Wrong Route Errors Research Articles

ISMP cautions against injection and wrong-route errors

ISMP cautions against injection and wrong-route errors

Safer Enteral Syringes

A common example of wrong route errors is when parenteral syringes are used to draw up medications that are then inadvertently administered into an intravenous line rather than an enteral feeding tube. With the transition to safer enteral syringes with ENFit connectors in the United States, it is critical that nurses use the correct enteral syringes to prepare and administer medications. These wrong route errors are still happening and the need to move to the safer connectors and use them appropriately is vital.

Beware of wrong route errors with bupivacaine liposome

Beware of wrong route errors with bupivacaine liposome

Medication administration errors and related deviations from safe practice: an observational study.

To determine the incidence of medication administration errors, medication administration-related deviations from safe practice as well as factors associated with these errors in medical and surgical units of public hospitals in the Gauteng Province of South Africa. Several studies have been published on the incidence of medication administration errors, but only a few have studied the incidence of medication administration-related deviations from safe practice. Context-specific research on the incidence of medication administration errors and associated factors (patient acuity, bed occupancy, staffing levels, medication administrators' qualifications, dose calculation skills, level of hospital, unit type, medication administration route and interruptions) within the continent of Africa is lacking. A cross-sectional, observational design. Direct observation was conducted incorporating a previously validated checklist based on basic medication guidelines including the five rights, asepsis and medication documentation. In addition, a knowledge test on dose calculations was performed. Medication administration to 315 patients (1847 medications administered) was observed between February-August 2015 in medical and surgical units from eight public hospitals. Twenty-five medication administrators completed dose calculations. In total, 296 medication errors were identified, of which most were wrong-time errors and omissions. Interruptions and patient acuity were significantly associated with wrong-dose and wrong-route errors, respectively. Most medication administration-related deviations from safe practice were related to patient identification or asepsis. Sixteen of 50 dosage calculations were answered incorrectly. Incorrect answers most often occurred in the calculation of parenteral dosages. Medication administration errors, especially wrong-time errors and omissions, are prevalent in public hospitals in the Gauteng Province. Interruptions lower the risk of wrong-dose errors, while patient acuity exacerbates this risk. Factors associated with wrong-time errors and omissions should be addressed. Patient identification and asepsis protocols should be adhered to. Dosage calculation training is indicated.

The Effects of Bar-coding Technology on Medication Errors: A Systematic Literature Review.

The bar-coding technology adoptions have risen drastically in U.S. health systems in the past decade. However, few studies have addressed the impact of bar-coding technology with strong prospective methodologies and the research, which has been conducted from both in-pharmacy and bedside implementations. This systematic literature review is to examine the effectiveness of bar-coding technology on preventing medication errors and what types of medication errors may be prevented in the hospital setting. A systematic search of databases was performed from 1998 to December 2016. Studies measuring the effect of bar-coding technology on medication errors were included in a full-text review. Studies with the outcomes other than medication errors such as efficiency or workarounds were excluded. The outcomes were measured and findings were summarized for each retained study. A total of 2603 articles were initially identified and 10 studies, which used prospective before-and-after study design, were fully reviewed in this article. Of the 10 included studies, 9 took place in the United States, whereas the remaining was conducted in the United Kingdom. One research article focused on bar-coding implementation in a pharmacy setting, whereas the other 9 focused on bar coding within patient care areas. All 10 studies showed overall positive effects associated with bar-coding implementation. The results of this review show that bar-coding technology may reduce medication errors in hospital settings, particularly on preventing targeted wrong dose, wrong drug, wrong patient, unauthorized drug, and wrong route errors.

Non‐Luer connectors: are we nearly there yet?

