Drug Administration Errors Research Articles

Drug administration errors in infants: don't blame individuals, fix the system

Drug administration errors in infants: don't blame individuals, fix the system

Errors in drug administration: knowledge diffusion and identification of the patients as important aspects

The administration of medications is a multi-system process. Errors can happen in all the stages of that process. Strategies can be used and it should be published to minimize the occurrence of errors. This study had the following objectives: to identify and to analyze publications with themes about the administration of medication in nursing, hospital and pharmacy journals and to verify the identification in the bed and in the patients' forearm in impatient clinics. To reach the first objective it was realized a revision of the literature in three journals of larger national circulation of the described areas, in the period from 1987 to 1997. The identified articles were classified in 5 types: nursing staff, teaching, medications, research and technique. It was identified 19 articles on the thematic studied, being 42.1% of these related to the technical aspects of the administration of medications. To reach the second objective it was taken an investigation of one day, chosen accidentally, being verified the identification of the beds and the patients in the 360 beds of the institution. Of these, 74.7% were busy and 75.8% properly identified. It was observed that 23.8% of the patients have gotten bracelet of placed identification, in the day previous to the surgery and not in the moment of the hospitalization. The results evidenced the need to increase the publication of the studies about errors and to increase actions that minimize the occurrence of errors in the medication in impatient patients.

Common errors of drug administration in infants: causes and avoidance.

Drug administration errors are common in infants. Although the infant population has a high exposure to drugs, there are few data concerning pharmacokinetics or pharmacodynamics, or the influence of paediatric diseases on these processes. Children remain therapeutic orphans. Formulations are often suitable only for adults; in addition, the lack of maturation of drug elimination processes, alteration of body composition and influence of size render the calculation of drug doses complex in infants. The commonest drug administration error in infants is one of dose, and the commonest hospital site for this error is the intensive care unit. Drug errors are a consequence of system error, and preventive strategies are possible through system analysis. The goal of a zero drug error rate should be aggressively sought, with systems in place that aim to eliminate the effects of inevitable human error. This involves review of the entire system from drug manufacture to drug administration. The nuclear industry, telecommunications and air traffic control services all practise error reduction policies with zero error as a clear goal, not by finding fault in the individual, but by identifying faults in the system and building into that system mechanisms for picking up faults before they occur. Such policies could be adapted to medicine using interventions both specific (the production of formulations which are for children only and clearly labelled, regular audit by pharmacists, legible prescriptions, standardised dose tables) and general (paediatric drug trials, education programmes, nonpunitive error reporting) to reduce the number of errors made in giving medication to infants.

Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-Analysis of Prospective Studies

Objective.—To estimate the incidence of serious and fatal adverse drug reactions (ADR) in hospital patients.Data Sources.—Four electronic databases were searched from 1966 to 1996.Study Selection.—Of 153, we selected 39 prospective studies from US hospitals.Data Extraction.—Data extracted independently by 2 investigators were analyzed by a random-effects model. To obtain the overall incidence of ADRs in hospitalized patients, we combined the incidence of ADRs occurring while in the hospital plus the incidence of ADRs causing admission to hospital. We excluded errors in drug administration, noncompliance, overdose, drug abuse, therapeutic failures, and possible ADRs. Serious ADRs were defined as those that required hospitalization, were permanently disabling, or resulted in death.Data Synthesis.—The overall incidence of serious ADRs was 6.7% (95% confidence interval [CI], 5.2%-8.2%) and of fatal ADRs was 0.32% (95% CI, 0.23%-0.41%) of hospitalized patients. We estimated that in 1994 overall 2216000 (1721000-2711000) hospitalized patients had serious ADRs and 106000 (76000-137000) had fatal ADRs, making these reactions between the fourth and sixth leading cause of death.Conclusions.—The incidence of serious and fatal ADRs in US hospitals was found to be extremely high. While our results must be viewed with circumspection because of heterogeneity among studies and small biases in the samples, these data nevertheless suggest that ADRs represent an important clinical issue.

Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies.

To estimate the incidence of serious and fatal adverse drug reactions (ADR) in hospital patients. Four electronic databases were searched from 1966 to 1996. Of 153, we selected 39 prospective studies from US hospitals. Data extracted independently by 2 investigators were analyzed by a random-effects model. To obtain the overall incidence of ADRs in hospitalized patients, we combined the incidence of ADRs occurring while in the hospital plus the incidence of ADRs causing admission to hospital. We excluded errors in drug administration, noncompliance, overdose, drug abuse, therapeutic failures, and possible ADRs. Serious ADRs were defined as those that required hospitalization, were permanently disabling, or resulted in death. The overall incidence of serious ADRs was 6.7% (95% confidence interval [CI], 5.2%-8.2%) and of fatal ADRs was 0.32% (95% CI, 0.23%-0.41%) of hospitalized patients. We estimated that in 1994 overall 2216000 (1721000-2711000) hospitalized patients had serious ADRs and 106000 (76000-137000) had fatal ADRs, making these reactions between the fourth and sixth leading cause of death. The incidence of serious and fatal ADRs in US hospitals was found to be extremely high. While our results must be viewed with circumspection because of heterogeneity among studies and small biases in the samples, these data nevertheless suggest that ADRs represent an important clinical issue.

