Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment.

INTRODUCTION: In the USA over 30% of medication errors occur at the point of administration. Among non-surgical patients in US hospitals exposed to opioids, 0.6% experience a severe opioid-related adverse event. In September 2018, Sierra View Medical Center identified two areas of opportunity for quality improvement: bedside bar code medication administration (BCMA) and pain reassessments. At baseline (April 2018 to September 2018) only 81% of medications were scanned prior to administration with pain reassessments completed only 41% of the time 1 hour postopioid administration. OBJECTIVE: To improve BCMA scanning rates (goal ≥95%) and pain reassessments within 1 hour postopioid administration (goal ≥90%). METHODS: Implementation methods included data transparency, weekly dashboards, education and plan-do-study-act (PDSA) cycles informed by feedback from key stakeholders. RESULTS: Following a series of PDSA cycle implementations, barcode medication administration (BCMA) scanning rates improved by 14% (from 81% to 95%) and pain reassessments improved by 50% (from 41% to 91%), sustained 17 months postproject implementation (October 2018 to February 2019). The number of adverse drug events (ADEs) related to administration errors decreased by 17% (estimated annual cost savings of $120 750-239 725 per year) and opioid-related ADEs decreased by 2.6% (estimated annual cost savings of $72 855-80 928 per year). CONCLUSION: Adopting John Kotter's model for change, developing performance dashboards and sustaining engagement among stakeholders on a weekly basis improved bar code medication scanning rates and pain reassessment compliance. The stakeholders created momentum for change in both practice and culture resulting in improved patient safety with a favourable financial impact.

Factors associated with workarounds in barcode-assisted medication administration in hospitals.

AIMS AND OBJECTIVES: To identify that workarounds (defined as "informal temporary practices for handling exceptions to normal procedures or workflow") by nurses using information technology potentially compromise medication safety. Therefore, we aimed to identify potential risk factors associated with workarounds performed by nurses in Barcode-assisted Medication Administration in hospitals. BACKGROUND: Medication errors occur during the prescribing, distribution and administration of medication. Errors could harm patients and be a tragedy for both nurses and medical doctors involved. Interventions to prevent errors have been developed, including those based on information technology. To cope with shortcomings in information technology-based interventions as Barcode-assisted Medication Administration, nurses perform workarounds. Identification of workarounds in information technology is essential to implement better-designed software and processes which fit the nurse workflow. DESIGN: We used the data from our previous prospective observational study, performed in four general hospitals in the Netherlands using Barcode techniques, to administer medication to inpatients. METHODS: Data were collected from 2014-2016. The disguised observation was used to gather information on potential risk factors and workarounds. The outcome was a medication administration with one or more workarounds. Logistic mixed models were used to determine the association between potential risk factors and workarounds. The STROBE checklist was used for reporting our data. RESULTS: We included 5,793 medication administrations among 1,230 patients given by 272 nurses. In 3,633 (62.7%) of the administrations, one or more workarounds were observed. In the multivariate analysis, factors significantly associated with workarounds were the medication round at 02 p.m.-06 p.m. (adjusted odds ratio [OR]: 1.60, 95% CI: 1.05-2.45) and 06 p.m.-10 p.m. (adjusted OR: 3.60, 95% CI: 2.11-6.14) versus the morning shift 06 a.m.-10 a.m., the workdays Monday (adjusted OR: 2.59, 95% CI: 1.51-4.44), Wednesday (adjusted OR: 1.92, 95% CI: 1.2-3.07) and Saturday (adjusted OR: 2.24, 95% CI: 1.31-3.84) versus Sunday, the route of medication, nonoral (adjusted OR: 1.28, 95% CI: 1.05-1.57) versus the oral route of drug administration, the Anatomic Therapeutic Chemical classification-coded medication "other" (consisting of the irregularly used Anatomic Therapeutic Chemical classes [D, G, H, L, P, V, Y, Z]) (adjusted OR: 1.49, 95% CI: 1.05-2.11) versus Anatomic Therapeutic Chemical class A (alimentary tract and metabolism), and the patient-nurse ratio ≥6-1 (adjusted OR: 5.61, 95% CI: 2.9-10.83) versus ≤5-1. CONCLUSIONS: We identified several potential risk factors associated with workarounds performed by nurses that could be used to target future improvement efforts in Barcode-assisted Medication Administration. RELEVANCE TO CLINICAL PRACTICE: Nurses administering medication in hospitals using Barcode-assisted Medication Administration frequently perform workarounds, which may compromise medication safety. In particular, nurse workload and the patient-nurse ratio could be the focus for improvement measures as these are the most clearly modifiable factors identified in this study.

