Medication errors in emergency rooms, intensive care units and pediatric wards

Medication safety is a major concern worldwide that directly relates to patient care quality and safety. Reducing medication error incidents is a critical medication safety issue. This literature review article summarizes medication error issues related specifically to three hospital units, namely emergency rooms (ERs), intensive care units (ICUs), and pediatric wards. Time constrains, lack of patient history details and the frequent need to use rapid response life-saving medications are key factors behind high ER medication error rates. Patient hypo-responsiveness, complex medication administration and frequent need to use high-alert medications are key factors behind high ICU medication error rates. Medication error in pediatric wards are often linked to errors made by nurses in calculating dosage based on patient body weight. This article summarizes the major types of medication errors reported by these three units in order to increase nurse awareness of medication errors and further encourage nurses to apply proper standard operational procedures to medication administration.     

对新护士进行高警讯药物知识专题培训的实践

目的研究如何通过培训提高新护士的高警讯药物知识及用药安全意识。方法对进院2年内的新护士进行专题培训20学时,并进行考核。结果新护士高警讯药物理论与操作技能考试成绩显著高于培训前（P〈0．01）,用药差错与护理缺陷明显减少。结论高警讯药物知识专题培训可提高护士的相关药物知识与临床用药安全管理质量。     

A medication safety education program to reduce the risk of harm caused by medication errors

A medication safety education program was developed and implemented to reduce the harm caused to patients by medication errors, specifically errors related to the intravenous infusion of high-alert medications. Participants were required to complete two 30-minute computer modules focusing on medication safety. Changes in the climate of safety, nurses' knowledge and behavior, and the number of infusion pump alerts and reported medication errors were evaluated both before and after completion of the education program. A statistically significant change in knowledge regarding medication errors occurred, but there was no change in the climate of safety scores, the use of behaviors advocated in the medication safety education program to improve medication infusion safety, the number of infusion pump alerts, or the number of reported errors. It was concluded that there was a need for strong administrative support and follow-up to foster changes in behavior, which can lead to a reduction in harm caused by medication errors.     

高危药品说明书中高风险人群儿童用药信息调查

目的 调查北京军区总医院高危药品说明书中高风险人群儿童用药信息的描述情况.方法 以该院在用高危药品品种为研究对象,分别查阅各药品的说明书,对其在儿童用药信息方面的说明情况进行分析.结果 该院在用高危药品共201种,仅78种在儿童用药方面有准确详细的描述,占高危药品总品种数的38.8％.结论 儿童属于高风险用药人群,在高危药品使用中应给予特别关注,但高危药品说明书在儿童用药方面的信息缺失,使儿童在应用高危药品时面临的风险增加,亟需加强说明书中儿童用药信息的补充工作,以保证儿童用药安全.     

加强病区高危药品安全管理的实践与效果

目的 加强对病区高危药品的安全管理,确保患者用药安全.方法 2011年针对医院病区高危药品管理中存在的问题进行原因分析,通过建立安全管理组织、健全安全管理制度、规范使用流程、制订管理手册、组织培训与考核等一系列措施,加强病区高危药品的安全管理.结果 与2010年相比,2011年发生高危药品管理缺陷和用药安全隐患的事件明显下降,差异有统计学意义(x2=6.97,P＜0.05).护理人员对高危药品药学知识的掌握程度有显著提高.结论 加强病区高危药品的安全管理,能有效提高护理人员的安全用药能力,保障患者安全.     

Using Smart Pumps to Reduce Medication Errors in the NICU

Infants in the neonatal intensive care unit (NICU) are considered one of the most vulnerable patient populations, and medication errors in this population can result in devastating, life-threatening consequences. The use of "smart pump" technology has the potential to minimize risk of error by providing safety measures before medication administration. Successful integration of smart pumps requires a clear communication plan to facilitate staff education and acceptance of advanced technology systems. Unit adoption of smart pumps can enhance patient safety while supporting the implementation of evidenced-based practices in nursing care. DOI: 10.1111/j.1751-486X.2012.01721.x.     

Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project

The use of infusion pumps that incorporate "smart" technology (smart pumps) can reduce the risks associated with receiving IV therapies. Smart pump technology incorporates safeguards such as a list of high-alert medications, soft and hard dosage limits, and a drug library that can be tailored to specific patient care areas. Its use can help to improve patient safety and to avoid potentially catastrophic harm associated with medication errors. But when one independent community hospital in Massachusetts switched from older mechanical pumps to smart pumps, it neglected to assign an "owner" to oversee the implementation process. One result was that nurses were using the smart pump library for only 37% of all infusions.To increase pump library usage percentage-thereby reducing the risks associated with infusion and improving patient safety-the hospital undertook a continuous quality improvement project over a four-month period in 2009. With the involvement of direct care nurses, and using quantitative data available from the smart pump software, the nursing quality and pharmacy quality teams identified ways to improve pump and pump library use. A secondary goal was to calculate the hospital's return on investment for the purchase of the smart pumps. Several interventions were developed and, on the first of each month, implemented. By the end of the project, pump library usage had nearly doubled; and the hospital had completely recouped its initial investment.     

Improving medication safety and patient care in the emergency department.

INTRODUCTION: Medication errors are well documented in medical literature and the lay press. Through participation in a nationwide institute for healthcare improvement initiative, our emergency department performance improvement group focused on human and system factors that contributed to potential medication errors. METHODS: A survey conducted of ED staff examined barriers to reporting medication errors and potential "near misses." members of the emergency department performance improvement group examined contents of the ed Pyxis machines, assessing medications that physically resembled one another, similar sounding medications located in close proximity, and medications available in differing doses. RESULTS: Fifty-eight members participated in a 4-question survey. Half reported they would be likely to self-report a "near miss" if the patient was not harmed. About half would report the medication error of a colleague under certain circumstances. Fifty-one percent believed there would be repercussions for reporting medication error, but most believed they would receive support from supervisors for addressing other safety problems. Nearly one quarter of the 278 medications identified in the Pyxis survey were similar in appearance or name or existed in multidose formulations. DISCUSSION: Measures to decrease the potential of medication errors include: (1) a workplace environment that promotes reporting of medication errors or "close calls" by staff, with counseling events utilized as learning opportunities versus punitive incidents; (2) increased frequency of medication safety in-service sessions; and (3) periodic monitoring of Pyxis machine inventories to survey contents for optimum patient safety.     

Creating an organizational culture for medication safety

Medication errors are costly from human, economic, and societal perspectives. All patients are vulnerable to the detrimental effects of these errors. Recommendations regarding the problem of medication errors include: Prevention of error by learning from the nonpunitive reporting of errors and near misses; Evaluation of the system for potential causes of error through failure mode and effects analysis and encouragement of a questioning attitude; Elimination of system problems that increase the risk of error; Recognition that humans are fallible and that error will occur even in a perfect system; Minimization of the consequences of errors when they do occur. An important goal for healthcare organizations should be to create a culture that accepts the imperfection of human performance and solicits the assistance of team members in the development of safeguards for error prevention. Proposed interventions to prevent medication errors can be described by the PATIENT SAFE taxonomy, which includes: Patient participation; Adherence to established policy and procedures; Technology use; Information accessibility; Education regarding medication safety; Nonpunitive approach to reporting of errors and near misses; Teamwork, communication, and collaboration; Staffing: adequate number and staffing mix; Administration support for the clinical goal of patient safety; Failure mode and effects analysis with team member involvement; Environment and equipment to support patient safety     

Principles and practices of medication safety in the ICU

Medication errors are a significant public health problem in United States hospitals. Patients in the ICU are at particular risk for medication errors because of the characteristics of an ICU and the nature of its patients. This article reviews the principles of medication safety and applies these principles to the ICU, and suggests safe practices to improve medication safety in the ICU.     

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.     

西药房高危药品的管理与用药安全分析

目的分析西药房高危药品的管理与用药安全性。方法将2017年8月至2018年7月(常规高危药品管理)、2018年8月至2019年7月(针对性高危药品管理)两个时间段分别设为对照组、观察组,比较两组的高危药品不合理用药情况及药物不良事件发生情况,并调查两个时间段工作人员的高危药品知识知晓程度。结果观察组的不合理用药总发生率、药品不良事件总发生率分别为1.67%、4.00%,低于对照组的8.33%、14.00%,差异具有统计学意义(P<0.05)。观察组工作人员的高危药品知识知晓程度明显优于对照组,差异具有统计学意义(P<0.05)。结论在西药房实施针对性的高危药品管理,可提高用药安全性。     

