Identifying the latent failures underpinning medication administration errors: an exploratory study.
Ontology highlight
ABSTRACT:
SUBMITTER: Lawton R
PROVIDER: S-EPMC3401393 | biostudies-literature | 2012 Aug
REPOSITORIES: biostudies-literature
Publications
Identifying the latent failures underpinning medication administration errors: an exploratory study.
Lawton Rebecca R Carruthers Sam S Gardner Peter P Wright John J McEachan Rosie R C RR
Health services research 20120229 4
<h4>Objectives</h4>The primary aim of this article was to identify the latent failures that are perceived to underpin medication errors.<h4>Study setting</h4>The study was conducted within three medical wards in a hospital in the United Kingdom.<h4>Study design</h4>The study employed a cross-sectional qualitative design.<h4>Data collection methods</h4>Interviews were conducted with 12 nurses and eight managers. Interviews were transcribed and subject to thematic content analysis. A two-step inte ...[more]
Similar Datasets
Project description:BackgroundInformation technology-based methods such as bar code-assisted medication administration (BCMA) systems have the potential to reduce medication administration errors (MAEs) in hospitalized patients. In practice, however, systems are often not used as intended, leading to workarounds. Workarounds may result in MAEs that may harm patients.ObjectiveThe primary aim is to study the association of workarounds with MAEs in the BCMA process. Second, we will determine the frequency and type of workarounds and MAEs and explore the potential risk factors (determinants) for workarounds.MethodsThis is a multicenter prospective study on internal medicine and surgical wards of 4 Dutch hospitals using BCMA systems to administer medication. We will include a total of 6000 individual drug administrations using direct observation to collect data.ResultsThe project was funded in 2014 and enrollment was completed at the end of 2016. Data analysis is under way and the first results are expected to be submitted for publication at the end of 2017.ConclusionsIf an association between workarounds and MAEs is established, this information can be used to reduce the frequency of MAEs. Information on determinants of workarounds can aid in a focused approach to reduce workarounds and thus increase patient safety.Trial registrationNetherlands Trial Register NTR4355; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4355 (Archived by WebCite at http://www.webcitation.org/6pqTLxc6i).
| S-EPMC5429431 | biostudies-literature
Project description:BackgroundLiquid medication dosing errors (LMDE) made by caregivers affect treatment in children, but this is not a well-studied topic in many low-and middle-income countries including in India.MethodsAn intervention study was conducted among mothers attending a pediatric outpatient clinic of a tertiary care setting in Ujjain, India. The mothers randomly measured 12 volumes of a paracetamol liquid preparation by using a dropper (0.5 and 1 mL), measuring cup (2.5 and 5 mL), and calibrated spoon (2.5 and 5 mL) each with two instructions-oral-only measurement session (OMS) and oral plus pictogram measurement session (OPMS, the intervention). The main outcome was dosing error prevalence. The effectiveness of the intervention was assessed by measuring effect size. Risk factors for maximum LMDE were explored using backward multivariate logistic regression models. A P value of < 0.05 was considered statistically significant.ResultsIn total, 310 mothers [mean (± SD) age, 30.2 (± 4.18) years] were included. LMDE prevalence in the OMS versus OPMS for dropper 0.5 mL was 60% versus 48%; for l mL dropper was 63% versus 54%; for 2.5 mL cup 62% versus 54%; for 2.5 calibrated spoon 66% versus 59%; 5 mL cup 69% versus 57%; and 5 mL calibrated spoon 68% versus 55%. Comparing OMS with OPMS, underdosing was minimum with the calibrated spoon for 2.5 mL (OR 4.39) and maximum with the dropper for 1 mL (OR 9.40), and overdosing was minimum with the dropper for 0.5 mL (OR 7.12) and maximum with the calibrated spoon for 2.5 mL (OR 13.24). The effect size (dCohen) of the intervention OPMS was 1.86-6.4. Risk factors for the most prevalent dosing error, that is, with the calibrated spoon for 2.5 mL, were increasing age of the mother (aOR 1.08; P = 0.026) and nuclear family (aOR 2.83; P = 0.002). The risk of dosing errors decreased with higher education of the mothers.ConclusionsPictograms can effectively minimize LMDE even in less educated mothers.