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: A multi-centre study.

OBJECTIVE: Limited evidence concerning the burden and predictors of omitted medication doses within mental health hospitals could severely limit improvement efforts in this specialist setting. This study aimed to determine the prevalence, nature and predictors of omitted medication doses affecting hospital inpatients in two English National Health Service (NHS) mental health trusts. METHODS: Over 6 data collection days trained pharmacy teams screened inpatient prescription charts for scheduled and omitted medication doses within 27 adult and elderly wards across 9 psychiatric hospitals. Data were collected for inpatients admitted up to two weeks prior to each data collection day. Omitted doses were classified as 'time critical' and 'preventable' based on established criteria. Omitted dose frequencies were presented with 95% confidence intervals (CI). Multilevel logistic regression analyses determined the predictors of omitted dose occurrence, with omission risks presented as adjusted odds ratios (OR) with 95% CI. RESULTS: 18,664 scheduled medication doses were screened for 444 inpatients and 2,717 omissions were identified, resulting in a rate of 14.6% (95% CI 14.1-15.1). The rate of 'time critical' omitted doses was 19.3% (95% CI 16.3-22.6%). 'Preventable' omitted doses comprised one third of all omissions (34.5%, 930/2694). Logistic regression analysis revealed that medicines affecting the central nervous system were 55% less likely to be omitted compared to all other medication classes (9.9% vs. 18.8%, OR 0.45 (0.40-0.52)) and that scheduled doses administered using non-oral routes were more likely to be omitted compared the oral route (inhaled OR 3.47 (2.64-4.57), topical 2.71 (2.11-3.46), 'other' 2.15 (1.19-3.90)). 'Preventable' dose omissions were more than twice as likely to occur for 'time critical' medications than non-time critical medications (50.4% vs. 33.8%, OR 2.24 (1.22-4.11)). CONCLUSIONS: Omitted medication doses occur commonly in mental health hospitals with 'preventable' omissions a key contributor to this burden. Important targets for remedial intervention have been identified.

Pooled Dosing and Efficacy Analysis of the Sufentanil Sublingual Tablet 30 mcg Across Demographic Subgroups for the Management of Moderate-to-Severe Acute Pain.

PURPOSE: To aid nurses in dosing sufentanil sublingual tablet (SST) 30 mcg administered via a single-dose applicator, dosing requirements and efficacy of SST 30 mcg were analyzed across age, sex, race, and body mass index subgroups. DESIGN: Patient characteristics were pooled from three postoperative studies (two placebo-controlled and one open-label) and one open-label emergency department study. Drug dosing and efficacy data were pooled from the postoperative studies. METHODS: Efficacy was assessed through summed pain intensity difference to baseline during 12 hours across subgroups. FINDINGS: Mean (standard deviation) drug doses administered from 0 to 12 hours was 3.9 (2.0) for SST 30 mcg and was less frequent for older (≥65 years) versus younger patients. The summed pain intensity difference to baseline during 12 hours was superior with SST 30 mcg versus placebo across all subgroups. CONCLUSIONS: SST 30 mcg is a sublingual opioid analgesic with efficacy across demographic subgroups.

