.

Exposures

Four raters (2 attending physicians and 2 senior resident physicians) were recruited to classify these cases according to 3 classification systems: the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Clavien-Dindo, and our novel Quality Improvement Classification System (QICS).

Main Outcomes and Measures

The primary outcome was overall interrater agreements using Fleiss κ.

Results

Across all 4 raters grading 174 cases, the NCC-MERP, Clavien-Dindo, and QICS received a κ score. Fair-to-moderate interrater reliability was observed between the resident and attending physician groups across the 3 classification systems: NCC-MERP (κ = 0.33; 95% CI, 0.30-0.35), Clavien-Dindo (κ = 0.47; 95% CI, 0.43-0.50), and QICS (κ = 0.42; 95% CI, 0.39-0.44). Strong interrater concordance was observed for complications across all scenarios.

Conclusion and Relevance

This cross-sectional study found that the new QICS classification scheme was applicable to wide-ranging clinical scenarios with a focus on patient-centered outcomes including near miss events. In addition, QICS allowed for the comparison of patient outcome data in a multitude of settings.

Evaluation of a method for drug-related problems identification and classification in hospital setting: applicability and reliability

Background Prescription evaluation by pharmacists has potential to improve pharmacotherapy management. It requires the use of robust methods to identify drug-related problems (DRP), which are important issues in pharmacotherapy. Objective To evaluate the applicability and reliability of Grupo de Investigação em Cuidados Farmacêuticos (GIGUF) method for prescription analysis, identification and classification of drug-related problems in inpatients prescriptions. Setting Department of Medical Clinic of a tertiary and teaching Brazilian hospital. Method An observational and retrospective study of identification and classification of drug-related problems. GIGUF method was used to evaluate prescriptions of hematological patients hospitalized between August and October 2015. The problems were categorized using GICUF-method classification. Three pharmacists performed inter-rater agreement analysis of the method using Kappa. Differences in prevalence of DRP was calculated by age, sex, pharmacotherapy complexity, length of stay and number of drugs. Main outcome measure (a) frequency and characteristics and (b) inter-rater agreement in identification and classification of the drug-related problems. Results A total of 211 problems were identified and 'inadequate dosing' was the most common problem. There was an association between the occurence of a drug-reklated problem and complexity of pharmacotherapy (p = 0.001) and number of drugs used (p = 0.010). The overall inter-rater agreement was moderate (k = 0.44 IC 95% 0.34-0.55) and the problem 'not suitable drug' (k = 0.55 IC 95% 0.44-0.66) had greater inter-rater agreement. Conclusion The method "Evaluation Drug Use Process" was useful for prescription analysis since it made the identification and classification of DRPs possible. The method demonstrated a moderate inter-rater agreement, and can contribute to pharmacotherapy management by hospital pharmacists.

Factors, influencing medication errors in prehospital care: A retrospective observational study

To determine the frequency of medication errors in prehospital care and to investigate the influencing factors - diagnostic agreement (DA), the medical educational status, the specialty, the approval for emergency medicine of the prehospital emergency physician, the patient age and sex and the time of deployment.We retrospectively reviewed 708 patients from 2013 to 2015, treated by the prehospital emergency physicians of the emergency medical service center Bad Belzig, Germany. The medication appropriateness was determined by a systematic comparison of the administered medication in prehospital deployments with the discharge diagnosis, according to current guidelines. The influencing factors were examined by univariate analysis of medication appropriateness (MA), using the χ, the Mann-Whtiney U and the Welch tests. We calculated a cut-off value with the Youden index to predict absent MA, according to patients age. The significance level was P = .05.MA was absent in 220 of 708 patients (31.1%). In the case of present DA, MA was absent in 103 of 491 patients (20.9%). In the case of absent DA, MA was absent in 117 of 217 patients (53.9%) (P = .01). MA was absent in 82 of 227 patients (36.1%), treated by specialist and in 138 of 481 patients (28.7%), treated by resident physicians (P = .04). The calculated cut-off value to predict absent MA was 75.5 years. MA was absent in 100 of 375 patients (26.7%) of the younger patient age group (≤75.5 years), MA was absent 120 of 333 patients (36.0%) of the older patient age group (>75.5 years) (P = .01). Absent MA showed peak values (46.7%-60%) at night from 3 to 6 AM (P = .01) The other investigated factors had no influence on MA.The correctness of medication as a quality feature in prehospital care shows a necessity for improvement with a proportion of 31.1% medication errors. The correct diagnosis by the prehospital emergency physician and his rapid accumulation of experience had an impact on the correctness of medication in prehospital care. Elderly patients (75+ years) and nighttime prehospital deployments (3-6 AM) were identified as high risk for medication errors by the emergency physicians.

Where are we in patient safety in the ED in Turkey?

Near misses and unsafe conditions have become more serious for patients in emergency departments (EDs). We aimed to search the near misses and unsafe conditions that occurred in an ED to improve patient safety.This was a retrospective analysis of a 10-year observational period from January 1, 2007 to December 31, 2016. We gained access to the adverse event notification forms (AENFs) sent to the hospital quality department from the ED. Patient age, sex, and date of presentation were recorded. The near misses and unsafe conditions were classified into 7 types: medication errors, falls, management errors, penetrative-sharp tool injuries, incidents due to institution security, incidents due to medical equipment, and forensic events. The outcome of these events was recorded.A total of 220 AENF were reported from 294,673 ED visits. The median age of the 166 patients was 60 (21-95) years. Of these, 57.1% of the patients were females and 47.9% were males. The most commonly reported events were medication errors (32.7%) and management errors (27.3%). The median age of falling patients was 67.5 years. The nurse-patient ratio between 2007 to 2011 and 2011 to 2016 were 1/10 and 1/7, respectively. We found that when this ratio increased, the adverse events results were less significant (P < .003).This was the 1st study investigating the adverse events in ED in Turkey. The reporting ratio of 0.07% for the total ED visits was too low. This showed that adverse events were under-reported.

Investigating health information systems-induced errors

PURPOSE

The purpose of this paper is to present a review of health information system (HIS)-induced errors and its management. This paper concludes that the occurrence of errors is inevitable but it can be minimised with preventive measures. The review of classifications can be used to evaluate medical errors related to HISs using a socio-technical approach. The evaluation could provide an understanding of errors as a learning process in managing medical errors.

