Richard Keers

Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

BackgroundUnderlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence.ObjectiveThis study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings.Data SourcesNine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013.Study SelectionInclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail.Data Appraisal and Synthesis MethodsA total of 54 unique studies were included. Causes of MAEs were categorised according to Reason’s model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used.ResultsSlips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality), patient factors (availability, acuity), staff health status (fatigue, stress) and interruptions/distractions during drug administration. Few studies sought to determine the causes of intravenous MAEs. A number of latent pathway conditions were less well explored, including local working culture and high-level managerial decisions. Causes were often described superficially; this may be related to the use of quantitative surveys and observation methods in many studies, limited use of established error causation frameworks to analyse data and a predominant focus on issues other than the causes of MAEs among studies.LimitationsAs only English language publications were included, some relevant studies may have been missed.ConclusionsLimited evidence from studies included in this systematic review suggests that MAEs are influenced by multiple systems factors, but if and how these arise and interconnect to lead to errors remains to be fully determined. Further research with a theoretical focus is needed to investigate the MAE causation pathway, with an emphasis on ensuring interventions designed to minimise MAEs target recognised underlying causes of errors to maximise their impact.

Prevalence and Nature of Medication Administration Errors in Health Care Settings: A Systematic Review of Direct Observational Evidence:

OBJECTIVE: To systematically review empirical evidence on the prevalence and nature of medication administration errors (MAEs) in health care settings. DATA SOURCES: Ten electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, Scopus, Applied Social Sciences Index and Abstracts, PsycINFO, Cochrane Reviews and Trials, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, and Health Management Information Consortium) were searched (1985-May 2012). STUDY SELECTION AND DATA EXTRACTION: English-language publications reporting MAE data using the direct observation method were included, providing an error rate could be determined. Reference lists of all included articles were screened for additional studies. DATA SYNTHESIS: In all, 91 unique studies were included. The median error rate (interquartile range) was 19.6% (8.6–28.3%) of total opportunities for error including wrong-time errors and 8.0% (5.1–10.9%) without timing errors, when each dose could be considered only correct or incorrect. The median rate of error when more than 1 error could be counted per dose was 25.6% (20.8–41.7%) and 20.7% (9.7–30.3%), excluding wrong-time errors. A higher median MAE rate was observed for the intravenous route (53.3% excluding timing errors (IQR 26.6–57.9%)) compared to when all administration routes were studied (20.1%; 9.0–24.6%), where each dose could accumulate more than one error. Studies consistently reported wrong time, omission, and wrong dosage among the 3 most common MAE subtypes. Common medication groups associated with MAEs were those affecting nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antiinfectives. Medication administration error rates varied greatly as a product of differing medication error definitions, data collection methods, and settings of included studies. Although MAEs remained a common occurrence in health care settings throughout the time covered by this review, potential targets for intervention to minimize MAEs were identified. CONCLUSIONS: Future research should attend to the wide methodological inconsistencies between studies to gain a greater measure of comparability to help guide any forthcoming interventions.

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study.

Objectives To investigate the underlying causes of intravenous medication administration errors (MAEs) in National Health Service (NHS) hospitals. Setting Two NHS teaching hospitals in the North West of England. Participants Twenty nurses working in a range of inpatient clinical environments were identified and recruited using purposive sampling at each study site. Primary outcome measures Semistructured interviews were conducted with nurse participants using the critical incident technique, where they were asked to discuss perceived causes of intravenous MAEs that they had been directly involved with. Transcribed interviews were analysed using the Framework approach and emerging themes were categorised according to Reasons model of accident causation. Results In total, 21 intravenous MAEs were discussed containing 23 individual active failures which included slips and lapses (n=11), mistakes (n=8) and deliberate violations of policy (n=4). Each active failure was associated with a range of error and violation provoking conditions. The working environment was implicated when nurses lacked healthcare team support and/or were exposed to a perceived increased workload during ward rounds, shift changes or emergencies. Nurses frequently reported that the quality of intravenous dose-checking activities was compromised due to high perceived workload and working relationships. Nurses described using approaches such as subconscious functioning and prioritising to manage their duties, which at times contributed to errors. Conclusions Complex interactions between active and latent failures can lead to intravenous MAEs in hospitals. Future interventions may need to be multimodal in design in order to mitigate these risks and reduce the burden of intravenous MAEs.

Prevalence, nature and predictors of prescribing errors in mental health hospitals: a prospective multicentre study

Objective To determine the prevalence, nature and predictors of prescribing errors (PEs) in three mental health hospitals. Setting Inpatient units in three National Health Service (NHS) mental health hospitals in the North West of England. Participants Trained clinical pharmacists prospectively recorded the number of PEs in newly written or omitted prescription items screened during their routine work on 10 data collection days. A multidisciplinary panel reviewed PE data using established methods to confirm (1) the presence of a PE, (2) the type of PE and (3) whether errors were clinically relevant and likely to cause harm. Primary outcome measures Frequency, nature and predictors of PEs. Results Of 4427 screened prescription items, 281 were found to have one or more PEs (error rate 6.3% (95% CI 5.6 to 7.1%)). Multivariate analysis revealed that specialty trainees (OR 1.23 (1.01 to 1.51)) and staff grade psychiatrists (OR 1.50 (1.05 to 2.13)) were more likely to make PEs when compared to foundation year (FY) one doctors, and that specialty trainees and consultant psychiatrists were twice as likely to make clinically relevant PEs (OR 2.61 (2.11 to 3.22) and 2.03 (1.66 to 2.50), respectively) compared to FY one staff. Prescription items screened during the prescription chart rewrite (OR 0.52 (0.33 to 0.82)) or at discharge (OR 0.87 (0.79 to 0.97)) were less likely to be associated with PEs than items assessed during inpatient stay, although they were more likely to be associated with clinically relevant PEs (OR 2.27 (1.72 to 2.99) and 4.23 (3.68 to 4.87), respectively). Prescription items screened at hospital admission were five times more likely (OR 5.39 (2.72 to 10.69)) to be associated with clinically relevant errors than those screened during patient stay. Conclusions PEs may be more common in mental health hospitals than previously reported and important targets to minimise these errors have been identified.