Análisis del impacto económico, de consumo y de calidad en el uso de los medicamentos, tras la implantación de la prescripción electrónica y de un sistema automatizado de dispensación / Economic impact and acceptance of electronic prescription and dispensing automation

OBJETIVO: Evaluar el impacto en el gasto, consumo y aceptabilidad tras la implantación de prescripción electrónica y un sistema de dispensación automático en una unidad de hospitalización. MATERIAL Y MÉTODOS: Estudio retrospectivo pre-post implantación, comparativo en consumo (unidades) y gasto (euros) de medicamentos durante los periodos enero-noviembre 2017 y enero-noviembre 2018. Se midió impacto económico de la implantación aplicando costes de 2017 a la actividad 2018. Se realizó una encuesta de valoración de la seguridad, calidad asistencial y aceptación al personal de enfermería. RESULTADOS: El consumo en medicamentos tras la implantación fue un 5,76% inferior con respecto al periodo anterior. La distribución porcentual del consumo de unidades según vía de administración fue similar entre ambos periodos. Durante el periodo 2018, el gasto fue un 2,76% superior, asociado a un aumento en la actividad y al incremento del coste por unidad de medicamento. Sin embargo, el gasto y consumo ponderados por ingreso, fueron un 10% y 16,5% inferiores, respectivamente. El impacto económico de la implantación supuso una disminución del gasto en medicamentos de 15.656 euros. El resultado de las encuestas arrojó una valoración positiva en seguridad, más del 70% de los encuestados consideraron que los armarios previenen administraciones innecesarias, alergias y errores en la selección de medicamentos. CONCLUSIÓN: La implantación de la prescripción electrónica y de un sistema automatizado de dispensación disminuye los costes asociados al consumo de medicamentos. Mejora la adaptación de las presentaciones farmacéuticas a la prescripción y la seguridad en el uso de los medicamentos

OBJECTIVE: Impact evaluation of expenditure, consumption and acceptability in the implementation of the electronic prescription and the automatic dispensing cabinet in a hospitalization unit. MATERIAL AND METHODS: Pre-post implantation comparative retrospective study, in which the consumption (units) and expenditure (euros) of drugs were compared during 2 periods, pre-period (January-November 2017) and post-period (January-November 2018). The economic impact of the implementation was measured by applying the costs of 2017 to the activity of 2018. A survey was also carried out to assess the safety, quality of care and acceptability of nursing staff of the unit. RESULTS: Total units of drugs consumed after implementation were 5.76% lower compared to the previous period. The distribution of unit consumption according to the route of administration was similar between both periods. During the period of 2018, spending on medicines was 2.76% higher, associated with an increase in activity, spending and consumption weighted by income, 10% and 16.5% lower, respectively. The economic impact of the implementation meant a decrease in the cost of medicines of 15,656 euros. The result of the surveys yielded a positive evaluation in security, more than 70% of the nurses considered the automated dispensing cabinet prevent administration in case the allergies and the errors in the selection of medicines. CONCLUSIONS: complementation of electronic prescription and automatic dispensing cabinet produce a decrease in the healthcare costs. As well as a better adaptation to the prescription and an increase in the safety use of medicines. The nursing staff recognizes this new system as safer than the manual floor stock system

Impact of discharge medication bedside delivery service on hospital reutilization.

