Medicine Administration Errors Research Articles

Oral medicine administration errors in a patient with an enteral feeding tube

Proper nutrition is vital for all patients with an expected lifespan. It is strongly recommended that patients whose oral intake is impaired or suspected to be impaired should be provided nutritional support. Concurrent medication administration during enteral nutrition may result in complications unless necessary precautions are taken. This study presents a case of a 94-year-old male patient with poor general health condition and being treated in a palliative care service. The patient was fed with an enteral feeding tube for seven drugs. There have been two tube occlusions causing the replacement of the tube since the enteral feeding tube was placed.The clinical pharmacist checked how the patient’s drugs were given through a nasogastric tube and how the patient’s relatives administered the drugs. Inappropriate dosage form selections and errors in administration through the nasogastric tube were identified. The interaction and incompatibility of the patient’s medications with the nutritional formula were also investigated. The clinical pharmacist informed the person giving the medicine to the patient about the correct administration of the medicine from the tube. The proper method for administering medications from the tube was ensured accordingly. Following the clinical pharmacist’s training, it was observed that the nasogastric tube was correctly used to administer the drug and the patient being monitored had no tube obstruction in the later phases of the treatment.It may be beneficial for a pharmacist to review drug dosage forms and applications in patients with a feeding tube in order to ensure correct administration and avoid undesired drug interactions.

Costs and Cost-Effectiveness of User-Testing of Health Professionals' Guidelines to Reduce the Frequency of Intravenous Medicines Administration Errors by Nurses in the United Kingdom: A Probabilistic Model Based on Voriconazole Administration.

AimIn the UK, injectable medicines are often prepared and administered by nurses following the Injectable Medicines Guide (IMG). Our earlier study confirmed a higher frequency of correct administration with user-tested versus standard IMG guidelines. This current study aimed to model the cost-effectiveness of user-testing.MethodsThe costs and cost-effectiveness of user-testing were explored by modifying an existing probabilistic decision-analytic model. The adapted model considered administration of intravenous voriconazole to hospital inpatients by nurses. It included 11 error types, their probability of detection and level of harm. Model inputs (including costs) were derived from our previous study and other published data. Monte Carlo simulation using 20,000 samples (sufficient for convergence) was performed with a 5-year time horizon from the perspective of the 121 NHS trusts and health boards that use the IMG. Sensitivity analyses were undertaken for the risk of a medication error and other sources of uncertainty.ResultsThe net monetary benefit at £20,000/quality-adjusted life year was £3,190,064 (95% credible interval (CrI): −346,709 to 8,480,665), favouring user-testing with a 96% chance of cost-effectiveness. Incremental cost-savings were £240,943 (95% CrI 43,527–491,576), also favouring user-tested guidelines with a 99% chance of cost-saving. The total user testing cost was £6317 (95% CrI 6012–6627). These findings were robust to assumptions about a range of input parameters, but greater uncertainty was seen with a lower medication error risk.ConclusionsUser-testing of injectable medicines guidelines is a low-cost intervention that is highly likely to be cost-effective, especially for high-risk medicines.

Medicine Administration in People with Parkinson's Disease in New Zealand: An Interprofessional, Stakeholder-Driven Online Survey.

Medicine administration errors are twice as frequent in people with dysphagia than in those without. Medicine administration is particularly critical for people with Parkinson's disease where late, or missed doses reduce medicine effectiveness and impact on the quality of life. The aim of this study was to explore the current medicine administration practices of people with Parkinson's disease in New Zealand. A self-administered online survey was developed by an interprofessional group including people with Parkinson's disease (the primary stakeholders), speech-language pathologists and pharmacists. The survey was administered using a cross-sectional study design and asked respondents about self-reported swallowing difficulties [using Eating Assessment Tool (EAT-10)], medicine regimes and strategies used to swallow medicines. Seventy-one people with Parkinson's disease responded to the survey (69% male, mean age 72years, mean years with Parkinson's disease 9years). Respondents reported complex daily multi-medicine consumption (mean no. of pills 11, range 2-25). Analyses showed that 57% of respondents scored outside the normal range for EAT-10 (> 3) with 57% complaining of difficulties with pills. Many respondents admitted to missing medicines and requiring external reminders. Multiple strategies for swallowing pills were described including crushing tablets, using yoghurt or fruit juice, and swallowing strategies (such as head tilt, effortful swallow, chin down and altered pill placement in the mouth). Medicine administration is complex and challenging for people with Parkinson's disease. The development of educational packages for people with Parkinson's disease, their carers and health professionals is much needed.

