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Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey
Abstract
Background:
Medication errors are common in residential aged care facilities (RACFs) due to several factors. Effective medication management is essential to prevent medication errors among older people particularly due to the complexity of co-morbidities they can experience.
Objectives:
This study aimed to examine and quantify the contributing factors of medication errors from nurses' perspectives and the prevention strategies to reduce medication errors among older adults living in RACFs.
Methods:
A survey with 140 completed responses from registered nurses (RNs) and endorsed enrolled nurses (EENs) working in RACFs across Australia were included in the study. The survey had 24 items, related to contributing factors of medication errors, and the prevention strategies. Descriptive statistics and exploratory factor analysis were used in the data analysis process.
Results:
The study identified medication errors are caused by contributing factors such as use of agency staffing (70.4%) and delays in receipt of laboratory results (94.3%). However, it also identified suggestions to reduce medication errors in RACFs, for example use of electronic alerts (88.3%), and efficient laboratory communication (91.8%). Our results revealed three key factors for causes (workload, interprofessional involvement and interruptions) and suggestions (medication safety alerts, medication process improvement and effective reporting).
Conclusion:
Medication errors in RACFs are a global problem being one of the leading causes of morbidity and mortality. The knowledge and awareness of the factors associated with medication errors and the prevention strategies can guide potential quality improvement plans and contribute to minimisation of risk associated with medication safety in RACFs.
Implications for practice:
The study recommends strategies for best practices in medication management such as interprofessional collaboration, implementing standardised policies and electronic alerts to reduce medication errors in RACFs.
... The increasing prevalence of multimorbidity (6) and polypharmacy (7), along with diverse administration schedules and complex dosages, collectively create a highly complex environment for medication management (8) in RAC facilities. Moreover, residents in these care facilities demonstrate distinct lifestyle, pharmacokinetic, and pharmacodynamic traits compared to those of other age groups (9), and the complexities of medication management and high staff turnover can lead to medication incidents (10)(11)(12). ...
... National Residential Medication Charts (eNRMCs)), which have the potential to deliver timely and accurate information to all stakeholders. This also implies that streamlining communication channels between stakeholders within and across medication management stages is important for reducing avoidable medication incidents (11). Importantly, a low proportion (0.3%) of incidents required the resident to be transferred to the hospital and reported an adverse reaction (< 10) in our study sample. ...
Background
Problems with medication management are consistently identified as key concerns for the quality of residential aged care (RAC). Incident reports can provide valuable information on key issues related to medication management; however, few studies have explored medication incidents in residential aged care (RAC) settings. Therefore, this study investigates the characteristics of medication incidents at different stages of medication management and identifies risk factors associated with incidents.
Methods
A retrospective cohort study was conducted using medication incidence data from 25 RAC facilities in New South Wales, Australia. All medication incidents reported between 1st July 2014 and 31st August 2021 relating to 5709 aged care residents aged ≥ 65 years were included. The outcome measure was the medication incidence rate (IR), quantified as the number of medication incidents per 1000 resident days. A multilevel Poisson regression model was performed to identify risk factors associated with exposure to medication incidents.
Results
A total of 5708 medication incidents were reported. The overall medication IR was 1.81 per 1000 resident days (95% CI 1.76, 1.86). Of 5709 residents, 35% (n = 2,016) had at least one recorded medication incident, of which 1,095 had more than one. The majority of the incidents were associated with medication administration (3023 incidents, 53%), followed by supply (n = 1546, 27%) and monitoring the response to the medication (n = 548, 9.6%). The outcome of the incident on residents was reported in 5165 (90%) incidents, with 724 (14%) requiring the resident to be monitored by the hospital, general practitioner (GP), or staff. Respite admissions were associated with a higher risk of medication incidents compared with permanent admissions (rate ratio (RR) = 1.908, 95% CI 1.646, 2.211, p < 0.01). Residents with Parkinson’s disease had a 1.5-fold greater risk of a medication incident (RR = 1.586, 95% CI 1.318, 1.908) compared to other residents. The administration of more than five medications (polypharmacy) was associated with an increased risk of medication incidents (RR = 2.019, 95% CI 1.930, 2.111).
Conclusion
Medication incidents affected more than one-third of older adults in RAC facilities. Improvement strategies should focus on medication administration, supply and monitoring, with particular attention given to respite residents and those with multimorbidity and polypharmacy.
Background
People living in residential aged care homes are entitled to a safe environment 24 hours a day, 7 days a week. Unfortunately, past evidence tells us this is not always the case and that our most vulnerable population experience high rates of adverse events.
Aim
To determine whether after-hours shifts are associated with number of adverse events, independent of registered nurse staffing levels and residential aged care home size.
Methods
Retrospective cohort design with multilevel modelling. Adverse events, registered nurse staffing and facility size were collected via routine reporting from ten homes (1020 beds) in one Australian state for three months in 2017.
Findings
Residents records (n = 1560) of adverse events were collected from ten Residential Aged Care Homes with 1020 beds. An adverse event was reported, on average, every second shift per home. During afterhours shifts, there was an inverse association between nurse staffing and adverse events, such that lower nurse staffing was associated with higher rates of adverse events, specifically for falls and pressure injuries/skin tears. During day shifts, this effect was not seen.
Discussion
The findings support statements made at the Royal Commission into Aged Care Quality and Safety regarding the lack of adequacy of nurse staffing supervision during and after hours and may contribute to considerations of upcoming mandated registered nursing contact hours for 16 of the 24 hours in a day.
Conclusion
During after-hour shifts, but not day shifts, having fewer nurses is associated with more likelihood of adverse event occurrences in Australian residential aged care homes. More research, in more sites and across more organisations, with better granulation across day, evening, night and weekend/public holiday shifts will improve understanding and responsiveness to the phenomena. Future research examining falls should include staffing levels.