PURPOSE: To evaluate the impact of a medication to bedside delivery (meds-to-beds) service on hospital reutilization in an adult population. METHODS: A retrospective, single-center, observational cohort study was conducted within a regional academic medical center from January 2017 to July 2017. Adult patients discharged from an internal medicine unit with at least one maintenance medication were evaluated. The primary outcome was the incidence of 30-day hospital reutilization between two groups: discharged patients who received meds-to-beds versus those who did not. Additionally, the incidence of 30-day hospital reutilization between the two groups was compared within predefined subgroup patient populations: polypharmacy, high-risk medication use, and patients with a principal discharge diagnosis meeting the criteria set by the Centers for Medicare and Medicaid Services 30-day risk standardized readmission measures. RESULTS: A total of 600 patients were included in the study (300 patients in the meds-to-beds group and 300 patients in the control group). The 30-day hospital reutilization (emergency department visits and/or hospital readmissions) related to the index visit was lower in the meds-to-beds group, but the difference was not statistically significant between the two groups (8.0% in the meds-to-beds group versus 10.0% in the control group; odds ratio, 0.78; 95% confidence interval, 0.45-1.37). There was no significant difference in the 30-day hospital reutilization related to the index visit between the control and meds-to-beds groups within the three subgroups analyzed. CONCLUSION: There was no difference in 30-day hospital reutilization related to the index visit with the implementation of meds-to-beds service in the absence of other transitions-of-care interventions.

Analysis of dosing-button compliance.

PURPOSE: A project was undertaken at an academic medical center to assess use of available dosing buttons within the computerized provider-order-entry (CPOE) system in order to identify opportunities for optimization of medication builds. METHODS: A retrospective observational study was conducted to identify medication records within a CPOE system meeting prespecified inclusion and exclusion criteria. A report capturing all inpatient adult medication orders associated with the identified medication records over a 6-month period was generated. The primary endpoint was percent dosing-button compliance, calculated as the number of orders with doses consistent with existing dosing-button options divided by the total number of orders during the study period. Secondary study objectives included a comparison of high- and low-performing medication record samples and identification of potential reasons for lack of dosing-button use. RESULTS: A total of 2,506 CPOE medication records associated with a total of 694,877 medication orders entered during the study period were analyzed. Median percent dosing-button compliance was 99.92% (interquartile range, 83.33-100%). High-performing records (n = 1243) were more likely to be associated with anti-infective medications (p = 0.041) and medications not on formulary at the study institution (p < 0.001). Medications in the sample of poor-performing CPOE records (n = 614) were more likely to be agents delivered via the i.v. route (p < 0.001). There were 45 records for which poor dosing-button compliance was attributed to lack of a clinically reasonable dosing option. CONCLUSION: A high level of dosing-button compliance was demonstrated despite the lack of routine revalidation of dosing buttons after initial medication builds. Some opportunity for optimization was identified during the project, which established a quality assurance method to facilitate future auditing of medication builds.

Analysis of Ornidazole Injection in Clinical Use at Post-marketing Stage by Centralized Hospital Monitoring System.

This study aims to analyze the clinical use of ornidazole injection at the post-marketing stage by centralized hospital monitoring system method, and investigate its widespread use in patients, in order to regulate and guide the rational drug use, improve the drug specificity and provide a basis for drug therapy. The study adopts a prospective, multi-center, large sample size, centralized hospital monitoring system. We selected five leading hospitals in Hubei province, and observed the inpatients who received the ornidazole injection from July 1, 2015 to October 31, 2015. The basic information of patients was recorded, as well as the drug use and adverse events. The statistical analysis was performed based on these data. A total of 4396 individuals were enrolled in this study, most of them were middle-aged female patients and the ornidazole injection was mainly used as prophylactic prior to surgery to prevent the infections, and surgical treatment of anaerobic infections, abdominal infections and pelvic infections. The irrational drug use existed mainly in the prescribing and administration process, including unreasonable dosing frequency, rapid intravenous drip speed and extended duration of drug use. Eleven cases of adverse reactions were collected during the monitoring, incidence rate of adverse reactions was 2.5‰; adverse drug reactions occurred within 30 min. The study results fully reflected the usage of ornidazole injection in the real world. Based on the study, we calculated the adverse reaction incidence of ornidazole and identified the risk factors which may affect the safety of ornidazole injection. Study results strongly recommend that the manufacturers should publish standards for inpatient use and doctors should prescribe with caution accordingly.