The Impact of Information and Communication Technology (ICT) on Community Pharmacy

Information and communication technologies (ICTs) are transforming health services throughout the world. Health information and technologies (HITs) involve application of information processing using computer for storage, retrieval, sharing and use of information and knowledge for communication by a pharmacist. Similarly electronic prescription (EP) services have made the dispensing and reimbursement processes more efficient. Maintenance of patient record become easy by using ICTs. Barcode identification of medicines can be used to reduce medicine administration errors and to improve the medication history of patients. Telecare using digital communications technology provides healthcare consultations and other health care services to rural, old & handicap patients easily and improves their access to healthcare by reducing their hospital attendance. In developing countries like India, it is quite a challenging task to provide access to information and communication technologies. As the geographical diversity is also a challenging for implementation of ICTs at everywhere. Information and technologies are giving a way to access the data all over the globe. ICTs have brought transformation in education in all over the world. Information and technologies are removing barriers from learning education. ICT applications are becoming indispensable tools for traditional and vocational education. In the field of pharmaceutical sciences, ICTs can further enhance the quality of education. As lots of modifications and newer drugs are coming in the market, it is quite a challenging task to a pharmacist to update knowledge to serve the society in an efficient way. ICT can be utilized in health care to improve quality of patient centric services.

Challenges faced by the visually disabled in use of medication, consequences of medication errors and their self-adopted coping strategies at a tertiary care hospital in Goa, India

Background: Visual impairment (VI) does limit individual’s ability to complete everyday tasks and impact their quality of life and ability to interact with their environment. The objectives of this study are to determine challenges faced by people with Visually Disability, medicine administration errors and self-adopted coping strategies.Methods: An observational case series study design was used for the data collection. The data was collected from January-June 2014. The study participants were included all patients more than 18 years who were certified as visually handicap.Results: The major challenges faced by total 146 visually disabled patients studied were, 51.36% couldn’t locate the place of medication and 45.89% couldn’t identify the separate containers of medications. The major Medications errors included of 30.13% study participants had missed doses and spilled medications. The most commonly used coping measures were keeping medications at specific places, identifying separate drugs by feeling the shape of the container.Conclusions: The challenges included, inability to locate the place of medication, inability to identify the separate containers of medications, unaware of correct dose, inability to maintain dose schedule and difficulty in using liquid medications. Medication errors included, missing doses, spillage of medications, consumption of wrong medication, wrong dosage, inability to complete course of prescribed medications. The coping strategies adopted included, keeping medications at specific places, identifying separate drugs by feeling the shape of the container, tracking the time of routine medications with the timings of the TV serials/shows.

Pattern of medication errors among inpatients in a resource-limited hospital setting

Purpose of the studyThere are limited studies on medication errors in South Asian and South East Asian regions. To bridge this gap, we assessed prescribing errors and selected medicine administration...

Compliance aids reduce medicine administration errors in care homes

Compliance aids reduce medicine administration errors in care homes

CP-150 Implementation of an integrated multifaceted approach to improve crushing practice on hospital wards

BackgroundCrushing tablets is an important risk factor for medicines administration errors in patients with swallowing problems and feeding tubes. Information regarding patients requiring crushed medicines does not routinely reach the...

Blame medication errors on the system, not the individual

I agree with Kerri Wright (Art & Science July 3) that nurses receive a disproportionate blame for medication errors. I congratulate her for asserting the influence of context and environment in medicine administration errors.

The role of nurses in medicine administration errors

This article explores the commonly held belief that nurses are to blame for the high rate of medication administration errors in health care. The article argues for a need to move away from a culture of blame and to consider changes to medicine and the increasing complexity of administration as potential reasons for error. Medicine administration should be viewed within the wider context of health care rather than as an isolated process in order to develop effective solutions to reduce medicine-related errors.

