Improving medication safety and patient care in the emergency department.

INTRODUCTION: Medication errors are well documented in medical literature and the lay press. Through participation in a nationwide institute for healthcare improvement initiative, our emergency department performance improvement group focused on human and system factors that contributed to potential medication errors. METHODS: A survey conducted of ED staff examined barriers to reporting medication errors and potential "near misses." members of the emergency department performance improvement group examined contents of the ed Pyxis machines, assessing medications that physically resembled one another, similar sounding medications located in close proximity, and medications available in differing doses. RESULTS: Fifty-eight members participated in a 4-question survey. Half reported they would be likely to self-report a "near miss" if the patient was not harmed. About half would report the medication error of a colleague under certain circumstances. Fifty-one percent believed there would be repercussions for reporting medication error, but most believed they would receive support from supervisors for addressing other safety problems. Nearly one quarter of the 278 medications identified in the Pyxis survey were similar in appearance or name or existed in multidose formulations. DISCUSSION: Measures to decrease the potential of medication errors include: (1) a workplace environment that promotes reporting of medication errors or "close calls" by staff, with counseling events utilized as learning opportunities versus punitive incidents; (2) increased frequency of medication safety in-service sessions; and (3) periodic monitoring of Pyxis machine inventories to survey contents for optimum patient safety.     

信息化给药闭环管理模式对护理给药不良事件的影响

目的调查信息化给药闭环管理模式对护理给药不良事件的影响,并对实施信息化给药闭环管理模式后的46例护理给药不良事件进行分析,了解事件发生的特点,并制订对策,以减少护理给药错误的发生。方法回顾性分析厦门大学附属第一医院实施信息化给药闭环管理后(2018年1—12月)系统上报的46起护理给药不良事件,对46起事件从差错的类别、原因、环节等方面进行分析,并将各类事件与信息化给药闭环系统实施前的2017年全年发生的护理给药不良事件进行比较。结果实施给药闭环管理后,各类给药不良事件与2017年比较有所降低,但差异无统计学意义(P>0.05),其中身份识别错误17起(17/46,36.96%),给药遗漏8起(8/46,17.39%),剂量和途径错误分别7起(7/46,15.22%)和5起(5/46,10.87%)。发生给药差错的环节主要为给药环节(26起)和摆药环节(14起)。结论给药不良事件最常发生在给药环节,而身份错误是最常见的错误类型,护理管理者应针对护理给药错误的种类及特点制订针对性的预防措施,持续监控并提高给药闭环扫码率,加强护士培训,做好给药及摆药时的查对。     

Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection

OBJECTIVE: To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence. DESIGN: Prospective, direct observation study. SETTING: Tertiary care academic medical center. PATIENTS: Patients in a medical/surgical intensive care unit. INTERVENTIONS: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. MEASUREMENTS AND MAIN RESULTS: The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%). CONCLUSIONS: Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.     

The District Nursing Clinical Error Reduction Programme

The District Nursing Clinical Error Reduction (DANCER) Programme was initiated in NHS Islington following an increase in the number of reported medication errors. The objectives were to reduce the actual degree of harm and the potential risk of harm associated with medication errors and to maintain the existing positive reporting culture, while robustly addressing performance issues. One hundred medication errors reported in 2007/08 were analysed using a framework that specifies the factors that predispose to adverse medication events in domiciliary care. Various contributory factors were identified and interventions were subsequently developed to address poor drug calculation and medication problem-solving skills and incorrectly transcribed medication administration record charts. Follow up data were obtained at 12 months and two years. The evaluation has shown that although medication errors do still occur, the programme has resulted in a marked shift towards a reduction in the associated actual degree of harm and the potential risk of harm.     

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.     

Improving pediatric chemotherapy safety through voluntary incident reporting: lessons from the field.

