Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era

Wang, Huafen; Jin, Jingfen; Feng, Xiuqin; Huang, Xin; Zhu, Lingling; Zhao, Xiaoying; Zhou, Quan

doi:10.2147/tcrm.s79238

Cited by 29 publications

(18 citation statements)

References 19 publications

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“…That is to say that these are actions that were reported in the literature that were taken as a result of an event. In regards to action, the major areas were documentation [ 10 , 32 , 37 , 41 , 46 , 56 , 58 ], implementation [ 10 , 32 , 37 , 58 ], and culture [ 10 , 29 , 41 , 53 , 58 ] relative to the use of health IT.…”

Section: Resultsmentioning

confidence: 99%

Health Information Technology in Healthcare Quality and Patient Safety: Literature Review

2018

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BackgroundThe area of healthcare quality and patient safety is starting to use health information technology to prevent reportable events, identify them before they become issues, and act on events that are thought to be unavoidable. As healthcare organizations begin to explore the use of health information technology in this realm, it is often unclear where fiscal and human efforts should be focused.ObjectiveThe purpose of this study was to provide a foundation for understanding where to focus health information technology fiscal and human resources as well as expectations for the use of health information technology in healthcare quality and patient safety.MethodsA literature review was conducted to identify peer-reviewed publications reporting on the actual use of health information technology in healthcare quality and patient safety. Inductive thematic analysis with open coding was used to categorize a total of 41 studies. Three pre-set categories were used: prevention, identification, and action. Three additional categories were formed through coding: challenges, outcomes, and location.ResultsThis study identifies five main categories across seven study settings. A majority of the studies used health IT for identification and prevention of healthcare quality and patient safety issues. In this realm, alerts, clinical decision support, and customized health IT solutions were most often implemented. Implementation, interface design, and culture were most often noted as challenges.ConclusionsThis study provides valuable information as organizations determine where they stand to get the most “bang for their buck” relative to health IT for quality and patient safety. Knowing what implementations are being effectivity used by other organizations helps with fiscal and human resource planning as well as managing expectations relative to cost, scope, and outcomes. The findings from this scan of the literature suggest that having organizational champion leaders that can shepherd implementation, impact culture, and bridge knowledge with developers would be a valuable resource allocation to consider.

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Section: Resultsmentioning

confidence: 99%

Health Information Technology in Healthcare Quality and Patient Safety: Literature Review

2018

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“…Dentre os tipos de erros na AM encontrados nesta revisão, o principal deles diz respeito à dosagem medicamentosa, presente em 27 estudos (67,5%) (8,(10)(11)(13)(14)(16)(17)(19)(20)(23)(24)(25)(26)(27)(28)(30)(31)(32)34,36,(42)(43)(44)(45)(46)(47)(48)(49) . Corroborando com tal achado, uma pesquisa (50) que teve como um dos objetivos identificar o perfil dos erros cometidos durante o preparo, encontrou que 67,7% dos erros estavam associados a doses preparadas erroneamente.…”

Section: Discussionunclassified

“…Esta realidade também foi encontrada na presente pesquisa, em que a administração da medicação errada foi o segundo erro mais comum entre os estudos analisados e esteve presente em 62,5% (n=25) (8)(9)(10)(11)13,16,(20)(21)(23)(24)(25)(26)(28)(29)(30)(31)(36)(37)(42)(43)(45)(46)(48)(49)53) da amostra, seguido pelo medicamento administrado ao paciente errado (n=21;52,5%) (8)(9)(10)(11)16,18,22,(23)(24)(25)(26)(27)(28)(30)(31)(33)(34)(36)(37)(46)(47) .…”

Section: Discussionunclassified

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Erros Na Administração De Medicamentos: Evidências E Implicações Na Segurança Do Paciente

Gomes¹,

Assis²,

Silva³

et al. 2016

Cogitare Enferm.

