Undergraduate paramedic students cannot do drug calculations

BACKGROUND:

Previous investigation of drug calculation skills of qualified paramedics has highlighted poor mathematical ability with no published studies having been undertaken on undergraduate paramedics. There are three major error classifications. Conceptual errors involve an inability to formulate an equation from information given, arithmetical errors involve an inability to operate a given equation, and finally computation errors are simple errors of addition, subtraction, division and multiplication. The objective of this study was to determine if undergraduate paramedics at a large Australia university could accurately perform common drug calculations and basic mathematical equations normally required in the workplace.

METHODS:

A cross-sectional study methodology using a paper-based questionnaire was administered to undergraduate paramedic students to collect demographical data, student attitudes regarding their drug calculation performance, and answers to a series of basic mathematical and drug calculation questions. Ethics approval was granted.

RESULTS:

The mean score of correct answers was 39.5% with one student scoring 100%, 3.3% of students (n=3) scoring greater than 90%, and 63% (n=58) scoring 50% or less, despite 62% (n=57) of the students stating they ‘did not have any drug calculations issues’. On average those who completed a minimum of year 12 Specialist Maths achieved scores over 50%. Conceptual errors made up 48.5%, arithmetical 31.1% and computational 17.4%.

CONCLUSIONS:

This study suggests undergraduate paramedics have deficiencies in performing accurate calculations, with conceptual errors indicating a fundamental lack of mathematical understanding. The results suggest an unacceptable level of mathematical competence to practice safely in the unpredictable prehospital environment.KEY WORDS: Emergency medical technician, Education, Medication errors, Safety management     

Rivaroxaban program for acute venous thromboembolism upon ED discharge,with focus on utility of commercially available dose pack

Objective

To evaluate the impact of a rivaroxaban discharge initiative on the efficacy and safety of acute venous thromboembolism treatment in emergency department patients.

Error reporting in the emergency department: do we do what we say we do?

BACKGROUND:

The Joint Commission accreditation manual contains standards in improving organization performance related to report and review of patient care issues causing unexpected harm. In spite of regulations mandating reporting, it remains inconsistent, varying by provider type and hospital. Our purpose was to determine current attitudes, knowledge, and practice of error reporting among emergency department (ED) providers.

METHODS:

We administered a survey assessing ED staff practice regarding error reporting. Questions involved reporting of errors in which the practitioner was directly involved, errors the practitioner observed, and general awareness of reporting mandates. We also questioned individuals regarding fear of repercussions for reporting.

RESULTS:

Fifty-two surveys were returned. For most errors, providers were more likely to tell their supervisor about the issue than to tell the patient. Seventeen percent of respondents did not think that referring errors for review was their job. Only 31% of respondents were aware of standardized institution-wide pathways to report errors. Any respondent who was aware of the institution-wide pathway also felt responsibility for error reporting. Thirty-three percent of the respondents were concerned about negative repercussions from reporting errors. In querying the hospital reporting system, 263 cases were referred for quality issues over the previous year, 51% of them were referred by nurses, 27% by medical technicians (MTs), 2% by mid-level providers (MLPs), 1% by physicians, and 19% by other personnel.

CONCLUSION:

Although most of the ED staff are responsible for patient safety, most are not aware of systems available to assist in reporting, and even many do not utilize those systems.KEY WORDS: Error reporting, Quality assurance, Medical error     

Poor communication on patients’ medication across health care levels leads to potentially harmful medication errors

Objective

General practitioners have a key role in updating their patients’ medication. Poor communication regarding patients’ drug use may easily occur when patients cross health care levels. We wanted to explore whether such inadequate communication leads to errors in patients’ medication on admission, during hospital stay, and after discharge, and whether these errors were potentially harmful.

Design

Exploratory case study of 30 patients.

Setting

General practices in central Norway and medical ward of Innlandet Hospital Trust Gjøvik, Norway.

Subjects

30 patients urgently admitted to the medical ward, and using three or more drugs on admission.

Main outcome measures

Discrepancies between the patients’ actual drugs taken and what was recorded on admission to hospital, during hospitalization, at discharge, and five weeks after hospital stay. The discrepancies were grouped according to the NCC Merp Index for Categorizing Medication Errors to assess their potential harm.

