An intravenous medication safety system: preventing high-risk medication errors at the point of care

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.     

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.     

Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.

The Institute of Medicine report To Err Is Human: Building a Safe Health System greatly increased national awareness of the need to improve patient safety in general and medication safety in particular. Infusion-related errors are associated with the greatest risk of harm, and "smart" (computerized) infusion systems are currently available that can avert high-risk errors and provide previously unavailable data for continuous quality improvement (CQI) efforts. As healthcare organizations consider how to invest scarce dollars, infusion nurses have a key role to play in assessing need, evaluating technology, and selecting and implementing specific products. This article reviews the need to improve intravenous medication safety. It describes smart infusion systems and the results they have achieved. Finally, it details the lessons learned and the opportunities identified through the use of smart infusion technology at Brigham and Women's Hospital in Boston, Massachusetts.     

Intravenous medication errors in the emergency department,knowledge, tendency to make errors and affecting factors: An observational study

BackgroundIntravenous medication errors are common in hospital settings particularly emergency department. This study aimed to determine intravenous medication preparation and administration errors, contributing factors, tendency towards making errors and knowledge level of emergency department healthcare workers.MethodsA cross-sectional study using a structured, direct observation method was conducted. It was conducted with 23 emergency healthcare workers working in the emergency department of a university hospital in Turkey. Data were collected by questionnaires: Knowledge Test on Intravenous Medication Administration, Intravenous Drug Administration Standard Observation Form, Drug and Transfusion Administration Sub-Dimension scale, Perceived Stress Scale and Pittsburgh Sleep Quality Index.ResultsIt was determined that the knowledge level of the emergency healthcare workers about intravenous medication administration was moderate, and the tendency mistakes regarding drug and transfusion applications was very low. There was no relationship between education level, years of work, years of work in the emergency department, perceived stress level and sleep quality, and the tendency of making mistakes in drug and transfusion applications.ConclusionIt is important for patient safety to prevent medication errors by determining the factors affecting intravenous medication administration, tendency to make mistakes and knowledge levels, which are frequently used in emergency department.     

A clinical information system reduces medication errors in paediatric intensive care

Purpose  

To determine the effect of electronic prescribing (EP) with a clinical information system (Intellivue Clinical Information Portfolio, Philips, UK) on prescribing errors and omitted doses in a paediatric intensive care unit (PICU).     

Nurse perceptions of medication errors: what we need to know for patient safety

This study describes nurse perceptions about medication errors. Findings reveal that there are differences in the perceptions of nurses about the causes and reporting of medication errors. Causes include illegible physician handwriting and distracted, tired, and exhausted nurses. Only 45.6% of the 983 nurses believed that all drug errors are reported, and reasons for not reporting include fear of manager and peer reactions. The study findings can be used in programs designed to promote medication error recognition and reduce or eliminate barriers to reporting.     

Risperidone medication errors in children: an analysis of French poison centres data

Objectives: To describe clinical consequences of risperidone medication errors in children of less than 13 years and to estimate a clinically relevant toxic dose.

Methods: All cases of risperidone medication errors managed by French Poison Centres from 2001 to 2012 were analyzed. Inclusion criteria were a delay of at least 2?hours between ingestion and request to the FPC in asymptomatic children, an ingested dose above two-fold the maximal daily dose for children above 5 years or any symptomatic patient at the time of first contact.

Results: One hundred and sixty cases met our criteria. Median age was 8 years (range 0.9–12) and 28.1% were aged 5 years or less. Causes of the error were an incorrect dose in treated children (84.2%) or a dose given to a wrong child (15.8%). The median ingested dose was 0.1?mg/kg or 3.3-fold the maximum recommended dose. Overall, 59 children had no symptoms, 95 experienced minor symptoms and six moderate symptoms. Somnolence/sedation was the most common (73.3%). Of the 17 children who developed extrapyramidal disorders, all had minor or moderate symptoms and only five required a symptomatic treatment.

Conclusions: Risperidone medication errors in children cause minimal effects. Somnolence and mild to moderate extrapyramidal reactions were the main features of toxicity, and significant cardiac or other neurological features were not observed. No case with severe toxicity was noted. At home surveillance can be proposed for children exposed to a dose ≤0.15?mg/kg.     

Reducing medication errors: Teaching strategies that increase nursing students' awareness of medication errors and their prevention

Medication errors are a patient safety and quality of care issue. There is evidence to suggest many undergraduate nursing curricula do not adequately educate students about the factors that contribute to medication errors and possible strategies to prevent them. We designed and developed a suite of teaching strategies that raise students' awareness of medication error producing situations and their prevention.