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Approach to Improving Safety
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Search results for "Active Errors"

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Special or Theme Issue

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.

Journal Article > Study

Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit.

Solanki R, Mondal N, Mahalakshmy T, Bhat V. Arch Dis Child. 2017 May 3; [Epub ahead of print].

Pediatric patients are at high risk for medication errors. Researchers conducted a cross-sectional study on 166 infants younger than 3 months who were discharged from the hospital. They found a high frequency of medication errors by caregivers. In keeping with prior research, dose administration errors were the most common type of error.

Journal Article > Study

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study.

Gilmartin-Thomas JF, Smith F, Wolfe R, Jani Y. Int J Nurs Stud. 2017;72:15-23.

This prospective, direct-observation study examined medication administration accuracy of medications dispensed by nurses and caregivers in long-term care facilities. Investigators compared medication administration from original medication packaging to administration from multicompartment medication devices. The team observed nearly 2500 doses. When medications were dispensed from original packaging, the medication administration error rate was 9%. When multicompartment devices were used, the medication administration error rate was 3%. This difference persisted in settings where both original packaging and multicompartment medication devices were used. This study adds to the evidence about how literacy-friendly health systems can enhance medication safety.

Cases & Commentaries

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Journal Article > Study

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

Armstrong GE, Dietrich M, Norman L, Barnsteiner J, Mion L. J Nurs Care Qual. 2017;32:226-233.

Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.

Journal Article > Commentary

Medication errors in outpatient pediatrics.

Berrier K. MCN Am J Matern Child Nurs. 2016;41:280-286.

Medication errors occur in various care environments, and they are common in the outpatient setting. This commentary describes factors that contribute to incorrect medication administration by parents, such as misunderstanding of instructions due to insufficient health literacy. The author proposes several tactics to promote safe medication practices by parents which include picture-based instructions and standardized dosing instruments.

Newspaper/Magazine Article

Correct use of inhalers: help patients breathe easier.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.

Patients and clinicians can make medication administration mistakes when new drug delivery mechanisms are introduced. This newsletter article reviews common errors associated with the use of inhalers and offers recommendations for patients, nurses, respiratory therapists, pharmacists, and health care organizations to educate patients on the use of these medications.

Journal Article > Commentary

Case report of a medication error: in the eye of the beholder.

Naunton M, Nor K, Bartholomaeus A, Thomas J, Kosari S. Medicine (Baltimore). 2016;95:e4186.

Look-alike drug names or packaging are known to contribute to medication errors. This case discussion reviews an error in the community setting involving a nonocular medication mistakenly administered as an eye drop due to look-alike packaging and recommends ways to improve storage and disposal processes to avoid similar incidents.

Journal Article > Study

Standardization of compounded oral liquids for pediatric patients in Michigan.

Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.

When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.

Journal Article > Review

Systematic review and meta-analysis of educational interventions designed to improve medication administration skills and safety of registered nurses.

Härkänen M, Voutilainen A, Turunen E, Vehviläinen-Julkunen K. Nurse Educ Today. 2016;41:36-43.

Adverse drug events can result from errors in medication administration by nurses. This meta-analysis found that a broad range of nursing education interventions, from simulation to traditional didactic curricula, can improve the safety of medication administration. This suggests that multiple nursing educational strategies can be used to enhance inpatient medication safety.

Journal Article > Study

The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors.

Sears K, O'Brien-Pallas L, Stevens B, Murphy GT. J Pediatr Nurs. 2016;31:e283-e290.

This Canadian study found that nurses with more experience reported a greater number of pediatric medication administration errors, but these errors were less severe compared to other units. This finding suggests widespread underreporting of medication errors by nurses with a lower level of experience.

Journal Article > Commentary

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.

Graudins LV, Downey G, Bui T, Dooley MJ. Jt Comm J Qual Patient Saf. 2016;42:86-95.

Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.

Book/Report

2016–2017 Targeted Medication Safety Best Practices for Hospitals.

Horsham, PA: Institute for Safe Medication Practices; 2015.

This updated report outlines 11 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to storage and use of neuromuscular blocking agents, smart pumps, and standardized protocols for rescue agents.

Journal Article > Review

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

Hayes C, Jackson D, Davidson PM, Power T. J Clin Nurs. 2015;24:3063-3076.

This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.

Journal Article > Review

Interruptions and medication administration in critical care.

Bower R, Jackson C, Manning JC. Nurs Crit Care. 2015;20:183-195.

Interruptions occur frequently during the medication process, and previous studies examined whether they increase risks. This review explores the literature on the impact of interruptions during medication administration to determine factors that contribute to interruptions and how to address them.

Newspaper/Magazine Article

FDA begins inquiry after death and illness from saline bags meant for training.

Tavernise S. New York Times. January 15, 2015.

This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.

Tools/Toolkit > Fact Sheet/FAQs

Explicit and Standardized Prescription Medicine Instructions.

Rockville, MD: Agency for Healthcare Research and Quality; December 2014.

Standardization has been embraced as a strategy to improve health literacy and to reduce patient misunderstanding of medication instructions. This tool provides standard language that clarifies directions for patients regarding when they should take their medications.

Journal Article > Study

Medication-administration errors in an urban mental health hospital: a direct observation study.

Cottney A, Innes J. Int J Ment Health Nurs. 2015;24:65-74.

In this prospective observational study at a psychiatric hospital, errors were identified in 3% of medication administration episodes, with omission being the most common error type. As in prior studies, interruptions and higher patient volume were associated with increased risk of mistakes.

Journal Article > Study

Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.

Donaldson N, Aydin C, Fridman M, Foley M. J Healthc Qual. 2014;36:58-68.

This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.

Journal Article > Study

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

Shaw RE, Litman RS. Jt Comm J Qual Patient Saf. 2014;40:471-475.

In 2010, the Anesthesia Patient Safety Foundation recommended that hospital pharmacies supply premixed solutions or prefilled syringes of commonly used anesthetic medications. Despite this recommendation, this convenience sample of 34 children's hospitals across the United States found that the majority of medications administered by anesthesiologists in 2012 were still prepared by the provider at the bedside.

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