Drug selection errors in relation to medication labels: a simulation study

Abstract

SummaryThe aim of this study was to assess the impact of differences in drug label information on injectable drug selection errors. Differences in the display of drug strength information were assessed in a randomised controlled trial involving ward nurses, intensive care nurses, nurse anaesthetists, ward physicians, and anaesthetists. A set of 24 on-screen tasks were constructed. For each task, a label corresponding to an instruction consisting of two from three possible pieces of information (concentration, quantity, volume) had to be selected from a list of 10 items. The set was presented three times to participants using three different label formats. Format A provided two pieces of strength information different from those in the instruction. Format B and C provided all three pieces in a random and a fixed sequence, respectively. The frequency of errors was statistically higher with formats A and B than with format C, and greater in nurses than in anaesthetists. Regulatory bodies should therefore implement a standard requiring that the concentration (expressed in 'mg.ml Incorporating safety into the design of healthcare systems is essential for the prevention of medical errors [1]. In practice, however, many hospital care processes have not been designed for safety. Rather, they have developed over time and often contain intrinsic system weaknesses. One example is the design of drug labels. Labels represent the main 'drug ⁄ user' interface, and numerous case reports [2,3] suggest that their characteristics, such as the drug name, type-face, colour coding or expression of drug strength greatly contribute to the incidence of medication errors. However, the impact of drug label design on human performance has received little attention. Studies have shown that print characteristics affect the readability of labels [4,5], and that orthographic and phonetic similarity between drug names increases the probability of a false recognition error [6]. Printing a section of a drug name in capital letters has been shown to reduce errors in drug name recognition [7,8].As calculation errors are common amongst healthcare professionals [9][10][11], several authors have advised that the display of drug strength information on injectable medication labels be standardised [10,12]. To understand the potential impact of this measure on human reliability, we designed a computer-based experiment to compare the effect of three different drug strength information formats, incorporating various levels of standardisation, on the frequency of drug selection errors made by groups of healthcare professionals. Methods Study populationFive different professional groups (ward nurses, intensivecare nurses, nurse anaesthetists, ward physicians, anaesthetists) each group consisting of 15 volunteers, were involved in the experiment. The volunteers, who were recruited in the institution by an advertising campaign, were informed of the aim and design of the study, gave their written consent, and received monetary compensation of approximately €15....

Identifying Facilitators and Barriers for Patient Safety in a Medicine Label Design System Using Patient Simulation and Interviews

“…This way, challenges in using the medicine will become evident. The simulation environment further allows for investigating actual administration errors, 18,19 which would not be possible in the clinical setting because of ethical considerations. Simulation can thus serve as a relevant supplement to other investigation methods, such as incident reporting and postmarket surveillance.…”

“…25,41 Especially in the case of standardization, it would be essential not to force users to learn different systems of standardization. 18 Eventually, this might involve the coordination of medication names and other features of label design across disciplines during the approval of new products. 11 Any implementation would also need to take into account that it could take some time before any change would actually reach clinical practice because previously acquired units (with previous versions of the labels) might still be available for various amounts of time.…”

Medication errors in critical care: risk factors, prevention and disclosure

“…• Bar code technology [74][75][76] • New staff orientation (including residents) [77][78][79][80][81][82][83][84][85] • Adequate nurse staffing [86][87][88][89] • Intensivist staffing 90 • Adequate working conditions and caregiver fidelity*…”

Medicines labelling

“…www.australianprescriber.com considerably improved. 16 Various design techniques, such as the use of particular fonts, 14 judicious application of colour 17 and the layout of information, 18 can also be used to produce labels that are more easily read and identified. These principles can be equally applied to both manufacturers' labels and those produced by healthcare professionals.…”