Misreading Injectable Medications—Causes and Solutions: An Integrative Literature Review

Borradale, Heather; Andersen, Patrea; Wallis, Marianne; Oprescu, Florin

doi:10.1016/j.jcjq.2020.01.007

Cited by 2 publications

(2 citation statements)

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“…Poor labelling design can contribute to medication errors by making it difficult for end users to identify and understand critical safety information [ 12 ]. In an integrative review, Borradale et al [ 13 ] found that packaging and labelling design is the most commonly identified factor contributing to misreading injectable medications; the specific features named as problematic were as follows: look-alike injectable medications, similar colours, small text, lack of colour contrast on ampules, embossed information on plastic ampules, trade name prominence, and the design of ampule/vial labels. Literature suggests that pharmaceutical companies do not consider design for safety their responsibility [ 14 ] and assume that healthcare staff are those who should prevent medication errors [ 15 ].…”

Section: Introductionmentioning

confidence: 99%

Estimating the impact of label design on reducing the risk of medication errors by applying HEART in drug administration

Aceves-Gonzalez,

Caro-Rojas,

Rey-Galindo

et al. 2024

Eur J Clin Pharmacol

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Medication errors are one of the biggest problems in healthcare. The medicines’ poor labelling design (i.e. look-alike labels) is a well-recognised risk for potential confusion, wrong administration, and patient damage. Human factors and ergonomics (HFE) encourages the human-centred design of system elements, which might reduce medication errors and improve people’s well-being and system performance. Objective The aim of the present study is twofold: (i) to use a human reliability analysis technique to evaluate a medication administration task within a simulated scenario of a neonatal intensive care unit (NICU) and (ii) to estimate the impact of a human-centred design (HCD) label in medication administration compared to a look-alike (LA) label. Method This paper used a modified version of the human error assessment and reduction technique (HEART) to analyse a medication administration task in a simulated NICU scenario. The modified technique involved expert nurses quantifying the likelihood of unreliability of a task and rating the conditions, including medicine labels, which most affect the successful completion of the task. Results Findings suggest that error producing conditions (EPCs), such as a shortage of time available for error detection and correction, no independent checking of output, and distractions, might increase human error probability (HEP) in administering medications. Results also showed that the assessed HEP and the relative percentage of contribution to unreliability reduced by more than 40% when the HCD label was evaluated compared to the LA label. Conclusion Including labelling design based on HFE might help increase human reliability when administering medications under critical conditions.

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Section: Introductionmentioning

confidence: 99%

Estimating the impact of label design on reducing the risk of medication errors by applying HEART in drug administration

Aceves-Gonzalez,

Caro-Rojas,

Rey-Galindo

et al. 2024

Eur J Clin Pharmacol

View full text Add to dashboard Cite

show abstract

“…Poor labelling design can contribute to medication errors by making it di cult for end users to identify and understand critical safety information [12]. In an integrative review, Borradale et al [13] found that packaging and labelling design is the most commonly identi ed factor contributing to misreading injectable medications; the speci c features named as problematic were: look-alike injectable medications, similar colours, small text, lack of colour contrast on ampules, embossed information on plastic ampules, trade name prominence, and the design of ampule/vial labels. Literature suggests that pharmaceutical companies do not consider design for safety their responsibility [14] and assume that the perfection of practitioners should eliminate medication errors [15].…”

Section: Introductionmentioning

confidence: 99%

Estimating the impact of label design on reducing the risk of medication errors by applying HEART in drug administration

Aceves-Gonzalez,

Caro-Rojas,

Rey-Galindo

et al. 2023

Preprint

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Medication errors are one of the biggest problems in healthcare. The medicines ' poor labelling design (i.e., Look-Alike labels) is a well-recognised risk for potential confusion, wrong administration, and patient damage. Human Factors and Ergonomics (HFE) encourages the human-centred design of system elements, which might reduce medication errors and improve people's well-being and system performance. Objective: The aim of the present study is twofold: (i) to use a human reliability analysis technique to evaluate a medication administration task within a simulated scenario of a Neonatal Intensive Care Unit (NICU); (ii) to estimate the impact of a Human-Centred Design (HCD) label in medication administration compared to a Look-Alike (LA) label. Method: This paper used a modified Human Error Assessment and Reduction Technique (HEART) version to analyse a medication administration task in a simulated NICU scenario. The modified technique involved expert nurses quantifying the likelihood of unreliability of a task and rating the conditions, including medicine labels, which most affect the successful completion of the task. Results: Findings suggest that Error Producing Conditions (EPCs), such as a shortage of time available for error detection and correction, no independent checking of output, and distractions, might increase Human Error Probability (HEP) in administering medications. Results also showed that the assessed HEP and the relative percentage of contribution to unreliability reduced by more than 40% when the HCD label was assessed compared to the LA label. Conclusion: Including labelling design based on HFE might help increase human reliability when administering medications under critical conditions.

show abstract

Misreading Injectable Medications—Causes and Solutions: An Integrative Literature Review

Cited by 2 publications

References 66 publications

Estimating the impact of label design on reducing the risk of medication errors by applying HEART in drug administration

Estimating the impact of label design on reducing the risk of medication errors by applying HEART in drug administration

Estimating the impact of label design on reducing the risk of medication errors by applying HEART in drug administration

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