Automated detection of wrong-drug prescribing errors.

BACKGROUND: To assess the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. SETTING: Urban, academic medical centre, comprising a 495-bed hospital and outpatient clinic running on the Cerner EHR. We extracted 8 years of medication orders and diagnostic claims. We licensed a database of medication indications, refined it and merged it with the medication data. We developed an algorithm that triggered for LASA errors based on name similarity, the frequency with which a patient received a medication and whether the medication was justified by a diagnostic claim. We stratified triggers by similarity. Two clinicians reviewed a sample of charts for the presence of a true error, with disagreements resolved by a third reviewer. We computed specificity, positive predictive value (PPV) and yield. RESULTS: The algorithm analysed 488 481 orders and generated 2404 triggers (0.5% rate). Clinicians reviewed 506 cases and confirmed the presence of 61 errors, for an overall PPV of 12.1% (95% CI 10.7% to 13.5%). It was not possible to measure sensitivity or the false-negative rate. The specificity of the algorithm varied as a function of name similarity and whether the intended and dispensed drugs shared the same route of administration. CONCLUSION: Automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Real-time error detection is not possible with the current system, the main barrier being the real-time availability of accurate diagnostic information. Further development should replicate this analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.

Improving the medication-use process for 23.4% sodium chloride.

PURPOSE: Results of a study to evaluate medication storage, distribution, and safety outcomes after addition of 23.4% sodium chloride to a hospital formulary and development of a novel distribution process incorporating safeguards allowing for urgent medication removal from an automated dispensing cabinet (ADC) are reported. SUMMARY: A retrospective review of 23.4% sodium chloride injection doses dispensed during a 38-month period was performed at an academic medical center to evaluate times from order entry to pharmacist verification, dispensing, and administration; adverse events related to dispensing or administration; and other outcomes. Seventy doses of 23.4% sodium chloride injection were administered to 60 patients during the study period. The mean times from order entry to pharmacist verification, medication removal from an ADC, and administration were 8, 25, and 43 minutes, respectively, when the ADC override function was not used. After 23.4% sodium chloride injection's addition to the ADC override list, 16 of 30 doses were removed "on override," with order entry performed retrospectively for 9 of these doses. There were no documented adverse events related to medication distribution and 2 adverse effects possibly related to medication administration. CONCLUSION: Novel storage and distribution processes for 23.4% sodium chloride injection were implemented at a large academic medical center to optimize safety related to the medication-use process. A retrospective review of 70 administered doses found the process of maintaining this medication in ADCs to be a safe and efficient method of storing and dispensing a high-alert medication.

Interruptions experienced by nurses during pediatric medication administration in China: An observational study.

PURPOSE: The objectives of this study were to describe (a) the frequency of interruptions experienced by a pediatric nurse per hour, (b) the sources of interruptions experienced by a pediatric nurse, and (c) the interruption outcomes during pediatric medication administration. DESIGN AND METHODS: This design of this study was a cross-sectional observational study. A convenience sample of pediatric nurses was used in this study. The interruption observation sheet was used to collect data about the frequency, sources, and outcomes of interruptions. RESULTS: There was a total of 43 nurses were observed in more than 180 medication administration rounds. An interruption rate of 94.51% occurred during pediatric medication administration. The frequency of interruptions was three or more times (51.04%). The most common source of interruption was attributed to the working environment (32.37%). The second most frequent reason for interruption came from personnel, such as caregivers (24.48%), followed by physicians (10.79%), and other nursing staff (9.54%). The third most common source of interruption was communication issues, including patient interviews, patient reports, and case discussion (8.71%). Six errors (2.49%) were reported out of 241 interruptions as a result of interruptions. In specific, causes of errors during pediatric medication administration were due to wrong medication dose. PRACTICE IMPLICATIONS: This study provides important information on interruptions experienced by pediatric nurses during medication administration in Chinese hospital settings and found that interruptions frequently occur in pediatric units.

