A near miss involving cyclophosphamide.

Reports of near miss incidents offer valuable learning opportunities. In this article, the authors highlight a near miss incident that occurred in an intensive care unit with the cytotoxic medication cyclophosphamide, for a non-oncology indication. The learning from this incident, including recommendations, is shared.

Work interruptions and their contribution to medication administration errors: an evidence review.

BACKGROUND: In many surveys, nurses cite work interruptions as a significant contributor to medication administration errors. OBJECTIVES: To review the evidence on (1) nurses' interruption rates, (2) characteristics of such work interruptions, and (3) contribution of work interruptions to medication administration errors. SEARCH STRATEGY: CINHAL (1982-2008), MEDLINE (1980-2008), EMBASE (1980-2008), and PSYCINFO (1980-2008) were searched using a combination of keywords and reference lists. SELECTION CRITERIA: Original studies published in English using nurses as participants and for which work interruption frequencies are reported. DATA COLLECTION AND ANALYSIS: Studies were identified and selected by two reviewers. Once selected, a single reviewer extracted data and assessed quality based on established criteria. Data on nurses' work interruption rates were synthesized to produce a pooled estimate. RESULTS: Twenty-three studies were considered for analysis. A rate of 6.7 work interruptions per hour was obtained, based on 14 studies that reported both an observation time and work interruption frequency. Work interruptions are mostly initiated by nurses themselves through face-to-face interactions and are of short duration. A lower proportion of interruptions resulted from work system failures such as missing medication. One nonexperimental study documented the contribution of work interruptions to medication administration errors with evidence of a significant association (p = 0.01) when errors related to time of administration are excluded from the analysis. Conceptual shortcomings were noted in a majority of reviewed studies, which included the absence of theoretical underpinnings and a diversity of definitions of work interruptions. CONCLUSIONS: Future studies should demonstrate improved methodological rigor through a precise definition of work interruptions and reliability reporting to document work interruption characteristics and their potential contribution to medication administration errors, considering the limited evidence found. Meanwhile, efforts should be made to reduce the number of work interruptions experienced by nurses.

Patterns of concordance and non-concordance with clinician recommendations and parents' explanatory models in children with asthma.

OBJECTIVE: Many children with asthma do not take medications as prescribed. We studied parents of children with asthma to define patterns of non-concordance between families' use of asthma controller medications and clinicians' recommendations, examine parents' explanatory models (EMs) of asthma, and describe relationships between patterns of non-concordance and EM. METHODS: Qualitative study using semi-structured interviews with parents of children with persistent asthma. Grounded theory analysis identified recurrent themes and relationships between reported medication use, EMs, and other factors. RESULTS: Twelve of the 37 parents reported non-concordance with providers' recommendations. Three types of non-concordance were identified: unintentional--parents believed they were following recommendations; unplanned--parents reported intending to give controller medications but could not; and intentional--parents stated giving medication was the wrong course of action. Analysis revealed two EMs of asthma: chronic--parents believed their child always has asthma; and intermittent--parents believed asthma was a problem their child sometimes developed. CONCLUSIONS: Concordance or non-concordance with recommended use of medications were related to EM's and family context and took on three different patterns associated with medication underuse. PRACTICE IMPLICATIONS: Efforts to reduce medication underuse in children with asthma may be optimized by identifying different types of non-concordance and tailoring interventions accordingly.

Nursing peer review: developing a framework for patient safety.

Patient safety is of great concern to healthcare leaders and is a top priority in all healthcare organizations. It is essential to promote an organizational commitment that values a culture of safety through reporting of medical error and analysis of untoward events. Nursing peer review facilitates the establishment of a culture of safety, as it seeks to analyze medical errors and eliminate the reoccurrence of untoward events.

Nursing student medication errors: a retrospective review.