TCH-047 The Effect of a Robotic Unit Dose Drug Dispensing System on Medicines Administration Errors and the Cost of Drug Dispensing

BackgroundA Unit Dose Drug Dispensing System (UDDDS) by a robot (PillPick system, Swisslog) with daily pharmaceutical monitoring of medical prescriptions is being implemented in our hospital, to gradually replace the...

GRP-183 The Effect of a Clinical Pharmacist-Led Training Programme on Intravenous Preparation and Administration Errors in a Vietnamese Hospital

BackgroundMedication safety has been a concern for decades worldwide, but there is still relatively little research about interventions to reduce medicines administration errors in hospitals, especially in resource-restricted settings such...

GRP-057 Errors in Medicines Preparation and Administration in Vietnamese Hospitals

BackgroundErrors in the medication use process are common. Little is known about preparation and administration errors in resource-restricted settings, including Vietnam.Purpose To determine the frequency, type and severity of medicines...

Do patient bedside medicine lockers result in a safer and faster medicine administration round?

ObjectiveTo determine if the introduction of patient bedside medicine lockers leads to a safer and faster medicine administration round.MethodsThe undisguised observer technique was utilised to observe the medicine administration round...

Mentoring students in medicines management

Medicines management is an important part of the nurse's role. It covers elements such as cost-effectiveness, patient advice, infection control, optimising benefits from medicines, emerging technological developments, and drug administration and storage. The aim of this article is to enable mentors to support pre-registration nursing students to develop specific proficiencies in medicines management. The focus will be on applying pharmacological knowledge to practice, communicating patient information and avoiding medicine administration errors.

Recording medicines administration errors before introducing new technology

BackgroundDrug administration is one of the most important stages in the medication process. New technologies are being developed to improve patient safety. The majority of studies focus on administration errors,...

Medicine administration errors and their severity in secondary care older persons’ ward: a multi‐centre observational study

To assess the severity of medicine administration errors to older patients. Severity of medicine administration errors has been determined in a variety of settings but not in care-of-older-person wards, which this study aims to do. Undisguised observational study. Sixty-two nurses were observed administering oral medicines to 625 patients. Data were collected on the preparation and administration of oral medicines. Thirty-five cases of error were selected and analysed for their severity. In the 65 drug rounds observed 2129 potential drug administrations were made to 625 patients, of which 817 doses (38.4%) were given incorrectly (95% CI = 36.3-40.4). The overall mean harm score of the 35 incidents analysed was 4.1 (range 1.1-8.6, SD 1.8) on a scale of 0-10. The number and severity of MAEs observed is high compared with previous studies. There is a need to decrease the number and severity of MAEs, by increasing nurse awareness and error reporting.

Medicine administration errors in patients with dysphagia in secondary care: a multi-centre observational study

The aim of this study was to describe the interventions used by nurses when administering oral medicines to patients with and without dysphagia, to quantify the appropriateness of these interventions and the medicine administration error rate. The administration of medicines to patients with dysphagia is complex and potentially more error prone because of the need to match the medication's formulation to the swallowing ability of the patient. Data was collected on the preparation and administration of oral medicines to patients with and without dysphagia, including those with enteral feeding tubes, using undisguised direct observation of 65 nurse-led medicine administration rounds on stroke and care-of-the-elderly wards at four acute general hospitals in East of England between 1 March and 30 June 2008. Of the 2129 medicine administrations observed, 817 involved an error, and of these 313 involved patients with dysphagia. Excluding time errors, the normalized frequency of medicine administration errors for patients with dysphagia was 21.1% compared with 5.9% for patients without. Using a mixed effects model and excluding time errors, there is a higher risk of errors for patients with dysphagia (excluding patients with enteral tubes) compared with those without (P < 0.001) and a further increase in risk of error for patients with enteral tubes compared with dysphagic patients without tubes (P < 0.001). The increased medicine administration error rate in patients with dysphagia requires healthcare professionals to take extra care when prescribing, dispensing and administering medicines to this group.