Medication Administration Errors: Causes and Reporting Behaviors from Nurses Perspectives

2021 ◽  
Author(s):  
Alaa Yousef ◽  
Rana Abu Farha ◽  
Khaled Da’meh
Keyword(s):  
Medication Administration ◽  
Medication Administration Errors ◽  
Reporting Behaviors

scholarly journals Use of Pediatric Injectable Medicines Guidelines and Associated Medication Administration Errors: A Human Reliability Analysis

2021 ◽  
pp. 106002802199964
Author(s):  
Matthew D. Jones ◽  
Jonathan Clarke ◽  
Calandra Feather ◽  
Bryony Dean Franklin ◽  
Ruchi Sinha ◽  
...  
Keyword(s):  
Reliability Analysis ◽  
Medication Administration ◽  
Original Study ◽  
Human Reliability ◽  
Large Magnitude ◽  
Human Reliability Analysis ◽  
Video Recordings ◽  
Medication Administration Errors ◽  
Key Factor ◽  
Clinically Significant

Background: In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs). Objective: The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice ( discrepancies) that contributed to large-magnitude and/or clinically significant MAEs. Methods: Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study. Results: In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs. Conclusion and Relevance: Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.

The incidence and nature of prescribing and medication administration errors in paediatric inpatients

2010 ◽  
Vol 95 (2) ◽  
pp. 113-118 ◽  
Author(s):  
M. A. Ghaleb ◽  
N. Barber ◽  
B. D. Franklin ◽  
I. C. K. Wong
Keyword(s):  
Medication Administration ◽  
Medication Administration Errors

scholarly journals Prevalence of intravenous medication administration errors: a cross-sectional study

2017 ◽  
Vol Volume 6 ◽  
pp. 47-51 ◽  
Author(s):  
Tezeta Fekadu ◽  
Mebrahtu Teweldemedhin ◽  
Eyerusalem Esrael ◽  
Solomon Weldegebreal Asgedom
Keyword(s):  
Medication Administration ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Cross Sectional ◽  
Medication Administration Errors ◽  
Intravenous Medication

scholarly journals Analysis of Reported E-prescribing Medication Administration Errors at King Saud Medical City, Riyadh: A Cross-Sectional, Retrospective Study

2020 ◽  
pp. 34-45
Author(s):  
Dalal Salem Al- Dossari ◽  
Mohammed Ibrahim Alnami ◽  
Naseem Akhtar Qureshi
Keyword(s):  
Saudi Arabia ◽  
Retrospective Study ◽  
Medication Errors ◽  
Drug Administration ◽  
Medication Administration ◽  
Care Hospital ◽  
Cross Sectional ◽  
Common Error ◽  
Clinical Pharmacists ◽  
Medication Administration Errors

Background: Drug prescription error is a medication error that most frequently happens in healthcare organizations and adversely affects the healthcare consumers. Most medication errors (MEs) but not all are captured and corrected before reaching the patient by designed system controls. Medication administration errors (MAEs) mostly are made by nurses but frequently reported by clinical pharmacists in hospitals in Saudi Arabia. Objective: This study aimed to analyze exclusively the voluntarily reported drug administration errors in a tertiary care hospital in Riyadh city. Methods: This cross-sectional, retrospective study evaluated consecutively collected medication administration report forms over a period of one year from January 1, 2015 to December 31, 2015. Results: The number of MAEs occurring during stage of drug administration constituted 7.1% (n=971) of total medication errors (n=13677). The maximum number of MEs (n=6838, 50%) and MAEs (n=455, 46.9%) occurred during the 4th quarter of the year 2015. The most common MAE happened to be category C (n=888, 91.5%) which means error occurred, reached the patient but without causing any harm. Concerning MAE types, the most common error included wrong frequency (40%) followed by wrong drug (17%), wrong time of administration (16%) and wrong rate of infusion (10%). Nurses made the most of the errors (92.2%) while the clinical pharmacists reported the most MAEs (75.5%). High alert medications (HAM) errors constituted 32.3% (n=314) of MAEs (n=971) and most common HAM errors included the wrong route of administration of Lanus Insulin (15%) followed by Insulin Aspart (15%), Enoxaparin (13%) and Insulin Protamine-Nvomix (12%). Look-alike and sound-alike (LASA) errors constituted 55.2% of MAEs (971/536) and most common LASA drugs identified were Gentamycin (13%), Insulin Mixtard (11%), NPH Insulin (8%) Intralipid vial (8%) and Insulin regular (6%). Conclusion: This retrospective study provides some important tentative pharmacovigilance insights into MAEs, which are partially comparable with current international trends in drug administration errors. Further studies on MAEs are warranted not only in the Kingdom of Saudi Arabia but also other Gulf countries.