BACKGROUND: A multidisciplinary team within Vanderbilt Children's Hospital (VCH) designed, developed, and implemented a pediatric chemotherapy incident reporting and improvement system (CIRIS) for pediatric oncology nurse and pharmacists. The aim of this collaboration was to improve pediatric chemotherapy by translating recommendations made by the Institute of Medicine into an operational safety improvement system that is embedded into daily care processes. METHODS: CIRIS improves chemotherapy safety by linking two distinct components: (a) a technical component that uses desktop, laptop, and portable wireless handheld computers to interface the Web-based software application for point-of-care incident reporting and on-demand retrieval of patient support information, and (b) a human component that performs process analysis, data reporting, and clinical improvement. This integrated system facilitates and supports a blame-free culture for reporting of near misses and preventable adverse drug events. RESULTS: Between February 8, 2002, and March 9, 2003, pediatric oncology nurses and chemotherapy pharmacists electronically reported 97 chemotherapy-related incidents associated with 96 unique patients. Ordering errors were the most commonly reported incidents. CIRIS improved reporting performance demonstrated using the conventional paper-based reporting system.     

Using snowball sampling method with nurses to understand medication administration errors

Aims and objectives. We aimed to encourage nurses to release information about drug administration errors to increase understanding of error‐related circumstances and to identify high‐alert situations. Background. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Methods. Snowball sampling was conducted to recruit participants. A semi‐structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Results. Eighty‐five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one‐third of total errors. Among 259 actual errors, 83·8% resulted in no adverse effects; among remaining 16·2%, 6·6% had mild consequences and 9·6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double‐check procedures by colleagues and nurses responsible for errors; reporting rates were 62·5% (162/259) vs. 50·7% (35/69) and only 3·5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High‐alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR). Conclusions. Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high‐alert situations. Strategies for reducing drug administration errors by nurses are suggested. Relevance to clinical practice. Survey results suggest that nurses should double check medication administration in known high‐alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non‐reprimanding atmosphere, helping to establish standard operational procedures for known high‐alert situations.     

Potential underreporting of medication errors in a psychiatric general hospital in Japan

The purpose of this study was to explore a pattern of underreporting within a psychiatric general hospital in Japan. All the medication errors reported online in 2010 were analysed. This research was approved by the university and the study hospital. There were 651 incidents related to medication errors. Medication error rate per 1000 patient days was 2.14 (range: 0.45–6.05). Medication error rates between two acute care wards with comparable case and staff mix differed. A low proportion of intercepted near‐misses and low medication error rates around mealtime in acute care 1 were suggestive of under‐reporting. Two dementia care wards with low medication error rates had no report of intercepted errors, which was also suggestive of underreporting. Ward‐specific medication error rates and patterns are useful to identify wards with potential underreporting of medication error within the hospital.     

Creating an organizational culture for medication safety

Medication errors are costly from human, economic, and societal perspectives. All patients are vulnerable to the detrimental effects of these errors. Recommendations regarding the problem of medication errors include: Prevention of error by learning from the nonpunitive reporting of errors and near misses; Evaluation of the system for potential causes of error through failure mode and effects analysis and encouragement of a questioning attitude; Elimination of system problems that increase the risk of error; Recognition that humans are fallible and that error will occur even in a perfect system; Minimization of the consequences of errors when they do occur. An important goal for healthcare organizations should be to create a culture that accepts the imperfection of human performance and solicits the assistance of team members in the development of safeguards for error prevention. Proposed interventions to prevent medication errors can be described by the PATIENT SAFE taxonomy, which includes: Patient participation; Adherence to established policy and procedures; Technology use; Information accessibility; Education regarding medication safety; Nonpunitive approach to reporting of errors and near misses; Teamwork, communication, and collaboration; Staffing: adequate number and staffing mix; Administration support for the clinical goal of patient safety; Failure mode and effects analysis with team member involvement; Environment and equipment to support patient safety     

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.     

