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Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings Best Practice: evidence-based information sheets for health professionals. 2010; 14(4):1-4
Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings
Recommendations
Individual or patient dose systems should be in place within the hospital, rather than stock based medication systems. (Grade B) Medication administration should take place as close to the patient as possible either from a trolley or bedside locker. (Grade B) Including the patient more fully in the medication administration process through self administration or involvement in the checking process has some potential for reducing errors. (Grade B) Reduction of medication administration errors may be achieved through a consideration of nurses' perceptions of external factors including structures that are in place for medication administration and the organisation of care within acute, hospital based settings. (Grade A) Reduction of medication errors may be achieved through a consideration of nurses' perceptions of internal factors including personal characteristics and relationships that exist around medication administration processes in acute hospital based settings. (Grade A) Patients should be encouraged and included in the medication administration process through verbal and non-verbal communication. Nurses should listen to patients concerns and also provide written information on the drug administration process and drugs being administered. (Grade B)
Information Source
This Best Practice information sheet has been derived from a systematic review published in 2010 in JBI Library of Systematic Reviews. The full text of the systematic review report2 is available from the Joanna Briggs Institute (www.joannabriggs.edu.au)
Background
Medication errors occur worldwide and in many health care settings. The number of such errors is, on the whole, unknown, as many incidents are never discovered, acknowledged or reported. It has been suggested that up to 10 times more errors are committed than reported.3 Levels of medication administration errors (MAEs) have been reported as accounting for 38% of all adverse drug events and have been calculated as occurring in 3-8% of all administrations.4,5 Unlike other errors that occur earlier in the medication chain, which are often intercepted, such as with prescribing, only 2% of administration errors are detected. The process for routine medication administration has a number of factors which have been identified as contributing to errors: mathematical skills, knowledge of medications, the quality of the prescription, length of experience, shift patterns, workload and staffing levels, medication delivery systems, single-nurse administration, policies and procedures and distractions and interruptions.6 Acute care hospital settings bring additional concerns for routine medication administration, particularly increasing pressures on staff, increasing number of drugs, polypharmacy, increasingly similar sounding drug names, increased throughput of patients, ranges of illnesses and treatments, a greater variety of administration routes and pressures of time to complete administration rounds.
Grades of Recommendation
These Grades of Recommendation have been based on the JBI-developed 2006 Grades of Effectiveness1 Grade A Strong support that merits application Grade B Moderate support that warrants consideration of application Grade C Not supported JBI Roles and systems for routine medication administration to JBI Roles and systems for routine medication administration to prevent prevent medication medication errors errors in in hospital-based hospital-based acute acute care care settings settings Best Practice 14(4) Best Practice 14(4) 2010 2010 || 1 1
Definition of terms
For the purposes of this information sheet the following definitions were used: Medication error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of health professional, patient or consumer.7 Routine medication administration is that which is normally carried out by nurses at specified time intervals in hospital wards and units.
Outcomes measures
Perceptions of medication administration error
Nurses perceptions of causes of medication administration error Quantitative evidence for nurses perceptions of medication administration errors
A large survey of nurses in the US sought to identify nurses perceptions of causes of medication administration error. The highest score was for interruptions to nurses while administering medications and prescriptions from medical staff not being clear or legible were 2nd and 3rd. Another study reported transcription errors (usually refers to the transfer of a prescription onto a medication administration record (MAR)) as perceived most highly in respect of errors (73.6% of respondents), followed by distractions (56.3%) and legibility (49.3%). The lowest three scored items were all related to the drugs or pharmacy incorrectly filled (10.4%), mislabelled (11.1%), or look alike medications (11.8%). Factors related to individual nurse factors such as miscalculations (34%) and failure to follow procedure/policy (17.4%) were midway in the level of responses.