| S-EPMC8228905 | biostudies-literature
Project description:To improve neonatal patient safety through automated detection of medication administration errors (MAEs) in high alert medications including narcotics, vasoactive medication, intravenous fluids, parenteral nutrition, and insulin using the electronic health record (EHR); to evaluate rates of MAEs in neonatal care; and to compare the performance of computerized algorithms to traditional incident reporting for error detection.We developed novel computerized algorithms to identify MAEs within the EHR of all neonatal patients treated in a level four neonatal intensive care unit (NICU) in 2011 and 2012. We evaluated the rates and types of MAEs identified by the automated algorithms and compared their performance to incident reporting. Performance was evaluated by physician chart review.In the combined 2011 and 2012 NICU data sets, the automated algorithms identified MAEs at the following rates: fentanyl, 0.4% (4 errors/1005 fentanyl administration records); morphine, 0.3% (11/4009); dobutamine, 0 (0/10); and milrinone, 0.3% (5/1925). We found higher MAE rates for other vasoactive medications including: dopamine, 11.6% (5/43); epinephrine, 10.0% (289/2890); and vasopressin, 12.8% (54/421). Fluid administration error rates were similar: intravenous fluids, 3.2% (273/8567); parenteral nutrition, 3.2% (649/20124); and lipid administration, 1.3% (203/15227). We also found 13 insulin administration errors with a resulting rate of 2.9% (13/456). MAE rates were higher for medications that were adjusted frequently and fluids administered concurrently. The algorithms identified many previously unidentified errors, demonstrating significantly better sensitivity (82% vs. 5%) and precision (70% vs. 50%) than incident reporting for error recognition.Automated detection of medication administration errors through the EHR is feasible and performs better than currently used incident reporting systems. Automated algorithms may be useful for real-time error identification and mitigation.
| S-EPMC4715992 | biostudies-literature
Project description:BACKGROUND: Older people in long-term residential care are at increased risk of medication prescribing and administration errors. The main aim of this study was to measure the incidence of medication administration errors in nursing and residential homes using a barcode medication administration (BCMA) system. METHODS: A prospective study was conducted in 13 care homes (9 residential and 4 nursing). Data on all medication administrations for a cohort of 345 older residents were recorded in real-time using a disguised observation technique. Every attempt by social care and nursing staff to administer medication over a 3-month observation period was analysed using BCMA records to determine the incidence and types of potential medication administration errors (MAEs) and whether errors were averted. Error classifications included attempts to administer medication at the wrong time, to the wrong person or discontinued medication. Further analysis compared data for residential and nursing homes. In addition, staff were surveyed prior to BCMA system implementation to assess their awareness of administration errors. RESULTS: A total of 188,249 medication administration attempts were analysed using BCMA data. Typically each resident was receiving nine different drugs and was exposed to 206 medication administration episodes every month. During the observation period, 2,289 potential MAEs were recorded for the 345 residents; 90% of residents were exposed to at least one error. The most common (n = 1,021, 45% of errors) was attempting to give medication at the wrong time. Over the 3-month observation period, half (52%) of residents were exposed to a serious error such as attempting to give medication to the wrong resident. Error incidence rates were 1.43 as high (95% CI 1.32-1.56 p < 0.001) in nursing homes as in residential homes. The level of non-compliance with system alerts was very low in both settings (0.075% of administrations). The pre-study survey revealed that only 12/41 staff administering drugs reported they were aware of potential administration errors in their care home. CONCLUSIONS: The incidence of medication administration errors is high in long-term residential care. A barcode medication administration system can capture medication administration errors and prevent these from occurring.