This article presents the findings of a retrospective review of medication errors made and reported by nursing students in a 4-year baccalaureate program. Data were examined in relation to the semester of the program, kind of error according to the rights of medication administration, and contributing factors. Three categories of contributing factors were identified: rights violations, system factors, and knowledge and understanding. It became apparent that system factors, or the context in which medication administration takes place, are not fully considered when students are taught about medication administration. Teaching strategies need to account for the dynamic complexity of this process and incorporate experiential knowledge. This review raised several important questions about how this information guides our practice as educators in the clinical and classroom settings and how we can work collaboratively with practice partners to influence change and increase patient safety.

Can effective teaching and learning strategies help student nurses to retain drug calculation skills?

Student nurses need to develop and retain drug calculation skills in order accurately to calculate drug dosages in clinical practice. If student nurses are to qualify and be fit to practise accurate drug calculation skills, then educational strategies need to not only show that the skills of student nurses have improved but that these skills have been retained over a period of time. A quasi-experimental approach was used to test the effectiveness of a range of strategies in improving retention of drug calculation skills. The results from an IV additive drug calculation test were used to compare the drug calculation skills of student nurses between two groups of students who had received different approaches to teaching drug calculation skills. The sample group received specific teaching and learning strategies in relation to drug calculation skills and the second group received only lectures on drug calculation skills. All test results for students were anonymous. The results from the test for both groups were statistically analysed using the Mann Whitney test to ascertain whether the range of strategies improved the results for the IV additive test. The results were further analysed and compared to ascertain the types and numbers of errors made in each of the sample groups. The results showed that there is a highly significant difference between the two samples using a two-tailed test (U=39.5, p<0.001). The strategies implemented therefore did make a difference to the retention of drug calculation skills in the students in the intervention group. Further research is required into the retention of drug calculation skills by students and nurses, but there does appears to be evidence to suggest that sound teaching and learning strategies do result in better retention of drug calculation skills.

Inadvertent discogram during epidural steroid injection: a case report.

The obligatory use of fluoroscopy for placement of epidural steroids is controversial. Proponents of the use of fluoroscopy cite studies that report up to 35% rates of inaccurate placement of epidural needles without the aid of fluoroscopic imaging. This case study presents a situation in which a loss-of-resistance technique resulted in an inadvertent discogram.

Medication reconciliation matters.

Medication reconciliation is a powerful and effective tool in the fight against preventable ADEs. Consequently, it is a focus of national patient safety and health care organization initiatives. Nurses need to understand the requirements and actively support the process as the right thing to do for their patients.

Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study.

OBJECTIVE: To determine the frequency of medication errors that occurred during the preparation and administration of IV drugs in an intensive care unit. SETTING: The study was conducted in a 12-bed intensive care unit of one of the largest teaching hospitals in Tehran. DESIGN: Data were collected over 16 randomly selected days at different medication round times, between July and September 2006. A trained observer accompanied nurses during intravenous (IV) drug rounds. Medication errors were recorded during the observation times of IV drug administration and preparation. Drugs with the highest rate of use in the intensive care unit (ICU) were selected. Details of the process of preparation and administration of the selected drugs were compared to an informed checklist which was prepared using reference books and manufacturers' instructions. RESULTS: We observed a total of 524 preparations and administrations. The calculated number of opportunities for error was 4040. The number of errors identified were 380/4040 (9.4%). Of those, 33.6% were related to the preparation process and 66.4% to the administration process. The most common type of error (43.4%) was the injection of bolus doses faster than the recommended rate. Amikacin was involved in the highest rate of error (11%) among all the selected medications. It was found that the IV rounds conducted at 9:a.m. had the highest rate of error (19.8%). No significant correlation was found between the rate of error and the nurses' age, sex, qualification, work experience, marital status, and type of working contract (permanent or temporary). CONCLUSIONS: Since our system is devoid of a well-organized reporting system, errors are not detected and consequently not prevented. Administrators need to take the initiative of developing systems that guarantee safe medication administration.

Preventing substitution errors involving high-concentration heparin products.