DESIGN/METHODOLOGY/APPROACH

A literature review was performed on issues, sources, management and approaches to HISs-induced errors. A critical review of selected models was performed in order to identify medical error dimensions and elements based on human, process, technology and organisation factors.

FINDINGS

Various error classifications have resulted in the difficulty to understand the overall error incidents. Most classifications are based on clinical processes and settings. Medical errors are attributed to human, process, technology and organisation factors that influenced and need to be aligned with each other. Although most medical errors are caused by humans, they also originate from other latent factors such as poor system design and training. Existing evaluation models emphasise different aspects of medical errors and could be combined into a comprehensive evaluation model.

RESEARCH LIMITATIONS/IMPLICATIONS

Overview of the issues and discourses in HIS-induced errors could divulge its complexity and enable its causal analysis.

PRACTICAL IMPLICATIONS

This paper helps in understanding various types of HIS-induced errors and promising prevention and management approaches that call for further studies and improvement leading to good practices that help prevent medical errors.

ORIGINALITY/VALUE

Classification of HIS-induced errors and its management, which incorporates a socio-technical and multi-disciplinary approach, could guide researchers and practitioners to conduct a holistic and systematic evaluation.

Critical Incidents in a Multidisciplinary Intensive Care Unit

We aimed to determine the type and frequency of critical incidents in a multidisciplinary intensive care unit, to determine outcomes consequent to these incidents and to devise corrective strategies.

Prospectively collected data on critical incidents during a 33-month period were analysed. In all, 1918 patients were admitted to the unit during the study period. Each incident was analysed in detail. A system-based corrective strategy was sought for and implemented as appropriate.

In these patients, 280 critical incidents were reported during the study period, resulting in 3.4 incidents per 100 patient days. Airway-related incidents were the most frequent (32.8%) followed by line-related (21.8%) and drug-related (15%) incidents. Thirty-two incidents (11.4%) led to adverse outcomes. There were four deaths that occurred as a direct consequence of or contributed to by the incident, all due to airway-related incidents. A major physiological change occurred in 3.6% of incidents, while 6.4% of incidents resulted in a minor physiological change. Critical incidents were common in our multidisciplinary ICU, although adverse outcomes were rare.

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings

OBJECTIVE

To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings.

METHODS

Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method.

RESULTS

Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes.

CONCLUSIONS

The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors.

Errors in preparation and administration of parenteral drugs in neonatology: evaluation and corrective actions

BACKGROUND

The medication iatrogenic risk is quite unevaluated in neonatology Objective: Assessment of errors that occurred during the preparation and administration of injectable medicines in a neonatal unit in order to implement corrective actions to reduce the occurrence of these errors.

METHODS

A prospective, observational study was performed in a neonatal unit over a period of one month. The practice of preparing and administering injectable medications were identified through a standardized data collection form. These practices were compared with summaries of the characteristics of each product (RCP) and the bibliography.

RESULTS

One hundred preparations were observed of 13 different drugs. 85 errors during preparations and administration steps were detected. These errors were divided into preparation errors in 59% of cases such as changing the dilution protocol (32%), the use of bad solvent (11%) and administration errors in 41% of cases as errors timing of administration (18%) or omission of administration (9%).

CONCLUSION

This study showed a high rate of errors during stages of preparation and administration of injectable drugs. In order to optimize the care of newborns and reduce the risk of medication errors, corrective actions have been implemented through the establishment of a quality assurance system which consisted of the development of injectable drugs preparation procedures, the introduction of a labeling system and staff training.

The medication reconciliation process and classification of discrepancies: a systematic review

AIMS

Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has been conducted and how medication discrepancies have been classified.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstracts (IPA), and Web of Science (WOS), in accordance with the PRISMA statement up to April 2016. Studies were eligible for inclusion if they evaluated the types of medication discrepancy found through the medication reconciliation process and contained a classification system for discrepancies. Data were extracted by one author based on a predefined table, and 10% of included studies were verified by two authors.

RESULTS

Ninety-five studies met the inclusion criteria. Approximately one-third of included studies (n = 35, 36.8%) utilized a 'gold' standard medication list. The majority of studies (n = 57, 60%) used an empirical classification system and the number of classification terms ranged from 2 to 50 terms. Whilst we identified three taxonomies, only eight studies utilized these tools to categorize discrepancies, and 11.6% of included studies used different patient safety related terms rather than discrepancy to describe the disagreement between the medication lists.

CONCLUSIONS

We suggest that clear and consistent information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well-designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice.

Voluntary Medication Error Reporting Program in a Japanese National University Hospital

BACKGROUND:

In Japan, as in other countries, medical accidents arising from human error can seriously damage public confidence in medical services, as well as being intrinsically undesirable.

OBJECTIVE:

Errors voluntarily reported by the healthcare practitioners in our institution (Kanazawa University Hospital) were considered to assess the contributory factors by using the accumulated error database in the hospital information system.

METHODS:

Medical errors in our institution during the period from July 1, 2000, to June 30, 2002, were counted using the error reporting system database and were classified.

RESULTS:

The number of errors reported during the investigation period was 1378, of which 78% were reported by nursing staff. Medication errors involving administration of injectable or oral drugs to inpatients, dispensing, and prescription accounted for about 50% of that number. Among dispensing errors, 53% were detected by patients or their families and 36% by nurses.

CONCLUSIONS:

The best method of error prevention is to learn from previous errors. For this purpose, the error reporting program is effective. In patient safety management, it is important to take into account the potential risks of future errors, as well as to capture information about errors that have already happened. For safety management, adoption of appropriate information technology (e.g., implementation of a prescription order entry system) is effective in reducing medication errors. However, it is important to note that serious errors can also arise in computer-based systems.

Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital

This study aimed to identify temporal precursor and associated contributing factors for adverse clinical incidents in a hospital setting using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 498 clinical incidents were reviewed. The framework identified key precursor events (PE), contributing factors (CF) and the prime causes of incidents. Descriptive statistics and correspondence analysis were used to examine incident characteristics. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks or the administration of medication. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs. The HFCF for patient safety was able to identify patterns of causation for the clinical incidents, highlighting the need for targeted preventive approaches, based on an understanding of how and why incidents occur.

Prescription, Transcription and Administration Errors in Out- Patient Day Care Unit of a Regional Cancer Centre in South India

BACKGROUND

Medication errors are common but most often preventable events in any health care setup. Studies on medication errors involving chemotherapeutic drugs are limited.

