Navigating Independent Double Checks for Safer Care: A Nursing Perspective

Abstract The purpose of this study was to explore registered nurses’ understanding and practice of “independent double-checks” prior to administration of high-alert medications. The study used a qualitative descriptive design for data collection and data analysis. It included thirteen participants from a hospital located in southern New Hampshire. Results of the study revealed a core theme of navigating independent double checks (IDC) for safer care. Two major themes stemming from the core theme were also uncovered. Navigating IDC through knowing and navigating IDC through nurse partnership both focused on the perception and practice on IDC prior to administration of high alert medications. IDC was accepted and promoted as best practice, but the definition and process is still unclear. Having a universal definition will assist in clarity of the process and in turn, promote ensuring safe administration of high alert medications to patients. Keywords: independent double check, safer care, knowing, nurse partnershi

Annotated Bibliography: Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement.

The ambulatory care setting is an increasingly important component of the patient safety conversation. Inpatient safety is the primary focus of the vast majority of safety research and interventions, but the ambulatory setting is actually where most medical care is administered. Recent attention has shifted toward examining ambulatory care in order to implement better health care quality and safety practices. This annotated bibliography was created to analyze and augment the current literature on ambulatory care practices with regard to patient safety and quality improvement. By providing a thorough examination of current practices, potential improvement strategies in ambulatory care health care settings can be suggested. A better understanding of the myriad factors that influence delivery of patient care will catalyze future health care system development and implementation in the ambulatory setting

Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Comparison of the effectiveness of traditional nursing medication administration with the Color Coding Kids system in a sample of undergraduate nursing students

The problem of medication errors in hospitals and the vulnerability of pediatric patients to adverse drug events (ADE) was investigated and well substantiated. The estimated additional cost of inpatient care for ADE’s in the hospital setting alone was conservatively estimated at an annual rate per incident of 400,000 preventable events each incurring an extra cost of approximately $5,857. The purpose of the researcher was to compare the effectiveness of traditional nursing medication administration with the Color Coding Kids (CCK) system (developed by Broselow and Luten for standardizing dosages) to reduce pediatric medication errors. A simulated pediatric rapid response scenario was used in a randomized clinical study to measure the effects of the CCK system to the traditional method of treatment using last semester nursing students. Safe medication administration, workflow turnaround time and hand-off communication were variables studied. A multivariate analysis of variance was used to reveal a significant difference between the groups on safe medication administration. No significant difference between the groups on time and communication was found. The researcher provides substantial evidence that the CCK system of medication administration is a promising technological breakthrough in the prevention of pediatric medication errors

Process Improvement to Reduce Route of Medication Administration Errors in Patients with Enteral Feeding Tubes

Advances in health information management in the form electronic health records, computerized provider order entry systems, and clinical decision support systems and tools have enhanced the productivity, effectiveness, and efficiency of healthcare. However, the cost of these positive effects does come at the expense of other factors. Along with the introduction of Clinical Provider Order Entry (CPOE) systems, organizations have experienced new possibilities for medication errors and risks to patient safety. Factors associated with these errors should be evaluated in detail in order to mitigate the causes of these types of errors and to plan strategies for prevention. Continued research into how to improve the quality of these systems is necessary to promote the usability and acceptance of CPOE systems by prescribers and to continue to make an impact on the frequency of medication errors within health care organizations. Health care organizations must develop strategies to improve the rate of medication errors caused by CPOE systems. Strategies may vary from organization to organization, and depend upon organization-specific resources. Ideally, a plan to improve patient safety and prevent errors related to CPOE systems would include stakeholders such as the clinical team and providers, involve a system that can audit the frequency of errors, and include ongoing education about the problem and the proposed solution. A plan to prevent errors and improve patient safety that is not-dependent upon the intricacies of a specific electronic medical record is ideal. A strategy that can carry-over from one electronic medical record system to the next and that can address the central problem with accuracy, efficiency, and evidence-based research will be proposed

Understanding the Nature of Medication Errors in an ICU with a Computerized Physician Order Entry System

Objectives: 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. Methods: 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. Results: 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. Conclusion: 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

Off-label drug use, medication errors and adverse drug events : among Swedish pediatric inpatients

Background: In pediatrics, treatment with drugs is an important and fully integrated part of everyday medical practice. However, authorized drugs specified to be used in children are often lacking which leads to off-label use, i.e. outside of approved product monographs. Another challenge is medication errors (ME) which is an important cause of adverse drug events (ADE) in hospitalized children. The consequences and effects of these conditions are largely unknown. Studies within the field of pediatric, and especially neonatal, drug safety are lacking. Unsafe drug use may be an important and unrecognized contributor to suboptimal health in this vulnerable group with limited capacity for drug metabolism and excretion. Aim: The general aim of the thesis was to explore the magnitude of drug safety issues within Swedish pediatric inpatients. More specifically we aimed to investigate; I. National extent of off-label drug-use, II. Contents in national ME incident reports, III. Type of ADEs in a pediatric inpatient setting and IV. The views of pediatricians on a clinical decision support system (CDSS) to aid in prescribing drugs. Methods: In the four papers we used different study approaches. In paper I we performed a descriptive cross-sectional study based on collection of drug charts during two time-points. In paper II we used an analytic cross-sectional register-based study on Lex Maria incident reports and complaints from the Health and Social Care Inspectorate. In paper III we carried out a cohort study using a chart review with a pediatric trigger tool covering 600 admissions stratified in four different units, and in paper IV we used qualitative semi-structured interviews with pediatricians. Results: Paper I showed that half of all drug orders received by pediatric inpatients was outside approved product monographs, extemporaneously prepared or unlicensed. In paper II the ME reports indicated frequent occurrence of substances from three previously known high-alert lists with specified error characteristics among the different drug handling processes. In paper III we showed that skin/tissue/vascular harm, omission of analgesic drug therapy and hospital acquired infections are the most abundant ADEs as identified by an extended set of medical record triggers. In paper IV the CDSS-experiences of pediatricians emerged into six categories being: use, benefit, confidence, situations of disregards, misgivings/risks and development potential. Conclusions: Paper I found a similar situation in Sweden regarding off-label and unlicensed drug use as in many other countries. Paper II found that the existing high-alert lists are relevant for pediatric inpatients and suggested the use of process dependent high-alert lists. Paper III found that ADEs are common in pediatric inpatients and that the incidence varied with ADE-type, depending on ward and time after admission. In paper IV the experiences of pediatricians after the implementation of a CDSS gave insights on usability and the need for future developments

Can the Heinrich ratio be used to predict harm from medication errors?

The purpose of this study was to establish whether, for medication errors, there exists a fixed Heinrich ratio between the number of incidents which did not result in harm, the number that caused minor harm, and the number that caused serious harm. If this were the case then it would be very useful in estimating any changes in harm following an intervention. Serious harm resulting from medication errors is relatively rare, so it can take a great deal of time and resource to detect a significant change. If the Heinrich ratio exists for medication errors, then it would be possible, and far easier, to measure the much more frequent number of incidents that did not result in harm and the extent to which they changed following an intervention; any reduction in harm could be extrapolated from this