Evaluating dispensing error detection rates in a hospital pharmacy.

OBJECTIVES: The filling of unit dose orders and checking for filling errors are two essential distributive responsibilities of a hospital pharmacy. Previous studies have shown that nonpharmacists, usually technicians, are capable of assuming these distributive tasks traditionally performed by hospital pharmacists. The study tested whether nonpharmacists, in this case licensed practical nurses/medication nurses, were as competent as pharmacists in checking for errors in unit dose cassettes prepared for hospital patients. METHODS: A university teaching hospital was used for the study. Artificial errors (n = 812) were introduced into the drug distribution system during a 4-month period in 1995. Included in the study were seven staff pharmacists and nine medication nurses (licensed practical nurses) involved in the decentralized drug distribution system. The primary measure was the ratio of errors detected to the number of artificial errors introduced into the system. This primary measure is different from those used in prior studies that do not separate dispensing errors and checking errors. RESULTS: Overall, pharmacists were significantly more accurate in detecting errors (87.7% vs. 82.1%). In one category of serious errors, that of wrong strength, the difference between pharmacists and licensed practical nurses was even greater (93.3% vs. 83.3%). CONCLUSIONS: This study's results do not support conclusions of prior studies that nonpharmacists can match the error detection accuracy of pharmacists. It demonstrates the importance of considering the types of errors under examination and of using appropriate measures of error checkers when drawing conclusions on relative competence.     

A controlled trial of smart infusion pumps to improve medication safety in critically ill patients

OBJECTIVE: Intravenous medications are vital during inpatient management. Errors associated with the administration of medications through intravenous infusion pumps to critically ill patients can result in adverse drug events. We sought to assess the impact of smart pumps with integrated decision support software on the incidence and nature of medication errors and adverse drug events. DESIGN: We performed a prospective, randomized time-series trial and compared the serious medication error rate between intervention (decision support on) and control (decision support off) periods. Serious medication errors included both near-misses and preventable adverse drug events. Pump software produced log reports to help identify potential events. Events were presented to physicians for rating of event type, preventability, and severity. SETTING: Cardiac surgical intensive care and step-down units between February and December 2002. PATIENTS: Pump data were available for 744 cardiac surgery admissions. INTERVENTIONS: Decision support during medication administration provided feedback including alerts, reminders, and unit-specific drug rate limits. MEASUREMENTS AND MAIN RESULTS: We found a total of 180 serious medication errors, including 14 and 11 preventable adverse drug events and 73 and 82 nonintercepted potential adverse drug events in the control and intervention periods, respectively. The serious medication error rates in the control and intervention periods were 2.03 and 2.41 per 100 patient-pump-days, respectively (p = .124). We also found numerous opportunities for safety improvement. Violations of infusion practice during the intervention periods included 571 (25%) bypasses of the drug library. Medications were also frequently administered without documentation of physician orders in both periods (n = 823; 7.7%). CONCLUSION: Intravenous medication errors and adverse drug events were frequent and could be detected using smart pumps. We found no measurable impact on the serious medication error rate, likely in part due to poor compliance. Although smart pumps have great promise, technological and nursing behavioral factors must be addressed if these pumps are to achieve their potential for improving medication safety.     

Using snowball sampling method with nurses to understand medication administration errors

Aims and objectives. We aimed to encourage nurses to release information about drug administration errors to increase understanding of error‐related circumstances and to identify high‐alert situations. Background. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Methods. Snowball sampling was conducted to recruit participants. A semi‐structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Results. Eighty‐five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one‐third of total errors. Among 259 actual errors, 83·8% resulted in no adverse effects; among remaining 16·2%, 6·6% had mild consequences and 9·6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double‐check procedures by colleagues and nurses responsible for errors; reporting rates were 62·5% (162/259) vs. 50·7% (35/69) and only 3·5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High‐alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR). Conclusions. Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high‐alert situations. Strategies for reducing drug administration errors by nurses are suggested. Relevance to clinical practice. Survey results suggest that nurses should double check medication administration in known high‐alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non‐reprimanding atmosphere, helping to establish standard operational procedures for known high‐alert situations.     