| S-EPMC3254134 | biostudies-literature
Project description:PurposeMedications are mostly taken in patients' own homes, increasingly administered by carers, yet studies of medication safety have been largely conducted in the hospital setting. We aimed to review studies of how carers cause and/or prevent medication administration errors (MAEs) within the patient's home; to identify types, prevalence and causes of these MAEs and any interventions to prevent them.MethodsA narrative systematic review of literature published between 1 Jan 1946 and 23 Sep 2013 was carried out across the databases EMBASE, MEDLINE, PSYCHINFO, COCHRANE and CINAHL. Empirical studies were included where carers were responsible for preventing/causing MAEs in the home and standardised tools used for data extraction and quality assessment.ResultsThirty-six papers met the criteria for narrative review, 33 of which included parents caring for children, two predominantly comprised adult children and spouses caring for older parents/partners, and one focused on paid carers mostly looking after older adults. The carer administration error rate ranged from 1.9 to 33% of medications administered and from 12 to 92.7% of carers administering medication. These included dosage errors, omitted administration, wrong medication and wrong time or route of administration. Contributory factors included individual carer factors (e.g. carer age), environmental factors (e.g. storage), medication factors (e.g. number of medicines), prescription communication factors (e.g. comprehensibility of instructions), psychosocial factors (e.g. carer-to-carer communication), and care-recipient factors (e.g. recipient age). The few interventions effective in preventing MAEs involved carer training and tailored equipment.ConclusionThis review shows that home medication administration errors made by carers are a potentially serious patient safety issue. Carers made similar errors to those made by professionals in other contexts and a wide variety of contributory factors were identified. The home care setting should be a priority for the development of patient safety interventions.
| S-EPMC5132322 | biostudies-literature
Project description:ObjectiveMedication 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.MethodsRegistered 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.ResultsA 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.ConclusionsTo 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.
| S-EPMC6203370 | biostudies-literature
Project description:Aims and objectivesTo identify the prevalence and determinants of medication administration errors (MAEs).BackgroundInsight into determinants of MAEs is necessary to identify interventions to prevent MAEs.DesignA prospective observational study in two Dutch hospitals, a university and teaching hospital.MethodsData were collected by observation. The primary outcome was the proportion of administrations with one or more MAEs. Secondary outcomes were the type, severity and determinants of MAEs. Multivariable mixed-effects logistic regression analyses were used for determinant analysis. Reporting adheres to the STROBE guideline.ResultsMAEs occurred in 352 of 2576 medication administrations (13.7%). Of all MAEs (n = 380), the most prevalent types were omission (n = 87) and wrong medication handling (n = 75). Forty-five MAEs (11.8%) were potentially harmful. The pharmaceutical forms oral liquid (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43-7.25), infusion (OR 1.73, CI 1.02-2.94), injection (OR 3.52, CI 2.00-6.21), ointment (OR 10.78, CI 2.10-55.26), suppository/enema (OR 6.39, CI 1.13-36.03) and miscellaneous (OR 6.17, CI 1.90-20.04) were more prone to MAEs compared to oral solid. MAEs were more likely to occur when medication was administered between 10 a.m.-2 p.m. (OR 1.91, CI 1.06-3.46) and 6 p.m.-7 a.m. (OR 1.88, CI 1.00-3.52) compared to 7 a.m.-10 a.m. and when administered by staff with higher professional education compared to staff with secondary vocational education (OR 1.68, CI 1.03-2.74). MAEs were less likely to occur in the teaching hospital (OR 0.17, CI 0.08-0.33). Day of the week, patient-to-nurse ratio, interruptions and other nurse characteristics (degree, experience, employment type) were not associated with MAEs.ConclusionsThis study identified a high MAE prevalence. Identified determinants suggest that focusing interventions on complex pharmaceutical forms and error-prone administration times may contribute to MAE reduction.Relevance to clinical practiceThe findings of this study can be used to develop targeted interventions to improve patient safety.
