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

Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation in an English hospital

BACKGROUND: Few studies have applied a systems approach to understanding the causes of specific prescribing errors in the context of hospital electronic prescribing (EP). A comprehensive understanding of underlying causes is essential for developing effective interventions to improve prescribing safety. Our objectives were to explore prescribers' perspectives of the causes of errors occurring with EP and to make recommendations to maximise benefits and minimise risks. METHODS: We studied a large hospital using inpatient EP. From April to June 2016, semistructured interviews were conducted with purposively sampled prescribers involved with a prescribing error. Interviews explored prescribers' perceived causes of the error and views about EP; they were audio-recorded and transcribed verbatim. Data were thematically analysed against a framework based on Reason's accident causation model, with a focus on identifying latent conditions. RESULTS: Twenty-five interviews explored causes of 32 errors. Slips and rule-based mistakes were the most common active failures. Error causation was multifactorial; environmental, individual, team, task and technology error-producing conditions were all influenced by EP. There were three broad groups of latent conditions: the EP system's functionality and design; the organisation's decisions around EP implementation and use; and prescribing behaviours in the context of EP. CONCLUSIONS: Errors were associated with the design of EP itself and its integration within the healthcare environment. Findings suggest that EP vendors should focus on revolutionising interface design and usability issues, bearing in mind the wider healthcare context in which such software is used. Healthcare organisations should draw upon human factors principles when implementing EP. Consideration of work environment, infrastructure, training, prescribing responsibilities and behaviours should be considered to address local issues identified

Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to improve patient outcomes. Protocol for an observational study

INTRODUCTION: Medicines optimisation is a key role for hospital pharmacists, but with ever-increasing demands on services there is a need to increase efficiency while maintaining patient safety. The aim of this study is to develop a prognostic model, the Medicines Optimisation Assessment Tool (MOAT), which can be used to target patients most in need of pharmacists' input while in hospital. METHODS AND ANALYSIS: The MOAT will be developed following recommendations of the Prognosis Research Strategy partnership. Using a cohort study we will prospectively include 1500 adult patients from the medical wards of two UK hospitals. Data on medication-related problems (MRPs) experienced by study patients will be collected by pharmacists at the study sites as part of their routine daily clinical assessment of patients. Data on potential risk factors such as polypharmacy, renal impairment and the use of 'high risk' medicines will be collected retrospectively from the information departments at the study sites, laboratory reporting systems and patient medical records. Multivariable logistic regression models will then be used to determine the relationship between potential risk factors and the study outcome of preventable MRPs that are at least moderate in severity. Bootstrapping will be used to adjust the MOAT for optimism, and predictive performance will be assessed using calibration and discrimination. A simplified scoring system will also be developed, which will be assessed for sensitivity and specificity. ETHICS AND DISSEMINATION: This study has been approved by the Proportionate Review Service Sub-Committee of the National Health Service Research Ethics Committee Wales REC 7 (16/WA/0016) and the Health Research Authority (project ID 197298). We plan to disseminate the results via presentations at relevant patient/public, professional, academic and scientific meetings and conferences, and will submit findings for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02582463

Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses' Medication Administration Processes and Systems (the MAPS Study).

Research has documented the problem of medication administration errors and their causes. However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety

Analysis of the third WHO Global Safety Challenge 'Medication Without Harm' patient-facing materials: exploratory descriptive study