ASHP national survey of pharmacy practice in hospital settings: Workforce-2018.

PURPOSE: Results of the 2018 ASHP national survey of pharmacy practice in hospital settings pertaining to the pharmacy workforce are presented. METHODS: Pharmacy directors at 4,897 general and children's medical-surgical hospitals in the United States were surveyed using a mixed-mode method of contact by mail and email. Survey completion was online. IMS Health supplied data on hospital characteristics; the survey sample was drawn from the IMS hospital database. RESULTS: The survey response rate was 16.6%. The results indicate that inpatient staffing has increased for both pharmacists and pharmacy technicians. More than half of the respondents reported shortages of pharmacy managers, experienced technicians, and experienced pharmacy technicians with sterile compounding experience. More than half of the respondents reported an excess of entry-level frontline pharmacists. The perceived shortage of pharmacists is in decline, while the perceived shortage of pharmacy technicians, especially those with years of experience, is increasing. Pharmacists commonly chair multidisciplinary committees within health systems, and pharmacy leaders often report directly to the chief executive officer or chief operating officer; they are often responsible for reporting quality information associated with medication use to the health system's board. The use of a pharmacist credentialing and privileging process beyond licensure has increased over the past 4 years. Attention is being devoted to stress in the work place and addressing burnout among healthcare professionals, including pharmacists. CONCLUSION: The profession is fostering a workforce that is appropriate in composition, sufficient in number, and has the competence to improve the value and safety of medication use.

ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education-2018.

PURPOSE: The results of the 2018 ASHP national survey of pharmacy practice in hospital settings are presented. METHODS: Pharmacy directors at 4,897 general and children's medical-surgical hospitals in the United States were surveyed using a mixed-mode method of contact by mail and email. Survey completion was online using Qualtrics. IMS Health supplied data on hospital characteristics; the survey sample was drawn from IMS's hospital database. RESULTS: The response rate was 16.6%. The percentage of hospitals that routinely have pharmacists assigned to provide drug therapy management has increased. Transitions-of-care processes have generally increased over the last 6 years. The percentage of hospitals with pharmacists in a wide variety of clinic types and clinical practice areas has increased over the last 2 years. Opioid stewardship programs are emerging in many U.S. hospitals, with pharmacists participating or taking the lead in program implementation. Outsourcing of compounded sterile product preparation is common. The proportion of hospitals not using any technology when compounding sterile preparations has declined. Pharmacy departments commonly track and monitor trends for administrative, operational, quality, and outcome metrics. CONCLUSION: Pharmacists continue to improve drug therapy monitoring for patients in U.S. hospitals. They are also responding to public health issues related to medication use. These advancements include taking an active role in opioid stewardship programs, safe compounding of sterile medications for patients, and reducing the need for hospital-based care.

Nurses' satisfaction with barcode medication-administration technology: Results of a cross-sectional study.

Medication administration is a critical task of nurses that, if not done appropriately, can lead to fatal errors. New technologies, including barcode medication administration, are intended to decrease medication errors and enhance verification of medication-administration rights. Therefore, in this study, we examined the effect of introducing barcode medication administration on nurses' satisfaction and identified correlates of nurses' satisfaction with barcode medication administration. A descriptive, cross-sectional design using self-reported questionnaires was utilized to recruit 207 nurses from three public hospitals. Participants reported being moderately satisfied with barcode medication administration, especially with its efficacy and safety aspects. Their satisfaction had a significant negative correlation with their age, nursing experience, and experience using barcode medication administration, and a significant positive correlation with barcode medication-administration training satisfaction, computer competence, comfort with using barcode medication administration, and perceived job productivity using barcode medication administration. This study provides important information about Jordanian nurses' satisfaction with barcode medication-administration technology and provides greater understanding of different clinical correlates to barcode medication-administration satisfaction. It is recommended that effective barcode medication-administration training and computer skills training be provided prior to establishing barcode medication administration in hospitals and that the safety features of barcode medication administration be integrated in clinical education and training.