Iatrogenic magnesium overdose: Two case reports

We report two cases of iatrogenic intravenous magnesium overdose. Both patients presented to the emergency department in alcohol withdrawal, and during the course of their therapy were ordered to receive 2 g of magnesium sulfate intravenously. The patients were erroneously given 20 g of magnesium sulfate, causing cardiac arrest in both cases. The patients were both successfully resuscitated. One patient was discharged neurologically intact and the other died three days later. Review of the literature identified one previous report of iatrogenic overdose of intravenous magnesium causing death. Hypermagnesemia is a rare occurrence, particularly in the absence of renal failure. The cause is often iatrogenic. The major life-threatening clinical manifestations are cardiac conduction delays, asystole, apnea, and coma. A particular hazard of intravenous magnesium therapy is the variety of units of measurement used in written orders and on drug labels. This can easily lead to errors in drug administration.

Medication errors during hospital drug rounds.

Objective--To determine the nature and rate of drug administration errors in one National Health Service hospital. Design--Covert observational survey be tween January and April 1993 of drug rounds with intervention to stop drug administration errors reaching the patient. Setting--Two medical, two surgical, and two medicine for the elderly wards in a former district general hospital, now a NHS trust hospital. Subjects--37 Nurses performing routine single nurse drug rounds. Main measures--Drug administration errors recorded by trained observers. Results--Seventy four drug rounds were observed in which 115 errors occurred during 3312 drug administrations. The overall error rate was 3.5% (95% confidence interval 2.9% to 4.1%). Errors owing to omissions, because the drug had not been supplied or located or the prescription had not been seen, accounted for most (68%, 78) of the errors. Wrong doses accounted for 15% (17) errors, four of which were greater than the prescribed dose. The dose was given within two hours of the time indicated by the prescriber in 98.2% of cases. Conclusion--The observed rate of drug administration errors is too high. It might be reduced by a multidisciplinary review of practices in prescribing, supply, and administration of drugs.

■Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital

Articles

Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital.

Drug administration is one of the highest risk areas of nursing practice and a matter of considerable concern for both managers and practitioners. The aim of this study, carried out in a district general hospital, was to identify any common themes that underlie the occurrence and reporting of drug administration errors. Data were collected from a variety of sources: drug error reports, questionnaires to nurses and nurse managers, and interviews with nurses who had been involved in drug errors. Several areas of particular concern emerged, including: the nurses' confusion regarding the definition of drug errors and the appropriate actions to take when they occurred; their fear of disciplinary action; their loss of clinical confidence; the variation in managerial response; and a possible lack of nurses' mathematical skills. The results from the study demonstrated that it was likely that many drug errors were not reported, for a variety of reasons. It is recommended that all of these issues are addressed as a matter of urgency, for the sake of both patients and nurse practitioners.

Drug error detectives

Hazel InksterandSepe Sehatireport how they have managed to cut ward drug-administration errors by tracking patterns of mistakes with the help of a computer system

Errors in administration of intravenous drugs

EDITOR,—An audit to identify the type, rate, and potential severity of errors associated with medical and nursing staff administering intravenous drugs was carried out at the Royal Belfast Hospital for Sick Children over a four week period. The disguised observation technique was used, whereby the observer accompanied the person involved in preparing and giving each dose.1 The errors were classified as incorrect administration rate and time (>30 minutes from the prescribed time) and as incorrect diluent or volume, …

Errors in drug administration by nurses

Errors in drug administration by nurses

Professional updating through open learning as a method of reducing errors in the administration of medicines.

Errors in administration of medicines can have repercussions for the patient, the nurse and the organization. Reducing the incidence of drug administration errors must be a constant endeavour on the part of nurses and the organization as a whole. The organization can be proactive in providing support for the nurse before errors occur through refresher courses, however, the cost-effectiveness of such courses should be considered. Traditional teacher-centred approaches may not encourage nurses to reflect upon their own practice, and may only entail attendance rather than participation at a study session. An approach to drugs administration update is proposed which employs an open learning format. Consideration of the mechanisms for preparing, disseminating and evaluating such programmes are provided. Quantitative data to support positive evaluation of the update programme is not yet available. Qualitative evaluation by staff who have undertaken the module is very favourable. Staff have indicated that they have been enabled to reflect on their own performance, at their own pace, and that they have enjoyed active participation in the learning process. The possible future, and potential benefits, of such programmes in a time of scarce resources is discussed.