This study examined the effects of nurse staffing levels, work environment, and education levels on adverse events in nursing homes. A cross-sectional study was conducted involving 216 nurses working in 62 nursing homes in South Korea, using self-reported questionnaires and data from the National Health Insurance Service of South Korea. A logistic regression model was used to investigate the effects of nurse staffing levels, work environment, and nursing education levels on the adverse events experienced by residents. An increase of one resident per nurse was significantly associated with a higher incidence of medication error, pressure ulcers and urinary tract infections. A poor work environment increased the incidence of adverse events. Compared to nurses with a bachelor’s degree or higher, those with diplomas reported increased incidence rates of pressure ulcers. Improving the health outcomes of residents in nursing homes requires efforts that strengthen the nursing workforce in terms of numbers and educational level, and which improve their work environment at institutional and policy levels.
Background
Medication management in residential aged care facilities is an ongoing concern. Numerous studies have reported high rates of inappropriate prescribing and medication use in aged care facilities, which contribute to residents’ adverse health outcomes. There is a need for new models of care that enhance inter-disciplinary collaboration between residential aged care facility staff and healthcare professionals, to improve medication management. Pilot research has demonstrated the feasibility and benefits of integrating a pharmacist into the aged care facility team to improve the quality use of medicines. This protocol describes the design and methods for a cluster randomised controlled trial to evaluate the outcomes and conduct economic evaluation of a service model where on-site pharmacists are integrated into residential aged care facility healthcare teams to improve medication management.
Methods
Intervention aged care facilities will employ on-site pharmacists to work as part of their healthcare teams 2 to 2.5 days per week for 12 months. On-site pharmacists, in collaboration with facility nurses, prescribers, community pharmacists, residents and families will conduct medication management activities to improve the quality use of medicines. Aged care facilities in the control group will continue usual care. The target sample size is 1188 residents from a minimum of 13 aged care facilities. The primary outcome is the appropriateness of prescribing, measured by the proportion of residents who are prescribed at least one potentially inappropriate medicine according to the 2019 Beers Criteria. Secondary outcomes include hospital and emergency department presentations, fall rates, prevalence and dose of antipsychotics and benzodiazepines, Anticholinergic Cognitive Burden Score, staff influenza vaccination rate, time spent on medication rounds, appropriateness of dose form modification and completeness of resident’s allergy and adverse drug reaction documentation. A cost-consequence and cost-effectiveness analysis will be embedded in the trial.
Discussion
The results of this study will provide information on clinical and economic outcomes of a model that integrates on-site pharmacists into Australian residential aged care facilities. The results will provide policymakers with recommendations relevant to further implementation of this model.
Trial registration
ACTRN12620000430932 . Registered on 1 April 2020 with ANZCTR
Physicians should be aware of look‐alike/sound‐alike (LASA) drug names. Clearly legible drug prescriptions, preferably via electronic drug prescription systems, and the use of Tall Man lettering may help to prevent LASA medication errors. Physicians should be aware of look‐alike/sound‐alike (LASA) drug names. Clearly legible drug prescriptions, preferably via electronic drug prescription systems, and the use of Tall Man lettering may help to prevent LASA medication errors.
Background
Medication errors (MEs) in hospital settings are attributed to various factors including the human factors. Human factors researches are aiming to implement the knowledge regarding human nature and their interaction with surrounding equipment and environment to design efficient and safe systems. Human Factors Frameworks (HFF) developed awareness regarding main system's components that influence healthcare system and patients' safety. An in-depth evaluation of human factors contributing to medication errors in the hospital pharmacy is crucial to prevent such errors.
Objective
This study, therefore, aims to identify and categorize the human factors of MEs in hospital pharmacy using the Human Factors Framework (HFF).
Method
A qualitative study conducted in King Saud Medical City, Riyadh, Kingdom of Saudi Arabia. Data collection was carried out in two stages; the first stage was the semi-structured interview with the pharmacist or technician involved in the medication error. Then, occupational burnout and personal fatigue scores of participants were assessed. Data analysis was done using thematic analysis.
Results
A total of 19 interviews were done with pharmacists and technicians. Themes were categorized using HFF into five categories; individual, organization and management, task, work, and team factors. Examples of these themes are poor staff competency, insufficient staff support, Lack of standardization, workload, and prescriber behaviour respectively. Scores of fatigue, work disengagement, and emotional exhaustion are correlating with medium fatigue, high work disengagement, and high emotional exhaustion, respectively.
Conclusions
The study provided a unique insight into the contributing factors to MEs in the hospital pharmacy. Emotional stress, lack of motivation, high workload, poor communication, and missed patient information on the information system, are examples of the human factors contributing to medication errors. Our study found that among those factors, organizational factors had a major contribution to medication safety and staff wellbeing.
Background Medication errors are avoidable events that may occur at any stage of the medication use process. Implementing a clinical pharmacist is one strategy that is believed to reduce the number of medication errors. Pediatric patients, who are more vulnerable to medication errors due to several contributing factors, may benefit from the interventions of a pharmacist. Aim of the review To qualitatively and quantitatively evaluate the impact of clinical pharmacist interventions on medication error rates for hospitalized pediatric patients. Methods PubMed, EMBASE, Cochrane Controlled Trials Register and Google Scholar search engines were searched from database inception to February 2020. Study selection, data extraction and quality assessment was conducted by two independent reviewers. Observational and interventional studies were included. Data extraction was done manually and the Crowe Critical Appraisal Tool was used to critically appraise eligible articles. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Results 19 studies were systematically reviewed and 6 studies (29,291 patients) were included in the meta-analysis. Pharmacist interventions involved delivering educational sessions, reviewing prescriptions, attending rounds and implementing a unit-based clinical pharmacist. The systematic review indicated that the most common trigger for pharmacist interventions was inappropriate dosing. Pharmacist involvement was associated with significant reductions in the overall rate of medication errors occurrence (OR 0.27; 95% CI 0.15 to 0.49). Conclusion Pharmacist interventions are effective for reducing medication error rates in hospitalized pediatric patients.
The Australian government has reduced restrictions on ownership of residential aged care facilities (RACF) as part of aged care reform enabling the growth of private‐for‐profit ownership. This study explores the impact of private‐for‐profit ownership through comparison of perceptions of the volume of missed care in government, private‐not‐profit and for‐profit RACF in Australia. Data were collected through development and administration of a MISSCARE survey to 3,206 nurses and personal care workers (PCW) working in RACF and hospitals providing aged care services. Employees working within government owned facilities reported levels of missed care that are significantly lower than privately owned facilities on six activities: moving patients who cannot walk; assisting residents’ toileting within 5 min of request; assisting resident mouth care; assessing skin integrity; answering call bells within 5 min and wound care. Staffing levels were identified as the most common reason for missed care across all settings. Of the 27 factors identified as causing missed care, government employees reported significantly lower scores for 16 items. Further research is needed on the impact of facility ownership upon capacity of nurses and personal care workers to deliver care.
