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      Effects of sharing information on drug administration errors in pediatric wards: a pre–post intervention study

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          Abstract

          Background and purpose

          Drug administration errors are more likely to reach the patient than other medication errors. The main aim of this study was to determine whether the sharing of information on drug administration errors among health care providers would reduce such problems.

          Patients and methods

          This study involved direct, undisguised observations of drug administrations in two pediatric wards of a major teaching hospital in Kuala Lumpur, Malaysia. This study consisted of two phases: Phase 1 (pre-intervention) and Phase 2 (post-intervention). Data were collected by two observers over a 40-day period in both Phase 1 and Phase 2 of the study. Both observers were pharmacy graduates: Observer 1 just completed her undergraduate pharmacy degree, whereas Observer 2 was doing her one-year internship as a provisionally registered pharmacist in the hospital under study. A drug administration error was defined as a discrepancy between the drug regimen received by the patient and that intended by the prescriber and also drug administration procedures that did not follow standard hospital policies and procedures. Results from Phase 1 of the study were analyzed, presented and discussed with the ward staff before commencement of data collection in Phase 2.

          Results

          A total of 1,284 and 1,401 doses of drugs were administered in Phase 1 and Phase 2, respectively. The rate of drug administration errors reduced significantly from Phase 1 to Phase 2 (44.3% versus 28.6%, respectively; P<0.001). Logistic regression analysis showed that the adjusted odds of drug administration errors in Phase 1 of the study were almost three times that in Phase 2 ( P<0.001). The most common types of errors were incorrect administration technique and incorrect drug preparation. Nasogastric and intravenous routes of drug administration contributed significantly to the rate of drug administration errors.

          Conclusion

          This study showed that sharing of the types of errors that had occurred was significantly associated with a reduction in drug administration errors.

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          Most cited references 35

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          Medication errors observed in 36 health care facilities.

          Medication errors are a national concern. To identify the prevalence of medication errors (doses administered differently than ordered). A prospective cohort study. Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado. A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication-volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered. Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians. Medication errors reaching patients. In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P =.82) or by size (P =.39). Error rates were higher in Colorado than in Georgia (P =.04) Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.
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            Causes of prescribing errors in hospital inpatients: a prospective study.

            To prevent errors made during the prescription of drugs, we need to know why they arise. Theories of human error used to understand the causes of mistakes made in high-risk industries are being used in health-care. They have not, however, been applied to prescribing errors, which are a great cause of patient harm. Our aim was to use this approach to investigate the causes of such errors. Pharmacists at a UK teaching hospital prospectively identified 88 potentially serious prescribing errors. We interviewed the prescribers who made 44 of these, and analysed our findings with human error theory. Our results suggest that most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. Doctors identified many risk factors-work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organisational factors were also identified, and included inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors. To reduce prescribing errors, hospitals should train junior doctors in the principles of drug dosing before they start prescribing, and enforce good practice in documentation. They should also create a culture in which prescription writing is seen as important, and formally review interventions made by pharmacists, locum arrangements, and the workload of junior doctors, and make doctors aware of situations in which they are likely to commit errors.
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              Practical statistics for medical research

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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2017
                23 March 2017
                : 13
                : 345-353
                Affiliations
                [1 ]Department of Pharmacy, Faculty of Medicine, University of Malaya
                [2 ]Pharmacy Department, University Malaya Medical Centre
                [3 ]Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
                Author notes
                Correspondence: Siew-Siang Chua, Department of Pharmacy, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia, Tel +60 19 336 3223, Fax +60 3 7967 4964, Email chua_ss@ 123456hotmail.com
                Article
                tcrm-13-345
                10.2147/TCRM.S128504
                5367452
                © 2017 Chua et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

                Medicine

                sharing, pediatric, intervention, drug administration error, medication error

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