Marja Härkänen

Medication errors: what hospital reports reveal about staff views: Marja Härkänen and colleagues examine a study to help nurses reduce the risk of making mistakes when administering medicines to patients

Nurses are generally responsible for administering medication to patients and are, therefore, able to monitor or report medication errors. However, nurses can sometimes be responsible for causing errors, so it is important that they understand the consequences of these mistakes and how to prevent them. This article reports the results of a study that analysed the views of nurses, pharmacists and physicians at a Finnish university hospital on the prevention of medication errors. The findings suggest errors can be prevented by improving work environments and allowing healthcare staff, particularly nurses, to concentrate on the task at hand when dealing with medicines.

Differences Between Methods of Detecting Medication Errors: A Secondary Analysis of Medication Administration Errors Using Incident Reports, the Global Trigger Tool Method, and Observations.

Supplemental digital content is available in the text. Objectives This study aimed to compare medication administration errors detected by 3 different methods in terms of severity, type, and contributing factors. Methods The study was performed in one university hospital in Finland. A convenience sample of medication administration errors (n = 451) reported on incident reports or detected by reviewing randomly selected patient records via the Global Trigger Tool method and direct observations of patient record reviews were collected for reanalysis. The severity of the medication administration errors, the types thereof, and factors contributing to such errors were reclassified using the National Coordinating Council for Medication Error Reporting and Prevention’s taxonomy of medication errors. Results The observational method revealed fewer medication errors that were more likely to cause harm to patients than did the incident reports or the Global Trigger Tool method. The incident reports and the Global Trigger Tool method mainly revealed wrong doses, whereas most medication administration errors in the observational data were errors involving the use of the incorrect technique. In addition, each method produced different information regarding the factors contributing to medication administration errors. Conclusions Based on the study’s findings and the limitations of each method, a combination of different methods should be used to discover representative information concerning medication administration errors. To increase medication administration safety, advanced multiprofessional collaboration, effective communication, adequate skills, more systematic medication processes, and distraction-free work environments are needed.

Detecting medication errors: analysis based on a hospital's incident reports.

The aim of this paper is to analyse how medication incidents are detected in different phases of the medication process. The study design is a retrospective register study. The material was collected from one university hospitals web-based incident reporting database in Finland. In 2010, 1617 incident reports were made, 671 of those were medication incidents and analysed in this study. Statistical methods were used to analyse the material. Results were reported using frequencies and percentages. Twenty-one percent of all medication incidents were detected during documenting or reading the documents. One-sixth of medication incidents were detected during medicating the patients, and approximately one-tenth were detected during verifying of the medicines. It is important to learn how to break the chain of medication errors as early as possible. Findings showed that for nurses, the ability to concentrate on documenting and medicating the patient is essential.

558 Educational interventions designed to improve medication administration safety

Background Increasing the medication administration safety is vital to improving patient safety. The aim of this study is to analyse educational interventions designed to increase the medication administration skills and safety of registered nurses. Methods A systematic review of the literature using six databases was conducted to identify intervention studies published between January 2000 and April 2015. The quality of studies was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. The efficacy of the interventions was determined by calculating the effect sizes and conducting a meta-analysis. Results Fourteen intervention studies were included in this systematic review. Quality was strong only in one study and moderate in another four. The interventions differed significantly from one study to the next, and the original investigators reported significant improvement in the skills and medication safety owing to the interventions. The meta-analyses, however, revealed that the effect of the intervention was strong in only four of the studies. Those interventions were the 60-minute educational intervention (PowerPoint presentation), a blended learning programme inclusive of e-learning, wall poster and informative pamphlets, and a combination of three different interventions (classroom or self-study methods). In two out of four cases, the quality of the study was weak and moderate in two cases, and only one of the effective interventions was a randomised controlled trial. Conclusions Based on the original analysis, all the interventions reviewed had a positive impact on medication administration safety. Nonetheless, these positive outcomes do not necessarily indicate effective interventions. The most effective interventions in this review were methodologically dissimilar. Studies should be assessed for their quality and a meta-analysis performed when searching for the best, effective and highest quality educational interventions.