OBJECTIVE

We studied three aspects of medication errors - prescription, transcription and administration errors in 500 cancer patients who received ambulatory cancer chemotherapy at a resource limited setting government hospital attached cancer centre in South India. The frequency of medication errors, their types and the possible reasons for their occurrence were analysed.

DESIGN AND METHODS

Cross-sectional study using direct observation and chart review in anmbulatory day care unit of a Regional Cancer Centre in South India. Prescription charts of 500 patients during a three month time period were studied and errors analysed. Transcription errors were estimated from the nurses records for these 500 patients who were prescribed anticancer medications or premedication to be administered in the day care centre, direct observations were made during drug administration and administration errors analysed. Medical oncologists prescribing anticancer medications and nurses administering medications also participated.

RESULTS

A total of 500 patient observations were made and 41.6% medication errors were detected. Among the total observed errors, 114 (54.8%) were prescription errors, 51(24.5%) were transcribing errors and 43 (20.7%) were administration errors. The majority of the prescription errors were due to missing information (45.5%) and administration errors were mainly due to errors in drug reconstitution (55.8%). There were no life threatening events during the observation period since most of the errors were either intercepted before reaching the patient or were trivial.

CONCLUSIONS

A high rate of potentially harmful medication errors were intercepted at the ambulatory day care unit of our regional cancer centre. Suggestions have been made to reduce errors in the future by adoption of computerised prescriptions and periodic sensitisation of the responsible health personnel.

Analysis of medication prescribing errors in critically ill children

Medication prescribing errors (MPE) can result in serious consequences for patients. In order to reduce errors, we need to know more about the frequency, the type and the severity of such errors. We therefore performed a prospective observational study to determine the number and type of medication prescribing errors in critically ill children in a paediatric intensive care unit (PICU). Prescribing errors were prospectively identified by a clinical pharmacist. A total of 1129 medication orders were analysed. There were 151 prescribing errors, giving an overall error rate of 14 % (95 % CI 11 to 16). The medication groups with the highest proportion of MPEs were antihypertensives, antimycotics and drugs for nasal preparation with error rates of each 50 %, followed by antiasthmatic drugs (25 %), antibiotics (15 %) and analgesics (14 %). One hundred four errors (70 %) were classified as MPEs which required interventions and/or resulted in patient harm equivalent to 9 % of all medication orders (95 % CI 6.5 to 14.4). Forty-five MPEs (30 %) did not result in patient harm.

CONCLUSION

With a view to reduce MPEs and to improve patient safety, our data may help to prevent errors before they occur.

WHAT IS KNOWN

• Prescribing errors may be the most frequent medication errors. • In paediatric populations, the incidence of prescribing errors is higher than in adults. What is New: • Several risk factors for medication prescribing errors, such as medication groups, long PICU stay, and mechanical ventilation could be presented. • Analysing the combination of the most frequent prescribing errors and the severity of these errors.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Effect of automated drug distribution systems on medication error rates in a short-stay geriatric unit

RATIONALE, AIMS AND OBJECTIVES

To assess the impact of an automated drug distribution system on medication errors (MEs).

METHODS

Before-after observational study in a 40-bed short stay geriatric unit within a 1800 bed general hospital in Valenciennes, France. Researchers attended nurse medication administration rounds and compared administered to prescribed drugs, before and after the drug distribution system changed from a ward stock system (WSS) to a unit dose dispensing system (UDDS), integrating a unit dose dispensing robot and automated medication dispensing cabinet (AMDC).

RESULTS

A total of 615 opportunities of errors (OEs) were observed among 148 patients treated during the WSS period, and 783 OEs were observed among 166 patients treated during the UDDS period. ME [medication administration error (MAE)] rates were calculated and compared between the two periods. Secondary measures included type of errors, seriousness of errors and risk reduction for the patients. The implementation of an automated drug dispensing system resulted in a 53% reduction in MAEs. All error types were reduced in the UDDS period compared with the WSS period (P<0.001). Wrong dose and wrong drug errors were reduced by 79.1% (2.4% versus 0.5%, P=0.005) and 93.7% (1.9% versus 0.01%, P=0.009), respectively.

CONCLUSION

An automated UDDS combining a unit dose dispensing robot and AMDCs could reduce discrepancies between ordered and administered drugs, thus improving medication safety among the elderly.

Occurrence of medication errors and comparison of manual and computerized prescription systems in public sector hospitals in Lahore, Pakistan

The knowledge of medication errors is an essential prerequisite for better healthcare delivery. The present study investigated prescribing errors in prescriptions from outpatient departments (OPDs) and emergency wards of two public sector hospitals in Lahore, Pakistan. A manual prescription system was followed in Hospital A. Hospital B was running a semi-computerised prescription system in the OPD and a fully computerised prescription system in the emergency ward. A total of 510 prescriptions from both departments of these two hospitals were evaluated for patient characteristics, demographics and medication errors. The data was analysed using a chi square test for comparison of errors between both the hospitals. The medical departments in OPDs of both hospitals were the highest prescribers at 45%–60%. The age group receiving the most treatment in emergency wards of both the hospitals was 21–30 years (21%–24%). A trend of omitting patient addresses and diagnoses was observed in almost all prescriptions from both of the hospitals. Nevertheless, patient information such as name, age, gender and legibility of the prescriber’s signature were found in almost 100% of the electronic-prescriptions. In addition, no prescribing error was found pertaining to drug concentrations, quantity and rate of administration in e-prescriptions. The total prescribing errors in the OPD and emergency ward of Hospital A were found to be 44% and 60%, respectively. In hospital B, the OPD had 39% medication errors and the emergency department had 73.5% errors; this unexpected difference between the emergency ward and OPD of hospital B was mainly due to the inclusion of 69.4% omissions of route of administration in the prescriptions. The incidence of prescription overdose was approximately 7%–19% in the manual system and approximately 8% in semi and fully electronic system. The omission of information and incomplete information are contributors of prescribing errors in both manual and electronic prescriptions.

