Prevalence and factors associated with medication administration errors in the neonatal intensive care unit: A multicentre, nationwide direct observational study.

AIM(S): To determine the prevalence of medication administration errors and identify factors associated with medication administration errors among neonates in the neonatal intensive care units. DESIGN: Prospective direct observational study. METHODS: The study was conducted in the neonatal intensive care units of five public hospitals in Malaysia from April 2022 to March 2023. The preparation and administration of medications were observed using a standardized data collection form followed by chart review. After data collection, error identification was independently performed by two clinical pharmacists. Multivariable logistic regression was used to identify factors associated with medication administration errors. RESULTS: A total of 743 out of 1093 observed doses had at least one error, affecting 92.4% (157/170) neonates. The rate of medication administration errors was 68.0%. The top three most frequently occurring types of medication administration errors were wrong rate of administration (21.2%), wrong drug preparation (17.9%) and wrong dose (17.0%). Factors significantly associated with medication administration errors were medications administered intravenously, unavailability of a protocol, the number of prescribed medications, nursing experience, non-ventilated neonates and gestational age in weeks. CONCLUSION: Medication administration errors among neonates in the neonatal intensive care units are still common. The intravenous route of administration, absence of a protocol, younger gestational age, non-ventilated neonates, higher number of medications prescribed and increased years of nursing experience were significantly associated with medication administration errors. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The findings of this study will enable the implementation of effective and sustainable interventions to target the factors identified in reducing medication administration errors among neonates in the neonatal intensive care unit. REPORTING METHOD: We adhered to the STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION: An expert panel consisting of healthcare professionals was involved in the identification of independent variables.

Nurses' perception of medication administration errors and factors associated with their reporting in the neonatal intensive care unit.

Medication administration is a complex process, and nurses play a central role in this process. Errors during administration are associated with severe patient harm and significant economic burden. However, the prevalence of under-reporting makes it challenging when analysing the current landscape of medication administration error (MAE) and hinders the implementation of improvements to the existing system. The aim of this study is to describe the reasons for the occurrence of MAEs and the reasons behind the under-reporting of MAEs, to determine the estimated percentage of MAE reporting and to identify factors associated with them from the nurses' perspective. This cross-sectional study was conducted using a validated self-administered questionnaire. The questionnaire contained 65 questions which were divided into three sections: (i) reasons for the occurrence of MAEs, which consisted of 29 items; (ii) reasons for not reporting MAEs, which consisted of 16 items; and (iii) percentage of MAEs actually reported, which consisted of 20 items. It was distributed to 143 nurses in the neonatal intensive care units of five public hospitals in Malaysia. Multivariable logistic regression was used to identify the factors associated with MAE reporting. The estimated percentage of MAE reporting was 30.6%. The most common reasons for MAEs were inadequate nursing staff (5.14 [SD 1.25]), followed by drugs which look alike (4.65 [SD 1.06]) and similar drug packaging (4.41 [SD 1.18]). The most common reasons for not reporting MAEs were that nursing administration focuses on the individual rather than looking at the systems as a potential cause of the error (4.56 [SD 1.32]) and that too much emphasis is placed on MAEs as a measure of the quality of nursing care (4.31 [SD 1.23]). Factors statistically significant with MAE reporting were administration response (adjusted odds ratio [AOR] = 6.90; 95% confidence interval (CI) = 2.01-23.67; P = 0.002), reporting effort (AOR = 3.67; 95% CI = 1.68-8.01; P = 0.001), and nurses with advanced diploma (AOR = 0.29; 95% CI = 0.13-0.65; P = 0.003). Our findings show that under-reporting of MAEs is still common and less than a third of the respondents reported MAEs. Therefore, to encourage error reporting, emphasis should be placed on the benefits of reporting, adopting a non-punitive approach, and creating a blame-free culture.

Impact of a pharmacist led diabetes mellitus intervention on HbA1c, medication adherence and quality of life: A randomised controlled study.

