A practical guide to the implementation of an effective incident reporting scheme to reduce medication error on the hospital ward

This paper discusses an anonymous incident reporting scheme to reduce drug administration error on the hospital ward, as part of an effective, non-punitive, systems-focused approach to safety. Drug error is costly in terms of increased hospital stay, resources consumed, patient harm, lives lost and careers ruined. Safety initiatives that focus, not on blaming individuals, but on improving the wider system in which personnel work have been adopted in a number of branches of health care. However, in nursing, blame remains the predominant approach for dealing with error, and the ward has seen little application of the systems approach to safety. Safety interventions founded on an effective incident scheme typically pay for themselves in terms of dollar savings arising from averted harm. Recent calls for greater health-care safety require finding new ways to make drug administration safer throughout the hospital, and the scope for such safety gains on the hospital ward remains considerable.     

The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre

cutter j. & jordan s. (2012) Journal of Nursing Management
The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre Aim To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Background Surgeons and peri-operative nurses risk acquiring blood-borne viral infections during surgical procedures. Appropriate first-aid and prophylactic treatment after an injury can significantly reduce the risk of infection. However, studies indicate that injuries often go unreported. The ‘systems approach’ to error reduction relies on reporting incidents and near misses. Failure to report will compromise safety. Methods A postal survey of all surgeons and peri-operative nurses engaged in exposure prone procedures in nine Welsh hospitals, face-to-face interviews with selected participants and telephone interviews with Infection Control Nurses. Results The response rate was 51.47% (315/612). Most respondents reported one or more percutaneous (183/315, 58.1%) and/or mucocutaneous injuries (68/315, 21.6%) in the 5 years preceding the study. Only 54.9% (112/204) reported every injury. Surgeons were poorer at reporting: 70/133 (52.6%) reported all or >50% of their injuries compared with 65/71 nurses (91.5%). Conclusions Injuries are frequently under-reported, possibly compromising safety in operating theatres. Implications for nursing management A significant number of inoculation injuries are not reported. Factors influencing under-reporting were identified. This knowledge can assist managers in improving reporting and encouraging a robust safety culture within operating departments.     

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.     

The impact of type of manual medication cart filling method on the frequency of medication administration errors: a prospective before and after study

Background

The medication cart can be filled using an automated system or a manual method and when using a manual method the medication can be arranged either by round time or by medication name. For the manual methods, it is hypothesized that the latter method would result in a lower frequency of medication administration errors because nurses are forced to read the medication labels, but evidence for this hypothesis is lacking.

Objectives

The aim of this study was to compare the frequency of medication administration errors of two different manual medication cart filling methods, namely arranging medication by round time or by medication name.

Design

A prospective, observational study with a before-after design.

Participants and settings

Eighty-six patients who stayed on an orthopaedic ward in one university medical centre in the Netherlands were included.

Methods

Disguised observation was used to detect medication administration errors. The medication cart filling method in usual care was to fill the cart with medication arranged by round time. The intervention was the implementation of the second medication cart filling method, where the medication cart was filled by arranging medicines by their names. The primary outcome was the frequency of medication administrations with one or more error(s) after the intervention compared with before the intervention. The secondary outcome was the frequency of subtypes of medication administration errors.

Results

After the intervention 170 of 740 (23.0%) medication administrations with one or more medication administration error(s) were observed compared to 114 of 589 (19.4%) before the intervention (odds ratio 1.24 [95% confidence interval 0.95-1.62]). The distribution of subtypes of medication administration errors before and after the intervention was statistically significantly different (p < 0.001). Analysis of subtypes revealed more omissions and wrong time errors after the intervention than before the intervention. Unauthorized medication errors were detected more frequently before the intervention than after the intervention.

Conclusion

The frequency of medication administration errors with the medication cart filling method where the medication is arranged by name was not statistically significantly different compared to the medication cart filling method where the medication is arranged by round time.     

The potential for intelligent decision support systems to improve the quality and consistency of medication reviews

What is known and Objective: Drug‐related problems (DRPs) are of serious concern worldwide, particularly for the elderly who often take many medications simultaneously. Medication reviews have been demonstrated to improve medication usage, leading to reductions in DRPs and potential savings in healthcare costs. However, medication reviews are not always of a consistently high standard, and there is often room for improvement in the quality of their findings. Our aim was to produce computerized intelligent decision support software that can improve the consistency and quality of medication review reports, by helping to ensure that DRPs relevant to a patient are overlooked less frequently. A system that largely achieved this goal was previously published, but refinements have been made. This paper examines the results of both the earlier and newer systems. Methods: Two prototype multiple‐classification ripple‐down rules medication review systems were built, the second being a refinement of the first. Each of the systems was trained incrementally using a human medication review expert. The resultant knowledge bases were analysed and compared, showing factors such as accuracy, time taken to train, and potential errors avoided. Results and Discussion: The two systems performed well, achieving accuracies of approximately 80% and 90%, after being trained on only a small number of cases (126 and 244 cases, respectively). Through analysis of the available data, it was estimated that without the system intervening, the expert training the first prototype would have missed approximately 36% of potentially relevant DRPs, and the second 43%. However, the system appeared to prevent the majority of these potential expert errors by correctly identifying the DRPs for them, leaving only an estimated 8% error rate for the first expert and 4% for the second. What is new and conclusion: These intelligent decision support systems have shown a clear potential to substantially improve the quality and consistency of medication reviews, which should in turn translate into improved medication usage if they were implemented into routine use.     

Prevalence of medication administration errors in hospitalized adults: A systematic review and meta-analysis up to 2017 to explore sources of heterogeneity

Previous estimates to meta-analyze administration error rates were limited by the high statistical heterogeneity, restricting their use. This study aimed to investigate sources of heterogeneity in pooled administration error rates in hospitalized adults. We systematically searched scientific databases up to November 2017 for studies presenting error rates/relevant numerical data in hospitalized adults. We conducted separate meta-analyses for the numerators: One Medication Error (OME) (each dose can be correct or incorrect) and Total Number of Errors (TNE) (more than one error per dose could be counted), using the generic inverse variance with a 95% confidence interval. Heterogeneity was assessed using the I² and Cochran's Q test. We meta-analyzed 33 studies. The global pooled analyses based on the OME and TNE numerators showed very high heterogeneity (I² = 100%; p < 0.00001). For each meta-analysis, subgroup analyses based on study characteristics (countries, wards, population, routes of administration, error detection methods, and medications) yielded results with consistently elevated heterogeneity. Beyond these characteristics, we stratified the studies according to the mean error prevalence level as the threshold. Based on the OME numerator, we identified two subgroups of low (0.15[0.13–0.17]; I² = 0%; p = 0.43) and high (0.26[0.24–0.27]; I² = 38%; p = 0.17) pooled prevalence rates, with controlled heterogeneity. Similarly, for the TNE numerator, we identified two subgroups of low (0.10[0.09–0.10]; I² = 0%; p = 0.76) and high (0.28[0.27–0.29]; I² = 0%; p = 0.89) pooled prevalence rates, with controlled heterogeneity. These subgroups differed regarding the denominators used: Total opportunities for errors versus others (doses, observations, administrations). Calculation methods, specifically the denominator, seem a primary factor in explaining heterogeneity in error rates. Standardizing numerators, denominators, and definitions is necessary.