Medication errors during medical emergencies in a large, tertiary care, academic medical center

Purpose

Evaluate the rate, type and severity of medication errors occurring during Medical Emergency Team (MET) care at a large, tertiary-care, academic medical center.

Methods

A prospective, observational evaluation of 50 patients that required MET care was conducted. Data on medication use were collected using a direct-observation method whereby an observer documented drug information such as drug, dose, frequency, rate of administration and administration technique. Subsequently, a team of three clinicians assessed rate, type and severity of medication errors using definitions consistent with United States Pharmacopeia MEDMARX system. Severity was assessed on a scale of minor, moderate and severe.

Results

One hundred eighty six doses were observed for 36 different medications. A total of 296 errors were identified; of these 196 errors (66%) were inappropriate aseptic technique. Of the remaining 100 errors, 46% were prescribing errors, 28% administration technique errors, 14% mislabeling errors, 10% drug preparation errors and 2% improper dose prescribing. Examples included: (1) prescribing errors, (2) administering wrong doses, (3) mislabeling, and (4) wrong administration technique such as not flushing intravenous medication through intravenous access. The rate of medication administration errors was 1.6 errors/dose including aseptic technique and 0.5 errors/dose excluding aseptic technique. A notable portion (14%) of errors was considered at least moderate in severity.

Conclusions

One out of 2 doses was administered in error after errors of using inappropriate aseptic technique were excluded. There is a need for education and systematic changes to prevent medication errors during medical emergencies as an effort to avoid harm.     

优化护理流程在血液净化中心护理中的应用疗效观察

目的 研究优化护理流程在血液净化中心护理中的应用疗效观察.方法 选取2018年1月至2020年1月收治血液净化患者120例为研究对象,抽签分组原则分为观察组和对照组,各60例,分别采取优化护理流程方式、常规护理流程方式,分析对比两组各项指标.结果 观察组急诊透析次数少于对照组(P＜0.05);观察组并发症发生率低于对照...     

The Influence of Patient Safety Culture and Patient Safety Error Experience on Safety Nursing Activities of Emergency Nurses in South Korea

IntroductionThe unique nature of the space and environment of emergency departments is a threat to patient safety. Enhancing patient safety and minimizing safety-related issues are important tasks for ED health care staff. The purpose of this study was to examine the relationships among patient safety culture, patient safety error, and safety nursing activities of emergency nurses in South Korea.MethodsA convenience sample of 200 emergency nurses working in 12 general hospitals in South Korea were surveyed for safety nursing activities using the Hospital Survey of Patients’ Safety Culture, a 4-item questionnaire for patient safety error and ED safety management items in the Guidelines for Patient Safety (seventh revision).ResultsHierarchical regression analysis revealed that the potential factors associated with safety nursing activities were safety training experience (β = 0.180, P=.01), organizational learning–continuous improvement (β = 0.170, P=.04), age (β = 0.160, P=.02), and implementation of domestic and foreign accreditation (β = 0.147, P=.03).DiscussionTo improve patient safety, it is essential to identify problems in medical institutions, determine areas of improvement, and improve the organization’s patient safety activity system on the basis of patient safety error experience reports. After training the emergency nurses for continuous improvement, the effect of patient safety activities must be analyzed.     

Parents of Children with Disabilities: Resilience, Coping, and Future Expectations

On the basis of characteristics of family resilience, the study examined the perspectives of parents of children with an intellectual, physical, or learning disability. Thirty-two parents were interviewed as to past, present, and the modes of coping. The questions examined various aspects of family ecology domains: parents' responses to the child's diagnosis; patterns of adjustment; family support and services used by parents; and parents' feelings and future expectations. Although, it was found that most parents had to make changes in their social life and expressed high levels of frustration and dissatisfaction, many try to maintain their routine life. The majority expressed the need for a strong belief in the child and in the child's future, an optimistic outlook, and a realistic view and acceptance of the disability. The study highlighted the importance of social resources and support, and the need for effective programs of intervention.     

安徽省老年人潜在不适当用药的风险调查及相关因素分析

目的了解老年人潜在不适当用药（PIM）带来的健康风险,为有效实施老年人用药安全的风险管理与保护老年人的健康权益提供依据。方法采用分级抽样方法选择了安徽省8个代表性的城乡社区,用基于 Beers 准则设计的问卷进行实地调查。调查获得的数据用 Epidata 和 SPSS 软件进行分析。结果抽样地区的老年人群总体不适当使用药物种类较多,频率较高,排在前10名的药物不适当使用频率均高于30％。城乡地区老年人在治疗感冒、抗细菌性感染、防治高血压与冠心病等药物的不适当使用频率的差异在统计学上有意义（P ＜0．05）,其中农村社区老年人群在治疗感冒药物方面的不适当使用频率比城市社区低,而其他药物的不适当使用频率明显比城市社区高。在同一社区,受教育程度与家庭收入较高的老年人用药安全风险意识往往强些,其 PIM流行率也明显低于受教育程度与家庭收入较低的老年人。结论安徽省部分地区老年人不适当的用药情况较为普遍,老年人用药安全风险意识较低。     

