A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care.

AIMS AND OBJECTIVES: To prevent medication errors in drug handling in a paediatric ward. BACKGROUND: One in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce. DESIGN: A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling. METHODS: After approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors. RESULTS: The number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct 'volume of solvent for IV drugs' from 49-25%. CONCLUSION: Paediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes. RELEVANCE TO CLINICAL PRACTICE: Worldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings.

Managing of oral medicines in paediatric oncology: can a handbook and a pharmaceutical counselling intervention for patients and their parents prevent knowledge deficits? A pilot study.

OBJECTIVES: To assess knowledge deficits of patients/parents and prevention strategies. METHODS: After receiving ethics approval, we performed a controlled, quasi-randomised, prospective intervention study. We enrolled patients/parents involved in managing oral medicines in three groups: control (routine care only), handbook intervention and pharmaceutical counselling intervention group. At baseline and after the interventions, we assessed patients'/parents' knowledge deficits (incorrect or missing answers) by questionnaire. RESULTS: We enrolled 64 patients/parents. At baseline, knowledge deficits among the groups were similar: 17% in controls, 22% in the handbook group and 24% in the pharmaceutical counselling group. After the intervention, knowledge deficits decreased to 13% in the handbook group and to 8% in the pharmaceutical counselling group (NS; p=0.003 compared with controls, respectively). For controls, knowledge deficits remained almost unchanged (19%). Results for the pharmaceutical counselling group showed a strong correlation between baseline knowledge deficits and the extent of the deficit decrease after the intervention (τ=-0.74; p<0.001), whereas no significant correlation was found in the control or handbook group. CONCLUSIONS: In paediatric oncology, patients'/parents' knowledge of managing oral medicines was improved. Pharmaceutical counselling substantially reduced high knowledge deficits but no significant improvement was seen with the handbook approach. Pharmaceutical counselling should be offered to patients/parents with high knowledge deficits to reduce errors in managing medicines and increase safety.

Prioritising the prevention of medication handling errors.

OBJECTIVE: Medication errors are frequent in a hospital setting and often caused by inappropriate drug handling. Systematic strategies for their prevention however are still lacking. We developed and applied a classification model to categorise medication handling errors and defined the urgency of correction on the basis of these findings. SETTING: Nurses on medical wards (including intensive and intermediate care units) of a 1,680-bed teaching hospital. METHOD: In a prospective observational study we evaluated the prevalence of 20 predefined medication handling errors on the ward. In a concurrent questionnaire survey, we assessed the knowledge of the nurses on medication handling. The severity of errors observed in individual areas was scored considering prevalence, potential risk of an error, and the involved drug. These scores and the prevalence of corresponding knowledge deficits were used to define the urgency of preventive strategies according to a four-field decision matrix. MAIN OUTCOME MEASURE: Prevalence and potential risk of medication handling errors, corresponding knowledge deficits in nurses committing the errors, and priority of quality improvement. RESULTS: In 1,376 observed processes 833 medication handling errors were detected. Errors concerning preparation (mean 0.88 errors per observed process [95% CI: 0.81-0.96], N = 645) were more frequent than administration errors (0.36 [0.32-0.41], N = 701, P < 0.001). Parenteral drugs (1.10 [1.00-1.19], N = 492) were more often involved in errors than enteral drugs (0.32 [0.28-0.36], N = 794, P < 0.001). Of the 833 observed medication errors 30.9% concerned processes of high risk, 19.0% of moderate risk, and 50.1% of low risk. Of these errors 11.4% were caused by critical dose drugs, 81.6% by uncomplicated drugs, and 6.9% by nutritional supplements or diluents without active ingredient. According to the decision matrix that also considered knowledge deficits two error types concerning enteral drugs (flaws in light protection and prescribing information) were given maximum priority for quality improvement. For parenteral drugs five errors (incompatibilities, flaws in hygiene, duration of administration, check for visible abnormalities, and again prescribing information) appeared most important. CONCLUSION: We successfully applied a newly developed classification model to prioritise medication handling errors for prevention strategies.