General prescribing principles. Errors and near misses

Remember... Mistakes happen. Know the common medication errors. Take active steps to avoid them in your practice. Know the procedures for reporting errors and near misses. Reflect and learn from mistakes and near misses. Know about your local compliants procedures.     

Barriers to reporting medication errors and near misses among nurses: A systematic review

ObjectiveTo explore barriers to nurses’ reporting of medication errors and near misses in hospital settings.DesignSystematic review.Data sourcesMedline, CINAHL, PubMed and Cochrane Library in addition to Google and Google Scholar and reference lists of relevant studies published in English between January 1981 and April 2015 were searched for relevant qualitative, quantitative or mixed methods empirical studies or unpublished PhD theses. Papers with a primary focus on barriers to reporting medication errors and near misses in nursing were included.Review methodsThe titles and abstracts of the search results were assessed for eligibility and relevance by one of the authors. After retrieval of the full texts, two of the authors independently made decisions concerning the final inclusion and these were validated by the third reviewer. Three authors independently assessed methodological quality of studies. Relevant data were extracted and findings were synthesised using thematic synthesis.ResultsFrom 4038 identified records, 38 studies were included in the synthesis. Findings suggest that organizational barriers such as culture, the reporting system and management behaviour in addition to personal and professional barriers such as fear, accountability and characteristics of nurses are barriers to reporting medication errors.ConclusionsTo overcome reported barriers it is necessary to develop a non-blaming, non-punitive and non-fearful learning culture at unit and organizational level. Anonymous, effective, uncomplicated and efficient reporting systems and supportive management behaviour that provides open feedback to nurses is needed. Nurses are accountable for patients’ safety, so they need to be educated and skilled in error management. Lack of research into barriers to reporting of near misses’ and low awareness of reporting suggests the need for further research and development of educational and management approaches to overcome these barriers.     

ICU incident reporting systems

Intensive care is one of the largest and most expensive components of American health care. Studies suggest that errors and resulting adverse events are common in intensive care units (ICUs). The incidence may be as high as 2 errors per patient per day; 1 in 5 ICU patients may sustain a serious adverse event, and virtually all are exposed to serious risk for harm. Theories of error developed in aviation and other high-risk industries suggest that errors are likely to occur in all complex systems. Reporting of incidents, including both adverse events and near misses, is an essential component for improving safety. Voluntary, confidential reporting is likely to be more important than mandatory reporting. There have been a few efforts to apply such systems in medicine. In intensive care, the Australian Incident Monitoring System (AIMS)-ICU has been the most prominent.We have designed a Web-based ICU Safety Reporting System (ICUSRS). The goal is to identify high-risk situations and working conditions, to help change systems, and reduce the risk for error. The analysis and feedback of reports will inform the design of interventions to improve patient safety. The effort is aided substantially by collaboration with the 30 participating ICUs and important stakeholders including the Society of Critical Care Medicine, the American Society for Health-care Risk Management, the Food and Drug Administration Center for Devices and Radiological Health, the Foundation for Accountability, and the Leapfrog Group. A demonstration and evaluation of the system is underway, funded by the Agency for Healthcare Re-search and Quality.     

Establishment and application of medication error classification standards in nursing care based on the International Classification of Patient Safety

ObjectiveTo standardize the classification, reporting and analysis of medication errors in nursing in order to improve patient safety management by achieving real-time monitoring and systemic analysis.MethodsA system of classifying nurse-related adverse drug effects into four category grades was developed based on the framework provided by the International Classification of Patient Safety. Three investigators used the system to classify 1343 nursing-related drug adverse events reported between January 2006 and December 2010 at 15 tertiary medical institutions in Shanghai.ResultsThe classification standard incorporated all relevant information provided in the reporting system and revealed that the greatest frequency of drug adverse events resulted from staff-related factors. In particular, the largest number of events resulted from routine violations, followed by technology type errors of negligence and fault.ConclusionApplication of this classification system will help nursing administrators to accurately detect system- and process-related defects leading to medication errors, and enable the factors to be targeted to improve the level of patient safety management.     