Therapy Expectations: Preliminary Exploration and Measurement in Adults with Intellectual Disabilities

Objectives To carry out a preliminary exploration and measurement of therapy expectancy in adults with intellectual disabilities through the development and psychometric evaluation of the therapy expectation measure (TEAM). Design The initial scale development phase combined top‐down theory‐driven and bottom‐up data‐driven processes to identify TEAM items and format. The subsequent scale evaluation phase piloted the TEAM and used correlational analyses to evaluate reliability and validity. Method Six adults with intellectual disabilities took part in semi‐structured interviews about therapy expectancy and motivation to identify TEAM items. A further 22 participants piloted the measure for initial psychometric evaluation. Results Preliminary psychometric evaluation confirmed that the TEAM has acceptable test–retest reliability and internal consistency. Assessment of construct validity found a strong and positive relationship with a measure of general self‐efficacy. Client expectations of therapy were largely positive and congruent with therapy as a goal‐oriented process in which they will be an active participant. However, a number of individuals were unclear about the reason for referral and felt a low level of involvement in the process. Client and carer perceptions of referral understanding were significantly different. Conclusions The TEAM may help clinicians to identify potential barriers to engagement in therapy and find ways of enhancing the therapeutic experience of adults with an intellectual disability. Further psychometric evaluation of the TEAMM with larger samples is required to confirm the factorial structure of the scale and enhance its clinical utility.     

Clinical pharmacy services in the emergency department

The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal policy statements from several notable organizations, including the American College of Emergency Physicians (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clinical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs, the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes, and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to implementing EM clinical pharmacy programs and limitations are considered.     

Inter-Rater Reliability of the Tracking and Reporting Outcomes of Procedural Sedation Tool

Clinical guidelines recommend that procedural sedation outcomes should be audited. The Tracking and Reporting Outcomes of Procedural Sedation (TROOPS) tool, developed by the International Consortium for the Advancement of Procedural Sedation, is intended to be suitable for use in all locations by sedation providers. We evaluated the feasibility and reliability of using a modified version of the TROOPS tool for sedation that is administered by nurses in the cardiac catheterization laboratory. The version of TROOPS we used contained items in the minor, intermediate, and sentinel categories. Two nurses independently completed the TROOPS tool for 40 patients who underwent a procedure with sedation. A sedation-related adverse event was selected by at least one of the raters for 21 of the patients (52%; 95% confidence interval [CI] = 0.38 to 0.67). Most were minor events related to the airway and breathing category of the TROOPS tool (n = 17; 42%; 95% CI = 0.29 to 0.58). The remaining were intermediate-severity events related to sedation quality. No events for the other categories of the TROOPS tool were selected. The intraclass correlation coefficient between paired nurse ratings of the TROOPS tool was 0.78 (95% CI = 0.43 to 0.92). Most nurses (85%, 95% CI = 73% to 92%) reported that it took less than 1 minute to complete the tool. In summary, paired ratings of sedation-related adverse events by nurses achieved moderate consistency using a modified version of the TROOPS tool containing items from the minor category of the airway and breathing domain. Use of this tool in clinical practice is feasible and reliable.     

Transfusion Safety Officers in the United States: Survey of characteristics and approaches to implementation

BackgroundTransfusion safety officers (TSO) function as liaisons between the blood bank and clinical staff, utilizing audits, quality improvement, reviews, communication, education, and general vigilance to enhance transfusion safety. While hospitals in Europe and Canada have long employed TSOs, a majority of institutions in the United States (US) have yet to implement this resource, despite the mounting evidence to support their effectiveness.Study design and methodsAn anonymous 20-question survey was administered to 104 hospitals with valid email contact information. Survey questions addressed the presence of a TSO, characteristics, backgrounds, and education of TSOs, the reporting and funding structure of the position, and role responsibilities.Results53 responses were received, with 52 surveys completed (51 % response rate). The majority of responding institutions have a patient blood management (PBM) program (n = 40, 77 %) and 33 (63 %) have at least 1 TSO. 61 % of TSOs report an educational background in nursing, with 11 additional unique training backgrounds identified. TSO responsibilities are varied and include quality improvement, education, transfusion safety event analysis, and participation in PBM initiatives. Barriers to implementing a TSO position include lack of resources, financial impediments, and a lack of understanding of the position and its value by administrators and clinicians.DiscussionThe results of this survey highlight how TSOs contribute to transfusion safety and PBM and may provide guidance to hospitals interested in implementing a TSO position. It also elucidates the range of TSO responsibilities and approaches that institutions utilize to advocate for, and implement, this position in the US.     

Lessons learned: use of event reporting by nurses to improve patient safety and quality

The Magnet Recognition Program encourages nurse-initiated, data-driven quality projects. Using data gained from medical error event reporting has been cited as a strategy to improve safety and quality. This article describes a process by which nurses at the Children's Hospital Boston increased error reporting and used knowledge gained from event reports to provide education and implement practice changes. The medical and surgical units experienced a 35% increase in reported events and a decrease in the severity level of events over a 2-year period. Meaningful data from event reporting systems are critical in helping nurses develop interventions to prevent errors. The Magnet Model components are illustrated in the steps of this project.