The epidemiology of medication errors: how many,how serious?

1. Errors will always occur in any system, but it is essential to identify causes and attempt to minimize risks.
2. Although it is difficult to quantify precisely the extent of medication errors, they are clearly frequent and often avoidable, representing a major threat to patient safety.
3. Many of the consequences of these errors can be prevented by the intervention of pharmacists.
4. Some errors are due to the conditions under which prescribers work; where possible these should be improved (for example, low staffing levels).
5. Computerized prescribing can help but can also generate its own inherent errors.
6. Improved training of prescribers at the undergraduate and postgraduate levels is vital, a fact that is now being belatedly recognized.     

A Computer-based Module for Prescribing Error Instruction

Objective

To evaluate an instructional module''s effectiveness at changing third-year doctor of pharmacy (PharmD) students'' ability to identify and correct prescribing errors.

Design

Students were randomized into 2 groups. Using a computer-based module, group 1 completed worksheet A, watched a presentation on medication errors, and then completed worksheets B and C. Group 2 completed worksheets A and B, watched the presentation, and then completed worksheet C.

Assessment

Both groups scored a median 50% on worksheet A and 66.7% on worksheet C (p < 0.001). Median scores on worksheet B differed between groups (p = 0.0014). Group 1 viewed the presentation before completing worksheet B and scored 62.5%, while group 2 viewed the presentation after scoring 50% on worksheet B.

Conclusion

The module effectively taught pharmacy students to identify and correct prescribing errors.     

Testing a trigger tool as a method of detecting harm from medication errors in a UK hospital: a pilot study

Objectives The aim was to adapt a US adverse drug event (ADE) trigger tool for UK use, and to establish its positive predictive value (PPV) and sensitivity in comparison to retrospective health record review for the identification of preventable ADEs, in a pilot study on one hospital ward. Methods An established US trigger tool was adapted for UK use. We applied it retrospectively to 207 patients' health records, following up positive triggers to identify any ADEs (both preventable and non‐preventable). We compared the preventable ADEs to those identified using full health record review. Key findings We identified 168 positive triggers in 127 (61%) of 207 patients. Seven ADEs were identified, representing an ADE in 3.4% of patients or 0.7 ADEs per 100 patient days. Five were non‐preventable adverse drug reactions and two were due to preventable errors. The prevalence of preventable ADEs was 1.0% of patients, or 0.2 per 100 patient days. The overall PPV was 0.04 for all ADEs, and 0.01 for preventable ADEs. PPVs for individual triggers varied widely. Five preventable ADEs were identified using health record review. The sensitivity of the trigger tool for identifying preventable ADEs was 0.40, when compared to health record review. Conclusions Although we identified some ADEs using the trigger tool, more work is needed to further refine the trigger tool to reduce the false positives and increase sensitivity. To comprehensively identify preventable ADEs, retrospective health record review remains the gold standard and we found no efficiency gain in using the trigger tool.     

Dispensing‐label errors in hospital: types and potential causes

Objective The aim was to evaluate the potential causes of dispensing‐label errors at a hospital. Methods The study took place at a 1200‐bed NHS Foundation Trust with two main pharmacy dispensaries (one manual and one automated). Face‐to‐face interviews were conducted with staff involved in label‐generation errors to obtain in‐depth understanding of dispensing‐label errors. Interviews were tape‐recorded, transcribed and analysed with the aid of Nvivo into themes. Key findings Factors suggested as causing label‐generation errors were illegible handwriting, lack of knowledge, hurrying through tasks, distractions, interruptions and the use of past medical records in generating labels. Self‐checking every stage of the labelling process was suggested as the key to detecting and preventing errors. Conclusions The study highlights the vulnerability of the label‐generation process to errors, with potential causes linked to organisational, environmental, task, team and individual factors.     

Incidence,type and causes of dispensing errors: A review of the literature

Objectives To identify, review and evaluate the published literature on the incidence, type and causes of dispensing errors in community and hospital pharmacy. Method Electronic databases were searched from 1966 to February 2008. This was supplemented by hand‐searching the bibliographies of retrieved articles. Analysis of the findings explored the research methods, operational definitions, incidence, type and causes of dispensing errors. Key findings Sixty papers were identified investigating dispensing errors in the UK, US, Australia, Spain and Brazil. In general, the incidence of dispensing errors varied depending on the study setting, dispensing system, research method and operational definitions. The most common dispensing errors identified by community and hospital pharmacies were dispensing the wrong drug, strength, form or quantity, or labelling medication with the incorrect directions. Factors subjectively reported as contributing to dispensing errors were look‐alike, sound‐alike drugs, low staffing and computer software. High workload, interruptions, distractions and inadequate lighting were objectively shown to increase the occurrence of dispensing errors. Conclusions Comparison of the reviewed studies was confounded by differences in study setting, research method and operational definitions for dispensing errors, error rate and classification of error types. The World Health Organization is currently developing global patient safety taxonomy. Such a standardized taxonomy for dispensing errors would facilitate consistent data collection and assist the development of error‐reduction strategies.     