Critical care practitioners routinely administer heparin for various indications (e.g., treatment of acute coronary syndrome, venous thromboembolism prophylaxis, line maintenance) and by various routes (e.g., intravenously, subcutaneously). Knowledge of reported incidents involving high-concentration heparin products can increase practitioner awareness of risks for error-induced injury associated with storage and administration of anticoagulants, such as heparin. Substitution errors leading to administration of an incorrect dose of unfractionated heparin are highlighted and suggestions for system-based error prevention strategies are provided.

Desmopressin (dDAVP) incident signals the need for enhanced monitoring protocols.

In this article, the authors highlight the circumstances surrounding the death of a young adult neurosurgical patient, recently reported to ISMP Canada. The incident signals the need for enhanced safeguards for patients receiving desmopressin (also known as dDAVP) and intravenous therapy. The authors present information from a recent ISMP Canada Safety Bulletin relevant to critical care, including an outline of potential contributing factors and suggested recommendations.

Understanding medication errors: discussion of a case involving a urinary catheter implicated in a wrong route error.

Medication errors represent a failure in the medication use process leading to an increase in morbidity and mortality. In an effort to standardize reporting, evaluating, and trending of medication errors, the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) developed and maintains a medication error taxonomy. A case study involving a medication intended for administration via rectal tube and inadvertently given through a Foley catheter is discussed using the NCC MERP medication error taxonomy and critiqued using recent national findings. Awareness of national trends for patient safety, including emerging changes leading to best practices, updates to National Patient Safety Goals, and changes in national policy, can reduce the risk of error involvement.

Interruptions during drug rounds: an observational study.

Drug administration errors are a common problem; they contribute to unintended patient harm and may in part be due to distractions during the drug administration round. In this study, a prospective sample of 38 drug rounds on an acute surgical ward were observed, and their duration, time spent dealing with interruptions and nature of the interruptions were recorded. On average, 11% of each drug round was spent dealing with interruptions. There were one or more interruptions in two-thirds of the rounds studied (average 2.61 interruptions per round), with a mean duration of 1 minute per interruption. The interruptions came from doctors (21%), other nurses (17%), patients (11%), telephone enquiries (8%), relatives (3%) or were initiated by the nurse conducting the round (21%). This pattern contradicts the subjective impressions of nurses in previous questionnaire studies, but it was notable that the longest individual interruptions were from conversations with patients (mean 249 seconds) and phone calls (mean 212 seconds). The data confirm the frequency of interruptions, and their potential as a safety hazard. Objective information from direct observation will prove valuable in designing possible solutions to the problem. These will require local knowledge and frontline staff involvement to be sustainable.

Setting up and priming an intravenous infusion.

The setting up and priming of an intravenous infusion is a common nursing procedure. However, it is associated with certain complications, for example infection. This article describes a step-by-step guide to the equipment required, correct preparation of the patient and the procedure. It also provides readers with calculation of drip-rate formulae.

To err is human: patient misinterpretations of prescription drug label instructions.

OBJECTIVE: To examine the nature and cause of patients' misunderstanding common dosage instructions on prescription drug container labels. METHODS: In-person cognitive interviews including a literacy assessment were conducted among 395 patients at one of three primary care clinics in Shreveport, Louisiana, Jackson, Michigan and Chicago, Illinois. Patients were asked to read and demonstrate understanding of dosage instructions for five common prescription medications. Correct understanding was determined by a panel of blinded physician raters reviewing patient verbatim responses. Qualitative methods were employed to code incorrect responses and generate themes regarding causes for misunderstanding. RESULTS: Rates of misunderstanding for the five dosage instructions ranged from 8 to 33%. Patients with low literacy had higher rates of misunderstanding compared to those with marginal or adequate literacy (63% versus 51% versus 38%, p<0.001). The 374 (19%) incorrect responses were qualitatively reviewed. Six themes were derived to describe the common causes for misunderstanding: label language, complexity of instructions, implicit versus explicit dosage intervals, presence of distractors, label familiarity, and attentiveness to label instructions. CONCLUSION: Misunderstanding dosage instructions on prescription drug labels is common. While limited literacy is associated with misunderstanding, the instructions themselves are awkwardly phrased, vague, and unnecessarily difficult. PRACTICE IMPLICATIONS: Prescription drug labels should use explicit dosing intervals, clear and simple language, within a patient-friendly label format. Health literacy and cognitive factors research should be consulted.

