Systemic analysis of medication administration omission errors in a tertiary-care hospital in Quebec

Poder, Thomas G.; Maltais, Serge

doi:10.1177/1833358318781099

Cited by 7 publications

(11 citation statements)

References 15 publications

(25 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Consistently amongst the commonest three subtypes of medication administration error [41] Harm difficult to quantify, but an important, potentially remediable problem [42] P = within prescribing; A = within administration Box 2. Case study: using incident data to further investigate identified areas of risk…”

Section: Dosing Errors (Pa)mentioning

confidence: 99%

Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement

et al. 2020

View full text Add to dashboard Cite

BackgroundTo protect children from harm, clinicians, educators, and patient safety champions need information to direct improvement efforts. Critical incident data, often disregarded as a source of evidence because under-reporting makes them an inaccurate measure of error rates, could provide this. AimOur aim was to identify key targets for pediatric healthcare quality improvement. The objective was to evaluate the types, characteristics, and areas of risk within reported medication errors in pediatric patients. MethodsRetrospective study of a large regional dataset of 1522 pediatric medication errors reported from secondary care between 2011 and 2015, including all hospitals and community pediatric settings in Northern Ireland. Characteristics included: error severity; patient age; drug involved; error type; and area of practice. Two academic pediatricians, a senior medicines governance pharmacist, a Reader in Pharmacy Practice, and a Professor of Medical Education analysed the data. Validity checks included comparing the findings against key published literature and discussion by a practitioner panel representing five multidisciplinary stakeholder groups. ResultsNeonates, particularly in intensive care, were implicated in 19% of all errors. The medications most represented in risk were antimicrobials, paracetamol, vaccines, and intravenous fluids. The error types most implicated were dosing errors (32%) and omissions (21%). ConclusionsIncident reports identified neonates, a shortlist of drugs, and specific error types, associated with modifiable behaviours, as priority improvement targets. These findings direct further study and inform intervention development, such as specific training in calculations to prevent dosing errors. Involving experienced practitioners both endorsed the findings and engaged the practice community into their future implementation. The utility of incident reports to direct improvement efforts may offset limitations in their representativeness. Key points Critical incident reports can support medication safety by providing information on characteristics and nature of errors  Discussion with stakeholders and review of selected literature can offset incidents' lack of representativeness and support their validity  In pediatric medication safety, factors associated with risk of error included neonatal care, dosing and timely administration, and use of common drugs such as antimicrobials, paracetamol, IV fluids and vaccines

show abstract

Section: Dosing Errors (Pa)mentioning

confidence: 99%

Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement

et al. 2020

View full text Add to dashboard Cite

show abstract

“…Individuals confronted by stress and intimidating behaviour can also affect medication errors [ 8 ]. While past studies have considered who was responsible for, or contributed to, the occurrence of the medication error, there has been little emphasis on patient and family involvement [ 9 – 11 ].…”

Section: Introductionmentioning

confidence: 99%

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit

Manias

Street

Lowe

et al. 2021

BMC Health Serv Res

View full text Add to dashboard Cite

Background Efforts to ensure safe and optimal medication management are crucial in reducing the prevalence of medication errors. The aim of this study was to determine the associations of person-related, environment-related and communication-related factors on the severity of medication errors occurring in two health services. Methods A retrospective clinical audit of medication errors was undertaken over an 18-month period at two Australian health services comprising 16 hospitals. Descriptive statistical analysis, and univariate and multivariable regression analysis were undertaken. Results There were 11,540 medication errors reported to the online facility of both health services. Medication errors caused by doctors (Odds Ratio (OR) 0.690, 95% CI 0.618–0.771), or by pharmacists (OR 0.327, 95% CI 0.267–0.401), or by patients or families (OR 0.641, 95% CI 0.472–0.870) compared to those caused by nurses or midwives were significantly associated with reduced odds of possibly or probably harmful medication errors. The presence of double-checking of medication orders compared to single-checking (OR 0.905, 95% CI 0.826–0.991) was significantly associated with reduced odds of possibly or probably harmful medication errors. The presence of electronic systems for prescribing (OR 0.580, 95% CI 0.480–0.705) and dispensing (OR 0.350, 95% CI 0.199–0.618) were significantly associated with reduced odds of possibly or probably harmful medication errors compared to the absence of these systems. Conversely, insufficient counselling of patients (OR 3.511, 95% CI 2.512–4.908), movement across transitions of care (OR 1.461, 95% CI 1.190–1.793), presence of interruptions (OR 1.432, 95% CI 1.012–2.027), presence of covering personnel (OR 1.490, 95% 1.113–1.995), misread or unread orders (OR 2.411, 95% CI 2.162–2.690), informal bedside conversations (OR 1.221, 95% CI 1.085–1.373), and problems with clinical handovers (OR 1.559, 95% CI 1.136–2.139) were associated with increased odds of medication errors causing possible or probable harm. Patients or families were involved in the detection of 1100 (9.5%) medication errors. Conclusions Patients and families need to be engaged in discussions about medications, and health professionals need to provide teachable opportunities during bedside conversations, admission and discharge consultations, and medication administration activities. Patient counselling needs to be more targeted in effort to reduce medication errors associated with possible or probable harm.