The Department of Health aims to eliminate the use of devices with a Luer connector firstly from 'single shot' neuraxial procedures (April 2012) and subsequently from all neuraxial and regional anaesthesia procedures (April 2013). This initiative is important for all anaesthetists, oncologists, paediatricians and neurologists. Once achieved, non-Luer connectors for neuraxial procedures will create one more barrier to wrong-route errors. The period until full implementation and market stability remains problematic. Avoidance of unintended consequences requires professional and individual attention to detail. Considerable progress has been made by manufacturers in the last year in improving the quality and range of equipment available, but despite this not all the necessary equipment is available and there remains a lack of independent evaluation, which is urgently needed to enable clinicians to judge the absolute and relative performance of different connectors. Initial evaluation of devices with new connectors can (and should) take place in a laboratory with rigs and manikins, with patient-based evaluation following after the results of the technical and usability evaluations are available. A structured evaluation of all five current connectors is urgently needed. Non-Luer connectors, however successful, will not create barriers to several type of wrong-route error and solutions to these should also be actively sought. It is clear that the initiative has been more complex than the Health Select Committee, the National Patient Safety Agency and the External Reference Group anticipated, but while there is still much work to be done, we should acknowledge that much progress has been made.

Reducing the risk of wrong route errors by using oral liquid dispensers

Reducing the risk of wrong route errors by using oral liquid dispensers

Prevention of wrong route errors in a pediatric hemato-oncology ward

Three consecutive wrong route administration errors are described in detail and the ease by which enteral preparations can be given by the wrong route is discussed. By introducing the use of purple oral liquid dispensers in our pediatric department, we hope to prevent and reduce the risk of similar medications errors in the future and to improve patients safety.

Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists

Serious complications of central neuraxial block (CNB) are rare. Limited information on their incidence and impact impedes clinical decision-making and patient consent. The Royal College of Anaesthetists Third National Audit Project was designed to inform this situation. A 2 week national census estimated the number of CNB procedures performed annually in the UK National Health Service. All major complications of CNBs performed over 1 yr (vertebral canal abscess or haematoma, meningitis, nerve injury, spinal cord ischaemia, fatal cardiovascular collapse, and wrong route errors) were reported. Each case was reviewed by an expert panel to assess causation, severity, and outcome. 'Permanent' injury was defined as symptoms persisting for more than 6 months. Efforts were made to validate denominator (procedures performed) and numerator (complications) data through national databases. The census phase produced a denominator of 707,455 CNB. Eighty-four major complications were reported, of which 52 met the inclusion criteria at the time they were reported. Data were interpreted 'pessimistically' and 'optimistically'. 'Pessimistically' there were 30 permanent injuries and 'optimistically' 14. The incidence of permanent injury due to CNB (expressed per 100,000 cases) was 'pessimistically' 4.2 (95% confidence interval 2.9-6.1) and 'optimistically' 2.0 (1.1-3.3). 'Pessimistically' there were 13 deaths or paraplegias, 'optimistically' five. The incidence of paraplegia or death was 'pessimistically' 1.8 per 100,000 (1.0-3.1) and 'optimistically' 0.7 (0-1.6). Two-thirds of initially disabling injuries resolved fully. The data are reassuring and suggest that CNB has a low incidence of major complications, many of which resolve within 6 months.

Medication errors with opioids: Results from a national reporting system

Background: Errors may be more common and more likely to be harmful with opioids than with other medications, but little research has been conducted on these errors. Methods: The authors retrospectively analyzed MEDMARX®, an anonymous national medication error reporting database, and quantitatively described harmful opioid errors on inpatient units that did not involve devices such as patient-controlled analgesia. The authors compared patterns among opioids and qualitatively analyzed error descriptions to help explain the quantitative results. Results: The authors included 644 harmful errors from 222 facilities. Eighty-three percent caused only temporary harm; 60 percent were administration errors and 21 percent prescribing errors; and 23 percent caused underdosing and 52 percent overdosing. Morphine and hydromorphone had a significantly higher proportion of improper dose errors than other opioids (40 percent and 41 percent compared with 22 percent with meperidine). Hydromorphone errors were significantly more likely to be overdoses (78 percent vs 47 percent with other opioids). Omission errors were significantly more common with fentanyl patches (36 percent compared with 12 percent for other opioids). Wrong route errors were significantly more common with meperidine (given intravenously when prescribed as intramuscular, 34 percent vs 3 percent for morphine). Oxycodone errors were significantly more likely to be wrong drug errors (24 percent vs 11 percent for other opioids), often because of confusion between immediate- and sustained-release formulations. Conclusions: Reported opioid errors are usually associated with administration and prescribing and frequently cause uncontrolled pain as well as overdoses. These patterns of errors should be considered when using opioids and incorporated into pain guidelines, education, and quality improvement programs.

