Prevalence of errors in a pediatric hospital medication system: implications for error proofing

The purpose of this study was to determine the prevalence of errors in the medication system of a pediatric teaching hospital. Error was defined broadly to capture all deviations in the process from medication order through administration of the dose. The long-term goal was to provide direction to efforts to error-proof the system. The sample was 3,312 medication orders written during 669 patient-days for which a total of 11,978 doses were passed. Errors were categorized as intercepted errors (intercepted through the normal processes of the medication system) or administration errors (errors that involve the patient with or without adverse sequelae). Errors were also categorized as errors in primary activities (e.g., prescribing or preparing the medication for administration) or supporting activity (e.g., transferring the order to another record). A total of 784 errors were identified; 98% were intercepted and 2% were administration errors. More errors (71%) occurred in supporting activities than in primary activities. Medication systems are complex processes. Errors are imbedded in the medication system and are typically intercepted before patients are involved. Intercepting errors involves additional work that adds to an already cumbersome process. Error proofing will be different for errors in primary activities and for supporting activities.     

Evaluating medication errors

What is appropriate disciplinary action for medication errors? Believing the severity of the error is a critical factor in determining disciplinary actions, we developed a tool to assess medication error severity. The El Dorado Medication Error Tool (EDMET) is objective and simple to use. It ensures objectivity, fairness, and clarity of expectations for the staff nurse and ensures consistency of scoring medication errors and disciplinary actions among nurse administrators.     

Impact of pharmacists' interventions on the pediatric discharge medication process

BACKGROUND: To our knowledge, as of August 19, 2004, the impact of pharmacists' interventions on pediatric patients and their caregivers' ability to obtain discharge medications from community pharmacies in a timely fashion has not been described. OBJECTIVE: To evaluate the impact of pharmacists' interventions on patients' likelihood of obtaining medications within 24 hours of hospital discharge. METHODS: Patients meeting study criteria were randomized to an intervention or control group. The intervention was a proactive program of discharge planning by the pharmacy team. All study patients received a follow-up telephone interview to assess the amount of time needed to obtain medications and caregivers' knowledge of how to administer medications. A multivariate linear regression was conducted to assess the association between variables such as insurance, place of residence, number of prescribed medications, and the probability to obtain medications within 24 hours of hospital discharge. RESULTS: The final analysis included 81 control patients and 91 intervention patients. After controlling for a number of factors, the intervention group was able to have obtained medications within 24 hours more often than the control group (84% vs 69%; p = 0.027). Caregivers' knowledge of how to correctly administer medications did not differ between the 2 groups. CONCLUSIONS: Our results suggest that the coordinated efforts of pharmacists' interventions during the discharge process may have a positive impact. Our observations may be used to establish criteria for identifying patients at risk for problems with obtaining medications at discharge.     

Study of nurse workarounds in a hospital using bar code medication administration system

This study analyzed registered nurse workarounds in an academic medical center using bar code medication administration technology. Nurse focus groups and a survey were used to determine the frequency and potential causes of workarounds. More than half of the nurses surveyed indicated that they administered medications without scanning the patient or medications during the last shift worked. Benefits of this study include considerations when implementing bar code medication administration technology that may minimize the development of these workarounds in practice.     

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.     

Managing a new medication administration process

The national focus on medication errors has stimulated rapid adoption of medication administration technologies with bar code verification. The effectiveness of these technologies in preventing errors is directly related to how consistently practitioners use the technology to verify both patient identity and drug identity with each administration. The authors discuss management strategies that have proven effective at increasing staff compliance with using bar code-enabled medication systems.     

Implementing evidence-based nursing practice in a pediatric hospital

A commonly stated reason for dissatisfaction among nurses is that their input regarding patient care and suggestions for improvement in the workplace environment are not solicited or recognized. Nurses can have an active voice in their practice by using the five steps for implementing EBP and being involved in the process of EBP within the work setting. Pediatric nurses have the unique opportunity to become empowered and make a significant difference in their patients' and family's lives by continually asking questions about treatments and care, searching for and evaluating the evidence to support or refute traditional practices, implementing best practice, and evaluating the effectiveness of the evidence as it applies to nursing practice.     

Responding to a fire at a pediatric hospital

Disaster preparedness in health care organizations facilitates a formalized response to major incidents or disasters. This article reviews a man-made disaster, a fire at a large pediatric hospital. How the fire started, patient evacuation, redirecting services, timing of events, key players, geographic factors, communications, and recovery and restoration of care are discussed. Lessons learned and information on disaster preparedness also are presented. AORN J 75 (April 2002) 793-800     

Cerebral infarcts in a pediatric patient secondary to phenylpropanolamine, a recalled medication

Phenylpropanolamine (PPA) recently has been publicly implicated as a cause of stroke and other neurologic events. In November of 2000, the Food and Drug Administration (FDA) requested a voluntary recall of the product from all manufacturers. However, medications containing PPA still can be found in many homes of those unaware of the voluntary recall. We present a case of stroke after PPA ingestion that occurred 4 months after the recall in an 8-year-old boy on chronic peritoneal dialysis. The patient developed occipital infarcts and was found to have extremely elevated levels of PPA in his blood and dialysis fluid. Though the voluntary recall was in effect, the family already had a bottle of the medication at home. Physicians must be aware that the public is still ingesting the drug and remain rigorous in including its toxicity in the differential diagnosis of acute neurologic events.