护士发生用药错误心理体验质性研究的系统评价

目的 系统评价护士发生用药错误的体验,为管理者制订完善的用药错误管理体系,构建医疗安全不良事件护士支持项目提供理论依据。 方法 计算机检索中国生物医学文献数据库、中国知网、维普、万方、乔安娜布里格斯研究所（Joanna Briggs Institute,JBI）循证卫生保健中心图书馆、考克兰循证医学图书馆、PubMed、EMbase、Web of Science、EBSCO、CINAHL Complete、PsycINFO及opengrey数据库,检索时限均为从建库至2019年6月30日,收集护士发生用药错误体验的质性研究,采用英国牛津循证医学中心文献质量评价项目进行文章质量评价,采用主题综合法对结果进行整合。 结果 共纳入11项研究,提炼31个研究结果,归纳形成10个新类别,整合形成3大核心主题。①情绪情感体验:多数护士表现消极情感体验,渴望得到他人包括患者、家属及同事的支持和理解,有力的帮助和支持可减少护士负面情绪;②医疗应对体验:护士能及时采取相应措施避免或降低伤害,但向患者或家属的告知意愿和主动上报事件的意愿较低;③职业影响体验:用药错误事件对护士职业产生正性或负性影响。 结论 用药错误给护士带来较大的心理应激,患方的理解以及同事、家属的支持会帮助其积极应对错误事件,促进患者用药安全。     

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors

Background: Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. Study Objective: To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. Methods: A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. Results: There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time. Conclusion: ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.     

Nurses' families’ experiences of involvement in nursing errors: A qualitative study

BackgroundThe most important and irreversible consequence of medical errors is the human impact caused by unintended actions. In a few studies, the significant impact of this error on the private life of healthcare staff have been mentioned, but the problems of the involved nurses’ families had been ignored, as of now.AimsThis study aimed to explain the nurses' families’ experiences of involvement in nursing errors.MethodsThis is a qualitative study using conventional content analysis with 20 semi-structured interviews conducted with nurses and family members of nurses involved in medical errors, done through purposeful sampling and willingness to participate in the study.ResultsThe results of the data analysis consisted of five main categories including disruption in family functioning, the crisis of fear, oppression, damage, and neglect, along with 15 subcategories.ConclusionConsidering the effects of nursing errors on the families of nurses involved in the error, such as disruption of family functioning, the family of nurses involved in the error should also be considered and paid attention to. These families are abandoned and the need to promote the culture of supporting the family is tangible.     

Medication administration errors and the pediatric population: a systematic search of the literature

Medication administration errors are a serious concern for the pediatric population. This article presented an overview of medication errors and safe medication administration practices. Additional information was presented regarding the pediatric population and specific factors that make this population susceptible to medication errors. A systematic literature search on medication administration errors in the pediatric population was presented. From the search, five themes emerged, including the incidence rate of medication administration errors, specific medications involved in medication administration errors and classification of the errors, why medication administration errors occur, medication error reporting, and interventions to reduce medication errors.Differences in study design made it difficult to compare the articles with regard to some of the themes. However, it was apparent that medication administration errors do occur in the pediatric population, regardless of the exact incidence rate. As previously stated, the NCC MERP believes that there is no acceptable incidence rate for medication errors. Errors in dosage were found to be a common reason as to why medication errors occur. There was some discrepancy with regard to medication error reporting, as it was found that medication errors are underreported, but the extent of this varied. Systems used to report medication errors also varied. It was found that the more detailed the information reported on the medication error, the more potential impact it had on leading to a system change to prevent such errors from occurring again. It is recommended that reporting systems be nonpunitive so that nurses are not afraid to report errors. In addition, more emphasis should be placed on near miss medication errors, as these occur frequently but are rarely reported and may provide greater insight into system flaws. Lastly, interventions found to reduce medication administration errors were congruent with current recommendations for safe medication administration. This calls into question if the current recommendations are being followed uniformly. Implications for future research and practice include that a formalized system check for safe medication administration be developed and utilized. System checks have been developed and are widely used during the prescribing and preparing stage, and less medication errors are noted during this early part of the medication process. Having a formalized system check during medication administration would aid in ensuring that current recommendations are being followed, which would lead to a decrease in medication administration errors.Parents and caregivers naturally expect that their children will be safe when in the health care system. Yet, providing health care will always involve some degree of risk due to both the complexity of the health care environment and the role that human judgment plays within it. Nurses play a role in improving the safety of children within their care. The role of the nurse is much wider than simply reporting patient safety incidents or near misses; it includes taking preventative actions, sharing experiences, learning from mistakes, and helping to devise solutions.     

