Bar-code technology for documenting administration of large-volume intravenous solutions

The failure to properly document dispensing, administration, charging, and crediting of large-volume plain i.v. solutions in a hospital, along with the potential for using bar-code technology to reduce documentation discrepancies, was investigated. Portable bar-code scanners and preprinted bar-code labels were employed to identify large-volume plain i.v. solutions administered on two selected nursing units of a 1000-bed, private, not-for-profit hospital. Inservice training sessions were conducted to instruct hospital personnel in the use of the scanning equipment. Comparisons of patient statements and medication administration records for large-volume plain i.v. solutions established the level of documentation errors in the study hospital. The causes of these errors were traced to three primary sources: (1) failure to document administration of a solution to a patient (38%), (2) failure to credit patients for i.v. solutions returned to the pharmacy (37%), and (3) administration of a solution to a patient other than the patient for whom the solution was dispensed (25%). Accountability for large-volume plain i.v. solution charges to patients was improved by 19% using bar-code technology. The pharmacy manager desiring to employ bar-code technology should determine convenient methods for applying bar-code labels to solutions and for scanning the bar codes, as well as provide programming that can compensate for erroneous scans.     

Evaluation of a schizophrenia medication algorithm in a state hospital.

Provider's practice behaviors before and after physician and staff training in the use of a schizophrenia medication algorithm and the effects of education on physician adherence to the algorithm were evaluated. Medical records of 30 patients admitted between September 1 and November 30, 1999, and 30 patients admitted from September 1 to November 30, 2000, with an admitting and discharge diagnosis of schizophrenia and a minimum length of stay of 14 days were randomly selected and analyzed. Clinical data, including prescribed psychotropic medications and dosages, documentation of target symptoms and severity, adverse drug effects, appropriate clinical ratings, patient's response to treatment, and reason for medication change, were collected and compared with the recommendations in the schizophrenia medication algorithm. Efforts to implement the schizophrenia algorithm included staff education and uniform documentation. Progress notes were evaluated before and after training. After physician and staff training, only 5 of 359 progress notes were written using the recommended documentation form. The number of progress notes containing no documentation of symptoms decreased from 66 to 41, and those documenting three to five target symptoms increased from 74 to 140. Documentation of physician assessment of the presence or absence of adverse effects and their severity decreased from 35.2% to 18.7% and from 22.3% to 17.0%, respectively. Physicians increased the documentation of their clinical global impressions from 12.1% to 20.3%. The recording of medication changes increased twofold, but the difference was not significant. Physician and staff education alone did not significantly alter providers' practice behavior. Inadequate and inconsistent documentation of clinical outcomes made it difficult to assess physician adherence to the treatment algorithm.     

Cost-effectiveness of central automated unit dose dispensing with barcode-assisted medication administration in a hospital setting

BackgroundCentral automated unit dose dispensing (cADD) with barcode-assisted medication administration (BCMA) has been shown to reduce medication administration errors (MAEs). Little is known about the cost-effectiveness of this intervention.ObjectiveTo estimate the cost-effectiveness of cADD with BCMA compared to usual care.MethodsAn economic evaluation was conducted alongside a prospective before-and-after effectiveness study in a Dutch university hospital. The primary effect measure was the difference between the rate of MAEs before and after implementation of cADD with BCMA, obtained by disguised observation in six clinical wards and subsequent extrapolation to the entire hospital. The cost-analysis was conducted from a hospital perspective with a 12-month incremental costing approach. The total costs covered the pharmaceutical service, nurse medication handling, wastage, and materials related to cADD. The primary outcome was the cost-effectiveness ratio expressed as costs per avoided MAE, obtained by dividing the annual incremental costs by the number of avoided MAEs. The secondary outcome was the cost-effectiveness ratio expressed as costs per avoided potentially harmful MAE (i.e. MAEs with the potential to cause harm).ResultsThe intervention was associated with an absolute MAE reduction of 4.5% and a reduction of 2.7% for potentially harmful MAEs. Based on 2,260,870 administered medications in the entire hospital annually, a total of 102,210 MAEs and 59,830 potentially harmful MAEs were estimated to be avoided. The intervention was associated with an increased incremental cost of €1,808,600 annually. The cost-effectiveness ratio was €17.69 per avoided MAE and €30.23 per avoided potentially harmful MAE.ConclusionsThe implementation of cADD with BCMA was associated with a reduced rate of medication errors, including harmful ones, at higher overall costs. The costs per avoided error are relatively low, and therefore, this intervention could be an important strategy to improve patient safety in hospitals.     