Results

The 30 patients used a total of 250 drugs, and 50 medication errors were found, affecting 18 of the patients; 27 errors were potentially harmful, according to NCC Merp Index: 23 in category E, four in category F. Half of the errors originated from an incomplete medication list in the referral letter.

Conclusion

The majority of the medication errors were made when the patients were admitted to hospital, and a substantial proportion were potentially harmful. The medication list should be reviewed together with the patient on admission, and each patient should carry an updated medication list provided by his or her general practitioner.Key Words: Communication, general practice, medication errors, Norway, referral

• The number of medication errors comprised one-fifth of the number of drugs used by the included patients at referral.
• Half of the errors were potentially harmful.
• In patients with a proper medication list in the referral no mistake was made on admission.
• A review of the medication list together with the patient soon after admission and calling home care services could have corrected the majority of the errors.

     

Adverse event and error of unexpected life-threatening events within 24 hours of ED admission

Objectives

Errors and adverse events associated with unexpected life-threatening events including unplanned transfer to the intensive care unit (ICU) and unexpected death after emergency department (ED) hospitalization are not well characterized. We performed this study to investigate the role of unexpected life-threatening events as a trigger to capture errors and adverse events for ED patient safety.

Safety of epinephrine for anaphylaxis in the emergency setting

BACKGROUND:

While epinephrine is the recommended first-line therapy for the reversal of anaphylaxis symptoms, inappropriate use persists because of misunderstandings about proper dosing and administration or misconceptions about its safety. The objective of this review was to evaluate the safety of epinephrine for patients with anaphylaxis, including other emergent conditions, treated in emergency care settings.

METHODS:

A MEDLINE search using PubMed was conducted to identify articles that discuss the dosing, administration, and safety of epinephrine in the emergency setting for anaphylaxis and other conditions.

RESULTS:

Epinephrine is safe for anaphylaxis when given at the correct dose by intramuscular injection. The majority of dosing errors and cardiovascular adverse reactions occur when epinephrine is given intravenously or incorrectly dosed.

CONCLUSION:

Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.KEY WORDS: Allergy, Anaphylaxis, Epinephrine, Safety, Cardiovascular side effects     

Reasons for not reporting patient safety incidents in general practice: A qualitative study

Objective

To explore the reasons for not reporting patient safety incidents in general practice.

Design

Qualitative interviews with general practitioners and members of the project group.

Setting

General practice clinics in the Region of Northern Jutland in Denmark.

Subjects

Twelve general practitioners.

Main outcome measures

The experiences and reflections of the involved professionals with regard to system use and non-use.

Results

While most respondents were initially positive towards the idea of reporting and learning from patient safety incidents, they actually reported very few incidents. The major reasons for the low reporting rates are found to be a perceived lack of practical usefulness, issues of time and effort in a busy clinic with competing priorities, and considerations of appropriateness in relation to other professionals.

Conclusion

The results suggest that the visions of formal, comprehensive, and systematic reporting of (and learning from) patient safety incidents will be quite difficult to realize in general practice. Future studies should investigate how various ways of organizing incident reporting at the regional level influence local activities of reporting and learning in general practice.Key Words: Denmark, general practice, incident reporting, interviews, patient safety, qualitative researchPrevious studies have reported positive attitudes to incident reporting among Danish GPs.

• The results suggest, however, that formal reporting of patient safety incidents may be more attractive to GPs as an idea than as an integrated activity in a busy clinic. While most GPs in this study were initially positive towards the idea of reporting, they actually reported very few incidents.
• The reasons for the low reporting rates were found to be a perceived lack of usefulness, issues of time and effort, and considerations of appropriateness.
• Future research should compare how various ways of implementing and organizing incident reporting influence local activities of reporting and learning.

     

Lean techniques for the improvement of patients’ flow in emergency department

BACKGROUND:

Emergency departments (EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called “lean” management. This study aims to (1) evaluate the current patient flow in ED, (2) to identify and eliminate the non-valued added process, and (3) to modify the existing process.

METHODS:

It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage (PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T (hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.

RESULTS:

Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed (38.24 minutes; SD 66.35) and blood testing result (mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward (EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program (P<0.05).

