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 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.     

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.     

Examining medication errors in a tertiary hospital

This project examined the accuracy of medication administration by nurses at a large tertiary hospital. Registered nurses were prepared to directly observe medication administration. Observations were made of 1514 doses administered by 30 nurses on 3 units, on day and evening shifts. Few (5%) medication errors were found. The most frequent errors were wrong technique, wrong time, and omission. Results suggest examination of medication policies, assessment of medication administration competency, and targeted in-service education.     

Medication‐administration errors in an urban mental health hospital: A direct observation study

In the present study, we aimed to identify the incidence, type, and potential clinical consequence of medication‐administration errors made in a mental health hospital, and to investigate factors that might increase the risk of error. A prospective, direct observational technique was used to collect data from nurse medication rounds on each of the hospital's 43 inpatient wards. Regression analysis was used to identify potential error predictors. During the 172 medication rounds observed, 139 errors were detected in 4177 (3.3%) opportunities. The most common error was incorrect dose omission (52/139, 37%). Other common errors included incorrect dose (25/139, 18%), incorrect form (16/139, 12%), and incorrect time (12/139, 9%). Fifteen (11%) of the errors were of serious clinical severity; the rest were of negligible or minor severity. Factors that increased the risk of error included the nurse interrupting the medication round to attend to another activity, an increased number of ‘when required’ doses of medication administered, a higher number of patients on the ward, and an increased number of doses of medication due. These findings suggest that providers of inpatient mental health‐care services should adopt medicine‐administration systems that minimize task interruption and the use of ‘when required’ medication, as well as taking steps to reduce nursing workload.     

Factors contributing to medication errors: a literature review

Drug administration is an integral part of the nurse's role. Responsibility for correct administration of medication rests with the nurse, yet medication errors are a persistent problem associated with nursing practice. This review examines what constitutes a medication error and documents contributory factors in medication errors. These factors have been derived from reported medication errors and opinions of nurses as to factors which predispose to errors. A number of definitions exist as to what constitutes a medication error. The definition used should facilitate interpretation and comparison of a wide range of research reports. Medication errors are a multidisciplinary problem and a multidisciplinary approach is required in order to reduce the incidence of errors.     

Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection

OBJECTIVE: To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence. DESIGN: Prospective, direct observation study. SETTING: Tertiary care academic medical center. PATIENTS: Patients in a medical/surgical intensive care unit. INTERVENTIONS: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. MEASUREMENTS AND MAIN RESULTS: The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%). CONCLUSIONS: Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.     

Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany

Objective: The aim of this study was to quantify and classify errors associated with the repackaging of residents' medications in long-term care facilities in Germany.Methods: This was a prospective 8-week study conducted in 3 long-term care facilities. Pill organizers, each of which contained all repackaged solid oral dosage forms of long-term medications for a particular resident for an entire day, were inspected and checked against residents' medication sheets by the investigator-pharmacist. On agreement between the pharmacist and the registered nurse responsible for residents' medications, all errors were rectified before medications were administered. The primary study measure was the overall rate of incorrectly repackaged medications relative to all repackaged medications. Secondary measures were the proportion of all pill organizers with medication errors and the proportion of residents who would have been affected by these errors. Errors were categorized by type as follows: wrong time of administration, wrong dose, wrong medication, omission of a medication, extra dose, incorrect halving of tablets, and damaged medication.Results: One hundred ninety-six residents were included in the study, representing 8798 daily pill organizers and 48,512 inspected medications. Residents received a mean of 5.4 solid oral dosage forms of long-term medications per day. Six hundred forty-five errors were detected, for an error rate of 1.3%; the errors involved 7.3% of daily pill organizers and 53.0% of residents. The largest proportion of errors involved incorrect halving of tablets (49.1%), followed by omission of a medication (22.0%), extra dose (9.8%), wrong time of administration (8.4%), damaged medication (6.4%), wrong dose (4.2%), and wrong medication (0.2%). These results may underestimate true rates of repackaging errors across long-term care facilities in Germany, as the conditions in the 3 facilities in this study were near-optimal in terms of the environment, process, and quality of repackaging.Conclusions: Among 48,512 medications inspected over 8 weeks in 3 German long-term care facilities, the rate of repackaging errors was 1.3%, involving 7.3% of daily pill organizers and the medications of 53.00% of residents. The largest proportion of errors involved incorrect halving of tablets.     

