Adherence to a Medication Safety Protocol: Current Practice for Labeling Medications and Solutions on the Sterile Field

Medication labeling omissions in the OR and the adverse events that result from them remain a challenge in health care facilities. Standardization of protocols based on guidance from the Joint Commission, AORN, the Institute for Safe Medication Practices, and other organizations is important to ensure that patients do not mistakenly receive the wrong medication. A clinical nurse specialist and a perioperative education coordinator at the Cleveland Clinic, Cleveland, Ohio, undertook a direct observation quality improvement project to assess the adherence of 21 nurses and 19 surgical technologists to a revised medication and solution labeling protocol implemented in February 2008. Results showed that overall, 70% of staff members adhered to the medication and solution labeling protocol but adherence varied among specialty areas. There was increased adherence to the protocol by junior staff members compared with more experienced staff members.     

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.     

Antecedents of Severe and Nonsevere Medication Errors

Purpose: To investigate if differences in antecedents of severe and nonsevere medication errors exist.
Design: A longitudinal study of 6 months of data from 279 nursing units in 146 randomly selected hospitals in the United States (US).
Methods: Antecedents of severe and nonsevere medication errors included work environment factors (work dynamics and RN hours), team factors (communication with physicians and nurses' expertise), person factors (nurses' education and experience), patient factors (age, health status, and previous hospitalization), and medication-related support services. Generalized estimating equations with a negative binomial distribution were used with nursing units as the unit of analysis.
Findings: None of the antecedents allowed predicting both types of medication errors. Nurses' expertise had a negative and medication-related support services had a positive association with nonsevere medication errors. Nurses' educational level had a significant nonlinear relationship with severe medication errors only: As the percentage of unit BSN-prepared nurses increased, severe medication errors decreased until the percentage of BSN-prepared nurses reached 54%. In contrast, RN experience had a statistically significant relationship with nonsevere medication errors only and nursing units with more experienced nurses reported more nonsevere medication errors.
Conclusions: Severe and nonsevere medication errors might have different antecedents.
Clinical Relevance: Error prevention and management strategies should be targeted to specific types of medication errors for best results.     

Emergency department medication lists are not accurate

Background: Medication errors are a common source of adverse events. Errors in the home medication list may impact care in the Emergency Department (ED), the hospital, and the home. Medication reconciliation, a Joint Commission requirement, begins with an accurate home medication list. Objective: To evaluate the accuracy of the ED home medication list. Methods: Prospective, observational study of patients aged > 64 years admitted to the hospital. After obtaining informed consent, a home medication list was compiled by research staff after consultation with the patient, their family and, when appropriate, their pharmacy and primary care doctor. This home medication list was not available to ED staff and was not placed in the ED chart. ED records were then reviewed by a physician, blinded to the research-generated home medication list, using a standardized data sheet to record the ED list of medications. The research-generated home medication list was compared to the standard medication list and the number of omissions, duplications, and dosing errors was determined. Results: There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46–66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70–87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78–93%). Conclusion: Our findings now add the ED to the list of other areas within health care with inaccurate medication lists. Strategies are needed that support ED providers in obtaining and communicating accurate and complete medication histories.     

Profiles in Patient Safety: Medication Errors in the Emergency Department

Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here.     

Emergency Department Medication History Taking: Current Inefficiency and Potential for a Self-Administered Form

Background

Emergency Departments (EDs) struggle with obtaining accurate medication information from patients.

Objective

Our aim was to estimate the proportion of urban ED patients who are able to complete a self-administered medication form and record patient observations of the medication information process.

Methods

In this cross-sectional study, we consecutively sampled ED patients during various shifts between 8 am and 10 pm. We created a one-page medication questionnaire that included a list of 49 common medications, categorized by general indications. We asked patients to circle any medications they took and write the names of those not on the form in a dedicated area on the bottom of the page. After their visit, we asked patients to recall which providers had asked them about their medications.

Results

Research staff approached 354 patients; median age was 45 years (interquartile range 29–53 years). Two hundred and forty-nine (70%) completed a form, 61 (17%) were too ill, 19 (5%) could not read it, and 25 (7%) refused to participate. Excluding refusals, 249 of 329 (76%; 95% confidence interval 70–80%) were able to complete the form. Of 209 patients recalling their visit, 180 (86%) indicated that multiple providers took a history, including 103 in which every provider did so, and 9 (4%) indicated that no provider took a medication history.

Conclusions

The process of ED medication information transfer often involves redundant efforts by the health care team. More than 70% of patients presenting for Emergency care were able to complete a self-administered medication information form.     

Duplicate Orders: An Unintended Consequence of Computerized provider/physician order entry (CPOE) Implementation: Analysis and Mitigation Strategies

Objective

Computerized provider/physician order entry (CPOE) with clinical decision support (CDS) is designed to improve patient safety. However, a number of unintended consequences which include duplicate ordering have been reported. The objective of this time-series study was to characterize duplicate orders and devise strategies to minimize them.

Methods

Time series design with systematic weekly sampling for 84 weeks. Each week we queried the CPOE database, downloaded all active orders onto a spreadsheet, and highlighted duplicate orders. We noted the following details for each duplicate order: time, order details (e.g. drug, dose, route and frequency), ordering prescriber, including position and role, and whether the orders originated from a single order or from an order set (and the name of the order set). This analysis led to a number of interventions, including changes in: order sets, workflow, prescriber training, pharmacy procedures, and duplicate alerts.

Results

Duplicates were more likely to originate from different prescribers than from same prescribers; and from order sets than from single orders. After interventions, there was an 84.8% decrease in the duplication rate from weeks 1 to 84 and a 94.6% decrease from the highest (1) to the lowest week (75). Currently, we have negligible duplicate orders.

Conclusions

Duplicate orders can be a significant unintended consequence of CPOE. By analyzing these orders, we were able to devise and implement generalizable strategies that significantly reduced them. The incidence of duplicate orders before CPOE implementation is unknown, and our data originate from a weekly snapshot of active orders, which serves as a sample of total active orders. Thus, it should be noted that this methodology likely under-reports duplicate orders.