UNLABELLED: Malaysia is situated in Western Pacific region which bears 36.17% of total diabetes mellitus population. Pharmacist led diabetes interventions have been shown to improve the clinical outcomes amongst diabetes patients in various parts of the world. Despite high prevalence of disease in this region there is a lack of reported intervention outcomes from this region. The aim of this study was to evaluate the impact of a pharmacist led intervention on HbA1c, medication adherence, quality of life and other secondary outcomes amongst type 2 diabetes patients. METHOD: Type 2 diabetes mellitus patients (n = 73) attending endocrine clinic at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) were randomised to either control (n = 36) or intervention group (n = 37) after screening. Patients in the intervention group received an intervention from a pharmacist during the enrolment, after three and six months of the enrolment. Outcome measures such as HbA1c, BMI, lipid profile, Morisky scores and quality of life (QoL) scores were assessed at the enrolment and after 6 months of the study in both groups. Patients in the control group did not undergo intervention or educational module other than the standard care at UKMMC. RESULTS: HbA1c values reduced significantly from 9.66% to 8.47% (P = 0.001) in the intervention group. However, no significant changes were noted in the control group (9.64-9.26%, P = 0.14). BMI values showed significant reduction in the intervention group (29.34-28.92 kg/m(2); P = 0.03) and lipid profiles were unchanged in both groups. Morisky adherence scores significantly increased from 5.83 to 6.77 (P = 0.02) in the intervention group; however, no significant change was observed in the control group (5.95-5.98, P = 0.85). QoL profiles produced mixed results. CONCLUSION: This randomised controlled study provides evidence about favourable impact of a pharmacist led diabetes intervention programme on HbA1c, medication adherence and QoL scores amongst type 2 diabetes patients at UKMMC, Malaysia.

Clinical and economic impact of medication administration errors among neonates in neonatal intensive care units.

Despite efforts in improving medication safety, medication administration errors are still common, resulting in significant clinical and economic impact. Studies conducted using a valid and reliable tool to assess clinical impact are lacking, and to the best of our knowledge, studies evaluating the economic impact of medication administration errors among neonates are not yet available. Therefore, this study aimed to determine the potential clinical and economic impact of medication administration errors in neonatal intensive care units and identify the factors associated with these errors. A national level, multi centre, prospective direct observational study was conducted in the neonatal intensive care units of five Malaysian public hospitals. The nurses preparing and administering the medications were directly observed. After the data were collected, two clinical pharmacists conducted independent assessments to identify errors. An expert panel of healthcare professionals assessed each medication administration error for its potential clinical and economic outcome. A validated visual analogue scale was used to ascertain the potential clinical outcome. The mean severity index for each error was subsequently calculated. The potential economic impact of each error was determined by averaging each expert's input. Multinomial logistic regression and multiple linear regression were used to identify factors associated with the severity and cost of the errors, respectively. A total of 1,018 out of 1,288 (79.0%) errors were found to be potentially moderate in severity, while only 30 (2.3%) were found to be potentially severe. The potential economic impact was estimated at USD 27,452.10. Factors significantly associated with severe medication administration errors were the medications administered intravenously, the presence of high-alert medications, unavailability of a protocol, and younger neonates. Moreover, factors significantly associated with moderately severe errors were intravenous medication administration, younger neonates, and an increased number of medications administered. In the multiple linear regression analysis, the independent variables found to be significantly associated with cost were the intravenous route of administration and the use of high-alert medications. In conclusion, medication administration errors were judged to be mainly moderate in severity costing USD 14.04 (2.22-22.53) per error. This study revealed important insights and highlights the need to implement effective error reducing strategies to improve patient safety among neonates in the neonatal intensive care unit.

Development and validation of a risk prediction model for medication administration errors among neonates in the neonatal intensive care unit: a study protocol.

