Medication safety in intravenous drug administration : error causes and systemic defenses in hospital setting

Intravenous administration of drugs is associated with the highest medication error frequencies and more serious consequences to the patient than any other administration route. The bioavailability of intravenously administered medication is high, the therapeutic dose range is often narrow, and effects are hard to undo. Many intravenously administered drugs are high-alert medications, bearing a heightened risk of causing significant patient harm if used in error. Smart infusion pumps with dose error-reduction software can be used to prevent harmful medication errors in high-risk clinical settings, such as neonatal intensive care units. This study investigated intravenous medication safety in hospital settings by identifying recent research evidence related to systemic causes of medication errors (Study I) and systemic defenses to prevent these errors (Study II). The study also explored the development of dose-error reduction software in a neonatal intensive care unit (Study III). A systems approach to medication risk management based on the Theory of Human Error was applied as a theoretical framework. The study was conducted in two phases. In the first phase, a systematic review of recent research evidence on systemic causes of intravenous medication errors (Study I) and systemic defenses aiming to prevent these errors (Study II) was carried out. In Study I, 11 studies from six countries were included in the analysis. Systemic causes related to prescribing (n=6 studies), preparation (n=6), administration (n=6), dispensing and storage (n=5) and treatment monitoring (n=2) were identified. Insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, failures in calculation tasks and in double-checking procedures, and confusion between look-alike, sound-alike medications were the leading causes of intravenous medication errors. The number of the included studies was limited, all of them being observational studies and graded as low quality. In Study II, 46 studies from 11 countries were included in the analysis. Systemic defenses related to administration (n=24 studies), prescribing (n=8), preparation (n=6), treatment monitoring (n=2), and dispensing (n=1) were identified. In addition, five studies explored defenses related to multiple stages of the medication use process. Defenses including features of closed-loop medication management systems appeared in 61% of the studies, smart pumps being the defense most widely studied (24%). The evidence quality of the included articles was limited, as 83% were graded as low quality, 13% moderate quality, and only 4% high quality. A mixed-methods study was conducted in the second phase, applying qualitative and quantitative methods (Study III). Medication error reports were used to develop simulation-type test cases to assess the suitability of dosing limits in a neonatal intensive care unit’s smart infusion pump drug library. Of all medication errors reported in the neonatal intensive care unit, 3.5% (n=21/601) involved an error or near-miss related to wrong infusion rate. Based on the identified error mechanisms, 2-, 5-, and 10-fold infusion rates and mix-ups between infusion rates of different drugs were established as test cases. When conducting the pump programming for the test cases (n=226), no alerts were triggered with infusion rates responding to the usual dosages (n=32). Of the erroneous 2-, 5-, and 10-fold infusion rates, 73% (n = 70/96) caused an alert. Mix-ups between infusion rates triggered an alert only in 24% (n=24/98) of the test cases. This study provided an overview of recent research evidence related to intravenous medication safety in hospital settings. Current intravenous medication systems remain vulnerable, which can result in patient harm. While in-hospital intravenous medication use processes are developing towards closed-loop medication management systems, combinations of different defenses and their effectiveness in error prevention should be explored. In addition to improved medication safety, implementing new systemic defenses leads to new error types, emphasizing the importance of continuous proactive risk management as an essential part of clinical practice.Laskimonsisäiseen lääkkeen annosteluun liittyy merkittävä lääkityspoikkeamien ja vakavien haittatapahtumien riski. Sairaaloissa käytetään useita laskimoon annosteltavia suuren riskin lääkkeitä, joiden virheellinen käyttö johtaa muita lääkkeitä todennäköisemmin vakaviin haittoihin. Tässä tutkimuksessa tunnistettiin järjestelmällisen kirjallisuuskatsauksen perusteella lääkityspoikkeamien järjestelmälähtöisiä syitä (osatyö I) sekä lääkehoitoprosessin suojauksia (osatyö II). Lisäksi tutkittiin älyinfuusiopumppujen käyttöönottoa vastasyntyneiden teho-osastolla. Teoreettisena viitekehyksenä käytettiin inhimillisen erehdyksen teoriaa ja järjestelmänäkökulmaa lääkehoitoprosessin riskien hallinnassa. Osatyön I aineistosta (n=11 tutkimusta) tunnistettiin lääkityspoikkeamien syntyyn vaikuttavia järjestelmälähtöisiä syitä, jotka liittyivät lääkehoidon määräämiseen (n=6), käyttökuntoon saattoon (n=6), antoon (n=6), jakeluun ja varastointiin (n=5) sekä seurantaan (n=2). Yleisimpiä syitä olivat riittämättömät toimenpiteet suuren riskin lääkkeiden turvallisen käytön varmistamisessa, ammattilaisten heikot tiedot lääkkeistä, virheet laskutoimituksissa ja kaksoistarkistuksissa sekä toisiltaan näyttävien ja kuulostavien lääkkeiden sekaantuminen keskenään. Osatyön II aineistossa (n=46 tutkimusta) kuvattiin lääkehoitoprosessin suojauksia, jotka liittyivät lääkkeiden annosteluun (n=24), määräämiseen (n=8), käyttökuntoon saattoon (n=6), hoidon seurantaan (n=2) ja jakeluun (n=1). Lisäksi viidessä tutkimuksessa kuvattiin useaan lääkehoitoprosessin vaiheeseen liittyviä suojauksia. Katkeamattoman lääkehoitoprosessin piirteitä tunnistettiin 61 prosentissa tutkimuksista ja älyinfuusiopumput olivat eniten tutkittu suojaus (24 %). Osatyö III toteutettiin monimenetelmätutkimuksena. Vastasyntyneiden teho-osastolla raportoitujen lääkityspoikkeamien pohjalta kehitettiin simulaatiotyyppisiä testitapauksia, joilla arvioitiin annosrajojen sopivuutta älyinfuusiopumppujen lääkekirjastoon. Lääkityspoikkeamista 3,5 % (n=21/601) liittyi väärään infuusionopeuteen ja niiden perusteella testitapauksiksi määritettiin 2-, 5- ja 10-kertaiset infuusionopeudet sekä eri lääkkeiden antonopeuksien sekaantuminen keskenään. Testitapauksissa (n=226) infuusiopumput eivät hälyttäneet tavanomaisia nopeuksia ohjelmoitaessa (n=32), mutta virheellisistä infuusionopeuksista 73 % (n=70/96) aiheutti hälytyksen. Nopeuksien sekaantuminen keskenään laukaisi hälytyksen vain 24 %:ssa (n=24/98) testitapauksista. Sairaaloiden laskimonsisäinen lääkehoitoprosessi kehittyy kohti katkeamatonta lääkehoitoprosessia, mutta se on edelleen altis lääkityspoikkeamille. Kirjallisuuskatsauksiin sisällytettyjen tutkimusten laatu oli pääosin heikko, joten lääkityspoikkeamien riskitekijöitä ja suojauksia tulee edelleen tutkia yhä laadukkaammissa tutkimusasetelmissa. Uusien suojausten käyttöönotto muuttaa myös riskikohtia, mikä korostaa ennakoivan riskienhallinnan merkitystä osana sairaaloiden toimintaa

