Double checking medicines: defence against error or contributory factor?

Rationale and aim  The double checking of medicines in health care is a contestable procedure. It occupies an obvious position in health care practice and is understood to be an effective defence against medication error but the process is variable and the outcomes have not been exposed to testing. This paper presents an appraisal of the process using data from part of a larger study on the contributory factors in medication errors and their reporting.
Methods  Previous research studies are reviewed; data are analysed from a review of 991 drug error reports and a subsequent series of 40 in-depth interviews with health professionals in an acute hospital in northern England.
Results  The incident reports showed that errors occurred despite double checking but that action taken did not appear to investigate the checking process. Most interview participants (34) talked extensively about double checking but believed the process to be inconsistent. Four key categories were apparent: deference to authority, reduction of responsibility, automatic processing and lack of time. Solutions to the problems were also offered, which are discussed with several recommendations.
Conclusions  Double checking medicines should be a selective and systematic procedure informed by key principles and encompassing certain behaviours. Psychological research may be instructive in reducing checking errors but the aviation industry may also have a part to play in increasing error wisdom and reducing risk.     

Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation)

Rationale  Medication errors can lead to preventable adverse drug events (pADEs) that have significant cost and health implications. Errors often occur at care interfaces, and various interventions have been devised to reduce medication errors at the point of admission to hospital. The aim of this study is to assess the incremental costs and effects [measured as quality adjusted life years (QALYs)] of a range of such interventions for which evidence of effectiveness exists.
Methods  A previously published medication errors model was adapted to describe the pathway of errors occurring at admission through to the occurrence of pADEs. The baseline model was populated using literature-based values, and then calibrated to observed outputs. Evidence of effects was derived from a systematic review of interventions aimed at preventing medication error at hospital admission.
Results  All five interventions, for which evidence of effectiveness was identified, are estimated to be extremely cost-effective when compared with the baseline scenario. Pharmacist-led reconciliation intervention has the highest expected net benefits, and a probability of being cost-effective of over 60% by a QALY value of £10 000.
Conclusions  The medication errors model provides reasonably strong evidence that some form of intervention to improve medicines reconciliation is a cost-effective use of NHS resources. The variation in the reported effectiveness of the few identified studies of medication error interventions illustrates the need for extreme attention to detail in the development of interventions, but also in their evaluation and may justify the primary evaluation of more than one specification of included interventions.     

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.     

Medication administration errors and the pediatric population: a systematic search of the literature

Medication administration errors are a serious concern for the pediatric population. This article presented an overview of medication errors and safe medication administration practices. Additional information was presented regarding the pediatric population and specific factors that make this population susceptible to medication errors. A systematic literature search on medication administration errors in the pediatric population was presented. From the search, five themes emerged, including the incidence rate of medication administration errors, specific medications involved in medication administration errors and classification of the errors, why medication administration errors occur, medication error reporting, and interventions to reduce medication errors.Differences in study design made it difficult to compare the articles with regard to some of the themes. However, it was apparent that medication administration errors do occur in the pediatric population, regardless of the exact incidence rate. As previously stated, the NCC MERP believes that there is no acceptable incidence rate for medication errors. Errors in dosage were found to be a common reason as to why medication errors occur. There was some discrepancy with regard to medication error reporting, as it was found that medication errors are underreported, but the extent of this varied. Systems used to report medication errors also varied. It was found that the more detailed the information reported on the medication error, the more potential impact it had on leading to a system change to prevent such errors from occurring again. It is recommended that reporting systems be nonpunitive so that nurses are not afraid to report errors. In addition, more emphasis should be placed on near miss medication errors, as these occur frequently but are rarely reported and may provide greater insight into system flaws. Lastly, interventions found to reduce medication administration errors were congruent with current recommendations for safe medication administration. This calls into question if the current recommendations are being followed uniformly. Implications for future research and practice include that a formalized system check for safe medication administration be developed and utilized. System checks have been developed and are widely used during the prescribing and preparing stage, and less medication errors are noted during this early part of the medication process. Having a formalized system check during medication administration would aid in ensuring that current recommendations are being followed, which would lead to a decrease in medication administration errors.Parents and caregivers naturally expect that their children will be safe when in the health care system. Yet, providing health care will always involve some degree of risk due to both the complexity of the health care environment and the role that human judgment plays within it. Nurses play a role in improving the safety of children within their care. The role of the nurse is much wider than simply reporting patient safety incidents or near misses; it includes taking preventative actions, sharing experiences, learning from mistakes, and helping to devise solutions.     

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.     

