Overnight and Postcall Errors in Medication Orders

Objective: To compare the error rates in medication orders by physicians who were off call, on overnight call, and postcall. Methods: This was a retrospective review of inpatient medication orders, pharmacy records, and resident physician work schedules in a university‐affiliated community teaching hospital with residency programs in emergency medicine, family practice, internal medicine, obstetrics, pediatrics, and surgery. The authors calculated error rates, odds ratios (ORs), and 95% confidence intervals (95% CIs) for physicians during April 2000. Results: In 8,195 medication orders, there were 177 errors (2.16% overall error rate). There was an increased error rate for overnight and postcall orders (2.71%, OR 1.44, 95% CI = 1.06 to 1.95) in comparison to orders written by off‐call physicians (1.90%). Error rates were significantly higher on the medical/surgical wards during the overnight (3.91%, OR 1.89, 95% CI = 1.22 to 2.92) and postcall (3.41%, OR 1.64, 95% CI = 1.10 to 2.43) periods compared with the off‐call (2.11%) period, and postgraduate year 1 (PGY1) physicians had a higher overnight error rate (4.23%, OR 2.28, 95% CI = 1.44 to 3.61). Error rates were also higher on the medical/surgical wards compared with critical care units (2.62% vs. 1.22%, OR 2.17, 95% CI = 1.48 to 3.18). The PGY1 physicians had error rates similar to those of the PGY2–5 physicians when off call, but were significantly higher on overnight call (4.23% vs. 0.52%, OR 8.47, 95% CI = 2.00 to 35.82). Conclusions: Medication‐ordering error rates were higher for overnight and postcall physicians, particularly on the general medical/surgical wards, and in PGY1 physicians during the overnight period.     

护理给药错误事件156例分析

目的分析护理给药错误发生的原因,为患者用药安全管理提供依据。方法回顾性分析长沙市某三级甲等医院2013年至2016年院内不良事件上报系统收集的156例给药错误事件。结果 156例给药错误中,以静脉给药错误最多,占62.8%;护士发生给药对象错误概率最高,占47.4%;其中,94.9%的给药错误未对患者造成伤害。给药错误的主要原因为未严格执行患者查对制度、疏忽粗心和沟通不良。结论护理管理者应鼓励医护人员主动上报所有的给药错误,对给药错误的资料进行分析,根据护士发生给药错误的特点制订针对性的预防措施。     

Profiles in Patient Safety: Medication Errors in the Emergency Department

Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here.     

Reducing Medication Errors Potential Benefits of Bolus Thrombolytic Agents

A recent Institute of Medicine report highlighted the high incidence of medical errors in clinical practice, and the important fact that errors are associated with increased mortality. The administration of thrombolytic therapy for acute myocardial infarction is a particularly high-risk situation for emergency physicians. The combination of extreme time pressure with a narrow "therapeutic window" increases the potential for adverse outcomes due to dosing errors. Numerous trials have found that the dose of thrombolytic therapy is closely related to outcomes, with too low a dose associated with lower rates of infarct-related artery patency and higher doses associated with increased bleeding and intracranial hemorrhage. In the GUSTO-I trial, 13.5% of patients treated with streptokinase and 11.5% of patients treated with tissue plasminogen activator (t-PA) had a medication error (i.e., incorrect dose or infusion length). Most importantly, 30-day mortality was significantly higher in patients with medication errors: for t-PA dosing errors mortality was 7.7% vs 5.5% for patients who received the correct t-PA dose (p < 0.001), with similar findings for streptokinase. More recent data from the InTIME2 trial and other studies showed that use of a bolus thrombolytic agent reduced the rate of medication errors. Thus, use of the simpler bolus thrombolytic agents may reduce emergency department medication errors, and thus improve overall clinical outcome.     