Standardization and use of colour for labelling of injectable drugs

Medication errors are one of the most common causes of patient injuries in healthcare systems. Poor labelling has been identified as a contributing factor of medication errors, particularly for those involving injectable drugs. Colour coding and colour differentiation are two major techniques being used on labels to aid drug identification. However, neither approach has been scientifically proven to minimize the occurrence of or harm from medication errors. This thesis investigates potential effects of different approaches for using colour on standardized labels on the task of identifying a specific drug from a storage area via a controlled experiment involving human users. Three different ways of using colour were compared: labels where only black, white and grey are used; labels where a unique colour scheme adopted from an existing manufacturer’s label is applied to each drug; colour coded labels based on the product’s strength level within the product line. The results show that people might be vulnerable to confusion from drugs that have look-alike labels and also have look-alike, sound-alike drug names. In particular, when each drug label had a fairly unique colour scheme, participants were more prone to misperceive the look-alike, sound-alike drug name as the correct drug name than when no colour was used or when colour was used on the labels with no apparent one-to-one association between the label colour and the drug identity. This result could suggest a perceptual bias to perceive stimuli as the expected stimuli especially when the task involved is familiar and the stimuli look similar to the expected stimuli. Moreover, the results suggest a potential problem that may arise from standardizing existing labels if careful consideration is not given to the effects of reduced visual variations among the labels of different products on how the colours of the labels are perceived and used for drug identification. The thesis concludes with recommendations for improving the existing standard for labelling of injectable drug containers and for avoiding medication errors due to labelling and packaging in general