Improving the reporting of adverse drug reactions in the hospital setting

The US Food and Drug Administration (FDA) is perceived by the public as having a substantial responsibility to ensure drug safety; however, the FDA has limited resources for active surveillance and relies on voluntary reporting of adverse events and potential adverse drug reactions. Studies have shown that underreporting of adverse events and adverse drug reactions is widespread. Furthermore, a review of several studies demonstrates that most adverse drug reactions are reported by pharmacists and nurses, with physicians reporting the fewest. The hospital setting, with its clearly defined patient population observed around the clock, is an ideal setting in which to identify potential adverse drug reaction signals and to report them to either the drug manufacturer or the FDA. In this article we describe the present system for addressing adverse events, obstacles to reporting them, and the important role any hospital physician could play in reporting adverse events and potential adverse drug reactions.     

ENT Self-Test

Abstract

The US Food and Drug Administration (FDA) is perceived by the public as having a substantial responsibility to ensure drug safety; however, the FDA has limited resources for active surveillance and relies on voluntary reporting of adverse events and potential adverse drug reactions. Studies have shown that underreporting of adverse events and adverse drug reactions is widespread. Furthermore, a review of several studies demonstrates that most adverse drug reactions are reported by pharmacists and nurses, with physicians reporting the fewest. The hospital setting, with its clearly defined patient population observed around the clock, is an ideal setting in which to identify potential adverse drug reaction signals and to report them to either the drug manufacturer or the FDA. In this article we describe the present system for addressing adverse events, obstacles to reporting them, and the important role any hospital physician could play in reporting adverse events and potential adverse drug reactions.     

我国护理不良事件报告现况调查及分析

目的:了解我国护理不良事件报告的现状,为完善我国护理不良事件报告系统提供依据.方法:对我国28 个省、自治区、直辖市的288 家医院的护理不良事件资料进行调查分析.结果:被检查的所有医院已全部开展了护理不良事件的上报工作;最早开展报告护理不良事件的277 家医院中,分别有152 家(54.9%) 和132 家(47.7%) 医院实施了给药差错和压疮上报制度 ;目前,分别已有248 家(89.5%)、245 家(88.4%)、227 家(81.9%)、215 家(77.6%) 和216 家(78.0%) 医院实施了给药差错、压疮、跌倒、管路滑脱和意外事件上报制度;省部级、市级医院护理不良事件上报率较县级、民营医院高.结论:我国护理不良事件报告制度已取得了长足的发展,我国还应尽快建立和完善符合国情的护理不良事件报告系统,有效地保障患者安全.     

Adverse effects and medication errors: incidence and role of the organization of drug distribution

The true incidence of adverse drug events is controversial and there are few data concerning the percentage of potentially preventable adverse drug events. Over 2 months, in two internal medicine units, we asked the staff to report adverse drug events. All incidents were evaluated: adverse drug events (preventable and non-preventable) and potential adverse drug events (non-intercepted potential adverse drug events and intercepted potential adverse drug events). The severity, the stage in the process at which the error occurred and the type of error were evaluated by a physician reviewer. Over the 240 admissions, the incidence of adverse drug events is 18 per 1000 patient-days. The system design caused 77 per cent of the incidents. The medication errors occurred at all stages from ordering to administration. Adverse drug events resulting in medication errors (n = 22) were more serious than non-preventable adverse drug events (n = 26) (p = 0.003). A prevention strategy by pharmacovigilance centres (Centres Régionaux de Pharmacovigilance) should target all stages of the drug delivery process.     

Nurses' perceptions: when is it a medication error?

This study investigates nurses' perceptions of medication errors and appropriate reporting. Results of the study suggest that nurses may not report because of fear of reprisal. Further, there may be a need to allow for nursing judgment in some instances; at those time, the term "medication error" may not be the most appropriate. Implications for nursing administration include further exploration of nonpunitive processes in response to adverse drug events.