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

When compared to general hospitals, relatively little is known about the quality and safety of discharge prescriptions from specialist mental health settings. We aimed to investigate the quality and safety of discharge prescriptions written at mental health hospitals.

Prescribing and Research in Medicines Management (UK & Ireland) Conference 2016 Health Foundation London January 29th 2016 "Ethics, Economics and the Future of Medicines - A Population Perspective"

Background: Poor communication of information at healthcare transition is responsible for over 50% of all medication errors and up to 20% of adverse events. It is well recognised that transfer of patients between different care settings presents significant risks to maintaining adequate communication about changes to medicines regimes. It is estimated that between 30 and 70% of patients have either an error or an unintentional change to their medicines when their care is transferred. The Royal Pharmaceutical Society published guidance in 2012 with the aim of improving the transfer of information across all care settings. An area that can easily be overlooked is where a cancer medicine is prescribed and/or directly supplied to patients by organisations outside of a general medical practice. The number of these medicines is likely to increase as long-term oral chemotherapy becomes the norm. This presents a challenge to primary care to ensure that clinicians are aware of these medicines in order to make effective clinical decisions, avoid interactions or other risks when a new medicine is prescribed. This study aimed to quantify the scale and nature of the how non-primary care cancer medicines are recorded in the patient’s clinical records.

Inferring Visual Behaviour from User Interaction Data on a Medical Dashboard

(its size and complexity) and its context of use. This results in user interfaces with a high-density of data that do not support optimal decision-making by clinicians. Anecdotal evidence indicates that clinicians demand the right amount of information to carry out their tasks. This suggests that adaptive user interfaces could be employed in order to cater for the information needs of the users and tackle information overload. Yet, since these information needs may vary, it is necessary first to identify and prioritise them, before implementing adaptations to the user interface. As gaze has long been known to be an indicator of interest, eye tracking allows us to unobtrusively observe where the users are looking, but it is not practical to use in a deployed system. Here, we address the question of whether we can infer visual behaviour on a medication safety dashboard through user interaction data. Our findings suggest that, there is indeed a relationship between the use of the mouse (in terms of clickstreams and mouse hovers) and visual behaviour in terms of cognitive load. We discuss the implications of this finding for the design of adaptive medical dashboards.

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff

Objective Medication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England. Methods Registered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants’ experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason’s model of accident causation. Results A total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication. Conclusions To our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent ‘system’ failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational ‘systems’ failures to reduce error.

Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care

Introduction Developments in information technology offer opportunities to enhance medication safety in primary care. We evaluated the implementation and adoption of a complex pharmacist-led intervention involving the use of an electronic audit and feedback surveillance dashboard to identify patients potentially at risk of hazardous prescribing or monitoring of medicines in general practices. The intervention aimed to create a rapid learning health system for medication safety in primary care. This study aimed to explore how the intervention was implemented, adopted and embedded into practice using a qualitative process evaluation. Methods Twenty two participants were purposively recruited from eighteen out of forty-three general practices receiving the intervention as well as clinical commissioning group staff across Salford UK, which reflected the range of contexts in which the intervention was implemented. Interviews explored how pharmacists and GP staff implemented the intervention and how this affected care practice. Data analysis was thematic with emerging themes developed into coding frameworks based on Normalisation Process Theory (NPT). Results Engagement with the dashboard involved a process of sense-making in which pharmacists considered it added value to their work. The intervention helped to build respect, improve trust and develop relationships between pharmacists and GPs. Collaboration and communication between pharmacists and clinicians was primarily initiated by pharmacists and was important for establishing the intervention. The intervention operated as a rapid learning health system as it allowed for the evidence in the dashboard to be translated into changes in work practices and into transformations in care. Conclusions Our study highlighted the importance of the combined use of information technology and the role of pharmacists working in general practice settings. Medicine optimisation activities in primary care may be enhanced by the implementation of a pharmacist-led electronic audit and feedback system. This intervention established a rapid learning health system that swiftly translated data from electronic health records into changes in practice to improve patient care. Using NPT provided valuable insights into the ways in which developing relationships, collaborations and communication between health professionals could lead to the implementation, adoption and sustainability of the intervention.

SMASH! The Salford medication safety dashboard

Background Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research has demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners (GPs) in a pharmacist-led intervention. We aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion. Method Based on initial system requirements, we designed the dashboard’s user interface over three iterations with six GPs, seven pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices. Results A web-based electronic dashboard was developed and linked to shared care records in Salford, UK. The completed dashboard was deployed in all but one (n = 43) general practices in the region. By November 2017, 36 pharmacists had been trained in delivering the intervention to practices. There were 135 registered users of the dashboard, with an average of 91 user sessions a week. Conclusion We have developed and successfully rolled out of a complex, pharmacist-led dashboard intervention in Salford, UK. System usage statistics indicate broad and sustained uptake of the intervention. The use of systems that provide regularly updated audit information may be an important contributor towards medication safety in primary care.