Complications of Acute Pain Management

Summary Acute pain management is rapidly evolving to become a challenging and gratifying subspecialty of anesthesiology that allows the anesthesiologist to extend his or her skills beyond the confines of the operating room. But our enthusiasm must be tempered by caution. Do the benefits outweigh the costs? There is still only preliminary evidence that improved analgesia has a salutary effect on outcome. However, as pain management becomes more complex, so too does the management and prevention of side effects, errors, and accidents. Problems common to opioid use by all routes of administration include nausea and vomiting, pruritus, and urinary retention; they are rarely dangerous but often distressing to the patient. Much more serious is the potential problem of respiratory depression. The overall incidence of dangerous respiratory depression is approximately 1%, regardless of route of administration, although patients who receive thoracic epidural opioids may be at increased risk. Other important factors include the general health of the patient, the dose administered, and in the case of spinal opioids, the concomitant administration of parenteral opioids. Errors in drug administration still account for many of the serious problems encountered with PCA and spinal opioid administration. With PCA, common errors include improper set up of the syringe and tubing and errors in programming. Fortunately, serious technical problems with PCA devices are rare. With epidural opioids errors include administration of the wrong dose or the wrong drug. The first line of defense against serious complications is to provide the necessary education and to develop the necessary policies and procedures that will permit nurses and physicians to safely care for these patients. Strategies directed at reducing or eliminating opioid administration are of secondary importance but are potentially exciting developments. Over the last four decades anesthesiology has progressed and matured to the point where it is difficult for the careful and prudent anesthesiologist to further improve surgical outcome by changes in the intraoperative management of anesthesia. The acute pain management service takes us beyond the operating room and provides us with a new and exciting opportunity to further improve patient care. The challenge is to ensure that the good we do outweighs the harm.

Paediatric drug therapy. II--Drug administration errors.

The incidence of drug administration errors was prospectively evaluated from 1098 drug administrations in 97 paediatric patients. The total incidence of errors was 12.9% in a previous study. An educational programme (lectures and a book on guidelines for drug administration) was offered to nurses in an attempt to decrease this error rate. In this follow-up study, the total incidence of errors declined from 12.9% to 5.1% (P less than 0.05). All types of drug administration errors decreased during this follow-up study. These results suggest that such efforts can maximize therapeutic benefit and minimize any potential adverse consequences of drug therapy in paediatric patients.

An analysis of critical incidents in a teaching department for quality assurance. A survey of mishaps during anaesthesia.

A prospective survey was conducted from April 1984-January 1985 and April 1985-January 1986 to study the frequency of critical incidents and factors associated with them. Eighty-six mishaps were reported in the first period, the majority of which were because of human error (80.3%); the most common were the transmission of gases and vapours and errors in drug administration. Factors frequently associated with these mishaps were failure to perform a normal check and lack of familiarity with equipment or technique. An anaesthesia equipment checklist was incorporated in the survey during the second period and 43 mishaps were reported. This decrease in incidence may have resulted from the anaesthesia apparatus checklist, awareness of mishaps since they were discussed regularly at departmental meetings, and new anaesthesia machines (eight older machines were replaced during the first period and 11 at the beginning of the second).

Drug Errors

To the Editor.— Excellent recommendations to avoid error in drug dosage and administration were made by Koren et al1 and in the "Letters to the Editor" correspondence between him and Dr Lamont.2 However, I believe two statements require further clarification. Dr Lamont's PEDICard gives an energy dose of 1 to 3 joules/kg for cardioversion. Cardioversion is the timed depolarization of myocardial cells used to restore a stable rhythm and must be synchronized with the QRS complex(es).

Errors in Drug Administration

To the Editor.— I read with interest the article by Koren et al, "Tenfold Errors in Administration of Drug Doses: A Neglected Iatrogenic Disease in Pediatrics" (Pediatrics 1986;77:848-849). Errors such as those described by the author are perhaps most likely to occur during an emergency resuscitation situation. Several factors contribute to this increased likelihood. (1) emotional stress of the situation, (2) the urgency of need for the medications, leading to excessive haste in their preparation for administration and at the same time a decrease in the likelihood that the dose will be double checked before administration, and (3) the relative lack of familiarity of the members of the resuscitating team with the medications being used.

Errors in Drug Administration

In Reply.— Although the ban of decimal points may resolve some confusion, it probably would not prevent mathematical incompetence of medical personnel which is a common and serious problem. The statement that tenfold errors in drug doses do not occur when the decimal point is banned has to be proven. Before I started studying the tenfold errors problem, I did not imagine how common and multifactorial it is. I believe that, if Dr Bury continuously and closely studies the problem in his hospital, he is likely to identify it.

Errors in Drug Administration

To the Editor.— Koren et al (Pediatrics 1986;77:848-849) report recommendations to avoid administration of incorrect drug doses. I must confess surprise, in view of the fact that tenfold errors seem to be the most common ones made, to find no recommendation to ban the decimal point. This is common practice in the hospital in which I work. If any decimal point has to be used, then that particular drug dose is written in long hand, eg, one point five mgs.