The phenomena of missed nursing care is usually measured through quantitative surveys that detail the specific tasks that are rationed or delayed, and the reasons why this is so. These studies report high levels of agreement within and across countries between the two major measures employed; the Kalisch’s MISSCARE tool and the RN4Cast Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Most of these studies have been conducted in acute care settings and demonstrate the impact of lack of human and other resources upon decisions to omit care. Less in known about missed care in residential aged care
Background: Medication error (ME) is a worldwide issue, but most studies on ME have been undertaken in developed countries and very little is known about ME in Southeast Asian countries. This study aimed systematically to identify and review research done on ME in Southeast Asian countries in order to identify common types of ME and estimate its prevalence in this region.
Methods: The literature relating to MEs in Southeast Asian countries was systematically reviewed in December 2014 by using; Embase®, Medline®, Pubmed®, ProQuest Central® and the CINAHL®. Inclusion criteria were studies (in any languages) that investigated the incidence and the contributing factors of ME in patients of all ages. Results: The 17 included studies reported data from six of the eleven Southeast Asian countries: five studies in Singapore, four in Malaysia, three in Thailand, three in Vietnam, one in the Philippines and one in Indonesia. There was no data on MEs in Brunei, Laos, Cambodia, Myanmar and Timor. Of the seventeen included studies, eleven measured administration errors, four focused on prescribing errors, three were done on preparation errors, three on dispensing errors and two on transcribing errors. There was only one study of reconciliation error. Three studies were interventional. Discussion: The most frequently reported types of administration error were incorrect time, omission error and incorrect dose. Staff shortages, and hence heavy workload for nurses, doctor/nurse distraction, and misinterpretation of the prescription/medication
chart, were identified as contributing factors of ME. There is a serious lack of studies on this topic in this region which needs to be addressed if the issue of ME is to be fully understood and addressed.
To measure the impact of electronic medication reconciliation implementation on reports of admission medication reconciliation errors (MREs).
Quality improvement project with time-series design.
A large, urban, tertiary care children's hospital.
All admitted patients from 2011 and 2012.
Implementation of an electronic medication reconciliation tool for hospital admissions and regular compliance reporting to inpatient units. The tool encourages active reconciliation by displaying the pre-admission medication list and admission medication orders side-by-side.
Rate of non-intercepted admission MREs identified via a voluntary reporting system.
During the study period, there were 33 070 hospital admissions. The pre-admission medication list was consistently recorded electronically throughout the study period. In the post-intervention period, the use of the electronic medication reconciliation tool increased to 84%. Reports identified 146 admission MREs during the study period, including 95 non-intercepted errors. Pre- to post-intervention, the rate of non-intercepted errors decreased by 53% (P = 0.02). Reported errors were categorized as intercepted potential adverse drug events (ADEs) (35%), non-intercepted potential ADEs (42%), minor ADEs (22%) or moderate ADEs (1%). There were no reported MREs that resulted in major or catastrophic ADEs.
We successfully implemented an electronic process for admission medication reconciliation, which was associated with a reduction in reports of non-intercepted admission MREs.
© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.
Warfarin is frequently administered to hospital patients. The prescription and administration of this medication are particularly susceptible to error. Factors contributing to this include the narrow therapeutic index, patient-specific target range, and the need for regular INR monitoring. NICE guidelines state that warfarin should be given at the same time every day and the Bristol Royal Infirmary guidelines are warfarin to be given at 14:00. The 14:00 dosing ensures standardisation of administration; poor adherence to this recommendation may cause patient harm. We noticed that many warfarin doses were often given outside of maximal staffing hours and it was often left to the on call doctor to prescribe warfarin at erratic and inconsistent times.
Our primary aim was to reduce the number of adverse outcomes associated with warfarin prescription and administration. We targeted two system measures: the proportion of warfarin administrations occurring within an hour of the 14:00 prescription and the proportion of INR results outside target range. We employed the model for improvement and carried out our project across seven acute medical wards. Baseline data showed that only 24% of doses were being given within an hour of the recommended time and 64% of doses were being given after 17:00 during minimal staffing hours. We successfully introduced a warfarin box within our trust which demonstrated an improvement in warfarin administration from 24% of patients receiving their warfarin within an hour of 14:00 to 49% and this was subsequently associated with a reduction in INRs above target range (23% to 9%).
Medication errors remain one of the most common causes of unintended harm to patients. They contribute to adverse events that compromise patient safety and result in a large financial burden to the health service. The prevention of medication errors, which can happen at every stage of the medication preparation and distribution process, is essential to maintain a safe healthcare system. One third of the errors that harm patients occur during the nurse administration phase: administering medication to patients is therefore a high-risk activity. This article highlights factors that contribute to medication errors, including the safety culture of institutions. It also discusses factors that relate specifically to nurses, such as patient acuity and nursing workload, the distractions and interruptions that can occur during medication administration, the complexity of some medication calculations and administration methods, and the failure of nurses to adhere to policies or guidelines.
Medical educators attempt to create reliable and valid tests and questionnaires in order to enhance the accuracy of their assessment and evaluations. Validity and reliability are two fundamental elements in the evaluation of a measurement instrument. Instruments can be conventional knowledge, skill or attitude tests, clinical simulations or survey questionnaires. Instruments can measure concepts, psychomotor skills or affective values. Validity is concerned with the extent to which an instrument measures what it is intended to measure. Reliability is concerned with the ability of an instrument to measure consistently.1 It should be noted that the reliability of an instrument is closely associated with its validity. An instrument cannot be valid unless it is reliable. However, the reliability of an instrument does not depend on its validity.2 It is possible to objectively measure the reliability of an instrument and in this paper we explain the meaning of Cronbach’s alpha, the most widely used objective measure of reliability.