Medication errors in a public hospital in Brazil

This article describes the analysis of the frequency, type and risk factors relating to errors in the preparation and administration of medications in patients admitted to a public hospital in Brasilia Federal District, Brazil, which serves a population of approximately 500,000 inhabitants. Patients are commonly affected and harmed by medication errors, almost half of which are preventable. This is a cross-sectional, descriptive and exploratory study conducted in a clinical medicine unit. Direct observations were made by eight nurse technicians. The type of error, the type of drug involved and associated risk factors were analysed. Relationships between the occurrence of errors and risk factors were studied with logistic regression models. Of the 484 observed doses, 69.5% errors occurred during drug administration, 69.6% during the preparation stage, 48.6% were timing errors, 1.7% were dose-related errors and 9.5% were errors of omission. More than one error was detected in 34.5% of occasions. Unlabelled drugs increased the risk of timing errors by a factor of 13.72. Interruptions in preparation increased the risk of errors by a factor of 3.75. Caring for a larger number of patients (8-9) increased the risk of timing errors by a factor of 8.27. The research shows the need to manage the risk of medication errors in their real-life contexts by interposing safety barriers between the hazards and potential errors.

Immunisation errors reported to a vaccine advice service: intelligence to improve practice

BACKGROUND

The success of immunisation programmes depends on the quality with which they are administered. The Vaccine Advice for CliniCians Service (VACCSline) is an advice service to support immunisers and promote excellence in immunisation practice, through specialist guidance and local education, covering a catchment population of two million people. All enquiries are recorded onto a database and categorised. Vaccine error is selected when a vaccine has not been prepared or administered according to national recommendations or relevant expert guidance.

METHOD

All enquiries from 2009 to 2011, categorised on the VACCSline database as 'vaccine error' were analysed and subjected to a detailed free-text review.

RESULTS

Of 4301 enquiries, 158 (3.7%) concerned vaccine errors. The greatest frequency of errors, 145 (92.9%) concerned immunisations delivered in primary care services; 92% of all errors occurred during either vaccine selection and preparation or history checking and scheduling. Administration of the wrong vaccine was the most frequent error recorded in 33.3% of reports. A shared first letter of the vaccine name was noted to occur in 13 error reports in which the incorrect vaccine was inadvertently administered. Consultations involving pairs of siblings were associated with various errors in seven enquiries. Failure to revaccinate after spillage (seven reports) showed a widespread knowledge gap in this area.

CONCLUSION

Advice line enquiries provide intelligence to alert immunisers to the errors that are commonly reported and may serve to highlight processes that predispose to errors, thus informing immuniser training and updating.

Medication Errors in Ambulatory Paediatric Patient Setting--How Close, or Far, are we from an Error Free Process?

The medication management pathway (MMP) outlines the medication journey from the decision to prescribe through to monitoring the outcomes. Medication errors (MEs) can occur at any point of the pathway. MEs in children may result in poor health outcomes; and as children are more vulnerable to dose calculation and administration errors especially in the ambulatory setting, this cohort may be at a higher risk of adverse outcomes. This review aimed to identify MEs in children and attribute them to the steps within the MMP for paediatric ambulatory patients. A systematic search of studies related to MEs in children was performed using MEDLINE, EMBASE and International Pharmaceutical Abstracts in the period from Jan 1991 to June 2011, using keywords pertaining to children, medication errors and ambulatory settings. Thirty articles met the review inclusion criteria and the findings of these studies were reported. Based on the MMP, 26 studies reported prescribing errors, 7 dispensing errors, and 12 administration errors. Twelve studies reported errors at more than one time point within the MMP; four studies at 2 stages and 8 studies at 3 stages. The most common types of the errors identified were dose errors which commonly occurred during prescribing, dispensing, or administration. Studies have highlighted that MEs occurring in children, with most of the errors reported at the prescribing stage. This could be a reflection of the studies' focus, and further work is needed to review errors occurring at other time points during the medication management cycle. Identifying where errors occur will contribute to the development of novel strategies to detect and prevent these errors in ambulatory settings.

An assessment of the rate, types and severity of prescribing errors in a tertiary hospital in southwestern Nigeria

BACKGROUND

Accurate medication prescribing is an important process in ensuring the best possible outcomes in patient care. Worldwide literature is replete with studies reporting high prevalence of prescribing error which are the most common type of avoidable medication errors and hence are an important target for improvement.

OBJECTIVES

This study assessed types and prevalence of prescribing errors, their clinical significance, when in the prescribing process they occurred and the medications commonly associated with prescribing errors.

METHODS

A retrospective review of 2010 in-patients' records from medical and paediatric specialties of a tertiary hospital in South West Nigeria was undertaken. Prescriptions that met the standard as enumerated in the Nigeria Standard Treatment Guideline (STG) were assessed. Prescription error rates for potentially clinically serious and total errors were determined.

RESULTS

The total prescribing error rate was 40.9% (95% CI 37.8 to 41.4) with 1.3% (95% CI -1.1 to 3.7) being clinically serious. Omitting to write an ending date or duration for therapy and unsafe abbreviations were the most common errors. Prescriptions involving antimicrobials produced the bulk of errant prescriptions.

CONCLUSION

Prescribing errors were found to be common. There was poor compliance with the Nigeria Standard Treatment Guidelines which outline the essential elements of a prescription. Continuing prescriber education on proper prescription writing and rational drug use is recommended as a way to reduce prescribing errors.

A medication safety model: a case study in Thai hospital

Reaching zero defects is vital in medication service. Medication error can be reduced if the causes are recognized. The purpose of this study is to search for a conceptual framework of the causes of medication error in Thailand and to examine relationship between these factors and its importance. The study was carried out upon an in-depth case study and survey of hospital personals who were involved in the drug use process. The structured survey was based on Emergency Care Research Institute (ECRI) (2008) questionnaires focusing on the important factors that affect the medication safety. Additional questionnaires included content to the context of Thailand's private hospital, validated by five-hospital qualified experts. By correlation Pearson analysis, the result revealed 14 important factors showing a linear relationship with drug administration error except the medication reconciliation. By independent sample t-test, the administration error in the hospital was significantly related to external impact. The multiple regression analysis of the detail of medication administration also indicated the patient identification before administration of medication, detection of the risk of medication adverse effects and assurance of medication administration at the right time, dosage and route were statistically significant at 0.05 level. The major implication of the study is to propose a medication safety model in a Thai private hospital.

Evaluation of clinical pharmacist's interventions in an infectious diseases ward and impact on patient's direct medication cost

BACKGROUND

A clinical pharmacist is a key member of the antimicrobial multidisciplinary team involved in patients' pharmacotherapy monitoring. The aim of this study was to determine the frequency and type of medication errors, the type of clinical pharmacy interventions, acceptance of pharmacist interventions by health-care provider team, nursing staff satisfaction with clinical pharmacy services, and the probable impact of clinical pharmacy interventions on decreasing direct medication costs at an infectious diseases ward in Iran.