INTRODUCTION: Medication administration errors (MAEs) are the most common type of medication error. Furthermore, they are more common among neonates as compared with adults. MAEs can result in severe patient harm, subsequently causing a significant economic burden to the healthcare system. Targeting and prioritising neonates at high risk of MAEs is crucial in reducing MAEs. To the best of our knowledge, there is no predictive risk score available for the identification of neonates at risk of MAEs. Therefore, this study aims to develop and validate a risk prediction model to identify neonates at risk of MAEs. METHODS AND ANALYSIS: This is a prospective direct observational study that will be conducted in five neonatal intensive care units. A minimum sample size of 820 drug preparations and administrations will be observed. Data including patient characteristics, drug preparation-related and administration-related information and other procedures will be recorded. After each round of observation, the observers will compare his/her observations with the prescriber's medication order, hospital policies and manufacturer's recommendations to determine whether MAE has occurred. To ensure reliability, the error identification will be independently performed by two clinical pharmacists after the completion of data collection for all study sites. Any disagreements will be discussed with the research team for consensus. To reduce overfitting and improve the quality of risk predictions, we have prespecified a priori the analytical plan, that is, prespecifying the candidate predictor variables, handling missing data and validation of the developed model. The model's performance will also be assessed. Finally, various modes of presentation formats such as a simplified scoring tool or web-based electronic risk calculators will be considered.

Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta-Analysis.

INTRODUCTION: Neonates are at greater risk of preventable adverse drug events as compared to children and adults. OBJECTIVE: This study aimed to estimate and critically appraise the evidence on the prevalence, causes and severity of medication administration errors (MAEs) amongst neonates in Neonatal Intensive Care Units (NICUs). METHODS: A systematic review and meta-analysis was conducted by searching nine electronic databases and the grey literature for studies, without language and publication date restrictions. The pooled prevalence of MAEs was estimated using a random-effects model. Data on error causation were synthesised using Reason's model of accident causation. RESULTS: Twenty unique studies were included. Amongst direct observation studies reporting total opportunity for errors as the denominator for MAEs, the pooled prevalence was 59.3% (95% confidence interval [CI] 35.4-81.3, I2 = 99.5%). Whereas, the non-direct observation studies reporting medication error reports as the denominator yielded a pooled prevalence of 64.8% (95% CI 46.6-81.1, I2 = 98.2%). The common reported causes were error-provoking environments (five studies), while active failures were reported by three studies. Only three studies examined the severity of MAEs, and each utilised a different method of assessment. CONCLUSIONS: This is the first comprehensive systematic review and meta-analysis estimating the prevalence, causes and severity of MAEs amongst neonates. There is a need to improve the quality and reporting of studies to produce a better estimate of the prevalence of MAEs amongst neonates. Important targets such as wrong administration-technique, wrong drug-preparation and wrong time errors have been identified to guide the implementation of remedial measures.

Engaging community pharmacists to eliminate inadvertent doping in sports: A study of their knowledge on doping.

This study aimed to evaluate the community pharmacists' knowledge of tackling the issue of inadvertent doping in Malaysia. A cross-sectional survey was conducted among 384 community pharmacists working in Malaysia using a self-administered questionnaire. All the respondents were pharmacists fully registered with the Pharmacy Board of Malaysia and had been working in the community setting for at least one year. Of the 426 community pharmacists approached, 384 community pharmacists participated in this study, giving a response rate of 90.14%. The majority of the respondents were females (63.5%), graduated from local universities (74.9%), with median years of practising as a community pharmacist of six years (interquartile range, IQR = 9 years). The respondents were found to have moderate levels of doping-related knowledge (median score of 52 out of 100). Anabolic steroids (95.8%), stimulants (78.6%) and growth factors (65.6%) were recognised as prohibited substances by most of the respondents. Around 65.9% did not recognise that inadvertent doping is also considered a doping violation. Most of them (90%) also have poor levels of knowledge of doping scenarios in the country. Community pharmacists in Malaysia have limited knowledge in the field of doping. More programmes and activities related to doping and drugs in sports should be held to enhance the community pharmacists' knowledge on the issue of inadvertent doping.

Exploring Culture, Religiosity and Spirituality Influence on Antihypertensive Medication Adherence Among Specialised Population: A Qualitative Ethnographic Approach.