住院病人静脉药物治疗给药错误环节分析与对策

目的分析住院病人静脉药物治疗过程中发生给药错误的环节,为制订改进措施提供依据。方法回顾性分析某三级甲等医院过去5年护理非惩罚性主动上报静脉药物治疗给药错误环节、给药错误类型及发生给药错误原因。结果静脉药物治疗发生给药错误的环节由高到低依次为：护士给药操作、护士医嘱处理、护士配药、医生开具医嘱、药房配药发药、病人依从性差;发生给药错误涉及护士、医生、药师、病人;给药错误类型为：药物错误、遗漏给药、发错病人等,操作不规范和流程设计不合理是发生给药错误的主要原因。结论由护士失误引起的给药错误所占比例最高,特别是由护士个人完成的环节,给药错误发生率最高;整体理念是研究预防给药错误发生对策的关键,提高护理管理水平,减少给药错误的发生要从多方面考虑。     

Medication errors in university-affiliated teaching hospitals as compared to non-university-affiliated teaching hospitals in Jordan

BACKGROUND. “Medication errors” is a serious underreported practice issue. This is the first study in Jordan and other countries that compare medication errors between university‐affiliated teaching hospitals (UATHs) and non‐university‐affiliated teaching hospitals (NUATHs). DESIGN AND SAMPLE. Survey method was used to collect data of the current study. A convenience sample of 171 nurses was recruited from two UATHs and a sample of 98 nurses from two NUATHs. RESULTS. There were significant differences between the two types of hospitals in terms of causes, percentage, and reporting of medication errors. More medication errors are committed in NUATHs, thus immediate interventions are needed. Nurses in NUATHs should be encouraged to report medication errors; those nurses were more subjected to disciplinary actions or at the risk of losing their jobs. CONCLUSIONS. Medication errors are escalating, and is a matter that requires immediate interventions in all types of hospitals, especially in NUATHs. More reporting methods should be established in NUATHs.     

Nursing management of medication errors

Medication error is the most common and consistent type of error occurring in hospitals. This article attempts to explore the ethical issues relating to the nursing management of medication errors in clinical areas in Macau, China. A qualitative approach was adopted. Seven registered nurses who were involved in medication errors were recruited for in-depth interviews. The interviews were transcribed and analyzed using content analysis. Regarding the management of patients, the nurses acknowledged the mistakes but did not disclose the incidents to patients and relatives. Concerning management of the nurses involved by senior staff, most participants experienced fairness, comfort and understanding during the process of reporting and investigation. The ethical issues relating to the incidents were discussed, particularly in the Chinese context. There is a need for further study relating to the disclosure of medication incidents to patients and some suggestions were made.     

Intravenous medication safety system averts high-risk medication errors and provides actionable data

A major responsibility of nursing leaders is to implement systems and policies to improve patient and staff safety, avoid medication errors, and most importantly safeguard patients against harm. In the medication use process, the nurse at the bedside is the most vulnerable, and intravenous (i.v.) drug administration often results in the most serious medication error outcomes. At a 675-bed, tertiary-care "Magnet Hospital System," nurses played a key role in a multidisciplinary process that led to successful implementation of a computerized i.v. medication safety system. Software customization, staff training and product set-up were completed in approximately 2 months; 685 devices were installed in 3 hospitals within 12 hours. Nursing acceptance is excellent, and implementation of the system is thought to enhance nursing retention and recruitment. Preliminary data indicate an estimated 849 programming changes ("near misses") annually, ie, potential infusion errors averted by the i.v. medication safety system. A chronogram created from safety data demonstrates that most infusion error warnings occurred between 3:00 PM and 9:00 PM, with an unexpected peak at 6:00 PM. Implementation of the i.v. medication safety system has prevented potentially serious infusion errors and has provided previously unavailable, actionable continuous quality improvement data for best practice improvements.     