show abstract

“…4,5 Such errors cause patients to suffer increased financial burden, unnecessary discomfort and prolonged hospitalization, morbidity and mortality, rendering these errors clinically significant. 6,7 Omission of drugs such as antimicrobial agents has the potential to cause patient harm through increased risk of treatment failure and development of more resistant strains of pathogenic microorganisms. 8,9 The earliest days of inpatient care are perhaps of the utmost significance in a patient's recovery; therefore, any omission of medications during this period has the possibility of increasing morbidity and mortality.…”

Section: Introductionmentioning

confidence: 99%

“…When the frequency of medication omission errors was compared, parenteral drugs (70.8% vs. 25.3%, [p=0.0001]), afternoon shift (48.5% vs. 15.8%, [p=0.0001]), and anti-infective medications (69.1% vs. 39.4%, [p=0.0001]) were found to be the most frequently omitted medications. There were also considerably more medication omissions in patients prescribed with more medications (median number: 4, I QR [2,6] vs. median number: 2, IQR [2, 4], [p=0. 0.001]).…”

mentioning

confidence: 99%

Medication omissions in the first 48 hours after admission: failure in prescribed medicines reaching in-patients in paediatrics wards at the University Teaching Hospitals, Children’s Hospital in Lusaka, Zambia

Kampamba

Mulolo

Phiri

et al. 2021

Int J Basic Clin Pharmacol

View full text Add to dashboard Cite

Background: The first few days of in-patient care are possibly the most significant in a patient’s recovery and any omitted medications during this period may harm the patient or increase their hospital length of stay. Therefore, our study aimed at assessing the frequency of medication administration omission errors and their reasons for the omission in the paediatric wards after admission at University Teaching Children’s Hospital.Methods: This was a descriptive study in which 259 patient files and drug charts were reviewed. Admission prescription charts were studied in detail over a period of four weeks and all drugs prescribed but then not given in the first 48 hours were recorded as omitted medications, along with the reason given for their omission.Results: From the 259 drug charts, a total of 1598 doses of drugs were ordered within 48 hours of admission. However, from this, only a total of 1132 doses were administered with the remaining 466 doses omitted, which accounted for a frequency of 29.2%. When the frequency of medication omission errors was compared, parenteral drugs (70.8% vs. 25.3%, [p=0.0001]), afternoon shift (48.5% vs. 15.8%, [p=0.0001]), and anti-infective medications (69.1% vs. 39.4%, [p=0.0001]) were found to be the most frequently omitted medications. There were also considerably more medication omissions in patients prescribed with more medications (median number: 4, I QR [2, 6] vs. median number: 2, IQR [2, 4], [p=0. 0.001]). The most common reason for the omission was medication unavailability (89.3%), followed by work overload (71.4%), and the patient is off the ward (71.4%).Conclusions: This study revealed that medication omissions are a continuing problem and this may result in increased morbidity and mortality rates. There is a need to put in place specific strategies to reduce this problem.

show abstract

Systemic analysis of medication administration omission errors in a tertiary-care hospital in Quebec

Abstract: The interdisciplinary committee formulated 10 main recommendations related to these 7 categories, including 3 for IV therapy and 4 for failure in using or creating/updating the MAR.

Cited by 7 publications

References 15 publications

Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement

Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit

Medication omissions in the first 48 hours after admission: failure in prescribed medicines reaching in-patients in paediatrics wards at the University Teaching Hospitals, Children’s Hospital in Lusaka, Zambia

Contact Info

Product

Resources

About