The Effect of Implementing Bar-Code Medication Administration in an Emergency Department on Medication Administration Errors and Nursing Satisfaction

IntroductionBar-code medication administration has been shown to reduce medication errors in inpatient settings with limited studies on its use in emergency departments. In addition, no studies have evaluated nursing satisfaction with implementing bar-code medication administration in an emergency department. This study was designed to determine the impact of implementing bar-code medication administration in an emergency department on medication errors and nursing satisfaction.MethodsThis is a before-and-after study, with no control group, of a bar-code medication administration intervention conducted in a community hospital emergency department. Direct observation was used to compare medication error rates before and 3 months after implementing bar-code medication administration. The Medication Administration System—Nurses Assessment of Satisfaction survey was used to assess the impact on nursing satisfaction before and 1 month after bar-code medication administration implementation.ResultsA total of 676 medication administrations were observed in the period before bar-code medication administration implementation and 656 after. The medication administration error rate preimplementation was 2.96% with “wrong dose” errors being the most common. After bar-code medication administration implementation, the medication administration error rate fell to 0.76%, a relative reduction of 74.2% (Fisher exact P < 0.01). The average (SD) Medication Administration System—Nurses Assessment of Satisfaction score preimplementation was 2.60 (0.75) and improved to 2.29 (0.66) (t = 2.00, P = 0.05) 1 month post implementation.DiscussionImplementing bar-code medication administration in a community emergency department was associated with a decrease in medication administration errors and an improvement in Medication Administration System—Nurses Assessment of Satisfaction scores. The results of this study suggest a benefit of bar-code medication administration in reducing medication administration errors and improved nursing satisfaction in the emergency department.     

Medication Errors in the Management of Anaphylaxis in a Pediatric Emergency Department

Background

Despite the publication of recent guidelines for anaphylaxis management, many studies show that physicians are still not at ease with the management of anaphylaxis.

Objectives

To evaluate the rate and severity of medication errors before and after implementation of a standard order form for anaphylaxis management.

Methods

A before-and-after study was conducted. All children <18 years of age presenting to a tertiary care pediatric hospital Emergency Department with anaphylaxis between September 2007 and November 2010 were included. Patients were divided into two groups according to intervention (Pre and Post). Intervention consisted of the implementation of a standard order form (SOF) for anaphylaxis management. The post-intervention group was further sub-divided into SOF+ (when the SOF was used) and SOF− (when the SOF was not used).

Results

A total of 96 medical charts were reviewed. There were 31 patients in Pre and 65 in Post (29 in SOF+ and 36 in SOF−). A total of 243 drugs were ordered. Thirty-five percent (85/243) of these orders contained at least one medication error. Fifty-five percent (47/85) were dosage errors. The rate of medication errors was the same between Pre and Post (60% vs. 59%, p = 0.95). However, the rate of dosage errors was significantly reduced when the SOF was used (21% in SOF+ vs. 50% in Pre, p = 0.02 and 21% in SOF+ vs. 50% in SOF−, p = 0.02).

Conclusions

Medication errors in the management of anaphylaxis were frequent. Use of an SOF significantly reduced the rate of dosage errors.     

The Benefit of Houseofficer Education on Proper Medication Dose Calculation and Ordering

OBJECTIVES: Drug dosing errors commonly cause morbidity and mortality. This prospective controlled study was performed to determine: 1) residents' understanding of drug dose calculations and ordering; and 2) the short-term effect of a brief educational intervention on the skills required to properly calculate dosages and order medications. METHODS: The study was conducted at an urban public hospital with a four-year emergency medicine (EM) residency program. The EM residents served as the study group and were unaware of the study design. A written, eight-question test (T1) with clinical situations and factual questions was administered. Immediately following the test, correct answers were discussed for 30 minutes. Key concepts were emphasized. Six weeks later, a repeat test (T2a) with a similar format was administered to the study group. The same test (T2b) was simultaneously administered to a control group, residents of similar training who did not take T1, in order to determine test equivalency (T1 vs T2). Tests were graded using explicit criteria by a single investigator blinded to the order of administration. RESULTS: Twenty residents completed both tests T1 and T2a. Their mean scores were 48% and 70%, respectively (p < 0.001, paired t-test). The control group of ten residents had a mean score of 49% (T2b), similar to the study group's scores on T1 (T1 vs T2b, p = 0.40, unpaired t-test). CONCLUSION: Emergency medicine residents require specific training in calculating and executing drug ordering. A brief educational intervention significantly improved short-term performance when retested six weeks later. Long-term retention is unknown.     

Paramedic Self-Reported Medication Errors

Background. Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, andtreatment. Methods. A survey was given to paramedics in San Diego County. The survey tool was established based on previous literature reviews andquestions developed based on previous CQI data. Results. A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average shift length of 25.4 hours and6.7 calls/shift. Thirty-two responding paramedics (9.1%) reported committing a medication error in the past 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), andwrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, andincorrect dosage given. Fatigue, training, andequipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% reported by the base hospital radio nurse, 8.3% found on chart review, and4.2% noted by the paramedic during the call but never reported. Conclusions. Nine percent of paramedics responding to an anonymous survey reported medication errors in the past 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.     