BACKGROUND: Hypertension is one of the major risk factors of stroke and leading risk factors for global death. Inadequate control of blood pressure due to medication non-adherence remains a challenge and identifying the underlying causes will provide useful information to formulate suitable interventions. PURPOSE: This study aimed to explore the roles of culture, religiosity, and spirituality on adherence to anti-hypertensive medications. METHODOLOGY: A semi-structured qualitative interview was used to explore promoters and barriers to medication adherence among hypertensive individuals residing in urban and rural areas of Perak State, West Malaysia. Study participants were individuals who are able to comprehend either in Malay or English, above 18 years old and on antihypertensive medications. Interview transcriptions from 23 participants were coded inductively and analyzed thematically. Codes generated were verified by three co-investigators who were not involved in transcribing process. The codes were matched with quotations and categorized using three levels of themes named as organizing, classifying and general themes. RESULTS: Cultural aspects categorized as societal and communication norms were related to non-adherence. The societal norms related to ignorance, belief in testimony and anything "natural is safe" affected medication adherence negatively. Communication norms manifested as superficiality, indirectness and non-confrontational were also linked to medication non-adherence. Internal and organizational religiosity was linked to increased motivation to take medication. In contrast, religious misconception about healing and treatment contributed towards medication non-adherence. The role of spirituality remains unclear and seemed to be understood as related to religiosity. CONCLUSION: Culture and religiosity (C/R) are highly regarded in many societies and shaped people's health belief and behaviour. Identifying the elements and mechanism through which C/R impacted adherence would be useful to provide essential information for linking adherence assessment to the interventions that specifically address causes of medication non-adherence.

Self-perceived competence and training needs analysis on antimicrobial stewardship among government ward pharmacists in Malaysia.

BACKGROUND: There is a paucity of data on pharmacists' competency and learning needs in antimicrobial stewardship (AMS). OBJECTIVES: To identify and prioritize learning needs based on self-perceived competence of ward pharmacists in AMS, to identify predictors of self-perceived competence, learning methods in AMS and perceived barriers to learning. METHODS: A cross-sectional survey involving ward pharmacists from Hospital Canselor Tuanku Muhriz (HCTM) and hospitals under the Ministry of Health was conducted from May to July 2018. RESULTS: A total of 553 ward pharmacists from 67 hospitals responded to this survey (71.3% response rate). Knowledge of infections, antimicrobials and AMS systems, confidence to advise on various issues relating to antimicrobial therapy and participation in clinical audit and evaluation were among the learning needs identified (median score 3.00). Meanwhile, knowledge on the epidemiology of infections, off-label use of antimicrobials and pharmacoeconomics relating to antimicrobials had lower median scores (2.00) and were thus prioritized as high learning needs. Significant predictors of self-perceived competence in AMS were: gender (P < 0.001); prior specific training in infections and AMS (P < 0.001); postgraduate degree (P < 0.001); practising in the area of infectious disease (P < 0.05); and years of working experience as a ward pharmacist (P < 0.005). Continuing medical education, seminars, courses and workshops were the most common (78.1%) and preferred (84.6%) learning methods in AMS. Lack of appropriate training (67.8%), time (44.5%) and funding (42.5%) topped the list of barriers to learning in AMS. CONCLUSIONS: Findings in this study suggest the need to establish and intensify standardized training in AMS among government ward pharmacists.

Determining hypertensive patients' beliefs towards medication and associations with medication adherence using machine learning methods.