We investigated incidence rates to understand the nature of medication errors potentially introduced by utilizing a computerized physician order entry (CPOE) system in the three clinical phases of the medication process: prescription, administration, and documentation.
Overt observations and chart reviews were employed at two surgical intensive care units of a 950-bed tertiary teaching hospital. Ten categories of high-risk drugs prescribed over a four-month period were noted and reviewed. Error definition and classifications were adapted from previous studies for use in the present research. Incidences of medication errors in the three phases of the medication process were analyzed. In addition, nurses' responses to prescription errors were also assessed.
Of the 534 prescriptions issued, 286 (53.6%) included at least one error. The proportion of errors was 19.0% (58) of the 306 drug administrations, of which two-thirds were verbal orders classified as errors due to incorrectly entered prescriptions. Documentation errors occurred in 205 (82.7%) of 248 correctly performed administrations. When tracking incorrectly entered prescriptions, 93% of the errors were intercepted by nurses, but two-thirds of them were recorded as prescribed rather than administered.
The number of errors occurring at each phase of the medication process was relatively high, despite long experience with a CPOE system. The main causes of administration errors and documentation errors were prescription errors and verbal order processes. To reduce these errors, hospital-level and unit-level efforts toward a better system are needed.
Patient safety is one of the main concepts in the field of healthcare provision and a major component of health services quality. One of the important stages in promotion of the safety level of patients is identification of medication errors and their causes. Medical errors such as medication errors are the most prevalent errors that threaten health and are a global problem. Execution of medication orders is an important part of the treatment and care process and is regarded as the main part of the nurses’ performance. The purpose of this study was to explore the medication error reporting rate, error types and their causes among nurses in the emergency department.
In this descriptive study, 94 nurses of the emergency department of Imam Khomeini Hospital Complex were selected based on census in 2010–2011. Data collection tool was a researcher-made questionnaire consisting of two parts: demographic information, and types and causes of medication errors. After confirming content-face validity, reliability of the questionnaire was determined to be 0.91 using Cronbach’s alpha test. Data analyses were performed by descriptive statistics and inferential statistics. SPSS-16 software was used in this study and P values less than 0.05 were considered significant.
The mean age of the nurses was 27.7 ± 3.4 years, and their working experience was 7.3 ± 3.4 years. Of participants 46.8% had committed medication errors in the past year, and the majority (69.04%) had committed the errors only once. Thirty two nurses (72.7%) had not reported medication errors to head nurses or the nursing office. The most prevalent types of medication errors were related to infusion rates (33.3%) and administering two doses of medicine instead of one (23.8%). The most important causes of medication errors were shortage of nurses (47.6%) and lack of sufficient pharmacological information (30.9%).
This study showed that the risk of medication errors among nurses is high and medication errors are a major problem of nursing in the emergency department. We recommend increasing the number of nurses, adjusting the workload of the nursing staff in the emergency department, retraining courses to improve the staff’s pharmacological information, modification of the education process, encouraging nurses to report medical errors and encouraging hospital managers to respond to errors in a constructive manner in order to enhance patient safety
Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence.
This study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings.
Nine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013.
Inclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail.
A total of 54 unique studies were included. Causes of MAEs were categorised according to Reason's model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used.
Slips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality), patient factors (availability, acuity), staff health status (fatigue, stress) and interruptions/distractions during drug administration. Few studies sought to determine the causes of intravenous MAEs. A number of latent pathway conditions were less well explored, including local working culture and high-level managerial decisions. Causes were often described superficially; this may be related to the use of quantitative surveys and observation methods in many studies, limited use of established error causation frameworks to analyse data and a predominant focus on issues other than the causes of MAEs among studies.
As only English language publications were included, some relevant studies may have been missed.
Limited evidence from studies included in this systematic review suggests that MAEs are influenced by multiple systems factors, but if and how these arise and interconnect to lead to errors remains to be fully determined. Further research with a theoretical focus is needed to investigate the MAE causation pathway, with an emphasis on ensuring interventions designed to minimise MAEs target recognised underlying causes of errors to maximise their impact.
Medication errors in hospitals are a worldwide concern. The World Health Organization has recommended the implementation of basic applications in healthcare systems to improve medication safety, but it is largely unknown whether these recommendations are adhered to by hospitals. We assessed the presence of core medication safety practices in Saudi Arabian hospitals.
We developed and validated a survey to assess medication safety practices in hospitals. Major headings included Look-Alike Sound-Alike (LASA) medications, control of concentrated electrolyte solutions, transitions in care, information technology, drug information and other medication safety practices. Trained pharmacists visited samples of hospitals from all regions of Saudi Arabia.
Seventy-eight hospitals were surveyed. Only 30% of the hospitals had a medication safety committee and 9% of hospitals had a medication safety officer. Only 33% of hospitals had a list of LASA medications and 50% had a list of error-prone abbreviations. Concentrated electrolytes were available in floor stock in 60% of the hospitals. No hospital involved pharmacists in obtaining medication histories and only 37% of the hospitals provided a medication list to the patients at discharge. While 61% of hospitals used a computer system in their pharmacy to enter prescriptions, only 29% of these hospitals required entry of patient's allergies before entering a drug order.
Core practices to improve medication safety were not implemented in many hospitals in Saudi Arabia. In developing countries, an effort must be made at the national level to increase the adoption of such practices.
Older people in long-term residential care are at increased risk of medication prescribing and administration errors. The main aim of this study was to measure the incidence of medication administration errors in nursing and residential homes using a barcode medication administration (BCMA) system.
A prospective study was conducted in 13 care homes (9 residential and 4 nursing). Data on all medication administrations for a cohort of 345 older residents were recorded in real-time using a disguised observation technique. Every attempt by social care and nursing staff to administer medication over a 3-month observation period was analysed using BCMA records to determine the incidence and types of potential medication administration errors (MAEs) and whether errors were averted. Error classifications included attempts to administer medication at the wrong time, to the wrong person or discontinued medication. Further analysis compared data for residential and nursing homes. In addition, staff were surveyed prior to BCMA system implementation to assess their awareness of administration errors.