Devising of a risk map on the management of high risk alert medication in a high level university hospital.

OBJECTIVE: To classify hospital units into three risk levels in order to define and prioritise  improvement and training measures in each of them. METHOD: The risk map was developed in two phases: First phase involved the setting up of a  multidisciplinary team, a bibliographic search, the identification of medications and of the criteria to  design the map: (1) Location: number of high-alert medications; (2) Staff turnover: the units were  classified in low turnover units = 1, medium turnover units = 2 and high turnover units = 3 according  to data provided by the human resource department; (3) Frequency: quotient between the number of high alert medicactions in each unit and the total of medications used, and (4) Severity: voluntary  survey of professionals. An accumulated risk of severity of each unit was calculated: Σ (severity of the  drug x number of its units). The Neperian logarithm was applied to this value to reduce the  variability of the values. Thus a risk probability index was established = staff turnover x frecuency x  Neperian logarithm of severity. In a  second phase, the units were classified into three groups and the  risk map of high-alert medication was elaborated in the hospital. In it, the units that had a risk  probability index higher than 2.9 were classified as high risk units, those that had between 1-2.9 as  intermediate risk units and those that had less than 1 as low risk units. According to the risk probability index, improvement measures were defined and priorities were set for each of them. RESULTS: A total 447 high-risk medications corresponding to 227 active ingredients were identified  during the study period. The units showing a higher risk were: Intensive Care Medicine (10.51),  Reanimation (4.01), and Palliative Care (3.90). Improvement actions (informative poster, visual  identification, alerts, training and double checks) were defined and prioritised in accordance with the  risk probability index. CONCLUSIONS: Knowing the degree of risk of hospitalization units in the management of high-alert  medications allows for the implementation of improvement plans in relation to the degree of  vulnerability detected.

Objetivo: Estratificar las unidades del hospital en tres niveles y elaborar un mapa de riesgos para  priorizar las mejoras y la formación sobre el manejo de medicamentos de alto riesgo. Método: La elaboración del mapa se realizó en dos fases: Primera fase, implicó la creación de un  equipo multidisciplinar, búsqueda bibliográfica, identificación de medicamentos y de criterios para  elaborar el mapa: (1) Localización: número de medicamentos de alto riego; (2) Rotación del personal:  se clasificaron las unidades en rotación baja = 1, media = 2 y alta = 3, según datos de recursos humanos; (3) Frecuencia: cociente entre el número de medicamentos de alto riesgo en  cada unidad y el total de medicamentos utilizados, y (4) Gravedad: encuesta voluntaria a  profesionales. Se calculó un riesgo acumulado de gravedad de cada unidad: Σ (gravedad del  medicamento x número de unidades del medicamento). Sobre este valor se aplicó el logaritmo  neperiano para reducir la variabilidad de los valores. Con ello se estableció el índice de probabilidad  de riesgo = rotación del personal x frecuencia x logaritmo neperiano del riesgo acumulado de  gravedad. En una segunda fase, a partir  de la ponderación de resultados, se clasificaron las unidades  en tres grupos y se construyó el mapa de riesgo de medicamentos de alto riesgo en el  hospital. En este se representaron las unidades que tuvieron un índice de probabilidad de riesgo  mayor de 2,9 como unidades de alto riesgo, las que lo tuvieron entre 1-2,9 como unidades de riesgo  intermedio y las que lo tuvieron menor a 1 como unidades de riesgo bajo. Y según el índice de  probabilidad de riesgo en la unidad, se definieron y priorizaron las medidas de mejora para cada una  de ellas.Resultados: Se identificaron 447 medicamentos de alto riesgo en el hospital, correspondientes a 227  principios activos. Las unidades de mayor riesgo fueron: Medicina Intensiva (10,51),  Reanimación (4,01) y Paliativos (3,90). Se definieron las acciones de mejora por índice de probabilidad de riesgo: póster informativo, identificación visual, alertas, formación y doble  chequeo.Conclusiones: Conocer el grado de riesgo de las unidades de hospitalización en el manejo de  medicamentos de alto riesgo permite aplicar planes de mejora dirigidos en función de la mayor o  menor vulnerabilidad detectada.

Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.

Objective The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Conclusions Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.

How to measure quantitative antibiotic use in order to support antimicrobial stewardship in acute care hospitals: a retrospective observational study.

A cornerstone of antimicrobial stewardship programs (ASPs) is monitoring quantitative antibiotic use. Frequently used metrics are defined daily dose (DDD) and days of therapy (DOT). The purpose of this study was (1) to explore for the hospital setting the possibilities of quantitative data retrieval on the level of medical specialty and (2) to describe factors affecting the usability and interpretation of these quantitative metrics. We performed a retrospective observational study, measuring overall systemic antibiotic use at specialty level over a 1-year period, from December 1st 2014 to December 1st 2015, in one university and 13 non-university hospitals in the Netherlands. We distinguished surgical and non-surgical adult specialties. The association between DDDs, calculated from aggregated dispensing data, and DOTs, calculated from patient-level prescription data, was explored descriptively and related to organizational factors, data sources (prescription versus dispensing data), data registration, and data extraction. Twelve hospitals were able to extract dispensing data (DDD), three of which on the level of medical specialty; 13 hospitals were able to extract prescription data (DOT), 11 of which by medical specialty. A large variation in quantitative antibiotic use was found between hospitals and the correlation between DDDs and DOTs at specialty level was low. Differences between hospitals related to organizational factors, data sources, data registration, and data extraction procedures likely contributed to the variation in quantitative use and the low correlation between DDDs and DOTs. The differences in healthcare organization, data sources, data registration, and data extraction procedures contributed to the variation in reported quantitative use between hospitals. Uniform registration and extraction procedures are necessary for appropriate measurement and interpretation and benchmarking of quantitative antibiotic use.

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.

OBJECTIVE: Medication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England. METHODS: Registered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants' experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason's model of accident causation. RESULTS: A total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication. CONCLUSIONS: To our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent 'system' failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational 'systems' failures to reduce error.

Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre-post study.

BACKGROUND: In this UK study, we investigated the impact of computerised physician order entry (CPOE) and clinical decision support (CDS) implementation on the rate of 78 high-risk prescribing errors amenable to CDS. METHODS: We conducted a preintervention/postintervention study in three acute hospitals in England. A predefined list of prescribing errors was incorporated into an audit tool. At each site, approximately 4000 prescriptions were reviewed both pre-CPOE and 6 months post-CPOE implementation. The number of opportunities for error and the number of errors that occurred were collated. Error rates were then calculated and compared between periods, as well as by the level of CDS. RESULTS: The prescriptions of 1244 patients were audited pre-CPOE and 1178 post-CPOE implementation. A total of 28 526 prescriptions were reviewed, with 21 138 opportunities for error identified based on 78 defined errors. Across the three sites, for those prescriptions where opportunities for error were identified, the error rate was found to reduce significantly post-CPOE implementation, from 5.0% to 4.0% (P<0.001). CDS implementation by error type was found to differ significantly between sites, ranging from 0% to 88% across clinical contraindication, dose/frequency, drug interactions and other error types (P<0.001). Overall, 43/78 (55%) of the errors had some degree of CDS implemented in at least one of the hospitals. CONCLUSIONS: Implementation of CPOE with CDS was associated with clinically important reductions in the rate of high-risk prescribing errors. Given the pre-post design, these findings however need to be interpreted with caution. The occurrence of errors was found to be highly dependent on the level of restriction of CDS presented to the prescriber, with the effect that different configurations of the same CPOE system can produce very different results.