Reducing the risk of wrong route errors

Infants in the neonatal intensive care unit are at particular risk from clinical errors because of their fragility and vulnerability, as well as the complex nature of medication and other treatment regimes. Wrong route errors have been well documented, particularly related to enteral nutrition and medication. Published guidance for preventing such errors should inform changes in practice at the local level. In 2005, the Regional Neonatal Intensive Care Unit at the University Hospital of Wales Cardiff undertook a change in clinical practice to improve standards of care for all babies requiring enteral nutrition and medication, thus reducing the risk of a wrong route error. A routine revision of departmental policy resulted in a review of available evidence to inform the practice changes. Colour-coded enteral/oral syringes with a new style nasogastric tube were introduced. By promoting best practice through networking with other colleagues, staff have worked towards standardising the delivery of care in order to minimise the risk wrong route errors.

Medication errors with opioids: Results from a national reporting system

Errors may be more common and more likely to be harmful with opioids than with other medications, but little research has been conducted on these errors. The authors retrospectively analyzed MEDMARX, an anonymous national medication error reporting database, and quantitatively described harmful opioid errors on inpatient units that did not involve devices such as patient-controlled analgesia. The authors compared patterns among opioids and qualitatively analyzed error descriptions to help explain the quantitative results. The authors included 644 harmful errors from 222 facilities. Eighty-three percent caused only temporary harm; 60 percent were administration errors and 21 percent prescribing errors; and 23 percent caused underdosing and 52 percent overdosing. Morphine and hydromorphone had a significantly higher proportion of improper dose errors than other opioids (40 percent and 41 percent compared with 22 percent with meperidine). Hydromorp hone errors were significantly more likely to be overdoses (78 percent vs 47 percent with other opioids). Omission errors were significantly more common with fentanyl patches (36 percent compared with 12 percent for other opioids). Wrong route errors were significantly more common with meperidine (given intravenously when prescribed as intramuscular, 34 percent vs 3 percent for morphine). Oxycodone errors were significantly more likely to be wrong drug errors (24 percent vs. 11 percent for other opioids), often because of confusion between immediate- and sustained-release formulations. Reported opioid errors are usually associated with administration and prescribing and frequently cause uncontrolled pain as well as overdoses. These patterns of errors should be considered when using opioids and incorporated into pain guidelines, education, and quality improvement programs.

Paramedic Self-Reported Medication Errors

Background. Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, andtreatment. Methods. A survey was given to paramedics in San Diego County. The survey tool was established on the basis of previous literature reviews andquestions developed with previous CQI data. Results. A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average of 25.4 hours and6.7 calls/shift. Thirty-two (9.1%) responding paramedics reported committing a medication error in the last 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), andwrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, andincorrect dosage given. Fatigue, training, andequipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% being reported by the base hospital radio nurse, 8.3% found upon chart review, and4.2% noted by paramedic during call but never reported. Conclusions. Nine percent of paramedics responding to an anonymous survey report medication errors in the last 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.

Paramedic Self-Reported Medication Errors

Background. Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, andtreatment. Methods. A survey was given to paramedics in San Diego County. The survey tool was established based on previous literature reviews andquestions developed based on previous CQI data. Results. A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average shift length of 25.4 hours and6.7 calls/shift. Thirty-two responding paramedics (9.1%) reported committing a medication error in the past 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), andwrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, andincorrect dosage given. Fatigue, training, andequipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% reported by the base hospital radio nurse, 8.3% found on chart review, and4.2% noted by the paramedic during the call but never reported. Conclusions. Nine percent of paramedics responding to an anonymous survey reported medication errors in the past 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.

Medication errors: causes, prevention and reduction.

Medication errors: causes, prevention and reduction.