A model of chemotherapy education for novice oncology nurses that supports a culture of safety.

Chemotherapy education at a mid-sized community hospital was redesigned to help novice oncology nurses improve patient safety and their own practice by implementing error prevention techniques during chemotherapy administration. Using a proactive approach with multidisciplinary participation and open communication, a systems analysis was conducted to identify potential chemotherapy errors. Then, chemotherapy processes were devised or strengthened to avoid errors. The project required a philosophical shift from error measurement to safety promotion.

Why nurses make medication errors: a simulation study.

The purpose of this study was to investigate about the communication problems in the team nursing systems, if the requests for medication between nurses happen. For this study, we developed a simulation involving a nurse giving a medication prepared by another nurse. Baseline data was collected from 100 third-year nursing students and 163 nurses of two municipal hospitals further subdivided into three groups by their service years. The responders attributing to the errors in the simulation were compared. As a result, the more service years the fewer nurses there were who attributed medication errors to no explanation and no confirmation between nurses. The nurses whose service years were less than five years had a low level of awareness regarding no explanation of a nurse leader requesting the medications as well as the students. These findings suggested that there is the possibility that some medication errors occur due to preoccupation that nurses feel it is less necessary to explain and confirm everything related to medication administrations as their length of service increase. Nurses have a communication problem that is influenced by the relationship in the workplace in the team nursing system. Therefore, the requests for medication should no be permitted.

Addressing medication errors--The role of undergraduate nurse education.

Medication errors are a persistent problem in today's National Health Service (NHS). Many factors contribute to drug incidents occurring, from the initial prescription stage through to administration and arise from both individual and system failures. The literature identifies the multi-disciplinary nature of the problem and highlights the important contribution that nurses make with regards to ensuring medication safety. However limited evidence exists in the literature regarding the extent to which the current content of undergraduate pharmacology education prepares nurses for their role in the prevention of errors. The report "Building a safer NHS for patients-improving medication safety" [Department of Health, 2004. Building a Safer NHS for Patients: Improving Medication Safety. The Stationary Office, London] concludes that it is now imperative that undergraduate education should emphasise the issue of medication safety. An educational initiative was therefore introduced to address this problem. A "Medication Safety Day" which focused on the causes of medication errors was implemented to highlight how and why drug incidents may occur. This initiative recognises that nurse education should not only ensure adequate theoretical knowledge of pharmacology but should also equip students with an awareness of how many diverse factors may contribute to the occurrence of medication errors.

Improving rational drug use in Africa: the example of Sudan.

The aim of this review is to determine the extent of irrational drug use and contributing factors in Sudan and to identify the interventions that need to be strengthened to promote the rational use of drugs in the country and to evaluate the impact of different types of intervention. We present an overview of studies describing patterns of drug prescribing, dispensing and self-medication. Rates for inappropriate prescribing and dispensing practices and prevalence of self-medication with antimicrobials and herbal products were alarmingly high. Indicators of rational drug use have worsened over the past decade despite the implementation of managerial, regulatory and training interventions. Multifaceted interventions have proved effective in changing suboptimal prescribing practices. Educational interventions are needed to address self-medication and adherence.

Medication errors in a rural hospital.

The purpose of this investigation was to compare and contrast three nursing shifts in a small rural Midwestern hospital with regard to the number of reported medication errors, the units on which they occurred, and the types and severity of errors. Results can be beneficial in planning and implementing a quality improvement program in the area of medication administration with the nursing staff.