A Comprehensive Survey on Rare Event Prediction

Rare event prediction involves identifying and forecasting events with a low probability using machine learning and data analysis. Due to the imbalanced data distributions, where the frequency of common events vastly outweighs that of rare events, it requires using specialized methods within each step of the machine learning pipeline, i.e., from data processing to algorithms to evaluation protocols. Predicting the occurrences of rare events is important for real-world applications, such as Industry 4.0, and is an active research area in statistical and machine learning. This paper comprehensively reviews the current approaches for rare event prediction along four dimensions: rare event data, data processing, algorithmic approaches, and evaluation approaches. Specifically, we consider 73 datasets from different modalities (i.e., numerical, image, text, and audio), four major categories of data processing, five major algorithmic groupings, and two broader evaluation approaches. This paper aims to identify gaps in the current literature and highlight the challenges of predicting rare events. It also suggests potential research directions, which can help guide practitioners and researchers.Comment: 44 page

The value of community pharmacy incident reporting in optimising the safety and quality use of medicines

Medication safety has emerged as a healthcare priority with the launch of the World Health Organization’s third global patient safety challenge. Understanding the complex interplay between human and system factors that potentiate medication incidents can illuminate improvement opportunities in organisational safeguards and safe medication practices. This thesis aimed to develop, implement, and evaluate systematic incident reporting system (IRS) to identify, characterise and address risks to medication safety and quality use of medicines (QUM) in primary care. The study was conducted in 30-community pharmacies in Sydney, Australia, through a confidential and anonymous IRS called QUMwatch. The study used the Advanced Incident Management System (AIMS) taxonomy, which is a hierarchical classification system based on error theory. Analysis of 1,013 incident reports collected over 30 months, identified medication incidents (MIs) that affected patients over 65 years old, the prescribing stage, and medicines acting on the cardiovascular and nervous systems. Human, task, and organisational factors contributed to MIs, particularly healthcare providers' cognitive errors, communication problems, poor risk management, and safety culture. Factors that facilitated error recovery included individual attributes, appropriate intervention, effective communication, and the use of standardised protocols. Remedial actions included changes in care plans, dosages, reviews of medicines, and medicine cessation. The study evaluated the QUMwatch program's tools and methods using a mixed-methods approach and found that 16 out of 20 variables on the data collection form had over 90% complete data, and data consistency was high. Anonymity was the preferred method of reporting. The stimulatory package significantly raised the reporting rate from a baseline average of 32.4 to 77.3 reports/month (p < .001). The AIMS taxonomy for MIs had substantial validity for high-order medication processes for the Australian community pharmacy context. The study demonstrated the feasibility of a well-designed IRS in community pharmacy to identify MIs and to generate safety lessons and recommendations

A study of the prescribing, dispensing and administration of medicines with reference to medication errors in the Armed Forces Hospital, Kuwait. An experimental investigation to determine the accuracy of the prescribing process, dispensing process and nurse administration of medication as compared with the prescriptions of physicians in the Armed Forces Hospital in Kuwait.