METHODS

All clinical pharmacist interventions such as preventing medication errors were recorded in a previously designed pharmacotherapy monitoring forms. Direct medication cost of patients admitted during the study period was compared with that of subjects hospitalized at the same ward during the year before the intervention period to determine the impact of clinical pharmacy interventions on direct medication costs.

RESULTS

The 3 most frequent medication error types were incorrect dose (35.5%), omission error (24.3%), and incorrect medication (14.3%). The mean number of clinical pharmacist intervention per patient was 3.2. Forty percent of clinical pharmacists' interventions are moderate to major clinical significant. Thirty nine percent of clinical pharmacist's interventions had moderate to major financial benefits in present study. The direct medication cost per patient was decreased about 3.8% following clinical pharmacist's interventions.

CONCLUSION

Our data demonstrated that incorrect dose was the most frequent medication error in the infectious diseases ward. Major portion of clinical pharmacist interventions were accepted by physicians and nursing staff. Clinical pharmacist interventions non-significantly decreased the direct medication cost of patients.

Development of a web-based observational tool for detecting intravenous medication errors with smart infusion pumps

Computerized smart infusion pumps have been widely implemented to decrease the rate of intravenous (IV) medication errors in hospitals. However, these devices have not always achieved their potential, and important IV errors still persist. Findings from a previous study [1] that assessed the frequency of IV medication errors and the impact of smart infusion pumps identified major issues related to use of smart infusion pumps in a single facility, but generalizability of these results is uncertain. Additionally, lack of standardized methodology for measuring these errors remains an issue. In this study, we developed an observational tool to capture IV medication errors through iterative participatory design with interdisciplinary experts and then tested the tool by using incident cases regarding smart pump errors. We found that the tool could capture all smart infusion pump errors and is ready for testing for use as standard data collection tool in different hospital settings.

[Patient safety: use of quality management to prevent medication errors in the hospital medication use cycle]

OBJECTIVES

To describe the medication errors in the medication use cycle in a general public hospital, and to identify intervention strategies in relation to the detection and prevention of these errors.

METHODS

Descriptive study with cross-sectional design. General public hospital of 190 beds, in Rosario (Argentina). Daily and systematic data collection of the circuit of use of medicines during May 2009. Once the errors were identified and classified, an interdisciplinary group sequentially applied different quality management tools to recognize and weigh causes, and propose solutions. (Flowchart, Cause Effect Diagram, Brainstorming, Nominal Group and Matrix Decision).

RESULTS

Information on 60 patients was retrieved during the study period, with 506 medication errors detected. The impact indicators showed the following values: 8.4 errors/patient and 88.6 errors/100 patients-day. From the causes identified, two were defined as relevant: "Double prescription" and "Lack of clear policy". Of the various solutions proposed, an intervention strategy was defined to include a differently designed form for "prescription/indication/administration" in the clinical history which could be updated daily, with a duplicate to Pharmacy for the distribution, as well as a Standard Operating Procedure to standardize this new way of working.

CONCLUSION

This work achieved, through quality management, the commitment of a team of health professionals to seek and make changes for patient safety, and to improve the quality of services provided by the hospital.

Medication problems are frequent and often serious in a Danish emergency department and may be discovered by clinical pharmacists

INTRODUCTION

Transferring a patient from one health-care sector to another implies a risk of medication errors. It is of interest to evaluate whether a specialist in clinical pharmacy is beneficial for the patients in the emergency departments (ED). The aim of the present study was to report the incidence, categories and seriousness of medication problems discovered by clinical pharmacists in an ED and to evaluate if it is possible for pharmacists to identify those groups of patients who are most at risk of medication problems.

MATERIAL AND METHODS

A pharmacist reviewed the patient files in the ED. If the pharmacists provided any kind of recommendations, a note was made describing the problem and a suggestion for a solution. After the study period, two medical specialists reviewed the files and rated the suggestions according to four levels of importance.

RESULTS

A total of 1,696 patient files were reviewed after excluding patients who had received no medication. A total of 420 pharmacist notes were written, corresponding to 25% of all the included admissions. 47% of the pharmaceutical suggestions were considered serious. Increasing age and one drug as opposed to 2-9 drugs were associated with serious recommendations. In the multivariate analysis, only age above 70 years remained of significance for the identification of patients with a risk of a serious medication problem.

CONCLUSION

A considerable amount of serious pharmaceutical problems were found in the ED. These problems had not been observed by the physicians and they were especially prevalent among the elderly and patients who were only prescribed a single drug.

FUNDING

The Amgros research foundation financed salaries for the independent specialists who reviewed the patient files.

TRIAL REGISTRATION

not relevant.

[Prescription errors in a neonatal intensive care unit from Buenos Aires]

BACKGROUND

Although error could be present in almost every medical practice, they are more frequent and potentially more dangerous in neonatal intensive care units (NICU).

OBJECTIVE

To determine prescription error rate of intravenous drugs in a Neonatal Intensive Care Unit (NICU), and to describe type of error (dose, dilution, and interval) and medication (antibiotics, inotropics, or analgesics).

METHODS

Observational study including medical records of patients hospitalized in a NICU, receiving any of the above mentioned drugs. Each prescription was compared with one provided by a specific software. Prescription error was defined as >10% of difference between both values.

RESULTS

362 prescriptions from 82 patients were analyzed. An error was observed in 42.5% (95%CI 37.4 - 47.8) of all prescriptions, including 148 (96.1%; 95%CI: 91.3-98.4) antibiotics prescriptions, 5 (3.2%; 95%CI: 1.2-7.7) inotropics prescriptions and 1 (0.7%; 95%CI: 0.01-4.2) analgesics prescriptions. Prescription errors were due to frequency error in 53.8% 95%CI: 45.6-61.8 of cases and to volume error in 46.1% (95%CI: 38.1-54.3).

CONCLUSION

Almost half of the intravenous drugs prescriptions included an error, being more frequently related to interval, followed by dosing; no errors in dilution were detected. Using prescription software could improve patient's safety.

Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study

BACKGROUND

Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries. Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use. This study evaluated the effectiveness of two commercial e-prescribing systems in reducing prescribing error rates and their propensities for introducing new types of error.