A total of 188,249 medication administration attempts were analysed using BCMA data. Typically each resident was receiving nine different drugs and was exposed to 206 medication administration episodes every month. During the observation period, 2,289 potential MAEs were recorded for the 345 residents; 90% of residents were exposed to at least one error. The most common (n = 1,021, 45% of errors) was attempting to give medication at the wrong time. Over the 3-month observation period, half (52%) of residents were exposed to a serious error such as attempting to give medication to the wrong resident. Error incidence rates were 1.43 as high (95% CI 1.32-1.56 p < 0.001) in nursing homes as in residential homes. The level of non-compliance with system alerts was very low in both settings (0.075% of administrations). The pre-study survey revealed that only 12/41 staff administering drugs reported they were aware of potential administration errors in their care home.
The incidence of medication administration errors is high in long-term residential care. A barcode medication administration system can capture medication administration errors and prevent these from occurring.
HEALTH POLITICAL BACKGROUND: Computerized physician order entry (CPOE) systems are software to electronically enter medication orders. They can be equipped with tools for decision support (CDS). In Germany, various vendors offer such systems for hospitals and physicians' offices. These systems have mostly been developed during the last five to ten years.
This HTA-report aims to evaluate the effectiveness and efficiency of CPOE-/CDS-systems and their ethical, social and legal aspects.
The systematic literature search (27 international data bases) yielded 791 abstracts. Following a two-part selection process, twelve publications were included in the assessment.
All reviews and studies included in the present report show that the use of CPOE-/CDS-systems can lead to a reduction of medication errors. Minor errors can be eliminated almost completely. The effect of CPOE-/CDS-systems on the rate of adverse drug events (ADE) is evaluated in only two primary studies with conflicting results. It is difficult to compare the results of economical studies because they evaluate different settings, interventions and time frames. In addition, the documentation often is not fully transparent. All four studies included measure costs and effects from the perspective of a hospital or hospital affiliation. Concerning social aspects, the literature points at changes regard competing interests of technology and humans that result from the implementation of CPOE-systems. The experience of institutions in which the implementation of CPOE-systems leads to problems showed that the importance of considering the socio-organisational context had partly been underestimated.
CPOE-/CDS-systems are able to reduce the rate of medication errors when ordering medications. The adherence to guidelines, communication, patient care and personnel satisfaction can also be affected positively. However, the literature also reports negative effects, as through the use of CPOE-/CDS-systems new errors can be generated. This makes continuous revisions of the system, as well as data-updates necessary. Concerning the cost-benefit-ratio from the hospital perspective, the two qualitatively best economic studies show contradictory results. Therefore, a positive cost-benefit-ratio for individual hospitals cannot be assumed, particularly as the study results cannot be generalized.
If the implementation of CPOE-/CDS-systems is well planned and conducted, the system adapted to the needs of the institution and continuously reviewed, and data used are updated on a regular basis, the rate of medication ordering errors can be reduced considerably by using CPOE-/CDS-systems. However, it is not clear how this results in a reduction of ADE. Prospective, systematic multi-centre evaluation-studies with clear methodology are needed, which include an analysis of the user-friendliness and of social and technical aspects of the system. Such studies should evaluate the impact a CPOE-/CDS-system has on ADE-rates and mortality. A detailed description of the system used and of the hospital evaluated is essential. If possible, costs and cost effects should be surveyed and documented transparently.
Medication errors have been increasingly recognized as a major cause of iatrogenic illness and system-wide improvements have been the focus of prevention efforts. Critically ill patients are particularly vulnerable to injury resulting from medication errors because of the severity of illness, need for high risk medications with a narrow therapeutic index and frequent use of intravenous infusions. Health information technology has been identified as method to reduce medication errors as well as improve the efficiency and quality of care; however, few studies regarding the impact of health information technology have focused on patients in the intensive care unit. Computerized physician order entry and clinical decision support systems can play a crucial role in decreasing errors in the ordering stage of the medication use process through improving the completeness and legibility of orders, alerting physicians to medication allergies and drug interactions and providing a means for standardization of practice. Electronic surveillance, reminders and alerts identify patients susceptible to an adverse event, communicate critical changes in a patient's condition, and facilitate timely and appropriate treatment. Bar code technology, intravenous infusion safety systems, and electronic medication administration records can target prevention of errors in medication dispensing and administration where other technologies would not be able to intercept a preventable adverse event. Systems integration and compliance are vital components in the implementation of health information technology and achievement of a safe medication use process.
Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.
A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.
The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff's high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.
That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.
A myriad of errors and lost improvement opportunities result from failure of clinical laboratory and pharmacy information systems to effectively communicate. Pharmacotherapy could benefit from enhanced laboratory-pharmacy linkage with respect to (1) drug choice (laboratory-based indications and contraindications), (2) drug dosing (renal or hepatic, blood level-guided adjustments), (3) laboratory monitoring (laboratory signals of toxicity, baseline and ongoing monitoring), (4) laboratory result interpretation (drug interfering with test), and (5) broader quality improvement (surveillance for unrecognized toxicity, monitoring clinician response delays). Linkages can be retrospective or real-time. Many organizations could benefit now by linking existing pharmacy and laboratory data. Greater improvement is possible through implementation of electronic order entry with real-time decision support incorporating linked laboratory and pharmacy data. While many guidelines, admonitions, and rules exist regarding drugs and the laboratory, substantial new knowledge and evidence in this area are needed. Focusing on these unmet needs and accompanying logistical challenges is a priority.
Diagnostic errors associated with the failure to follow up on abnormal diagnostic studies ("missed results") are a potential cause of treatment delay and a threat to patient safety. Few data exist concerning the frequency of missed results and associated treatment delays within the Veterans Health Administration (VA).
The primary objective of the current study was to assess the frequency of missed results and resulting treatment delays encountered by primary care providers in VA clinics.
An anonymous on-line survey of primary care providers was conducted as part of the health systems ongoing quality improvement programs. We collected information from providers concerning their clinical effort (e.g., number of clinic sessions, number of patient visits per session), number of patients with missed abnormal test results, and the number and types of treatment delays providers encountered during the two week period prior to administration of our survey.