CONCLUSION:

The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.KEYWORDS: Lean, Triage, Waiting time, Patient flow, Emergency department     

Perspectives From Academic and Practice Leaders on Nursing Student's Education and Role in Medication Reconciliation

Background

Medication reconciliation is a complex process that occurs during hospitalization at admission, transfer and discharge and at each outpatient clinic visit. Despite numerous quality improvement initiatives implemented by healthcare facilities nationwide to refine the process, medication errors still occur. Medication reconciliation processes are institution specific and undergo constant refinement. Few reports are available on the nursing student's role in this contemporary safety process.

Patient Characteristics Associated with Medication Adherence

Objective

Despite evidence indicating therapeutic benefit for adhering to a prescribed regimen, many patients do not take their medications as prescribed. Non-adherence often leads to morbidity and to higher health care costs. The objective of the study was to assess patient characteristics associated with medication adherence across eight diseases.

Design

Retrospective data from a repository within an integrated health system was used to identify patients ≥18 years of age with ICD-9-CM codes for primary or secondary diagnoses for any of eight conditions (depression, hypertension, hyperlipidemia, diabetes, asthma or chronic obstructive pulmonary disease, multiple sclerosis, cancer, or osteoporosis). Electronic pharmacy data was then obtained for 128 medications used for treatment.

Methods

Medication possession ratios (MPR) were calculated for those with one condition and one drug (n=15,334) and then for the total population having any of the eight diseases (n=31,636). The proportion of patients adherent (MPR ≥80%) was summarized by patient and living-area (census) characteristics. Bivariate associations between drug adherence and patient characteristics (age, sex, race, education, and comorbidity) were tested using contingency tables and chi-square tests. Logistic regression analysis examined predictors of adherence from patient and living area characteristics.

Results

Medication adherence for those with one condition was higher in males, Caucasians, older patients, and those living in areas with higher education rates and higher income. In the total population, adherence increased with lower comorbidity and increased number of medications. Substantial variation in adherence was found by condition with the lowest adherence for diabetes (51%) and asthma (33%).

Conclusions

The expectation of high adherence due to a covered pharmacy benefit, and to enhanced medication access did not hold. Differences in medication adherence were found across condition and by patient characteristics. Great room for improvement remains, specifically for diabetes and asthma.     

Medication prescribing errors in the prehospital setting and in the ED

Background

Medication errors are a common cause of iatrogenic adverse drug events. The incidence and nature of medication errors during prehospital treatment have not been fully described.

Objectives

The objectives of this study are to describe the incidence and characteristics of medication errors in adults during prehospital emergency treatment and in the emergency department (ED) and to identify risk factors for medication errors in those settings.

Methods

This is a retrospective study of adult patients transferred by emergency medical services to the ED of a university-affiliated hospital in Israel. The drugs administered in the mobile intensive care unit and in the ED were reviewed by 2 reviewers, who independently decided whether an error had occurred. The primary outcome was the number of drug errors per patient. Secondary outcomes were the type and severity of the errors and variables associated with increased incidence of drug errors.

Results

During the study period, 1837 patients were brought to the ED by mobile intensive care unit vehicles. Five hundred thirty-six patient charts (29%) were randomly selected for review; 65 charts (12.12%) could not be found; thus, 471 charts were reviewed. In the emergency vehicle, 188 patients (45.63%) received medications; of those, 12.76% (24 patients) were subject to a medication error. The number of drugs administered and long evacuation times were associated with higher risk for an error (P < .01 and P = .011, respectively). The presence of a physician in the emergency vehicle did not alter the risk of an error (P = .95). In the ED, 332 patients (72.6%) received medications. Of those, medication errors occurred in 120 patients (36.1%). The more medications administered, the higher the risk of error (P < .01). Less errors occurred in trauma patients (P = .041).

Conclusion

More medication errors occur in the ED than in the emergency vehicles. Patients treated with multiple medications are more prone to medication errors.     

ED overcrowding is associated with an increased frequency of medication errors

Objectives

Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists.

Methods

We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves.

Results

A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's ρ = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day.

Conclusions

We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.     