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RESUMO: O estudo objetiva identificar as evidências e as implicações dos erros na administração de medicamentos na segurança do paciente. Trate-se de uma revisão integrativa, com busca dos estudos em quatro bases de dados, em maio de 2015. Obteve-se uma amostra de 40 artigos e foram submetidos à estatística descritiva. Houve predomínio de estudos descritivos -nível de evidência 4 (n=28; 70%), publicados no Brasil (n=17; 42,5%). Quanto aos erros, destacaram-se: erro de dosagem (n=27; 67,5%), medicação errada (n=25; 62,5%); troca de paciente (n=21; 52,5%); erro de horário (n=20;5 0%); via errada (n=17;42,5%), além de erro documental, omissão de justificativas quando necessário e outras. Este tipo de evento é responsável por deixar sequelas irreparáveis nos pacientes ou até levar à morte. MEDICATION ADMINISTRATION ERRORS: EVIDENCES AND IMPLICATIONS FOR PATIENT SAFETY ABSTRACT:The objective is to identify the evidences and implications of medication administration errors for patient safety. An integrative review was undertaken through a search in four databases in May 2015. A sample of 40 articles was obtained, submitted to descriptive statistics. Descriptive studies of evidence level 4 were predominant (n=28; 70%), published in Brazil (n=17; 42.5%). The following errors stood out: dose errors (n=27; 67.5%), wrong drug (n=25; 62.5%); wrong patient (n=21; 52.5%); wrong time (n=20;50%); wrong route (n=17;42.5%), besides documentation errors, omission of justifications when necessary and others. This type of event is responsible for causing irreparable damage to the patient or even death. DESCRIPTORS: Medication errors; Patient safety; Nursing. ERRORES EN LA ADMINISTRACIÓN DE MEDICAMENTOS: EVIDENCIAS Y IMPLICACIONES EN LA SEGURIDAD DEL PACIENTERESUMEN: La finalidad del estudio es identificar las evidencias y las implicaciones de los errores en la administración de medicamentos en la seguridad del paciente. Se trata de una revisión integradora con búsqueda de estudios en cuatro bases de datos en mayo del 2015. Fue encontrada una muestra de 40 artículos, sometidos a la estadística descriptiva. Predominaron estudios descriptivos -nivel de evidencia 4 (n=28; 70%), publicados en Brasil (n=17; 42,5%). Entre los errores se destacaron: error de dosificación (n=27; 67,5%), medicación equivocada (n=25; 62,5%); cambio de paciente (n=21; 52,5%); error de horario (n=20;5 0%); vía equivocada (n=17;42,5%), además de error documental, omisión de justificativas cuando necesario y otras. Este tipo de evento es responsable por dejar secuelas irreparables en los pacientes o incluso llevar a la muerte. DESCRIPTORES: Errores de medicación; Seguridad del paciente; Enfermería.

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“…Since January 2013, SAHZU has required that two licensed health care professionals must perform a standardized independent double-check prior to barcode-assisted medication administration of narcotics, insulin infusion, chemotherapeutic drugs, and intravenous heparin. 30 On-site inspection results and retrospective review of nursing record system showed a 100% implementation rate. Morriss et al 31 reported that patients who were treated with an opioid in the absence of a barcode-assisted medication administration system had a 10% probability of an adverse drug event.…”

Section: Standardized Administration and Monitoringmentioning

confidence: 99%

Safe medication management and use of narcotics in a Joint Commission International-accredited academic medical center hospital in the People’s Republic of China

Fang¹,

Zhu²,

Pan³

et al. 2016

TCRM

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Safe medication management and use of high-alert narcotics should arouse concern. Risk management experiences in this respect in a large-scale Joint Commission International (JCI)-accredited academic medical center hospital in the People’s Republic of China during 2011–2015, focusing on organizational, educational, motivational, and information technological measures in storage, prescribing, preparing, dispensing, administration, and monitoring of medication are summarized. The intensity of use of meperidine in hospitalized patients in 2015 was one-fourth that in 2011. A 100% implementation rate of standard storage of narcotics has been achieved in the hospital since December 2012. A “Plan, Do, Check, Act” cycle was efficient because the ratio of number of inappropriate narcotics prescriptions to total number of narcotics prescriptions for inpatients decreased from August 2014 to December 2014 (28.22% versus 2.96%, P=0.0000), and it was controlled below 6% from then on. During the journey to good pain management ward accreditation by the Ministry of Health, People’s Republic of China, (April 2012–October 2012), the medical oncology ward successfully demonstrated an increase in the pain screening rate at admission from 43.5% to 100%, cancer pain control rate from 85% to 96%, and degree of satisfaction toward pain nursing from 95.4% to 100% (all P-values <0.05). Oral morphine equivalent dosage in the good pain management ward increased from 2.3 mg/patient before June 2012 to 54.74 mg/patient in 2014. From 2011 to 2015, the oral morphine equivalent dose per discharged patient increased from 8.52 mg/person to 20.36 mg/person. A 100% implementation rate of independent double-check prior to narcotics dosing has been achieved since January 2013. From 2014 to 2015, the ratio of number of narcotics-related medication errors to number of discharged patients significantly decreased (6.95% versus 0.99%, P=0.0000). Taken together, continuous quality improvements have been achieved in safe medication management and use of narcotics by an integrated multidisciplinary collaboration during the journey to JCI accreditation and in the post-JCI accreditation era.

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Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era

Cited by 29 publications

References 19 publications

Health Information Technology in Healthcare Quality and Patient Safety: Literature Review

Health Information Technology in Healthcare Quality and Patient Safety: Literature Review

Erros Na Administração De Medicamentos: Evidências E Implicações Na Segurança Do Paciente

Safe medication management and use of narcotics in a Joint Commission International-accredited academic medical center hospital in the People’s Republic of China

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Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era

Cited by 29 publications

References 19 publications

Health Information Technology in Healthcare Quality and Patient Safety: Literature Review

Health Information Technology in Healthcare Quality and Patient Safety: Literature Review

Erros Na Administração De Medicamentos: Evidências E Implicações Na Segurança Do Paciente

Safe medication management and use of narcotics in a Joint Commission International-accredited academic medical center hospital in the People&rsquo;s Republic of China

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Safe medication management and use of narcotics in a Joint Commission International-accredited academic medical center hospital in the People’s Republic of China