Doctor-Related Medication Safety Incidents on a Specialist Palliative Medicine Inpatient Unit: A Retrospective Analysis of Three Years of Voluntary Reporting

Patients receiving palliative care and those at the end of life are known to be susceptible to medical errors. Errors related to medications are the most avoidable cause of patient harm. This retrospective study examined reported anonymized medication safety incidents, related to physician errors, assessed by the risk committee in a specialist palliative care unit over a 3-year time period. The aim of the study was to describe medication errors, with specific attention paid to what type of errors occurred and when these errors happened. Of the 218 reported medication safety incidents 28% (n = 62) were related to doctor prescribing. The data showed that there was a wide variation per year in the numbers of reported medication safety incidents. Medication prescribing errors were the most common error, followed by medication omissions. Medication safety incidents are at least in part dependent on staff reporting. Fostering a culture of openness that is blame free is crucial to medication error reporting. Formal reporting may help to increase patient safety and forms an essential element in the clinical governance and risk management of an institution.     

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.     

A continuous quality improvement project to reduce medication error in the emergency department

BACKGROUND:

Medication errors are a common source of adverse healthcare incidents particularly in the emergency department (ED) that has a number of factors that make it prone to medication errors. This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED.

METHODS:

In 2009, a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems.

RESULTS:

Responsible officers were assigned to look after seven error-prone areas. Strategies were proposed, discussed, endorsed and promulgated to eliminate the problems identified. A reduction of medication incidents (MI) from 16 to 6 was achieved before and after the improvement work.

CONCLUSION:

This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.KEY WORDS: Medication error, Medication safety, Continuous Quality Improvement (CQI)     

Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke

Background & purposeAlteplase is the standard of care for early pharmacologic thrombolysis after acute ischemic stroke (AIS). Alteplase is also considered a high-alert medication and is fraught with potential for error. We sought to describe the difference in medication error rates in in patients receiving alteplase for acute ischemic stroke from regional hospitals compared to patients receiving alteplase at the Comprehensive Stroke Center.MethodsThis was a retrospective cohort comparison of patients who were greater than 18 years old that received intravenous alteplase for the treatment of AIS from June 2015 to June 2018. Several institution specific databases were utilized to obtain pertinent data. A standardized taxonomy was utilized to classify medication errors. Patients were excluded if they received any fibrinolytic other than alteplase or if alteplase was used for a non-stroke indication. Two cohorts (from regional hospitals or the Comprehensive Stroke Center (CSC)) were compared.ResultsA total of 676 patients received alteplase during the study period (34% from the CSC and 66% from regional hospitals). There were 133 (19.8%) errors identified. Ten errors (1.6%) occurred at the CSC and 123 (18.2%) errors occurred at regional hospitals. More patients who had an error with alteplase administration (12.7%) experienced a hemorrhagic conversion compared to those with no error in administration (7.2%, p = 0.04).ConclusionThe error rate of alteplase infusion for ischemic stroke is high, particularly in patients from referring centers. Errors may be associated with adverse events. Further education and administration safeguards should be implemented to decrease the risk of medication errors.     

A systems approach to the reduction of medication error on the hospital ward

AIMS: To discuss a potentially powerful approach to safer medication administration on the hospital ward, based on principles of safety developed in other high-risk industries, and consistent with recent national reports on safety in health care released in the United Kingdom (UK) and United States of America (USA). To discuss why punitive approaches to safety on the hospital ward and in the nursing literature do not work. BACKGROUND: Drug administration error on the hospital ward is an ever-present problem and its occurrence is too frequent. Administering medication is probably the highest-risk task a nurse can perform, and accidents can lead to devastating consequences for the patient and for the nurse's career. Drug errors in nursing are often dealt with by unsystematic, punitive, and ineffective means, with little knowledge of the factors influencing error generation. Typically, individual nurses are simply blamed for their carelessness. By focusing on the individual, the complete set of contributing factors cannot be known. Instead, vain attempts will be made to change human behaviour - one of the most change-resistant aspects of any system. A punitive, person-centred approach therefore, severely hampers effective improvements in safety. By contrast, in other high-risk industries, such as aviation and nuclear power, the systems-centred approach to error reduction is routine. CONCLUSIONS: Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports of near-misses and system problems in addition to actual accidents, the systems-approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targeted improvement in the workplace is also important to demonstrate that incident data are being used appropriately, and to maintain high levels of on-going reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well-reasoned approach to its improvement.