New Zealand newly graduated nurses medication management: Results of a survey

BackgroundNurses play a crucial role in medication management in in-patient settings where their knowledge and skills can detect adverse drug effects and prevent errors. Yet newly graduated nurses are new to practice and have little experience.ObjectivesThis exploratory study sought to understand how these new nurses applied their pharmacology knowledge to medication management.MethodA survey was distributed to all registered nurses working in one large urban New Zealand hospital who had graduated within the previous 24 months.FindingsOver 70% of nurses who participated in this study indicated strength in applying some principles; resources, formulation, correct dosage, why the drug was given, monitoring and when a drug was not given safely. Two pharmacological principles; understanding the mechanism of action of drugs and drug clearance were applied less well. Whilst previous studies have reported nurses have a lack of pharmacology knowledge, this study does not support this, but rather identifies strengths and areas for improvement.ConclusionRecommendations from this study are that orientations for new nurses include commonly used drugs in that setting, extra education for new drugs and continuing education to support new graduates to continue to consolidate their knowledge and skills.     

Nurses’ perspectives regarding the disclosure of errors to patients: A qualitative study

BackgroundThere is often a mismatch between patients’ desire to be informed about errors and clinical reality. In closing the “disclosure gap” an understanding of the views of all members of the healthcare team regarding errors and their disclosure to patients is needed. However, international research on nurses’ views regarding this issue is currently limited.ObjectivesExplore nurses’ attitudes and experiences concerning disclosing errors to patients and perceived barriers to disclosure.DesignInductive, exploratory study employing semi-structured interviews with participants, followed by conventional content analysis in which investigators read and discussed transcribed data to identify important themes.SettingsNursing departments from hospitals in two German-speaking cantons in Switzerland.ParticipantsPurposive sample of 18 nurses from a range of fields, positions in organisational hierarchy, work experience, hospitals, and religious perspectives.MethodsData were collected via individual, face-to-face interviews using a researcher–developed semi-structured interview guide. Interviews were transcribed in German and analysed using the qualitative data analysis software package Atlas-Ti (Berlin) and conventional content analysis. The most illustrative quotes were translated into English.ResultsNurses generally thought that patients should be informed about every error, but only a very few nurses actually reported disclosing errors in practice. Indeed, many nurses reported that most errors are not disclosed to the patient. Nurses identified a number of barriers to error disclosure that have already been reported in the literature among all clinicians, such as legal consequences and the fear of losing patients’ trust. However, nurses in this study more frequently reported personal characteristics and a lack of guidance from the organisation as barriers to disclosure. Both issues suggest the need for a systematic institutional approach to error disclosure in which the decision to inform the patient stems from within the organisation and is not shouldered by individual nurses alone.ConclusionsOur study suggests that hospitals need to do more to support and train nurses in relation to error disclosure. Such measures as hospitals establishing a disclosure support system, providing background disclosure education, ensuring that disclosure coaching is available at all times, and providing emotional support for all parties involved, would likely go a long way to address the barriers identified by nurses.     

Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital

Drug administration is one of the highest risk areas of nursing practice and a matter of considerable concern for both managers and practitioners The aim of this study, earned out in a district general hospital, was to identify any common themes that underlie the occurrence and reporting of drug administration errors Data were collected from a variety of sources drug error reports, questionnaires to nurses and nurse managers, and interviews with nurses who had been involved in drug errors Several areas of particular concern emerged, including the nurses' confusion regarding the definition of drug errors and the appropriate actions to take when they occurred, their fear of disciplinary action, their loss of clinical confidence, the variation in managerial response, and a possible lack of nurses' mathematical skills The results from the study demonstrated that it was likely that many drug errors were not reported, for a variety of reasons It is recommended that all of these issues are addressed as a matter of urgency, for the sake of both patients and nurse practitioners