scholarly journals Integrating and Evaluating the Data Quality and Utility of Smart Pump Information in Detecting Medication Administration Errors: Evaluation Study (Preprint)

2020 ◽  
Author(s):  
Yizhao Ni ◽  
Todd Lingren ◽  
Hannah Huth ◽  
Kristen Timmons ◽  
Krisin Melton ◽  
...  
Keyword(s):  
Data Quality ◽  
Error Detection ◽  
Clinical Setting ◽  
Infusion Pump ◽  
Medication Use ◽  
Primary Source ◽  
Evaluation Study ◽  
Medication Administration ◽  
Medication Administration Errors ◽  
Smart Pump

BACKGROUND At present, electronic health records (EHRs) are the central focus of clinical informatics given their role as the primary source of clinical data. Despite their granularity, the EHR data heavily rely on manual input and are prone to human errors. Many other sources of data exist in the clinical setting, including digital medical devices such as smart infusion pumps. When incorporated with prescribing data from EHRs, smart pump records (SPRs) are capable of shedding light on actions that take place during the medication use process. However, harmoniz-ing the 2 sources is hindered by multiple technical challenges, and the data quality and utility of SPRs have not been fully realized. OBJECTIVE This study aims to evaluate the quality and utility of SPRs incorporated with EHR data in detecting medication administration errors. Our overarching hypothesis is that SPRs would contribute unique information in the med-ication use process, enabling more comprehensive detection of discrepancies and potential errors in medication administration. METHODS We evaluated the medication use process of 9 high-risk medications for patients admitted to the neonatal inten-sive care unit during a 1-year period. An automated algorithm was developed to align SPRs with their medica-tion orders in the EHRs using patient ID, medication name, and timestamp. The aligned data were manually re-viewed by a clinical research coordinator and 2 pediatric physicians to identify discrepancies in medication ad-ministration. The data quality of SPRs was assessed with the proportion of information that was linked to valid EHR orders. To evaluate their utility, we compared the frequency and severity of discrepancies captured by the SPR and EHR data, respectively. A novel concordance assessment was also developed to understand the detec-tion power and capabilities of SPR and EHR data. RESULTS Approximately 70% of the SPRs contained valid patient IDs and medication names, making them feasible for data integration. After combining the 2 sources, the investigative team reviewed 2307 medication orders with 10,575 medication administration records (MARs) and 23,397 SPRs. A total of 321 MAR and 682 SPR dis-crepancies were identified, with vasopressors showing the highest discrepancy rates, followed by narcotics and total parenteral nutrition. Compared with EHR MARs, substantial dosing discrepancies were more commonly detectable using the SPRs. The concordance analysis showed little overlap between MAR and SPR discrepan-cies, with most discrepancies captured by the SPR data. CONCLUSIONS We integrated smart infusion pump information with EHR data to analyze the most error-prone phases of the medication lifecycle. The findings suggested that SPRs could be a more reliable data source for medication error detection. Ultimately, it is imperative to integrate SPR information with EHR data to fully detect and mitigate medication administration errors in the clinical setting.

scholarly journals The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incident Report Data

2019 ◽  
Vol 52 (1) ◽  
pp. 113-123 ◽  
Author(s):  
Marja Härkänen ◽  
Katri Vehviläinen‐Julkunen ◽  
Trevor Murrells ◽  
Jussi Paananen ◽  
Bryony D. Franklin ◽  
...  
Keyword(s):  
Text Mining ◽  
Medication Administration ◽  
Incident Report ◽  
Medication Administration Errors ◽  
Report Data

scholarly journals Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients

2020 ◽  
pp. bmjqs-2020-011473
Author(s):  
Johanna I Westbrook ◽  
Ling Li ◽  
Magdalena Z Raban ◽  
Amanda Woods ◽  
Alain K Koyama ◽  
...  
Keyword(s):  
Observational Study ◽  
Medical Records ◽  
Medication Administration ◽  
Clinical Settings ◽  
Paediatric Hospital ◽  
Factors Associated ◽  
Medication Administration Errors ◽  
Multivariable Regression ◽  
Very High ◽  
Considerable Resource