Introduction: Medication errors are a major cause of illness and hospitalization of patients throughout the world. This study examines the situation regarding medication errors in the Armed Forces Hospital, Kuwait since no literature exists of any such studies for this country. Several types of potential errors were studied by physicians, nurses and pharmacists. Their attitudes to the commission of errors and possible consequences were surveyed using questionnaires. Additionally, patient medical records were reviewed for possible errors arising from such actions such as the co-administration of interacting drugs. Methods: This study included direct observations of physicians during the prescribing process, pharmacists while they dispensed medications and nurses as they distributed and administered drugs to patients. Data were collected and compiled on Microsoft Excel spreadsheet and analyses were performed using SPSS. Where applicable, results were reported as counts and/ or percentages of error rates. Nurses, pharmacists and physicians survey questionnaires: From the 200 staff sent questionnaires a total of 149 respondents comprising nurses (52.3%), physicians (32.2%) and pharmacists (16.1%) returned the questionnaires a total response rate of 74.5%. All responses were analyzed and compared item-by-item to see if there were any significant differences between the three groups for each questionnaire item. All three groups were most in agreement about their perception of hospital administration as making patient safety a top priority with regard to communicating with staff and taking action when medication errors were reported (all means 3.0 and p > 0.05). Pharmacists were most assured of administration support when an error was reported whereas nurses were least likely to see the administration as being supportive ( p < 0.001), and were more afraid of the negative consequences associated with reporting of medication errors (p = 0.026). Although nurses were generally less likely to perceive themselves as being able to communicate freely regarding reporting of errors compared to pharmacists there was no significant difference between the two groups. Both however were significantly different from physicians (p< 0.001). Physicians had the most favorable response to perceiving new technology as helping to create a safer environment for patients and to the full utilization of such technologies within the institution in order to help prevent medical errors. Scenario response - Responses to two scenarios outlining possible consequences, should a staff member commit a medication error, tended to be very similar among the three groups and followed the same general trend in which the later the error was discovered and the more grievous the patient harm, the more severe would be the consequences to the staff member. Interestingly, physicians saw themselves as less likely to suffer consequences and nurses saw themselves as more likely to suffer consequences should they have committed a medication error. All three groups were more likely to see themselves as facing dismissal from their job if the patient were to die. RESULTS OF ALL THREE OBSERVATIONS: Result of Nursing observations: For 1124 doses studied, 194 resulted in some form of error. The error rate was 17.2% and the accuracy was 82.8%. The commonest errors in a descending order were: wrong time, wrong drug, omission, wrong strength/ dose, wrong route, wrong instruction and wrong technique. No wrong drug form was actually administered in the observational period. These were the total number of errors observed for the entire month period of the study. IV Result of Pharmacist observations: A total of 2472 doses were observed during the one month period. Observations were done for 3 hours per day each day that the study was carried out. The study showed that there were 118 errors detected which were in the following categories respectively: 52 no instructions, 28 wrong drug/unordered, 21 wrong strength/dose, ignored/omission 13, shortage of medication 3 and expired date 1. Result of Prescribers in Chart review for drug-drug interactions: The analysis of the drug-drug interactions showed that out of a total of 1000 prescriptions, 124 had drug-drug interactions. None were found to fall into the highest severity rating i.e. 4 (contraindicated). Only twenty-one interactions were rated 3 (major), 87 interactions were rated moderate and 15 interactions were rated minor according the modified Micromedex scale. Patient education: All health care such as physician, pharmacist, and nurses have a responsibility to educate patient about their medication use and their health conditions to protecting them from any error can occur by wrong using drugs. Conclusion This study has contributed to the field of medication errors by providing data for a Middle Eastern country for the very first time. The views and opinions of the nurses, pharmacists and physicians should be considered to enhance the systems to minimize any errors in the future

Prescription drug errors in Anand District

Not availabl

Healthcare Incident Reporting: The Impacts of Usability of Input Interfaces, Usability of Resulting Data, and Attitudes Towards Reporting

Research into improving the safety of healthcare systems has recently focused on learning how incidents of harm to patients happen and how to prevent them. Although it is acknowledged that low participation in incident-reporting systems contributes to the problem of poor error prevention, little research has focused on improving participation. This research is focused on how both participation in and use of incident-reporting systems can be improved by examining the usability of the reporting tools. A large private hospital in the northeastern United States and the incident reporting app used there were examined as a case study. A mixed-methods approach using Critical Decision Method interviews, heuristic usability tests, and surveys was used. Seemingly minor usability issues like inconvenient and hard to read menus were found to inhibit both the quantity and quality of incident reports. Additionally, despite the organization having a generally strong safety culture, there were organizational obstacles to the reporting of incidents and the adoption of useful interventions in response to incidents beyond what is normally encompassed by the term “safety culture”. Specific recommendations for hospital incident reporting process improvement are included

Word for Word PDF Book

This volume is a collection of columns from Word for Word, a blog providing advice on correct, precise word usage and other tips for biomedical writers. The blog is written and edited by members of Scientific Publications at The University of Texas MD Anderson Cancer Center. Each column represents the consensus of Scientific Publications’ editors and their hundreds of collective years of editorial experience. Columns from 2011 through 2017 are included in this updated edition and are arranged alphabetically by title. This is not intended to be a comprehensive grammar or style guidehttps://openworks.mdanderson.org/pdfbook/1000/thumbnail.jp