Chemotherapy administration precheck verification.

Inappropriate administration of antineoplastics can result in severe adverse reactions or potential therapeutic failure. This article reports the formation and evaluation of a program designed to assure appropriate antineoplastic administration and the creation of a continuous teaching document. The primary goal was to achieve and document safe and appropriate administration of antineoplastic medications. The program was organized, initiated, and evaluated by the clinical pharmacist and assistant director of nursing. Use of available resources allowed program development without additional cost to hospital departments. A teaching series and provision of reference data were made available, and completion of a chemotherapy verification form was required before the nurse administered the antineoplastic. Over 1,500 forms have been completed in a little more than 2 years. Nurses report a high level of compliance with form completion. One chemotherapy error report has been filed in the last 28 months, compared with three error reports in the 8 weeks prior to initiation of the program. Use of the chemotherapy verification form has achieved a high standard of correct administration without errors as defined by our institution and fostered continually conscientious and acceptable antineoplastic administration.     

When do medication administration errors happen to hospital inpatients?

The aim of this study was to determine when medication administration errors (MAEs) are most likely to occur. MAEs were identified by observing nurses preparing and administering medication on a care of the elderly ward during two eight-day periods. The exposure of individual patients to MAEs was also determined. A total of 119 MAEs was identified during the observation of 2,170 opportunities for error, representing an error rate of 5.5 per cent (95 per cent confidence interval, 4.5 per cent to 6.4 per cent). The omission of drugs that were not available on the ward was the predominant type of error. Of the 56 study patients, 35 experienced at least one MAE during the study period. Errors occurred at an average rate of at least 0.3 errors per patient day. The MAE rate was significantly higher on weekdays (6.4 per cent) than during weekends (4.0 per cent) and higher during pharmacy opening hours (7.8 per cent) than when the pharmacy was closed (4.6 per cent). Patients were at greatest risk of MAEs in the first 48 hours of admission and in the first 48 hours after prescribing. A multidisciplinary approach is required to design safer systems.     

Pharmacist-acquired medication histories in a university hospital emergency department.

PURPOSE: A study was conducted to identify discrepancies between medication histories taken by emergency department (ED) providers (physicians, nurses, and medical students) and medication histories taken by clinical pharmacists. METHODS: During a three-month period, a clinical pharmacist was assigned to the ED in a 475-bed, tertiary care teaching facility that serves as a level I trauma center. On the arrival of a patient, ED providers completed a standard assessment that included the patient's medication history. Patients to be admitted through the ED were interviewed by the clinical pharmacist. In addition to a medication history, the pharmacist collected the patient's height, weight, immunization history, and allergy information. The medication history obtained by the ED provider was compared with the history obtained by the clinical pharmacist, and discrepancies were documented. RESULTS: The clinical pharmacists in the ED performed 286 medication histories; 34 were excluded. The remaining 252 histories taken were used in the study. The pharmacists identified 1096 home medications versus 817 home medications documented by ED providers. Of the 817 home medications documented by the ED, the regimens of 637 (78%) were incomplete and were supplemented with dosing information by the pharmacists. Pharmacists reported 375 medication allergies versus 350 reported by ED providers. Immunization histories were obtained in 252 of the 252 (100%) pharmacist-acquired medication histories versus 45 of the 252 (18%) acquired by ED personnel. CONCLUSION: Pharmacist-acquired medication histories in the ED were more complete than those acquired by other health professionals.     