METHODS AND RESULTS

We conducted a before and after study involving medication chart audit of 3,291 admissions (1,923 at baseline and 1,368 post e-prescribing system) at two Australian teaching hospitals. In Hospital A, the Cerner Millennium e-prescribing system was implemented on one ward, and three wards, which did not receive the e-prescribing system, acted as controls. In Hospital B, the iSoft MedChart system was implemented on two wards and we compared before and after error rates. Procedural (e.g., unclear and incomplete prescribing orders) and clinical (e.g., wrong dose, wrong drug) errors were identified. Prescribing error rates per admission and per 100 patient days; rates of serious errors (5-point severity scale, those ≥3 were categorised as serious) by hospital and study period; and rates and categories of postintervention "system-related" errors (where system functionality or design contributed to the error) were calculated. Use of an e-prescribing system was associated with a statistically significant reduction in error rates in all three intervention wards (respectively reductions of 66.1% [95% CI 53.9%-78.3%]; 57.5% [33.8%-81.2%]; and 60.5% [48.5%-72.4%]). The use of the system resulted in a decline in errors at Hospital A from 6.25 per admission (95% CI 5.23-7.28) to 2.12 (95% CI 1.71-2.54; p<0.0001) and at Hospital B from 3.62 (95% CI 3.30-3.93) to 1.46 (95% CI 1.20-1.73; p<0.0001). This decrease was driven by a large reduction in unclear, illegal, and incomplete orders. The Hospital A control wards experienced no significant change (respectively -12.8% [95% CI -41.1% to 15.5%]; -11.3% [-40.1% to 17.5%]; -20.1% [-52.2% to 12.4%]). There was limited change in clinical error rates, but serious errors decreased by 44% (0.25 per admission to 0.14; p = 0.0002) across the intervention wards compared to the control wards (17% reduction; 0.30-0.25; p = 0.40). Both hospitals experienced system-related errors (0.73 and 0.51 per admission), which accounted for 35% of postsystem errors in the intervention wards; each system was associated with different types of system-related errors.

CONCLUSIONS

Implementation of these commercial e-prescribing systems resulted in statistically significant reductions in prescribing error rates. Reductions in clinical errors were limited in the absence of substantial decision support, but a statistically significant decline in serious errors was observed. System-related errors require close attention as they are frequent, but are potentially remediable by system redesign and user training. Limitations included a lack of control wards at Hospital B and an inability to randomize wards to the intervention.

Medication errors in an internal intensive care unit of a large teaching hospital: a direct observation study

Medication errors account for about 78% of serious medical errors in intensive care unit (ICU). So far no study has been performed in Iran to evaluate all type of possible medication errors in ICU. Therefore the objective of this study was to reveal the frequency, type and consequences of all type of errors in an ICU of a large teaching hospital. The prospective observational study was conducted in an 11 bed internal ICU of a university hospital in Shiraz. In each shift all processes that were performed on one selected patient was observed and recorded by a trained pharmacist. Observer would intervene only if medication error would cause substantial harm. The data was evaluated and then were entered in a form that was designed for this purpose. The study continued for 38 shifts. During this period, a total of 442 errors per 5785 opportunities for errors (7.6%) occurred. Of those, there were 9.8% administration errors, 6.8% prescribing errors, 3.3% transcription errors and, 2.3% dispensing errors. Totally 45 interventions were made, 40% of interventions result in the correction of errors. The most common causes of errors were observed to be: rule violations, slip and memory lapses and lack of drug knowledge. According to our results, the rate of errors is alarming and requires implementation of a serious solution. Since our system lacks a well-organize detection and reporting mechanism, there is no means for preventing errors in the first place. Hence, as the first step we must implement a system where errors are routinely detected and reported.

Electronic prescribing within an electronic health record reduces ambulatory prescribing errors

BACKGROUND

Health policy forces are promoting the adoption of interoperable electronic health records (EHRs) with electronic prescribing (e-prescribing). Despite the promise of EHRs with e-prescribing to improve medication safety in ambulatory care settings--where most prescribing occurs and where errors are common--few studies have demonstrated its effectiveness. A study was conducted to assess the effect of an e-prescribing system with clinical decision support, including checks for drug allergies and drug-drug interactions, that was integrated within an EHR on rates of ambulatory prescribing errors.

METHODS

In a prospective study using a nonrandomized, pre-post design with concurrent controls, 6 providers who used a commercial e-prescribing system were compared with 15 providers who remained paper-based from September 2005 through July 2008. Prescribing errors were identified by a standardized prescription and chart review.

RESULTS

Some 2,432 paper prescriptions at baseline and 2,079 prescriptions at one year were analyzed. Error rates for e-prescribing adopters decreased 1.5-fold--from 26.0 errors per 100 prescriptions at baseline (95% confidence interval [CI], 17.4-38.9) to 16.0 errors per 100 prescriptions at one year (95% CI, 12.7-20.2; p = .09). Error rates remained unchanged for nonadopters (37.3 per 100 prescriptions at baseline, 95% CI, 27.6-50.2, versus 38.4 per 100 prescriptions at one year, 95% CI 27.4-53.9; p = .54). Error rates for e-prescribing adopters were significantly lower than for nonadopters at one year (p < .001). Illegibility errors were high at baseline and eliminated by e-prescribing.

CONCLUSIONS

The preliminary findings from this small group of providers suggest that e-prescribing systems may decrease ambulatory prescribing errors, which are occurring at high rates among community-based providers.

Drug prescription errors in a Brazilian hospital

OBJECTIVE

To identify the prevalence of clinically significant prescription errors in a Brazilian university hospital compared with their occurrence in 2003 and 2007.

METHODS

Variables and group of variables, such as readability, compliance with legal and institutional procedures of prescription, and prescription errors analysis were analyzed.

RESULTS

When the prevalence rates of clinically significant prescription errors were calculated, a statistically significant decrease was shown [year of 2003 (29.25%), year of 2007 (24.20%); (z = 2.99; p = 0.03)], reflecting on the safety rate [year of 2003 (70.75%), year of 2007 (75.80%); (z = 3.30; p =0.0001)].

CONCLUSION

Despite significant, the increased safety rate reflected the quantitative reduction of errors, with no observed difference in severity between the studied periods. Our results suggest the institutional steps taken could reduce the number of errors, but they were ineffective in reducing the severity of the errors.

Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency

Patient safety incidents involving insulin are frequent and cause considerable distress to people with diabetes and anxieties to their families and carers. This article describes an analysis of the National Reporting and Learning System database of patient safety incidents concerning insulin reported from NHS providers in England and Wales over six years. The main causes are discussed and the ongoing developments by the National Patient Safety Agency and partner organisations to reduce insulin errors are described.

[HaiPro--what was learned from patient safety incidents in Finnish health care units in 2007 to 2009?]

Reports of the HaiPro reporting system are described and the role of reporting procedure aiming at internal development of the units and the possibilities of national development and monitoring of patient safety are discussed. The study material consisted of 64,405 reports of patient safety incidents accumulated from May 5, 2007 to December 31, 2009 to the HaiPro database from 36 user organizations. Of the reported incidents, 51% were associated with medicaments and the process of medication. The most common incidents were errors in registration, dispensing and administration of the drugs.

3,520 medication errors evaluated to assess the potential for IT-based decision support

We have previously studied system failures involved in medication errors using a limited number of root cause analyses as source. The aim of this study was to describe a larger number of medication errors with respect to harm, involved medicines and involved system problems - thus providing information for the development of IT-based decision support. We evaluated 3,520 medication error reports derived from 12 months of consecutive reporting from 13 hospitals in the Capital Region of Denmark. We found 0.65% errors with serious harm and 16% with moderate harm. A small number of medicines were involved in the majority of the errors. The problems in the medication error process were heterogeneous. Some were related to specific medicines and others were related to the computerized order entry system. Accordingly decision support targeted at specific medicines and improved IT systems are part of the continuing work to reduce the frequency of medication errors.

[Frequency of prescription and transcription errors for intravenous medications in four pediatric services]

BACKGROUND

Errors in the prescription and transcription of medications in pediatric services is a source of adverse events that can be prevented.

AIM

To determine and compare the frequency of prescription and transcription errors for intravenous drugs in four pediatric services in a regional general hospital.

MATERIAL AND METHODS

Cross sectional analysis of a probabilistic sample of 500 prescriptions of intravenous medications. Information was gathered using an instrument from the American Academy of Pediatrics.

RESULTS

The detected prescription errors were illegible indications in 20%, lack of dosing indication in 11%, omission of the administration route in 24% and omission of the frequency of administration in 15%. Transcription errors were illegible transcription in 3%, not transcribing all indicated medications in 4% and transcription of medications that were not prescribed in 3%. Twenty one percent of prescriptions and 6% of transcriptions had at least one incorrect action. In the different services studied there was a significant association between the percentage of incorrect prescriptions and transcriptions and between illegible prescriptions and transcriptions.

CONCLUSIONS

A high percentage of errors in prescription of intravenous medications and their transcriptions, was detected in these services. A better quality of care control is required.

What clinical learning contracts reveal about nursing education and patient safety

While it is widely accepted that adopting a systems perspective is important for understanding and addressing patient safety issues, nurse educators typically address these issues from the perspective of individual student performance. In this study, the authors explored unsafe patient care events recorded in 60 randomly selected clinical learning contracts initiated for students in years 2, 3, and 4 of the undergraduate nursing program at the University of Manitoba. The contracts had been drawn up for students whose nursing care did not meet clinical learning objectives and standards or whose performance was deemed unsafe. Using qualitative content analysis, the authors categorized data pertaining to 154 unsafe patient care events recorded in these contracts.Thirty-seven students precipitated these events. Most events were related to medication administration (56%) and skill application (20%). A breakdown of medication administration events showed that the highest number were errors related to time (33%) and dosage (24%). International students and male students were responsible for a higher number of events than their numbers in the sample would lead one to expect. The findings support further study related to patient safety and nursing education.

Nursing student medication errors involving tubing and catheters: a descriptive study

This retrospective case study examined reports (N=27) of medication errors made by nursing students involving tubing and catheter misconnections. Characteristics of misconnection errors included attributes of events recorded on MEDMARX error reports of the United States Pharmacopeia. Two near miss errors or Category B errors (medication error occurred, did not reach patient) were identified, with 21 Category C medication errors (occurred, with no resulting patient harm), and four Category D errors (need for increased patient monitoring, no patient harm) reported. Reported intravenous tubing errors were more frequent than other type of tubing errors and problems with clamps were present in 12 error reports. Registered nurses discovered most of the errors; some were implicated in the mistakes along with the students.

Medication errors: what they are, how they happen, and how to avoid them

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults--irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration). They can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors. Reporting of errors should be encouraged by creating a blame-free, non-punitive environment. Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. In balanced prescribing the mechanism of action of the drug should be married to the pathophysiology of the disease.

[Errors in hospital prescriptions of high-alert medications]

OBJECTIVE

Medication errors are currently a worldwide public health issue and it is one of the most serious prescription errors. The objective of the study was to evaluate the practice of prescribing high-alert medications and its association with the prevalence of medication errors in hospital settings.

METHODS

A retrospective cross-sectional study was conducted including 4,026 prescription order forms of high-alert medications. There were evaluated all prescriptions received at the pharmacy of a reference hospital in the state of Minas Gerais, southeastern Brazil, over a 30-day period in 2001. Prescription were checked for legibility, patient name, type of prescription, date, handwriting or writing, prescriber identification, drug prescribed, and use of abbreviations. Prescription errors were classified as writing or decision errors and how the type of prescription affected the occurrence of errors was assessed.

RESULTS

Most prescriptions were handwritten (45.7%). In 47.0% of handwritten, mixed and pre-typed prescriptions had patient name errors; the prescriber name was difficult to identify in 33.7%; 19.3% of them were hardly legible or illegible. Of a total of 7,148 high-alert drugs prescribed, 3,177 errors were found, and the most frequent one was missing information (86.5%). Errors occurred mostly in prescriptions of heparin, phentanyl, and midazolam. Intensive care and neurology units had the highest number of errors per prescription. Non-standard abbreviations were frequent and widespread. Overall it was estimated 3.3 errors per prescription order form. Pre-typed prescriptions were less likely to have errors compared to mixed or handwritten prescriptions.

CONCLUSIONS

The study results show there is a need for standardizing the prescription process and eliminating handwritten prescriptions. The use of pre-typed or edited prescriptions may reduce errors associated to high-alert medications.