BackgroundDouble-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades. While the practice is widespread, evidence of its effectiveness in reducing errors or harm is scarce.ObjectivesTo measure the association between double-checking, and the occurrence and potential severity of medication administration errors (MAEs); check duration; and factors associated with double-checking adherence.MethodsDirect observational study of 298 nurses, administering 5140 medication doses to 1523 patients, across nine wards, in a paediatric hospital. Independent observers recorded details of administrations and double-checking (independent; primed—one nurse shares information which may influence the checking nurse; incomplete; or none) in real time during weekdays and weekends between 07:00 and 22:00. Observational medication data were compared with patients’ medical records by a reviewer (blinded to checking-status), to identify MAEs. MAEs were rated for potential severity. Observations included administrations where double-checking was mandated, or optional. Multivariable regression examined the association between double-checking, MAEs and potential severity; and factors associated with policy adherence.ResultsFor 3563 administrations double-checking was mandated. Of these, 36 (1·0%) received independent double-checks, 3296 (92·5%) primed and 231 (6·5%) no/incomplete double-checks. For 1577 administrations double-checking was not mandatory, but in 26·3% (n=416) nurses chose to double-check. Where double-checking was mandated there was no significant association between double-checking and MAEs (OR 0·89 (0·65–1·21); p=0·44), or potential MAE severity (OR 0·86 (0·65–1·15); p=0·31). Where double-checking was not mandated, but performed, MAEs were less likely to occur (OR 0·71 (0·54–0·95); p=0·02) and had lower potential severity (OR 0·75 (0·57–0·99); p=0·04). Each double-check took an average of 6·4 min (107 hours/1000 administrations).ConclusionsCompliance with mandated double-checking was very high, but rarely independent. Primed double-checking was highly prevalent but compared with single-checking conferred no benefit in terms of reduced errors or severity. Our findings raise questions about if, when and how double-checking policies deliver safety benefits and warrant the considerable resource investments required in modern clinical settings.

scholarly journals Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals

2017 ◽  
Vol 25 (4) ◽  
pp. 385-392 ◽  
Author(s):  
Willem van der Veen ◽  
Patricia MLA van den Bemt ◽  
Hans Wouters ◽  
David W Bates ◽  
Jos WR Twisk ◽  
...  
Keyword(s):  
Prospective Observational Study ◽  
Primary Outcome ◽  
Outcome Measure ◽  
Medication Administration ◽  
Primary Outcome Measure ◽  
Secondary Outcome ◽  
Bar Code ◽  
Implementation Evaluation ◽  
Medication Administration Errors ◽  
Large Numbers

Abstract Objective To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors. Materials and Methods A prospective observational study in Dutch hospitals using BCMA to administer medication. Direct observation was used to collect data. Primary outcome measure was the proportion of medication administrations with one or more medication administration errors. Secondary outcome was the frequency and types of workarounds and medication administration errors. Univariate and multivariate multilevel logistic regression analysis were used to assess the association between workarounds and medication administration errors. Descriptive statistics were used for the secondary outcomes. Results We included 5793 medication administrations for 1230 inpatients. Workarounds were associated with medication administration errors (adjusted odds ratio 3.06 [95% CI: 2.49-3.78]). Most commonly, procedural workarounds were observed, such as not scanning at all (36%), not scanning patients because they did not wear a wristband (28%), incorrect medication scanning, multiple medication scanning, and ignoring alert signals (11%). Common types of medication administration errors were omissions (78%), administration of non-ordered drugs (8.0%), and wrong doses given (6.0%). Discussion Workarounds are associated with medication administration errors in hospitals using BCMA. These data suggest that BCMA needs more post-implementation evaluation if it is to achieve the intended benefits for medication safety. Conclusion In hospitals using barcode-assisted medication administration, workarounds occurred in 66% of medication administrations and were associated with large numbers of medication administration errors.

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