The survey was completed by 106 out of 198 providers (54 percent response rate). Respondents saw and average of 86 patients per 2 week period. Providers encountered 64 patients with missed results during the two week period leading up to the study and 52 patients with treatment delays. The most common missed results included imaging studies (29 percent), clinical laboratory (22 percent), anatomic pathology (9 percent), and other (40 percent). The most common diagnostic delays were cancer (34 percent), endocrine problems (26 percent), cardiac problems (16 percent), and others (24 percent).
Missed results leading to clinically important treatment delays are an important and likely underappreciated source of diagnostic error.
Background
The incidence of medication errors is of great concern in residential aged care facilities. However, registered nurses’ perceptions on medication errors and the strategies to reduce medication errors have not been previously explored.
Aim
The aim of this study was to explore nurses’ experiences of medication errors and their suggestions to reduce these in residential aged care facilities.
Methods
An exploratory descriptive design was employed; 12 registered nurses working in residential aged care facilities across Victoria participated in the study. Semi-structured interviews were used for data collection, and the data were thematically analysed.
Findings
Four themes emerged from the interviews: (i) work environment, with sub themes of inadequate staffing and unmanageable workload; (ii) external constraints, with sub themes of involvement of a multi-disciplinary team and work interruptions; (iii) psychological impact; and (iv) medication error prevention strategies.
Discussion
This study identified that medication errors occur because of inadequate staffing, work interruptions, and varying factors of multi-disciplinary team involvement. Medication errors negatively impact staff, residents, and family members causing additional stress and frustration surrounding follow-up and management. However, practical suggestions provided by registered nurses could be implemented in future to reduce the occurrence of such medication errors.
Conclusion
This study described the contributing factors to medication errors; their impact on the staff, residents, and family members; and practical strategies to reduce medication errors, based on the experience of registered nurses in residential aged care facilities. This study makes a novel contribution to knowledge and practice in medication management process in RACF.
Purpose:
(a) To describe trigger terms that can be used to identify reports of inadequate staffing contributing to medication administration errors, (b) to identify such reports, (c) to compare the degree of harm within incidents with and without those triggers, and (d) to examine the association between the most commonly reported inadequate staffing trigger terms and the incidence of omission errors and "no harm" terms.
Design and setting:
This was a retrospective study using descriptive statistical analysis, text mining, and manual analysis of free text descriptions of medication administration-related incident reports (N = 72,390) reported to the National Reporting and Learning System for England and Wales in 2016.
Methods:
Analysis included identifying terms indicating inadequate staffing (manual analysis), followed by text parsing, filtering, and concept linking (SAS Text Miner tool). IBM SPSS was used to describe the data, compare degree of harm for incidents with and without triggers, and to compare incidence of "omission errors" and "no harm" among the inadequate staffing trigger terms.
Findings:
The most effective trigger terms for identifying inadequate staffing were "short staffing" (n = 81), "workload" (n = 80), and "extremely busy" (n = 51). There was significant variation in omission errors across inadequate staffing trigger terms (Fisher's exact test = 44.11, p < .001), with those related to "workload" most likely to accompany a report of an omission, followed by terms that mention "staffing" and being "busy." Prevalence of "no harm" did not vary statistically between the trigger terms (Fisher's exact test = 11.45, p = 0.49), but the triggers "workload," "staffing level," "busy night," and "busy unit" identified incidents with lower levels of "no harm" than for incidents overall.
Conclusions:
Inadequate staffing levels, workload, and working in haste may increase the risk for omissions and other types of error, as well as for patient harm.
Clinical relevance:
This work lays the groundwork for creating automated text-analytical systems that could analyze incident reports in real time and flag or monitor staffing levels and related medication administration errors.
The need for facilities that provide residential aged care is expected to increase significantly in the near future as the global population ages at an unprecedented rate. Many older adults will need to be placed in a residential care setting, such as an assisted living facility (ALF) or nursing home, when their caregivers can no longer effectively manage serious medical or psychiatric conditions at home. Although the types of residential care settings worldwide vary considerably, long-term care residents (LTC) and staff benefit from environmental and cultural changes in LTC settings. Unlike traditional medical models of LTC, culture change advocates for a shift toward holistic, person-centered care that takes place in homelike environments and accounts for the psychosocial needs of residents. Carving out a role for family members and training professional caregivers to address behavioral problems and quality-of-life issues remain a challenge. In LTC settings, preliminary research indicates that implementing person-centered changes addressing resident and caregiver needs may lead to better health outcomes, as well as increased satisfaction among patients, families, and staff. With the burgeoning world population of older adults, it is incumbent that they be provided with optimal humane culturally sensitive care.
Medication administration (MA) holds a great threat to patient safety, as MA errors remain a global problem. Nurses are key role players in the MA process and can give valuable information from the grassroots level. The aim of the present study was to describe registered nurses’ perceptions related to challenges in the MA process. Focus group interviews with registered nurses (n = 20) in two central hospitals in Finland were conducted in 2015. Inductive content analysis was performed. Nurses described multiple challenges during MA, which made the process demanding. These were organized under five themes: (i) medications; (ii) collaboration between health‐care professionals; (iii) resources and work environment; (iv) skills and education; and (v) patient‐related factors. The MA process is prone to errors, and registered nurses described many challenges related to MA. While nurses are responsible for their various work‐related tasks and the maintenance of patient safety through applicable procedures and effective collaboration, health systems and hospital management should be stewards of patient safety by ensuring adequate staffing levels and providing educational resources related to the MA process.
This study describes a multidisciplinary approach to reducing insulin medication errors. In 1998, a medication error analysis at our institution demonstrated that insulin was the top drug associated with medication errors. A collaborative continuous quality improvement initiative was undertaken to develop recommendations for reducing insulin medication errors. Multidisciplinary root cause analysis revealed that during order prescribing and transcribing, the abbreviation of “u” for units—combined with the lack of a formal education program for physicians on appropriate use of abbreviations—was a major contributing cause to insulin medication errors. An extensive multidisciplinary education program was undertaken to target insulin orders for medication error reduction. To date, compliance with prescribing insulin orders within guidelines has increased from 30% to 74%, and compliance with transcribing insulin orders within guidelines has increased from 36% to 83%. This collaborative project increased awareness of insulin medication error causation and will be used as a template to reduce other types of medication errors.
Background:
Hospitals have attempted to reduce adverse drug events (ADEs) by investing in new technologies, but data regarding their efficacy are lacking.
