The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study

Nguyen, Huong-Thao; Pham, Hong-Tham; Vo, Dang-Khoa; Nguyen, Tuan-Dung; Heuvel, Edwin R. van den; Haaijer‐Ruskamp, Flora; Taxis, Katja

doi:10.1136/bmjqs-2013-002357

Cited by 43 publications

(71 citation statements)

References 35 publications

(31 reference statements)

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“…28 Studies demonstrated that nurse education is one type of intervention to reduce MEs. 18,30,31 Providing nurse training and information about the most frequent errors, "uniform mixing", "labeling", and "infusion rate", in our study may help to reduce these error types. In a study by Chua et al, an intervention between two observation periods showed a reduction in the administration errors from 44.3% to 28.6%.…”

Section: Discussionmentioning

confidence: 99%

<p>Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units</p>

Hermanspann¹,

Linden²,

Schoberer³

et al. 2019

DHPS

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Purpose: To determine the type, frequency, and factors associated with medication preparation and administration errors in adult intensive care units (ICUs) and neonatal ICUs (NICUs)/ pediatric ICUs (PICUs). Patients and methods: We conducted a prospective direct observation study in an adult ICU and NICU/PICU in a tertiary university hospital. Between June 2012 and June 2013, a clinical pharmacist and medical student observed the nursing care staff on weekdays during the preparation and administration of intravenous drugs. We analyzed the frequency and type of preparation and administration errors and factors associated with errors. Results: Six hundred and three preparations in the adult ICU and 281 in the NICU/PICU were observed. Three hundred and eighty-five errors occurred in the adult ICU and 38 in the NICU/ PICU. There were 5,040 and 2,514 error opportunities, with overall error rates of 7.6% and 1.5%, respectively. The total opportunities for error meant each single step of preparation and administration that was relevant for the drug. Most errors applied to the category "uniform mixing" (adult ICU: n=227, 59%; NICU/PICU: n=14, 37%). The multivariate logistic regression results showed a significantly different influence of the "preparation type" for the adult ICU compared with the NICU/PICU with regard to the occurrence of an error. Preparations for adult patients of the LCD type (liquid concentrate with diluent into syringe or infusion bag) were more often associated with errors than the P (powder in a glass vial that must be reconstituted and diluted if necessary), P=0.012, and LC (liquid concentrate into syringe), P=0.002 type. Conclusion: "Uniform mixing" was the most erroneous preparation step in intravenous drug preparations in two ICUs. Improvement of nurse training and the preparation of prefilled syringes in the pharmacy might reduce errors and improve the quality and safety of drug therapy.

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Section: Discussionmentioning

confidence: 99%

<p>Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units</p>

Hermanspann¹,

Linden²,

Schoberer³

et al. 2019

DHPS

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“…Selection of the wrong drug was a cause of error reported by the working group. In a recent study about intravenous medication administration errors in hospital, the prevalence of wrong drug was 0.4% . Scanning drugs at the time of storage in the unit cabinet would secure this critical step.…”

Section: Resultsmentioning

confidence: 99%

Performing a preliminary hazard analysis applied to administration of injectable drugs to infants

Hfaiedh

Kabiche

Delescluse

et al. 2017

Evaluation Clinical Practice

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“…While our intervention study was primarily targeted at medicine in tablet form, previous studies have found intravenous therapy to be associated with a higher prevalence of medication errors compared with orally administered medications 19 20. It would be relevant to include intravenous medicine in future technological endeavours to reduce medication errors.…”

Section: Discussionmentioning

confidence: 99%

An automated medication system reduces errors in the medication administration process: results from a Danish hospital study

2015

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ObjectivesImprovements in a hospital's medication administration process might reduce the prevalence of medication errors and improve patient safety. The objective of this study was to evaluate the success of an automated medication system in reducing medication administration errors.MethodsA controlled before-and-after study with follow-up after 4 months was conducted in two Danish haematological hospital wards. The occurrence of administration errors was observed in two 3-week periods. The error rate was calculated by dividing the number of doses with one or more errors by the number of doses (opportunities for errors). Logistic regression was used to assess changes in error rates after implementation of the automated medication system with time, group, and interaction between time and group as independent variables. The estimated parameter for the interaction term was interpreted as the incremental change (‘difference-in-difference’) caused by the new dispensing system.ResultsA total of 697 doses with one or more errors were identified out of 2245 doses. The error rate decreased from 0.35 at baseline to 0.17 at follow-up in the intervention ward and from 0.37 to 0.35 in the control ward. The overall risk of errors was reduced by 57% in the intervention ward compared with the control ward (OR 0.43; 95% CI 0.30 to 0.63).ConclusionsThe automated medication system reduced the error rate of the medication administration process and thus improved patient safety in the medication process.

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The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study

Abstract: The pharmacist-led training programme was effective, but the error rate remained relatively high. Further quality improvement strategies are needed, including changes to the working environment and promotion of a safety culture.

Cited by 43 publications

References 35 publications

<p>Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units</p>

<p>Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units</p>

Performing a preliminary hazard analysis applied to administration of injectable drugs to infants

An automated medication system reduces errors in the medication administration process: results from a Danish hospital study

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