Evidence-based practice, clinical simulations workshop, and intravenous medications: moving toward safer practice

In an era of increased emphasis on medication safety practice, a gap exists in the translation of research to clinical practice for administering intravenous continuous infusion medications. An educational initiative was designed for medical-surgical nurses in a tertiary care center to standardize operational procedures in a clinical model focusing on evidence-based practice.

Incidence, type and causes of dispensing errors: a review of the literature

OBJECTIVES

To identify, review and evaluate the published literature on the incidence, type and causes of dispensing errors in community and hospital pharmacy.

METHOD

Electronic databases were searched from 1966 to February 2008. This was supplemented by hand-searching the bibliographies of retrieved articles. Analysis of the findings explored the research methods, operational definitions, incidence, type and causes of dispensing errors.

KEY FINDINGS

Sixty papers were identified investigating dispensing errors in the UK, US, Australia, Spain and Brazil. In general, the incidence of dispensing errors varied depending on the study setting, dispensing system, research method and operational definitions. The most common dispensing errors identified by community and hospital pharmacies were dispensing the wrong drug, strength, form or quantity, or labelling medication with the incorrect directions. Factors subjectively reported as contributing to dispensing errors were look-alike, sound-alike drugs, low staffing and computer software. High workload, interruptions, distractions and inadequate lighting were objectively shown to increase the occurrence of dispensing errors.

CONCLUSIONS

Comparison of the reviewed studies was confounded by differences in study setting, research method and operational definitions for dispensing errors, error rate and classification of error types. The World Health Organization is currently developing global patient safety taxonomy. Such a standardized taxonomy for dispensing errors would facilitate consistent data collection and assist the development of error-reduction strategies.

Understanding medication errors: discussion of a case involving a urinary catheter implicated in a wrong route error

Medication errors represent a failure in the medication use process leading to an increase in morbidity and mortality. In an effort to standardize reporting, evaluating, and trending of medication errors, the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) developed and maintains a medication error taxonomy. A case study involving a medication intended for administration via rectal tube and inadvertently given through a Foley catheter is discussed using the NCC MERP medication error taxonomy and critiqued using recent national findings. Awareness of national trends for patient safety, including emerging changes leading to best practices, updates to National Patient Safety Goals, and changes in national policy, can reduce the risk of error involvement.

An adverse drug event and medication error reporting system for ambulatory care (MEADERS)

The Institute of Medicine (IOM) has identified the mitigation of Adverse Drug Events (ADEs) and Medication Errors (MEs) as top national priorities. Currently available reporting tools are fraught with inefficiencies that prevent widespread adoption into busy primary care practices. Using expert panel input we designed and built a new reporting tool that could be used in these settings with a variety of information technology capabilities. We pilot tested the system in four Practice Based Research Networks (PBRNs) comprising 24 practices. Over 10 weeks we recorded 507 reports, of which 200 were MEs, 116 ADEs and 68 were of other types. Clinicians found the system easy to use, with the average time to generating a report under 2 minutes. By using streamlined interface design techniques we were successfully able to improve reporting rates of ADEs and MEs in these practices.

[Updated classification for medication errors by the Ruiz-Jarabo 2000 Group]

OBJECTIVE

To update the classification system created by the Ruiz-Jarabo 2000 group to standardize detection, analysis, and recording of medication errors, with the aim of improving its capacity and functionality.

METHOD

The classification update was carried out by the Ruiz-Jarabo 2000 working group considering: a) other classifications used by incident reporting systems initiated after the original version had been created; b) suggestions offered by healthcare professionals with respect to the original version; and c) the experiences of the working group itself based on analyses of medication errors gathered in hospitals, and on analyses of reports notified to the ISMP-Spain medication error reporting and learning program.

RESULTS

This article presents the updated version of the medication error classification system and describes the main changes made on to the different sections and categories.

CONCLUSIONS

The new version may prove to be a useful tool for analyzing and reporting errors with regard to those detected within the framework of activities for improving safety in hospitals and primary care, as well as for those detected as a direct result of patient safety research. Thus, this document is expected to improve medication safety information management in such a way as to allow data to be used ever more efficiently for making medication use systems safer for patients.

Adverse drug events and medication errors in psychiatry: methodological issues regarding identification and classification

Abstract Adverse drug events and medication errors have received extensive study recently in a variety of clinical populations, though compared to many other areas relatively little work has focused on this area in psychiatry, especially with respect to the contribution of error to harm. The goal of this paper is to discuss methodological issues around measurement of medication safety in psychiatric patients. Against the background of a systems approach, a modern perspective of error management is discussed, and a multidimensional procedure for detection and classification of incidents related to the medication process is presented. This method has proven successful in non-psychiatric settings yielding the current best estimate of error rates and providing insight into the underlying causes. While this general approach can be adapted to the psychiatric setting, a number of issues make measurement especially challenging in psychiatry. These include the fluctuating course of psychiatric disorders, reduced patient adherence to the medication process, adverse effects which are often similar to symptoms of the underlying disorder, the frequent use of wide dose intervals depending on the clinical situation, and the presence of many drug-drug interactions. Data collected by means of the presented approach provide a basis for the development of effective strategies to reduce the risk of medication errors and thus improve patient safety in psychiatric care.

Types, prevalence, and potential clinical significance of medication administration errors in assisted living

OBJECTIVES

To describe the types and potential clinical significance of medication administration errors in assisted living (AL).

DESIGN

Cross-sectional observational study.

SETTING

This study was conducted in 12 AL settings in three states (Oregon, Washington, and New Jersey).

PARTICIPANTS

Participants included 29 unlicensed assistive personnel and 510 AL residents.

MEASUREMENTS

Medication administration observations, chart review, and determination of rates, types, and potential clinical significance of errors using standardized methodology.

RESULTS

Of 4,866 observations, 1,373 errors were observed (28.2% error rate). Of these, 70.8% were wrong time, 12.9% wrong dose, 11.1% omitted dose, 3.5% extra dose, 1.5% unauthorized drug, and 0.2% wrong drug. Excluding wrong time, the overall error rate dropped to 8.2%. Of the 1,373 errors, three were rated as having potential clinical significance.

CONCLUSION

A high number of daily medications are given in AL. Wrong time accounted for the majority of the errors. The bulk of the medications are low risk and routine; to promote optimal care delivery, clinicians need to focus on high-risk medications and residents with complex health problems.