Evaluation of Detected Medication Errors Within the Operating Room at an Academic Medical Center.

Background: Medication errors are preventable events that lead to inappropriate medication use and potential patient harm. This is especially prevalent within the operating room (OR) where one practitioner is involved in the entire medication-use process. Despite recent implementation of BD Pyxis™ Anesthesia ES, Codonics Safe Label System, and Epic One Step at the University of Kentucky Healthcare (UKHC) to prevent medication errors, errors continue to be reported. Curatolo et al found human error was the most frequent cause of medication error within the OR. Clumsy automation may be an explanation for this, which imposes burdens and promotes work arounds. This study endeavors to assess potential medication errors via chart review to identify risk reduction strategies. Methods: This a single-center retrospective cohort review of patients admitted to a UK HealthCare Main Operating Room, defined OR1A-OR5A and OR7A-OR16A, who were administered medications from 8/1/2021 to 9/30/2021. Results: Over a 2-month period, 145 cases were conducted at UK HealthCare. Of the 145 cases, 98.6% (n = 143) involved a medication error and 93.7% (n = 136) of the errors involved a high-alert medication. The top 5 classes of drugs involved in errors were all high-alert medications. Lastly, 46.6% (n = 67) of cases had documentation that Codonics was utilized. In addition to analyzing medication errors, the financial analysis found that $3154.04 in drug cost was lost in the study period. When extrapolating these results to all BD™ Pyxis Anesthesia Machines at UK HealthCare, $107 237.36 of drug cost is potentially lost per year. Conclusions: These findings add to previous data that have described the increased rate of medication errors when conducting chart review rather than rely on self-reported data. In this study, 98.6% of all cases involved a medication error. In addition, these findings provide additional insight in the increased use of technology within the operating room despite medication errors still occurring. These results can be applied to like institutions to critically evaluate anesthesia workflow to determine risk reduction strategies.

Review of Medication Error Sources Associated With Inpatient Subcutaneous Insulin: Recommendations for Safe and Cost-Effective Dispensing Practices.

Background: The challenge of addressing variation in practice is underlined by variation in institutional operational and financial limitations, which ultimately directs institutional insulin dispensing strategy. Insulin therapy is multi-modal, and inpatient pharmacies may be responsible for simultaneously managing up to 8 formulations. While available as a tool for glycemic management in the inpatient setting, intravenous (IV) insulin and insulin pumps are out of scope for this review. Considerations when designing subcutaneous insulin dispensing processes include medication safety, infection control, pharmacy workflow, nursing workflow, drug cost, hardware cost, and hospital policy. Objective: This review provides an overview of common inpatient subcutaneous insulin dispensing practices, describes the regulations directing current practice, and discusses the benefits and risks of each dispensing practice. Finally, the review provides recommendations for subcutaneous insulin dispensing practices with respect to institutional limitations that minimize patient safety risk and consider the variable costs that practices incur. Methods: Common formulations will be presented along with medication safety considerations and potential medication administration errors to preface strategies for management. Conclusion: Nearing the centennial anniversary of the invention of insulin, the practice of dispensing subcutaneous insulin products has remained a core responsibility of the hospital pharmacy as a primary treatment option for Diabetes Mellitus. Despite the continued presence of this product as a universal component of the hospital formulary, subcutaneous insulin dispensing practices remain varied institution-to-institution.

Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke.

BACKGROUND & PURPOSE: Alteplase is the standard of care for early pharmacologic thrombolysis after acute ischemic stroke (AIS). Alteplase is also considered a high-alert medication and is fraught with potential for error. We sought to describe the difference in medication error rates in in patients receiving alteplase for acute ischemic stroke from regional hospitals compared to patients receiving alteplase at the Comprehensive Stroke Center. METHODS: This was a retrospective cohort comparison of patients who were greater than 18 years old that received intravenous alteplase for the treatment of AIS from June 2015 to June 2018. Several institution specific databases were utilized to obtain pertinent data. A standardized taxonomy was utilized to classify medication errors. Patients were excluded if they received any fibrinolytic other than alteplase or if alteplase was used for a non-stroke indication. Two cohorts (from regional hospitals or the Comprehensive Stroke Center (CSC)) were compared. RESULTS: A total of 676 patients received alteplase during the study period (34% from the CSC and 66% from regional hospitals). There were 133 (19.8%) errors identified. Ten errors (1.6%) occurred at the CSC and 123 (18.2%) errors occurred at regional hospitals. More patients who had an error with alteplase administration (12.7%) experienced a hemorrhagic conversion compared to those with no error in administration (7.2%, p= 0.04). CONCLUSION: The error rate of alteplase infusion for ischemic stroke is high, particularly in patients from referring centers. Errors may be associated with adverse events. Further education and administration safeguards should be implemented to decrease the risk of medication errors.

Impact of an electronic health record transition on chemotherapy error reporting.