External factors
External factors consisted of a variety of categories related to the: use of policies, protocols and guidance, context and organisation of care and roles of people within the system. Nurses viewed policy type guidance as being both valuable, for example when double checking picked up potential errors or unhelpful when it wasnt specific enough about particular medications. Perceptions are reported that interruptions to the medication round contributed to error, as did not being organised in planning work to ensure that interruptions were minimised. Teamwork between professionals was noted by nurses as adversely affecting the medication administration process. Communication channels between different professionals was often viewed as ineffective and could impact on medication errors. The role that prescribers (in this case medical staff) play was identified as influential, specifically the manner in which orders are written (particularly legibility) and changes communicated to nurses. Nurses also perceived that the patient/client should, where possible, have an active participatory role as this could reduce error rates. There was a perception that nurses perceived the monitoring and follow up process for errors as punitive and that managers often place staff in unsafe situations which may both inhibit reporting and increase the risks associated with medication errors.
Objectives
The purpose of this Best Practice Information Sheet is to present the best available evidence for roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings.
JBI Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings 2 | Best Practice 14(4) 2010
Internal factors
Internal factors consisted of: interpersonal skills and relationships, individual knowledge and skills, personal responsibility. One study reported how nurses saw themselves as responsible for medication errors and how the overlay of contextual factors such as night shifts increased this perception. Tiredness, stress, lack of confidence in challenging doctors, concentration, complacency and even the personality of the nurse could be considered internal factors. There was also a perception that having good interpersonal skills in nurses can impact on medication administration and this can influence teamwork with medical staff and pharmacists. This can also increase the support available for those who are inexperienced and who need a context that is supportive at the outset. Level of knowledge was also seen to be a factor that impacted on medication errors. The more knowledge the less likely errors would be made.
JBI Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings Best Practice 14(4) 2010 | 3
Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings
Acknowledgments
This Best Practice information sheet was developed by The Joanna Briggs Institute.
References
1. The Joanna Briggs Institute. Levels of Evidence and Grades of Recommendations. http://www. joannabriggs.edu.au/pubs/approach.php 2. Wimpenny P, Kirkpatrick P. Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings: a systematic review. JBI Library of Systematic Reviews 2010; 8(10):405-446. 3. Ludwig-Beymer P, Czurylo KT, Gattuso MC, Nennessy KA and Ryan CJ The effect of testing on the reported incidence of medication errors in a medical centre. The Journal of Continuing Education in Nursing 1990; 21(1): 11-17. 4. Leape LL, Bates DW, Cullen DJ Systems analysis of adverse drug events. JAMA 1995; 274; 35-43.
Yes
No
Use individual or patient systems for medication administration Consider nurses perceptions of structures and relationships around medication administration process
5. Barber N, Franklin BD, Cornford T, Klecun E and Savage I Safer, Faster, Better? Evaluating Electronic Prescribing. Report to the Patient Safety Research Programme. Department of Health, London, 2006. 6. OShea E. Factors contributing to medication errors: a literature review. Journal of Clinical Nursing 1999; 8(5): 496-504. 7. Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY, Pamer C. Retrospective Analysis of Mortalities Associated With Medication Errors. American Journal of Health-System Pharmacy 2001; 58(19):1824-1829. 8. Pearson A, Wiechula R, Court A, Lockwood C. The JBI model of evidence-based healthcare. Int J of Evid Based Healthc 2005; 3(8):207-215.
The Joanna Briggs Institute The University of Adelaide South Australia 5005 AUSTRALIA www.joannabriggs.edu.au The Joanna Briggs Institute 2011 ph: +61 8 8303 4880 fax: +61 8 8303 4881 email: jbi@adelaide.edu.au
Published by Blackwell Publishing The procedures described in Best Practice must only be used by people who have appropriate expertise in the field to which the procedure relates. The applicability of any information must be established before relying on it. While care has been taken to ensure that this edition of Best Practice summarises available research and expert consensus, any loss, damage, cost, expense or liability suffered or incurred as a result of reliance on these procedures (whether arising in contract, negligence or otherwise) is, to the extent permitted by law, excluded.
Evidencebased Practice
This Best Practice information sheet presents the best available evidence on this topic. Implications for practice are made with an expectation that health professionals will utilisethis evidence with consideration of their context, their clients preference and theirclinical judgement.8
JBI Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings 4 | Best Practice 14(4) 2010