Implementation of a computerized medication administration record

Implementation of a computerized medication record reduces both medication errors and the time pharmacy and nursing services have to spend keeping records. A collaborative team approach to the development of the computerized medication record is integral to its success. The team at Day Kimball Hospital included representatives from departments who participated in goal-setting and problem-solving. The collaborative team also addressed the basic problem areas common to the implementation of the project as well as follow up for the purpose of continuous quality improvement. This article provides insight to professionals who wish to implement a computerized medication record through the collaboration of a team. The outcome of the project is a safe medication administration document, which decreases the potential for medication errors and improves patient outcomes.     

Using bar-code technology and medication observation methodology for safer medication administration.

PURPOSE: The implementation of a multidisciplinary approach to systematically decrease medication errors through the use of observation methodology and the deployment of electronic medication administration records (EMARs) and bar-coded-medication administration (BCMA) is described. SUMMARY: For a consistent and reliable approach to data collection, a direct-observation technique was used. The measurement of medication errors using the observation process occurred in two phases-preimplementation and postimplementation. Three inpatient nursing units participated. The control group was a 20-bed cardiac telemetry unit. Intervention group 1 was also a 20-bed cardiac telemetry unit. Intervention group 2 was a 36-bed medical-surgical unit. During the first phase of the study, all three study groups participated in evaluating the medication administration process associated with a manual five-day medication administration record (MAR). A total of 188 errors were reported. The pharmacy, nursing, and information services departments collaborated on the design and deployment of the EMAR and BCMA systems. The systems were implemented in one nursing unit in August 2003, with full implementation on all inpatient units by July 2004. During the second phase of the study, the control group continued to use the manual five-day MAR without a change in the process. Intervention groups 1 and 2 were measured to evaluate the medication administration process using EMAR and BCMA technology. The direct-observation accuracy rate before BCMA was 86.5%; after BCMA, the rate rose to 97%. CONCLUSION: The direct-observation methodology was used to monitor medication administration before and after the deployment of the EMAR and BCMA systems. A 54% reduction of medication administration errors was observed following implementation of a multidisciplinary, collaborative approach to medication safety.     

Nature and causes of clinically significant medication errors in a tertiary care hospital.

PURPOSE: Medication errors identified through solicited error reports in general medicine and specialty units of a major tertiary care teaching hospital were studied to identify prevalent patterns and causes. METHODS: Medication error reports by a multidisciplinary team of eight clinicians at adult medical and surgical, hematology and oncology, bone marrow transplantation, and medical and cardiac intensive care units were collected prospectively over a three-month period. The reports were validated in terms of clinical significance, causality, and true presence of an error by two independent reviewers. Cluster analysis of valid reports (reports accepted by both reviewers) was used to identify prominent error patterns. RESULTS: Of 321 medication error reports, 240 were included in the analysis. Of these, 95 represented manifested errors and the rest near misses (not manifested [94] or averted [51]). Most manifested errors involved uncontrolled infections associated with prescribed underdoses of antiinfectives (23%), renal failure associated with prescribed overdoses of antiinfectives (4%), central-nervous-system drug intoxication following prescribed overdoses (4%), or uncontrolled pain associated with prescribed underdoses (4%). Most errors were initiated during prescribing (72%) and were associated with deficits in pharmacotherapy knowledge (39%) or with failure to consider critical patient information (18%). Errors initiated during dispensing and administration were mostly associated with performance deficits (e.g., accidental slips and lapses). CONCLUSION: A limited number of prevalent medication-error patterns described more than half of all reported errors in a hospital and suggested excellent areas for quality improvement. Error causes varied with the node of the medication-use process where they arose and suggested the need for tailored interventions to improve clinicians' performance.