Errors in the administration of intravenous medication in Brazilian hospitals

Aim. To verify the frequency of errors in the preparation and administration of intravenous medication in three Brazilian hospitals in the State of Bahia. Background. The administration of intravenous medications constitutes a central activity in Brazilian nursing. Errors in performing this activity may result in irreparable damage to patients and may compromise the quality of care. Design. Cross‐sectional study, conducted in three hospitals in the State of Bahia, Brazil. Methods. Direct observation of the nursing staff (nurse technicians, auxiliary nurses and nurse attendants), preparing and administering intravenous medication. Results. When preparing medication, wrong patient error did not occur in any of the three hospitals, whereas omission dose was the most frequent error in all study sites. When administering medication, the most frequent errors in the three hospitals were wrong dose and omission dose. Conclusions. The rates of error found are considered low compared with similar studies. The most frequent types of errors were wrong dose and omission dose. The hospitals studied showed different results with the smallest rates of errors occurring in hospital 1 that presented the best working conditions. Relevance to clinical practice. Studies such as this one have the potential to improve the quality of care.     

Development and Prospective Federal State-Wide Evaluation of a Device for Height-Based Dose Recommendations in Prehospital Pediatric Emergencies: A Simple Tool to Prevent Most Severe Drug Errors

Objective: Drug dosing errors pose a particular threat to children in prehospital emergency care. With the Pediatric emergency ruler (PaedER), we developed a simple height-based dose recommendation system and evaluated its effectiveness in a pre–post interventional trial as the Ethics Committee disapproved randomization due to the expected positive effect of the PaedER on outcome. Methods: Pre-interventional data were retrospectively retrieved from the electronic records and medical protocols of the Cologne Emergency Medical Service over a two-year period prior to the introduction of the PaedER. Post-interventional data were collected prospectively over a six-year period in a federal state-wide open trial. The administered doses of either intravenous or intraosseous fentanyl, midazolam, ketamine or epinephrine were recorded. Primary outcome measure was the number and severity of drug dose deviation from recommended dose (DRD) based on the patient's weight. Results: Fifty-nine pre-interventional and 91 post-interventional prehospital drug administrations in children were analyzed. The rate of DRD > 300% overall medications were 22.0% in the pre- and 2.2% in the post-interventional group (p < 0.001). All administrations of epinephrine occurred excessive (DRD > 300%) in pre-interventional and none in post-interventional patients (p < 0.001). Conclusions: The use of the PaedER resulted in a 90% reduction of medication errors (95% CI: 57% to 98%; p < 0.001) and prevented all potentially life-threatening errors associated with epinephrine administration. There is an urgent need to increase the safety of emergency drug dosing in children during emergencies. A simple height-based system can support health care providers and helps to avoid life-threatening medication errors.     

Adherence to a Medication Safety Protocol: Current Practice for Labeling Medications and Solutions on the Sterile Field

Medication labeling omissions in the OR and the adverse events that result from them remain a challenge in health care facilities. Standardization of protocols based on guidance from the Joint Commission, AORN, the Institute for Safe Medication Practices, and other organizations is important to ensure that patients do not mistakenly receive the wrong medication. A clinical nurse specialist and a perioperative education coordinator at the Cleveland Clinic, Cleveland, Ohio, undertook a direct observation quality improvement project to assess the adherence of 21 nurses and 19 surgical technologists to a revised medication and solution labeling protocol implemented in February 2008. Results showed that overall, 70% of staff members adhered to the medication and solution labeling protocol but adherence varied among specialty areas. There was increased adherence to the protocol by junior staff members compared with more experienced staff members.     

Intervening at the Intersection of Medication Adherence and Health Literacy

Medications play a prominent role in the treatment of many illnesses. Failing to adhere to prescribed medication regimens contributes to an array of poor health outcomes. In addition to the cost in terms of human suffering, the financial cost of medication nonadherence is staggering. Poor health literacy has been identified as a major cause of medication nonadherence. This paper focuses on nonadherence related to health literacy in the older adult population in the United States. Eight simple interventions to aid health care personnel in working with this population to improve adherence are provided.