BACKGROUND: Incident reporting systems allow for frontline employees to report errors and are a critical component of healthcare patient safety programs. Although incident reporting systems cannot quantify total errors, organizations can utilize incident reporting systems to help identify risks and trends to act upon. The objective of this article is to utilize incident reporting systems to evaluate trends in medication error reporting before and after implementation of a new electronic health record system. METHODS: A five-month pre- and post-analysis was completed in a cancer hospital following electronic health record conversion by reviewing medication errors reported via the institution's voluntary incident reporting systems. Error reports included medication error category, date error was reported/occurred, patient location at time of error, harm severity score, medication(s) involved, medication use system node error originated/discovered in, medication source, narrative summary, and contributing factors. Data were analyzed using descriptive statistics within Office Excel. RESULTS: Oncology medication error reports submitted pre- and post-electronic health record were 68 vs. 57, respectively. During the pre- and post-electronic health record conversion, a majority of errors had a harm severity index of 0 or 1; 12 (18%) in pre-electronic health record and 3 (5%) in post-electronic health record were level 2, and one (1%) in pre-electronic health record vs. 0 in post-electronic health record were level 3. Reported medication errors originated most commonly during the prescribing, administration, and preparation/dispensing phase and were primarily identified in the administration phase of the medication use process. The most frequently reported error category was 'wrong dose' followed by 'other' and 'overdose' in the pre-electronic health record phase and 'missing dose/delayed delivery' and 'order incorrect' in the post-electronic health record phase. The most frequently reported medications included methotrexate, chemotherapy (unspecified), and cisplatin. CONCLUSION: Analyzing data from incident reporting system reports allowed our institution to understand different trends of reporting in the cancer hospital following electronic health record adoption. Utilization of incident reporting systems must be combined with proactive risk identification approaches to enable systems-focused improvements to improve patient safety.

Multicenter study to evaluate the benefits of technology-assisted workflow on i.v. room efficiency, costs, and safety.

PURPOSE: The benefits of technology-assisted workflow (TAWF) compared with manual workflow (non-TAWF) on i.v. room efficiency, costs, and safety at hospitals with more than 200 beds are evaluated. METHODS: Eight hospitals across the United States (4 with TAWF, 4 without) were evaluated, and the characteristics of medication errors and frequency of each error type were measured across the different institutions. The average turnaround time per workflow step and the cost to prepare each compounded sterile preparation (CSP) were also calculated, using descriptive statistics. RESULTS: The TAWF hospital sites detected errors at a significantly higher rate (3.13%) than the non-TAWF hospital sites (0.22%) (p < 0.05). The top error reporting category for the TAWF sites was incorrect medication (63.30%), while the top error reporting category for the non-TAWF sites was incorrect medication volume (18.34%). Use of TAWF was associated with a preparation time decrease of 2.82 min/CSP, a compounding time decrease of 2.94 min/CSP, and a decrease in overall cost to prepare of $1.60/CSP. CONCLUSION: The use of TAWF in the i.v. room was associated with the detection of 14 times more errors than the use of non-TAWF, demonstrating different frequency of error in the results. TAWF also led to a faster preparation time that had a lower cost for preparation.

Evaluation of gravimetric-based technology-assisted workflow for nonhazardous sterile product preparation.

PURPOSE: The impact of a gravimetric-based technology-assisted workflow (TAWF) system on the nonhazardous compounded sterile product (CSP) error capture rate, production times, and pharmacy staff perceptions of compounding methods was evaluated. METHODS: For 2 weeks prior to TAWF implementation, staff used a punch clock to document production times with a volumetric method. Preimplementation error data were captured in a previous study; TAWF software captured error and time data in the postimplementation period. An online staff survey was administered before and 90 days after TAWF implementation to evaluate perceptions of the 2 methods. RESULTS: The error capture rates were 0.47% in the preimplementation period and 41.48% in the postimplementation period. The median time to prepare CSPs was significantly shorter in the preimplementation period versus the postimplementation period (p < 0.0001). The median time to check CSPs was significantly shorter at both 90 days (p < 0.0001) and 180 days (p = 0.0006) after TAWF implementation. When asked if the current method was the safest and the most accurate method for preparation, staff members' perceptions improved from neutrality to agreement when the TAWF was implemented. Staff members were in agreement that the volumetric method was faster than the gravimetric TAWF method but were neutral as to whether the latter was the preferred compounding method. CONCLUSION: The study results indicated that gravimetric-based TAWF preparation of nonhazardous CSPs is slower than manual volumetric preparation but can improve the error capture rate. Staff perceived the gravimetric TAWF method to be the safest and most accurate for producing CSPs.

Determinants of enamel decalcification during simulated orthodontic treatment.

OBJECTIVE: To determine the relative effects that phosphoric acid etching, metal brackets, composite resin adhesives, and filled resin sealants have on enamel decalcification. MATERIALS AND METHODS: One hundred and fifty teeth were randomly divided into six groups to test the effects of acid etching, brackets, and a composite resin adhesive. The right side of each tooth was sealed. The teeth were submitted to a simulated carious challenge by Streptococcus mutans in a nutritive media for 42 days. Scanning electron photomicrographs (SEMs) were used to qualitatively evaluate the tooth surfaces. DIAGNOdent laser fluorescence was used to quantify the decalcification changes that occurred. RESULTS: SEMs showed normal enamel on the control teeth, etching patterns on the acid-etched teeth, surface degradation on the teeth that had resin, and sealant tags on the sealed side. The untreated control group showed significantly less decalcification (P ≤ .05) than did all groups except the no etch+bracket group. The no etch+bracket group showed significantly less decalcification than did the etch+bracket, no etch+resin, and the etch+resin groups. Acid-etched teeth demonstrated significantly more decalcification (34%) than did those that were not etched. The teeth with resin showed significantly more decalcification (24%) than did those without resin. There was no significant difference between teeth that did and did not have brackets. The unsealed side of the teeth showed small amounts of--but significantly more--decalcification (5%) compared to the sealed side. CONCLUSIONS: Acid etching and composite resin adhesives increase enamel decalcification in vitro, while brackets do not. Filled resin sealants protect the teeth from decalcification.