Response to Medication Dosing Alerts for Pediatric Inpatients Using a Computerized Provider Order Entry System

Objective

Medication dosing errors are of particular concern in hospitalized children. Avoidance of such errors is essential to quality improvement and patient safety. Computerized provider order entry (CPOE) systems with clinical decision support (CDS) have the potential to reduce medication errors. The objective of this study was to evaluate provider response to the dosing alerts in a CPOE system with CDS for pediatric inpatients and to identify differences in provider response based on clinician specialty.

Patients and methods

We conducted a retrospective analysis of all medication dosing alerts over a 1-year period (January 1 through December 31, 2008) for all pediatric inpatients at Hospital for Special Surgery. Alerts were analyzed with respect to medication dosing, prescriber, and action taken by the prescriber after the alert was triggered (i.e., accepted suggested change, ignored recommendation/overrode, or cancelled the order).

Results

During the study period, 18,163 medication orders were placed and 1,024 dosing alerts were fired. Overdosing of medications accounted for 91% of the alerts and underdosing 9%. The pediatric-trained providers ignored more alerts and cancelled fewer orders than the non-pediatric-trained providers (p<0.001). Both groups changed the order similarly based on CDS recommendations.

Conclusions

Differences in response to CDS were found between pediatric-trained and non-pediatric-trained providers caring for pediatric patients; however, both groups changed orders based on CDS similarly. CPOE with built-in CDS may be of particular value when providers with different specialties and types of training are caring for pediatric patients.     

Immigrants and the utilization of hospital emergency departments

BACKGROUND:

Immigrants with language barriers are at high risk of having poor access to health care services. However, several studies have indicated that immigrants tend to use emergency departments (EDs) as their primary source of care at the expense of primary care. This may place an additional burden on already overcrowded EDs and lead to a low level of patient satisfaction with ED care. The study was to review if immigrants utilize ED care differently from host populations and to assess immigrants’ satisfaction with ED care.

DATA SOURCES:

Studies about immigrants’ utilization of EDs in Australia and worldwide were reviewed.

RESULTS:

There are conflicting results in the literature about the pattern of ED care use among immigrants. Some studies have shown higher utilization by immigrants compared to host populations and others have shown lower utilization. Overall, immigrants use ED care heavily, make inappropriate visits to EDs, have a longer length of stay in EDs, and are less satisfied with ED care as compared to host populations.

CONCLUSIONS:

Immigrants might use ED care differently from host populations due to language and cultural barriers. There is sparse Australian literature regarding immigrants’ access to health care including ED care. To ensure equity, further research is needed to inform policy when planning health care provision to immigrants.KEY WORDS: Emergency department, Health service, Immigrants, Language, Utilization     

(How) do we learn from errors? A prospective study of the link between the ward's learning practices and medication administration errors

Background

Attention in the ward should shift from preventing medication administration errors to managing them. Nevertheless, little is known in regard with the practices nursing wards apply to learn from medication administration errors as a means of limiting them.

Aims

To test the effectiveness of four types of learning practices, namely, non-integrated, integrated, supervisory and patchy learning practices in limiting medication administration errors.

Methods

Data were collected from a convenient sample of 4 hospitals in Israel by multiple methods (observations and self-report questionnaires) at two time points. The sample included 76 wards (360 nurses). Medication administration error was defined as any deviation from prescribed medication processes and measured by a validated structured observation sheet. Wards’ use of medication administration technologies, location of the medication station, and workload were observed; learning practices and demographics were measured by validated questionnaires.

Findings

Results of the mixed linear model analysis indicated that the use of technology and quiet location of the medication cabinet were significantly associated with reduced medication administration errors (estimate = .03, p < .05 and estimate = −.17, p < .01 correspondently), while workload was significantly linked to inflated medication administration errors (estimate = .04, p < .05). Of the learning practices, supervisory learning was the only practice significantly linked to reduced medication administration errors (estimate = −.04, p < .05). Integrated and patchy learning were significantly linked to higher levels of medication administration errors (estimate = −.03, p < .05 and estimate = −.04, p < .01 correspondently). Non-integrated learning was not associated with it (p > .05).

Conclusions

How wards manage errors might have implications for medication administration errors beyond the effects of typical individual, organizational and technology risk factors. Head nurse can facilitate learning from errors by “management by walking around” and monitoring nurses’ medication administration behaviors.