OBJECTIVES: To evaluate patients' views on the content and use of the 'Five Moments for Medication Safety' materials developed as part of the WHO's 'Medication Without Harm' Global Patient Safety Challenge. These comprise a booklet, flyer, infographic poster, pamphlet and mobile application. They include recommended questions for patients to ask healthcare professionals to gain a better understanding of their medication. METHODS: Structured interviews were conducted with members of the public who entered an outpatient pharmacy in a London teaching hospital, using a combination of open and closed questions. Qualitative data were analysed thematically. Quantitative data were analysed descriptively. χ2, Fisher's exact, Mann-Whitney U and Kruskal-Wallis tests were used to test for associations between responses and variables such as age. RESULTS: We approached 147 people; 100 (68%) agreed to take part. Of these, 83% thought that the materials would be 'quite' or 'very' useful. Potential barriers to their use were patients being of the view that they already ask healthcare professionals about their medicines or that there would be limited time available to answer their questions during consultations. Fifty-nine per cent of participants stated that they would prefer to be given the materials in waiting areas before seeing a healthcare professional; 61% thought they should be displayed on television screens in general practice surgeries. Age was significantly associated with preference for the mobile application (χ2 test, p<0.01), with younger people preferring this format. CONCLUSIONS: Patients' views of the Five Moments for Medication Safety materials were generally positive. Our findings suggest that they should be displayed on television screens in waiting areas and given to patients prior to appointments. More advice is needed for patients on how to incorporate the questions suggested in the resources into a brief healthcare consultation

Analysis of pharmacist‐identified medication‐related problems at two United Kingdom hospitals: a prospective observational study

OBJECTIVE: Hospital pharmacy is undergoing a period of rapid change, with pharmacists needing to focus where they add most value. Our aim was to identify where pharmacists have potential for greatest impact by analysing data on clinically relevant medication-related problems (MRPs). METHODS: We included consecutive admissions from adult medical wards at two UK hospitals between April and November 2016. MRPs were identified by pharmacists at the study sites as part of their routine daily patient assessments, validated and assessed for preventability and severity. Descriptive analyses were performed on clinically relevant (moderate or severe preventable) MRPs to establish the stage of inpatient stay where identified and their types/categories (overall and by stage of inpatient stay). KEY FINDINGS: Among 1503 eligible admissions, 2614 validated MRPs were identified, of which 1153 were moderate or severe, and preventable. Over 70% of these clinically relevant MRPs were identified during/before the first ward-based pharmacy review of patients. The most frequent MRP subcategory was 'indication not treated/missing therapy', accounting for 46% of clinically relevant MRPs. Dose selection issues were the next most common, accounting for 24%. The subcategory 'indication not treated/missing therapy' was identified more frequently at admission and discharge (53% and 45% of MRPs, respectively) compared with during the inpatient stay (14%), P < 0.001. CONCLUSIONS: This research suggests patients are at greatest need of pharmacist input in terms of identification/resolution of clinically relevant MRPs during early stages of inpatient stay; however, clinically relevant MRPs continue to occur throughout their stay, suggesting need for ongoing pharmacy review

The effect of electronic prescribing and medication administration on nurses’ workflow and activities: an uncontrolled before and after study

Background: Electronic prescribing and medication administration (ePMA) is purported to improve patient safety through a number of benefits including reducing medication errors and facilitating identification of prescribers. However little is known of its effect on nurses’ workflow and the associated patient safety implications. Our objective was to explore differences in drug round duration, medication administration workflow and activities, interruptions, and timeliness of medication administration before and after implementation of ePMA. / Methods: The study was an uncontrolled before and after study starting one month before and continuing until one month after implementation of ePMA, in a medicine for the elderly ward in a UK teaching hospital. Observation of nursing staff and documentation of workflow patterns, activities, interruptions and timeliness of medication administration during 20 scheduled drug rounds pre-ePMA and 14 rounds afterwards. / Results: While the introduction of ePMA did not significantly affect drug round duration, it altered the distribution of tasks with a doubling of the time spent on documentation. As might be expected, it eliminated time spent searching for paper drug charts. While there was no significant change in interruption rate, the types of interruption changed with an increase in healthcare related interruptions and a decrease in non-healthcare related interruptions. The timeliness of medication administration improved. / Conclusion: This small exploratory study suggests that introduction of ePMA does not significantly affect drug round duration, but alters the time spent on different tasks. The timeliness of medication administration improved, with potential benefits to patient safety