Implementation of an intravenous medication infusion pump system: implications for nursing

AIM: To assess perceptions of nurses regarding the implementation of intravenous medication infusion system technology and its impact on nursing care, reporting of medication errors and job satisfaction. BACKGROUND: Medication errors are placing patients at high risk and creating an economic burden for hospitals and health care providers. Infusion pumps are available to decrease errors and promote safety. METHODS: Survey of 1056 nurses in a tertiary care Magnet hospital, using the Infusion System Perception Scale. Response rate was 65.43%. RESULTS: Nurses perceived the system would enhance their ability to provide quality nursing care, reduce medication errors. Job satisfaction was related to higher ratings of the management team and nursing staff. Perceptions verified the pump was designed to promote safe nursing practices. CONCLUSIONS: It is important to consider relationships with job satisfaction, safe nursing practice and the importance of ratings of nursing staff and management teams when implementing infusion technology. IMPLICATIONS FOR NURSING MANAGEMENT: Infusion pumps are perceived by nurses to enhance safe nursing practice. Results stress the importance of management teams in sociotechnological transformations and their impact on job satisfaction among nurses.     

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.     

临床护士对给药错误上报态度的现状调查分析

目的:调查分析临床护士对给药错误的上报态度及上报可能性。方法:采用自制调查表,对1家医院6个科室的89名护士进行调查。结果:护士给药错误上报率低,17.9%的护士认为所发生的给药错误全部被上报了,护士对不同类型给药错误的上报态度存在差异。结论:护士这种偏向于上报某几类给药错误,将给药错误告知医生的做法,应引起管理者重视,应加强培训、营造医院无责罚上报环境。     

Errors in the administration of intravenous medication in Brazilian hospitals

Aim. To verify the frequency of errors in the preparation and administration of intravenous medication in three Brazilian hospitals in the State of Bahia. Background. The administration of intravenous medications constitutes a central activity in Brazilian nursing. Errors in performing this activity may result in irreparable damage to patients and may compromise the quality of care. Design. Cross‐sectional study, conducted in three hospitals in the State of Bahia, Brazil. Methods. Direct observation of the nursing staff (nurse technicians, auxiliary nurses and nurse attendants), preparing and administering intravenous medication. Results. When preparing medication, wrong patient error did not occur in any of the three hospitals, whereas omission dose was the most frequent error in all study sites. When administering medication, the most frequent errors in the three hospitals were wrong dose and omission dose. Conclusions. The rates of error found are considered low compared with similar studies. The most frequent types of errors were wrong dose and omission dose. The hospitals studied showed different results with the smallest rates of errors occurring in hospital 1 that presented the best working conditions. Relevance to clinical practice. Studies such as this one have the potential to improve the quality of care.     

Improving the quality of drug error reporting

Background Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections. Aim The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital. Methods A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi‐disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting. Results The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems‐based. Staff felt obliged to report but rarely received feedback. Implications and conclusion Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi‐centred evaluation.     

住院病人静脉药物治疗给药错误环节分析与对策

目的分析住院病人静脉药物治疗过程中发生给药错误的环节,为制订改进措施提供依据。方法回顾性分析某三级甲等医院过去5年护理非惩罚性主动上报静脉药物治疗给药错误环节、给药错误类型及发生给药错误原因。结果静脉药物治疗发生给药错误的环节由高到低依次为：护士给药操作、护士医嘱处理、护士配药、医生开具医嘱、药房配药发药、病人依从性差;发生给药错误涉及护士、医生、药师、病人;给药错误类型为：药物错误、遗漏给药、发错病人等,操作不规范和流程设计不合理是发生给药错误的主要原因。结论由护士失误引起的给药错误所占比例最高,特别是由护士个人完成的环节,给药错误发生率最高;整体理念是研究预防给药错误发生对策的关键,提高护理管理水平,减少给药错误的发生要从多方面考虑。     

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors

Background: Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. Study Objective: To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. Methods: A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. Results: There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time. Conclusion: ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.     

Enhancing patient safety: The importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students

Reid‐Searl K, Moxham L, Happell B. International Journal of Nursing Practice 2010; 16 : 225–232
Enhancing patient safety: The importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students Medication errors have been the focus of considerable research attention in nursing; however, the extent to which nursing students might contribute to errors has not been researched. Using a grounded theory approach, in‐depth semi‐structured interviews were conducted with undergraduate nursing students based in a university in Queensland to explore their experiences of administering medication in the clinical setting. Almost a third of the participants reported making an actual medication error or a near miss. Where medication errors occurred, participants described not receiving direct and appropriate supervision by a registered nurse. Medication errors by nursing students have the potential to impact significantly on patient safety, quality of health care, and on nursing students' perceptions of their professional competence. Ensuring direct supervision is provided at all times must become an urgent priority for undergraduate nursing education.     

我院护理给药差错管理办法的实施与效果

目的有效控制护理给药差错的漏报率，提高住院病人的安全。方法成立护理给药差错评定小组，强化护理人员的安全意识，扩充有效的给药差错报告渠道，细化奖惩细则及评价标准。结果实施护理给药差错管理办法后，给药差错漏报率有明显降低，差异具有统计学意义（P〈0．01）。结论合理的护理给药差错管理办法能激励当事人和科室管理者主动上报差错的发生情况，使护理给药差错管理纳人良性循环。