Objectives:
This study evaluates the effects of the implementation of barcode medication administration (BCMA) and electronic medication administration record (eMAR) technology on the profile of ADEs in a hospital setting.
Methods:
We conducted a before-and-after study examining the effects of the implementation of BCMA and eMAR technology on the profile of ADEs at a 400-bed academic medical center by using incident reports. We compared reported ADEs in pre- and post-implementation periods of 5 months to determine whether there was a reduction in the rate of ADEs within medication use phases. We further examined the severity of errors and described changes in the distribution of types of errors.
Results:
A total of 775 electronic error-reporting system reports were included in this study: 397 (51%) in the pre-implementation period and 378 (49%) in the post-implementation period. The rate of ADEs significantly decreased from 0.26% to 0.20% after implementation of the technology (relative risk [RR], 0.78; 95% CI, 0.67-0.89). The rate of transcription errors decreased from 0.089% to 0.036% (RR, 0.40; 95% CI, 0.30-0.54), which was largely attributed to reduction of "wrong time" errors. The rate of administration errors was identical in both groups at 0.017% (RR, 0.98; 95% CI 0.58-1.66). The mean severity level of administration errors significantly decreased from 4.44 to 3.23 (p = .005).
Conclusion:
The implementation of eMAR and BCMA technology improved patient safety by decreasing the overall rate of ADEs and the rate of transcription errors. These technologies also reduced the harmful impact to patients caused by administration errors.
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.
The aim of this study was to examine the actions of geographically dispersed process stakeholders (doctors, community pharmacists and RACFs) in order to cope with the information silos that exist within and across different settings. The study setting involved three metropolitan RACFs in Sydney, Australia and employed a qualitative approach using semi-structured interviews, non-participant observations and artefact analysis. Findings showed that medication information was stored in silos which required specific actions by each setting to translate this information to fit their local requirements. A salient example of this was the way in which community pharmacists used the RACF medication charts to prepare residents' pharmaceutical records. This translation of medication information across settings was often accompanied by telephone or face-to-face conversations to cross-check, validate or obtain new information. Findings highlighted that technological interventions that work in silos can negatively impact the quality of medication management processes in RACF settings. The implementation of commercial software applications like electronic medication charts need to be appropriately integrated to satisfy the collaborative information requirements of the RACF medication process.
Background:
The implementation of preventive measures of look-alike/sound-alike drugs incidents has given rise to a fundamental rule in Clinical Risk Management, but the problem is underestimated, endorsed by the absence or inadequate presence of specific uniformed procedures. In literature, there are few reviews about look-alike/sound-alike drugs.
Aim of the review:
To collect and summarize best practice and significant technological solutions proposed by different disciplines involved in look-alike/soundalike drugs limiting solution research.
Method:
A PubMed (any date) and EMBASE (all years) search was conducted in January 2013 with look alike sound alike drug [look AND (sound/exp OR sound) AND alike AND (drug/exp OR drug)] as search term. Later, references were selected focusing on lookalike/sound-alike drugs original research describing incident, identifying health operator difficulty, testing any type of intervention against errors, reporting a qualitative or quantitative description of the look-alike/sound-alike drugs errors.
Results:
Forty and ninety-four articles were identified by a PubMed and Embase search respectively, with search term and limits described above. Later, articles not respecting selection criteria or overlapping were eliminated. In the end, 14 references were considered, 10 being from PubMed and 4 from Embase.
Conclusion:
Results show and confirm the multidisciplinary interest of the research on look-alike/sound-alike drugs, and the difficulty to perform systematic review or metaanalysis for many clinical questions that have great relevance. This review has identified technology and management solutions that could effectively limit, or eliminate, look-alike/sound-alike drugs errors in hospital wards, or outside the hospital where the risk is more uncontrollable: however look-alike/sound-alike drugs therapy errors are not supported by reliable statistics but events reported in the literature can not be underestimated.
To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process.
Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process.
An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16-24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process.
Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.
Background:
Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs.
Methods:
The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process.
Results:
The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs.
Conclusions:
Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents' safety.
Few studies examine physical environmental factors and their effects on staff health, effectiveness, work errors and job satisfaction. To address this gap, this study aims to examine environmental features and their role in medication and nursing errors in long-term care facilities.
A mixed methodological strategy was used. Data were collected via focus groups, observing medication preparation and administration, and a nursing staff survey in four facilities.
The paper reveals that, during the medication preparation phase, physical design, such as medication room layout, is a major source of potential errors. During medication administration, social environment is more likely to contribute to errors. Interruptions, noise and staff shortages were particular problems.
The survey's relatively small sample size needs to be considered when interpreting the findings. Also, actual error data could not be included as existing records were incomplete.
The study offers several relatively low-cost recommendations to help staff reduce medication errors. Physical environmental factors are important when addressing measures to reduce errors.
The findings of this study underscore the fact that the physical environment's influence on the possibility of medication errors is often neglected. This study contributes to the scarce empirical literature examining the relationship between physical design and patient safety.
In 1978, Comrey wrote a guide to factor analysis in the Journal of Consulting and Clinical Psychology. This paper provides an update of the information given by Comrey in relation to exploratory factor analysis (EFA) for work and organizational psychologists, and particularly those involved with test development, interpretation and validation. In doing so, it offers a user's guide to contemporary methods and available techniques and introduces heuristics for dealing with problems of skew and kurtosis, social desirability response set, and factor naming.
The use of temporary staff in healthcare is on the rise due in part to work-force shortages and perceived cost savings. They may present an increased risk of errors from insufficient training and orientation, and less familiarity with local culture and practice. However, their impact, particularly in the emergency department where the risk of preventable medication errors is high, has not been established. The objective of this study was to evaluate whether temporary staff medication errors would be associated with more severe harm than permanent staff medication errors. We used a national Internet-based medication error reporting system (MEDMARX) and did a cross-sectional study of the dataset between the years 2000 and 2005. After adjusting for clustering by facility, temporary staff errors were more likely than permanent staff errors to reach the patient (odds ratio [OR] 1.42, 95% confidence intervals [CI] 0.97-2.09), require patient monitoring (OR 1.91, 95% CI 1.21-3.03), result in temporary harm (OR 3.11, 95% CI 1.13-8.59), and be life-threatening (OR 8.63, 95% CI 1.22-61.0). In conclusion, emergency department medication errors associated with temporary staff were more harmful than those associated with permanent staff.