护士发生给药错误的特点及原因分析

目的分析护士给药错误发生的特点和原因,探讨如何预防给药错误的发生。方法回顾性分析某三级甲等医院2010年至2012年自愿非惩罚报告系统中上报的给药错误137例,分析护士给药错误的类别、特点及原因。结果给药错误主要发生在综合科室占31.39%,外科占24.82%;患者身份识别错误、药物遗漏、给药技术性错误是给药错误的主要类别;发生给药错误的药物种类,占前2位的分别是抗生素和心血管系统用药;在发生给药错误的原因中,操作过程中没有认真执行查对制度占48.91%。结论护理管理者应根据给药错误的特点制订相应的管理措施,加强护士药物知识的培训,严格执行查对制度,降低给药错误的发生。     

二级医院132例给药差错环节分析及管理对策

目的：分析给药差错各环节中存在的关键风险点,为护理管理者制定防范给药差错的管理措施提供依据。方法：收集上海郊区8家二级医院2009年1月至2011年6月主动上报的给药差错,分析各环节发生差错的原因。结果：共收集到132例给药差错,其中发生在用药环节的差错最多,占56．06％;发生在配置环节的差错占25．00％;发生在转录环节的差错占18．94％。结论：在给药流程的各环节中,始终存在给药差错的风险,护理管理者应根据可预见的风险,梳理给药过程各环节的风险要素,加强给药环节管理,从多元素、多角度着手,管理和防范关键风险点。     

Nurse staffing and medication errors: Cross‐sectional or longitudinal relationships?

We used autoregressive latent trajectory (ALT) modeling to examine the relationship between change in nurse staffing and change in medication errors over 6 months in 284 general medical-surgical nursing units. We also investigated the impact of select hospital and nursing unit characteristics on the baseline level and rate of change in medication errors. We found essentially no support for a nurse staffing-medication error relationship either cross-sectionally or longitudinally. Few hospital or nursing unit characteristics had significant relationships to either the baseline level or rate of change in medication errors. However, ALT modeling is a promising technique that can promote a deeper understanding of the theoretically complex relationships that may underlie the nurse staffing-medication error relationship.     

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.     

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.     

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.     

信息化给药闭环管理模式对护理给药不良事件的影响

目的调查信息化给药闭环管理模式对护理给药不良事件的影响,并对实施信息化给药闭环管理模式后的46例护理给药不良事件进行分析,了解事件发生的特点,并制订对策,以减少护理给药错误的发生。方法回顾性分析厦门大学附属第一医院实施信息化给药闭环管理后(2018年1—12月)系统上报的46起护理给药不良事件,对46起事件从差错的类别、原因、环节等方面进行分析,并将各类事件与信息化给药闭环系统实施前的2017年全年发生的护理给药不良事件进行比较。结果实施给药闭环管理后,各类给药不良事件与2017年比较有所降低,但差异无统计学意义(P>0.05),其中身份识别错误17起(17/46,36.96%),给药遗漏8起(8/46,17.39%),剂量和途径错误分别7起(7/46,15.22%)和5起(5/46,10.87%)。发生给药差错的环节主要为给药环节(26起)和摆药环节(14起)。结论给药不良事件最常发生在给药环节,而身份错误是最常见的错误类型,护理管理者应针对护理给药错误的种类及特点制订针对性的预防措施,持续监控并提高给药闭环扫码率,加强护士培训,做好给药及摆药时的查对。     

我院护理给药差错管理办法的实施与效果

目的有效控制护理给药差错的漏报率，提高住院病人的安全。方法成立护理给药差错评定小组，强化护理人员的安全意识，扩充有效的给药差错报告渠道，细化奖惩细则及评价标准。结果实施护理给药差错管理办法后，给药差错漏报率有明显降低，差异具有统计学意义（P〈0．01）。结论合理的护理给药差错管理办法能激励当事人和科室管理者主动上报差错的发生情况，使护理给药差错管理纳人良性循环。