Implementation of a Standardized Discharge Time-out Process to Reduce Prescribing Errors at Discharge

Background:

To reduce prescribing errors occurring on discharge from the hospital, a standardized discharge time-out process was implemented on a general medicine service at Wake Forest Baptist Medical Center. In the time-out process, the multidisciplinary care team reviewed the patient’s medical records together to determine the optimal discharge medication regimen. This regimen was recorded on a time-out form and then was used to develop the patient’s discharge documents.

Objective:

To evaluate the impact of a standardized discharge time-out process on prescribing errors that occur as patients are discharged from a general medicine service.

Methods:

The medical records of all patients discharged from a general medicine service during 60-day periods before (“pre-group”) and after (“post-group”) implementation of a standardized discharge time-out process were retrospectively reviewed by an internal medicine physician to determine the presence of discharge prescribing errors.

Results:

There were 142 and 124 evaluable patients in the pre- and post-groups, respectively. Compliance with the time-out process was 93% in the post-group. At least 1 prescribing error was detected in 49 (34.5%) of the discharges in the pre-group and 17 (13%) of the discharges in the post-group (P < .0001). All of the errors noted in the post-group occurred in discharges in which a clinical pharmacist was not involved.

Conclusions:

A multidisciplinary, standardized discharge time-out process was associated with a dramatic reduction in prescribing errors when patients were discharged from a general medicine service. The time-out process is one strategy to improve patient safety at hospital discharge.     

Junior doctors prescribing: enhancing their learning in practice

AIM

This aim of this paper was to explore new doctors'' preparedness for prescribing.

METHODS

This was a multiple methods study including face-to-face and telephone interviews, questionnaires and secondary data from a safe prescribing assessment (n = 284). Three medical schools with differing curricula and cohorts were included: Newcastle (systems-based, integrated curriculum); Warwick (graduate entry) and Glasgow [problem-based learning (PBL)], with graduates entering F1 in their local deanery. The primary sample consisted of final year medical students, stratified by academic quartile (n = 65) from each of the three UK medical schools. In addition an anonymous cohort questionnaire was distributed at each site (n = 480), triangulating interviews were conducted with 92 clinicians and questionnaire data were collected from 80 clinicians who had worked with F1s.

RESULTS

Data from the primary sample and cohort data highlighted that graduates entering F1 felt under-prepared for prescribing. However there was improvement over the F1 year through practical experience and support. Triangulating data reinforced the primary sample findings. Participants reported that learning in an applied setting would be helpful and increase confidence in prescribing. No clear differences were found in preparedness to prescribe between graduates of the three medical schools.

CONCLUSION

The results form part of a larger study ‘Are medical graduates fully prepared for practice?’. Prescribing was found to be the weakest area of practice in all sources of data. There is a need for more applied learning to develop skill-based, applied aspects of prescribing which would help to improve preparedness for prescribing.     

Prevention of medication errors: teaching and training

1. Poor prescribing is probably the most common cause of preventable medication errors in hospitals, and many of these events involve junior doctors who have recently graduated. Prescribing is a complex skill that depends on a sound knowledge of medicines, an understanding of the principles of clinical pharmacology, the ability to make judgements concerning risks and benefits, and ideally experience. It is not surprising that errors occur.
2. The challenge of being a prescriber is probably greater now than ever before. Medical education has changed radically in the last 20 years, reflecting concerns about an overburdened curriculum and lack of focus on social sciences. In the UK, these changes have resulted in less teaching in clinical pharmacology and practical prescribing as guaranteed features of undergraduate training and assessment. There has been growing concern, not least from students, that medical school training is not sufficient to prepare them for the pressures of becoming prescribers. Similar concerns are being expressed in other countries. While irrefutable evidence that these changes are related to medication errors identified in practice, there is circumstantial evidence that this is so.
3. Systems analysis of errors suggests that knowledge and training are relevant factors in causation and that focused education improves prescribing performance. We believe that there is already sufficient evidence to support a careful review of how students are trained to become prescribers and how these skills are fostered in the postgraduate years. We provide a list of guiding principles on which training might be based.     

Junior doctors' perceptions of their self-efficacy in prescribing,their prescribing errors and the possible causes of errors

Aims

The aim of the study was to explore and compare junior doctors'' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of those errors.

Methods

A cross-sectional questionnaire study was distributed to foundation doctors throughout Scotland, based on Bandura''s Social Cognitive Theory and Human Error Theory (HET).

Results

Five hundred and forty-eight questionnaires were completed (35.0% of the national cohort). F1s estimated a higher daytime error rate [median 6.7 (IQR 2–12.4)] than F2s [4.0 IQR (0–10) (P = 0.002)], calculated based on the total number of medicines prescribed. The majority of self-reported errors (250, 49.2%) resulted from unintentional actions. Interruptions and pressure from other staff were commonly cited causes of errors. F1s were more likely to report insufficient prescribing skills as a potential cause of error than F2s (P = 0.002). The prescribers did not believe that the outcomes of their errors were serious. F2s reported higher self-efficacy scores than F1s in most aspects of prescribing (P < 0.001).

Conclusion

Foundation doctors were aware of their prescribing errors, yet were confident in their prescribing skills and apparently complacent about the potential consequences of prescribing errors. Error causation is multi-factorial often due to environmental factors, but with lack of knowledge also contributing. Therefore interventions are needed at all levels, including environmental changes, improving knowledge, providing feedback and changing attitudes towards the role of prescribing as a major influence on patient outcome.