BACKGROUND: This study assesses the feasibility of using machine learning methods such as Random Forests (RF), Artificial Neural Networks (ANN), Support Vector Regression (SVR) and Self-Organizing Feature Maps (SOM) to identify and determine factors associated with hypertensive patients' adherence levels. Hypertension is the medical term for systolic and diastolic blood pressure higher than 140/90 mmHg. A conventional medication adherence scale was used to identify patients' adherence to their prescribed medication. Using machine learning applications to predict precise numeric adherence scores in hypertensive patients has not yet been reported in the literature. METHODS: Data from 160 hypertensive patients from a tertiary hospital in Kuala Lumpur, Malaysia, were used in this study. Variables were ranked based on their significance to adherence levels using the RF variable importance method. The backward elimination method was then performed using RF to obtain the variables significantly associated with the patients' adherence levels. RF, SVR and ANN models were developed to predict adherence using the identified significant variables. Visualizations of the relationships between hypertensive patients' adherence levels and variables were generated using SOM. RESULT: Machine learning models constructed using the selected variables reported RMSE values of 1.42 for ANN, 1.53 for RF, and 1.55 for SVR. The accuracy of the dichotomised scores, calculated based on a percentage of correctly identified adherence values, was used as an additional model performance measure, resulting in accuracies of 65% (ANN), 78% (RF) and 79% (SVR), respectively. The Wilcoxon signed ranked test reported that there was no significant difference between the predictions of the machine learning models and the actual scores. The significant variables identified from the RF variable importance method were educational level, marital status, General Overuse, monthly income, and Specific Concern. CONCLUSION: This study suggests an effective alternative to conventional methods in identifying the key variables to understand hypertensive patients' adherence levels. This can be used as a tool to educate patients on the importance of medication in managing hypertension.

A qualitative study exploring issues related to medication management in residential aged care facilities.

BACKGROUND: Globally, the population of older people is on the rise. As families are burdened with the high cost of care for aging members, demand is increasing for medical care and nursing homes. Thus, medication management is crucial to ensure that residents in a care center benefit and assist the management of the care center in reducing the burden of health care. This study is aimed to qualitatively explore issues related to medication management in residential aged care facilities (RACFs). PARTICIPANTS AND METHODS: A total of 11 stakeholders comprising health care providers, administrators, caretakers and residents were recruited from a list of registered government, nongovernmental organization and private RACFs in Malaysia from September 2016 to April 2017. An exploratory qualitative study adhering to Consolidated Criteria for Reporting Qualitative Studies was conducted. In-depth interview was conducted with consent of all participants, and the interviews were audio recorded for later verbatim transcription. Observational analysis was also conducted in a noninterfering manner. RESULTS AND DISCUSSION: Three themes, namely medication use process, personnel handling medications and culture, emerged in this study. Medication use process highlighted an unclaimed liability for residents' medication by the RACFs, whereas personnel handling medications were found to lack sufficient training in medication management. Culture of the organization did affect the medication safety and quality improvement. The empowerment of the residents in their medication management was limited. There were unclear roles and responsibility of who manages the medication in the nongovernment-funded RACFs, although they were well structured in the private nursing homes. CONCLUSION: There are important issues related to medication management in RACFs which require a need to establish policy and guidelines.

Respiratory drugs prescribed off-label among children in the outpatient clinics of a hospital in Malaysia.

BACKGROUND: Prescribing medicines in an unlicensed and off-label manner for children is a widespread practice around the world. OBJECTIVES: To determine the extent and predictors of off-label respiratory drug prescriptions for children in the outpatient clinics of a hospital in Malaysia. SETTING: Outpatient clinics at the Universiti Kebangsaan Malaysia Medical Centre, a tertiary teaching hospital in Malaysia. METHODS: The pharmacy-based computer system and medical records of the patients were utilized to collect data from 220 pediatric patients who were prescribed at least one respiratory drug from July 2011 to December 2011. MAIN OUTCOME MEASURE: Characteristics of the off-label respiratory drug prescriptions were measured. RESULTS: A total of 134 children (60.9 %) received at least one respiratory drug prescribed in an off-label manner. The most common reasons for the off-label prescribing of drugs were off-label use by indication (31.5 %), followed by higher than the recommended dose (24.9 %) and lower than the recommended frequency (17.1 %). Diphenhydramine was the most common respiratory drug prescribed off-label. The number of medications prescribed was the only significant predictor of off-label prescription of respiratory drugs. Pediatric patients receiving 4-6 medications were 7.8 times more likely to receive at least one off-label respiratory drug compared to pediatric patients that received 1-3 medications (OR 7.8, 95 % CI 1.74-37.44). CONCLUSION: There was substantial prescribing of respiratory drugs for children in an off-label manner at the outpatient clinics at the Universiti Kebangsaan Malaysia Medical Centre. This highlights the need for more research to be carried out on respiratory drugs in the pediatric population.