1111: Medication Errors at Transitions of Care for Intensive Care Unit Patients

Abstract Background Medication Errors (MEs) are considered the most common type of error in pediatric critical care services. Moreover, the ME rate in pediatric patients is up to three times higher than the rate for adults. Nevertheless, information in pediatric population is still limited, particularly in emergency/critical care practice. The purpose of this study was to describe and analyze MEs in the pediatric critical care services during the prescription stage in a Mexican secondary-tertiary level public hospital. Methods A cross-sectional study to detect MEs was performed in all pediatric critical care services [pediatric emergency care (PEC), pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and neonatal intermediate care unit (NIMCU)] of a public teaching hospital. A pharmacist identified MEs by direct observation as the error detection method and MEs were classified according to the updated classification for medication errors by the Ruíz-Jarabo 2000 working group. Thereafter, these were subclassified in clinically relevant MEs. Results In 2347 prescriptions from 301 patients from all critical care services, a total of 1252 potential MEs (72%) were identified, and of these 379 were considered as clinically relevant due to their potential harm. The area with the highest number of MEs was PICU (n = 867). The ME rate was > 50% in all pediatric critical care services and PICU had the highest ME/patient index (13.1). The most frequent MEs were use of abbreviations (50.9%) and wrong speed rate of administration (11.4%), and only 11.7% of the total drugs were considered as ideal medication orders. Conclusion Clinically relevant medication errors can range from mild skin reactions to severe conditions that place the patient’s life at risk. The role of pharmacists through the detection and timely intervention during the prescription and other stages of the medication use process can improve drug safety in pediatric critical care services.

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Pharmacy Personnel’s Involvement in Transitions of Care of Intensive Care Unit Patients: A Systematic Review

Journal of Pharmacy Practice ◽

10.1177/0897190020911524 ◽

2020 ◽

pp. 089719002091152

Author(s):

Mikhaila Rice ◽

Alyssa Lear ◽

Sandra Kane-Gill ◽

Amy L. Seybert ◽

Pamela L. Smithburger

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medication Safety ◽

English Language ◽

Health Care Team ◽

Error Rates ◽

Transitions Of Care ◽

Patient Centered ◽

Safety Measures ◽

Team Members

Objective: Do pharmacy personnel- (ie, pharmacist or pharmacy technician) driven interventions at transitions of care into or out of the intensive care unit (ICU) improve medication safety measures compared to interventions made by other health-care team members or no intervention? Data Sources: A literature search of MEDLINE and Embase limited to English language and humans was performed (from 1969 until January 2019). Bibliographies of included investigations were reviewed for additional citations. Methods: Investigations were selected if they described a pharmacy-driven intervention at any point of transfer into or out of an ICU setting. Ten investigations were included. Five described interventions relevant to the entire ICU population, and 5 described interventions targeted to specific medications or disease. Results: A variety of interventions were utilized in the 10 included investigations. A significant improvement was demonstrated with pharmacy-driven intervention in all 4 studies that evaluated the entire ICU patient population. Interventions specific to certain medication and disease improved medication safety measures but were not always statistically significant. Medication error rates are high in patients transferred into and out of the ICU, and limited data exist to address this concern. This review compares and evaluates the current literature to guide future interventions and research in this area. Conclusions: Although pharmacy-driven interventions demonstrated some benefit in various medication safety measures in the majority of studies, additional randomized and prospective trials with patient-centered outcomes that assess morbidity and mortality are needed.

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Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocx156 ◽

2018 ◽

Vol 25 (5) ◽

pp. 555-563 ◽

Cited By ~ 13

Author(s):

Yizhao Ni ◽

Todd Lingren ◽

Eric S Hall ◽

Matthew Leonard ◽

Kristin Melton ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Real Time ◽

Medication Errors ◽

Neonatal Intensive Care ◽

Current Practice ◽

Medication Administration ◽

Automated System ◽

Patient Exposure ◽

Potential Harm

Abstract Background Timely identification of medication administration errors (MAEs) promises great benefits for mitigating medication errors and associated harm. Despite previous efforts utilizing computerized methods to monitor medication errors, sustaining effective and accurate detection of MAEs remains challenging. In this study, we developed a real-time MAE detection system and evaluated its performance prior to system integration into institutional workflows. Methods Our prospective observational study included automated MAE detection of 10 high-risk medications and fluids for patients admitted to the neonatal intensive care unit at Cincinnati Children’s Hospital Medical Center during a 4-month period. The automated system extracted real-time medication use information from the institutional electronic health records and identified MAEs using logic-based rules and natural language processing techniques. The MAE summary was delivered via a real-time messaging platform to promote reduction of patient exposure to potential harm. System performance was validated using a physician-generated gold standard of MAE events, and results were compared with those of current practice (incident reporting and trigger tools). Results Physicians identified 116 MAEs from 10 104 medication administrations during the study period. Compared to current practice, the sensitivity with automated MAE detection was improved significantly from 4.3% to 85.3% (P = .009), with a positive predictive value of 78.0%. Furthermore, the system showed potential to reduce patient exposure to harm, from 256 min to 35 min (P < .001). Conclusions The automated system demonstrated improved capacity for identifying MAEs while guarding against alert fatigue. It also showed promise for reducing patient exposure to potential harm following MAE events.

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Reducing errors in the administration of medication with infusion pumps in the intensive care department: A lean approach

SAGE Open Medicine ◽

10.1177/2050312118822629 ◽

2019 ◽

Vol 7 ◽

pp. 205031211882262

Author(s):

Alexander F van der Sluijs ◽

Eline R van Slobbe-Bijlsma ◽

Astrid Goossens ◽

Alexander PJ Vlaar ◽

Dave A Dongelmans

Keyword(s):

Intensive Care Unit ◽

Patient Safety ◽

Intensive Care ◽

Confidence Interval ◽

Medication Errors ◽

Infusion Pump ◽

Baseline Measurement ◽

Infusion Pumps ◽

Improvement Measures ◽

The Impact

Background: Medication errors occur frequently and may potentially harm patients. Administering medication with infusion pumps carries specific risks, which lead to incidents that affect patient safety. Objective: Since previous attempts to reduce medication errors with infusion pumps failed in our intensive care unit, we chose the Lean approach to accomplish a 50% reduction of administration errors in 6 months. Besides improving quality of care and patient safety, we wanted to determine the effectiveness of Lean in healthcare. Methods: We conducted a before-and-after observational study. After baseline measurement, a value stream map (a detailed process description, used in Lean) was made to identify important underlying causes of medication errors. These causes were discussed with intensive care unit staff during frequent stand-up sessions, resulting in small improvement cycles and bottom-up defined improvement measures. Pre-intervention and post-intervention measurements were performed to determine the impact of the improvement measures. Infusion pump syringes and related administration errors were measured during unannounced sequential audits. Results: Including the baseline measurement, 1748 syringes were examined. The percentage of errors concerning the administration of medication by infusion pumps decreased from 17.7% (95% confidence interval, 13.7–22.4; 55 errors in 310 syringes) to 2.3% (95% confidence interval, 1–4.6; 7 errors in 307 syringes) in 18 months (p < 0.0001). Conclusion and Relevance: The Lean approach proved to be helpful in reducing errors in the administration of medication with infusion pumps in a high complex intensive care environment.

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