| S-EPMC10286768 | biostudies-literature
Project description:BackgroundMedication administration errors (MAEs) are a frequent cause of morbidity and mortality in acute care settings and can result in a prolonged hospital stay. The WHO estimated that medication errors cost up to $42 billion globally per a year. Therefore, MAEs was among the most common medical errors to occur in acute care settings. Studies of medication error usually focus on system factors, thus creating a gap between what researchers know about the causes of MAEs, and what frontline nurses actually do in the clinical setting. The purpose of this review is to fill a gap in the existing literature by focusing on the relationship between nurses' characteristics and MAEs.MethodsOnline databases were accessed, including CINAHL, PsycINFO, PubMed, Scopus, and Google Scholar from 2007-2020 period. This review was guided by the methods described by Whittemore and Knafl. Studies that addressed the occurrence of medication errors based on RN demographics were included in this review. The included studies were reviewed and analyzed by the two authors.ResultsOf the 1141 publications retrieved, 19 studies met inclusion criteria. The result provided strong evidence that nurses' level of education, length of experience, and attendance at training courses, are directly associated with the occurrence of MAEs. There is weak evidence of MAEs being influenced by the age and gender of nurses. Other nurse characteristics, such as cognitive load, frustration with technology, negligence, lack of attentiveness, and nurse ethnicity, are not adequately examined across the reviewed studies necessitates further research.ConclusionFocusing on nurses' characteristics might facilitate other researchers to suggest appropriate interventions that may reduce the incidence of MAEs. Interventional studies may provide convincing evidence as to whether one variable has a causal effect on another variable, and control the influence of confounding variables to enhance the generalizability of the findings.
| S-EPMC8223601 | biostudies-literature
Project description:BackgroundMedication administration errors are frequent and cause significant harm globally. However, only a few data are available on their prevalence, nature, and severity in developing countries, particularly in Brazil. This study attempts to determine the incidence, nature, and factors associated with medication administration errors observed in a university hospital.MethodsThis was a prospective observational study, conducted in a clinical and surgical unit of a University Hospital in Brazil. Two previously trained professionals directly observed medication preparation and administration for 15 days, 24 h a day, in February 2020. The type of error, the category of the medication involved, according to the anatomical therapeutic chemical classification system, and associated risk factors were analyzed. Multivariate logistic regression was adopted to identify factors associated with errors.ResultsThe administration of 561 drug doses was observed. The mean total medication administration error rate was 36.2% (95% confidence interval 32.3-40.2). The main factors associated with time errors were interruptions. Regarding technique errors, the primary factors observed were the route of administration, interruptions, and workload.ConclusionsHere, we identified a high total medication administration error rate, the most frequent being technique, wrong time, dose, and omission errors. The factors associated with errors were interruptions, route of administration and workload, which agrees well with the results of other national and international studies.
| S-EPMC9396806 | biostudies-literature
Project description:BackgroundDespite extensive research carried out on medication administration errors (MAEs) in the domain of infusion therapy, there is limited knowledge on nurse's perceptions on the occurrence of MAEs during infusion therapy. Since nurses are responsible for medication preparation and administration in Dutch hospitals, it is vital to understand their perspectives on the risk factors for MAEs.AimThe purpose of this study is to investigate the perception of nurses, working in adult ICUs, on the occurrence of MAEs during continuous infusion therapies.MethodsA digital web-based survey was distributed among 373 ICU nurses working in Dutch hospitals. The survey investigated nurses' perceptions on the frequency, severity of consequences and preventability of MAEs, factors for the occurrence of MAEs, and infusion pump and smart infusion safety technology.ResultsA total of 300 nurses started to fill out the survey but only 91 of them (30.3%) fully completed it and were included in analyses. Medication-related factors and Care professional-related factors were perceived as the two most important risk categories for the occurrence of MAEs. Important risk factors contributing to the occurrence of MAEs included high patient-nurse ratio, problems in communication between caregivers, frequent staff changes and transfers of care, and no/incorrect dosage/concentration on labels. Drug library was reported as the most important infusion pump feature and both Bar Code Medication Administration (BCMA) and medical device connectivity as the two most important smart infusion safety technologies. Nurses perceived the majority of MAEs as preventable.ConclusionsBased on ICU nurses' perceptions, the present study suggests that strategies to reduce MAEs in these units should focus on, among other factors, the high patient-to-nurse ratio, problems in communication between nurses, frequent staff changes and transfers of care, and no/incorrect dosage/concentration on drug labels.
| S-EPMC9930049 | biostudies-literature