This study describes nurses' perceptions about how and why medication errors occur and their personal experiences with medication errors. A survey was mailed to a random sample of registered nurses. Two hundred and two responded. Of those, 158 (78%) nurses admitted making medication errors and provided details about these errors. This study, by providing the perspective of frontline nurses, contributes to the body of knowledge on medication errors.
• 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.
Adverse drug events, especially those that may have been preventable, are among the most serious concerns about medication use in nursing homes. We studied the incidence and preventability of adverse drug events and potential adverse drug events in nursing homes.
We performed a cohort study of all long-term care residents of 18 community-based nursing homes in Massachusetts during a 12-month observation period. Potential drug-related incidents were detected by stimulated self-report by nursing home staff and by periodic review of the records of nursing home residents by trained nurse and pharmacist investigators. Each incident was classified by 2 independent physician-reviewers, using a structured implicit review process, by whether or not it constituted an adverse drug event or potential adverse drug event (those that may have caused harm, but did not because of chance or because they were detected), by the severity of the event (significant, serious, life-threatening, or fatal), and by whether it was preventable. Examples of significant events included nonurticarial rashes, falls without associated fracture, hemorrhage not requiring transfusion or hospitalization, and oversedation; examples of serious events included urticaria, falls with fracture, hemorrhage requiring transfusion or hospitalization, and delirium.
During 28,839 nursing home resident-months of observation in the 18 participating nursing homes, 546 adverse drug events (1.89 per 100 resident-months) and 188 potential adverse drug events (0.65 per 100 resident-months) were identified. Of the adverse drug events, 1 was fatal, 31 (6%) were life-threatening, 206 (38%) were serious, and 308 (56%) were significant. Overall, 51% of the adverse drug events were judged to be preventable, including 171 (72%) of the 238 fatal, life-threatening, or serious events and 105 (34%) of the 308 significant events (P < 0.001). Errors resulting in preventable adverse drug events occurred most often at the stages of ordering and monitoring; errors in transcription, dispensing, and administration were less commonly identified. Psychoactive medications (antipsychotics, antidepressants, and sedatives/hypnotics) and anticoagulants were the most common medications associated with preventable adverse drug events. Neuropsychiatric events were the most common types of preventable adverse drug events.
Adverse drug events are common and often preventable in nursing homes. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the ordering and monitoring stages of pharmaceutical care.
Medication administration errors can threaten patient outcomes and are a dimension of patient safety directly linked to nursing care. Children are particularly vulnerable to medication errors because of their unique physiology and developmental needs. This descriptive study surveyed a convenience sample of 57 pediatric and 227 adult hospital nurses regarding their perceptions of the proportion of medication errors reported on their units, why medication errors occur, and why medication errors are not always reported. In this study, which focuses on pediatric data, pediatric nurses indicated that a higher proportion of errors were reported (67%) than adult nurses indicated (56%). The medication error rates per 1,000 patient-days computed from actual occurrence reports were also higher on pediatric (14.80) as compared with adult units (5.66). Pediatric nurses selected distractions/interruptions and RN-to-patient ratios as major reasons medication errors occurred. Nursing administration's focus on the person rather than the system and the fear of adverse consequences (reprimand) were primary reasons selected for not reporting medication errors. Results suggest the need to explore both individual and systematic safeguards to focus on the reported causes and underreporting of medication errors.
The purpose of this study was to investigate about the communication problems in the team nursing systems, if the requests for medication between nurses happen. For this study, we developed a simulation involving a nurse giving a medication prepared by another nurse. Baseline data was collected from 100 third-year nursing students and 163 nurses of two municipal hospitals further subdivided into three groups by their service years. The responders attributing to the errors in the simulation were compared. As a result, the more service years the fewer nurses there were who attributed medication errors to no explanation and no confirmation between nurses. The nurses whose service years were less than five years had a low level of awareness regarding no explanation of a nurse leader requesting the medications as well as the students. These findings suggested that there is the possibility that some medication errors occur due to preoccupation that nurses feel it is less necessary to explain and confirm everything related to medication administrations as their length of service increase. Nurses have a communication problem that is influenced by the relationship in the workplace in the team nursing system. Therefore, the requests for medication should no be permitted.
Understanding the processes by which nurses administer medication is critical to the minimization of medication errors. This study investigates nurses' views on the factors contributing to medication errors in the hope of facilitating improvements to medication administration processes.
A focus group of nine Registered Nurses discussed medication errors with which they were familiar as a result of both their own experiences and of literature review. The group, along with other researchers, then developed a semi-structured questionnaire consisting of three parts: narrative description of the error, the nurse's background and contributing factors. After the contributing factors had been elicited and verified with eight categories and 34 conditions, additional Registered Nurses were invited to participate by recalling one of the most significant medication errors that they had experienced and identifying contributing factors from those listed on the questionnaire. Identities of the hospital, patient and participants involved in the study remain confidential.
Of the 72 female nurses who responded, 55 (76.4%) believed more than one factor contributed to medication errors. 'Personal neglect' (86.1%), 'heavy workload' (37.5%) and 'new staff' (37.5%) were the three main factors in the eight categories. 'Need to solve other problems while administering drugs,''advanced drug preparation without rechecking,' and 'new graduate' were the top three of the 34 conditions. Medical wards (36.1%) and intensive care units (33.3%) were the two most error-prone places. The errors common to the two were 'wrong dose' (36.1%) and 'wrong drug' (26.4%). Antibiotics (38.9%) were the most commonly misadministered drugs.
Although the majority of respondents considered nurse's personal neglect as the leading factor in medication errors, analysis indicated that additional factors involving the health care system, patients' conditions and doctors' prescriptions all contributed to administration errors.
Identification of the main factors and conditions contributing to medication errors allows clinical nurses and administration systems to eliminate situations that promote errors and to incorporate changes that minimize them, creating a safer patient environment.
The National Statement on Ethical Conduct in Human Research
- Nhmrc
Look‐alike, sound‐alike medication names
- World Health Organization