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Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings.

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 report (2) 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".

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.

Quality of the research

Seven quantitative (survey type) studies and three qualitative studies examined nurses perceptions of causes of medication administration error. Only one qualitative study explored the patient's perceptions of medication administration and errors. Two studies of self administration of medicines were included in the review. One RCT and 5 evaluation studies examined the roles and systems for medication administration.

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.

Qualitative evidence for nurses perceptions of medication administration errors

Three qualitative studies were included in the systematic review. The synthesis of findings from these three studies highlighted that there were External and Internal factors that were perceived as contributing to medication administration errors.

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 wasn't 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.

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.

Qualitative evidence for patient's perceptions of medication administration and errors

Only one qualitative study was identified on patient perceptions. From the perspective of the patient in acute care settings it appeared that their contribution to error reduction could be valuable. Patients should, wherever possible, be encouraged and included in the medication administration process through verbal and non-verbal communication. Patients highlighted how nurses may not listen to their concerns, may believe the nurse knows best and, for themselves, be unaware of the medication administration process in the acute setting.

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Roles and systems for medication administration

Individualised and Unit dose medication systems

Unit or patient dose systems

One study highlighted the potential that unit or patient dose systems can have on reducing missed doses as against administration from a ward stock (imprest system). Four hospitals with similar wards were utilised; three used the imprest system, one the unit dose system. Across the three hospitals using the imprest (stock based system) 5.7% of total doses were identified as missed. In the one hospital using unit dose approach 4.1% of total doses were identified as missed (p<0.005).

Unit supply/bedside system

In one study a comparison of a trolley based ward stock system with a unit supply system where medications were placed in a locked bedside drawer was undertaken on a medical and surgical ward and whilst only a small number of nurses participated, showed an overall reduction in errors from 62.8% with the ward stock system to 39.2% (p=0.00005) for the unit supply/bedside system in the medical ward and from 46.2% to 25% (p=0.00005) in the surgical ward. The majority of these errors were accounted for by minor timing errors. When timing errors were removed the rates were 8.5% for ward stock system in the medical ward to 1.2% for the unit supply/bedside system and from 13.4% to 3.6% in the surgical ward (p=0.00005).

Trolley vs fixed ward bay administration

In one small study medication errors (primarily administration errors) were compared in a 30 bed surgical ward which had a natural division whereby half of the ward had drug administration via a trolley and the other half fixed ward bay distribution points that could serve up to six patients. Two dispensing errors were observed and 20 administration errors. The trolley system had an error rate of 2.6%, the ward bay system an error rate of 9.2% (p=0.034).

Ward bay vs bedside

One study compared ward bay administration with bedside administration from the patient's locker. Errors using the bedside system were 7% vs Ward Bay errors 16.4% (p=0.02). Error rates when injections were removed from the results were that bedside administration remained at 7%, ward bay increased to 17.6% (p=0.02).

Self administration of medicines

Only two studies on self administration in acute care were identified that sought to measure error rates. One small study to evaluate the effectiveness of an Self Medication Programme (SMP) on a 26 beds medical and surgical unit found no patient initiated medication errors with the SMP but an increase in nurse initiated errors (from 1 to 2). The second study compared a co-operative care centre with "traditional nursing units" within the same medical centre. Co-operative care accounted for 19.4% of discharges, 10.3% of patient days but only 4.6% of all medication errors. A medication error rate of 3.6 per 1000 discharges in co-operative care was identified over a retrospective 4 year period whereas traditional nursing units had 17.8 errors per 1000 discharges. 80 errors occurred in 261,443 medication orders in co-operative care (3.06 per 10,000 orders) vs 1643 errors in 4,094,352 orders (4.01 per 10.000 orders) in traditional nursing units. 50% of errors in co-operative care were attributed to nursing staff.

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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.

(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.) O'Shea 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.

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)

Grades of Recommendation

These Grades of Recommendation have been based on the JBI-developed 2006 Grades of Effectiveness (1)

Grade A Strong support that merits application

Grade B Moderate support that warrants consideration of application

Grade C Not supported

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.
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Publication:Best Practice
Date:Mar 1, 2010
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