Error Rates and Causes: Selected Studies

Transcription

1 1 Author(s) Year Published 1 Taxis & Barber 2003 (BMJ) 2 Taxis & Barber 2003 (Qu Saf Heth Care) 3 Rothschild, Landrigan, et 4 Husch et Study Objectives incidence and importance of in preparation and of IV drugs and stage where they occur Identify causes of error in IV drug preparation and incidence and nature of adverse events and serious types, frequency, and severity of associated with IV pumps and likelihood of Error Rates and Causes: Selected Studies Study Methodology Study Duration Practice Setting and Location Type of Patients Prospective ethnographic study using disguised observation and inform staff interview 6- to 10-day data collection period 1 university teaching hospit and 1 non-teaching hospit in U.K. Disguised observation and inform staff interview 6- to 10-day data collection period 1 university teaching hospit and 1 non-teaching hospit in the U.K. Various (e.g., ICU, pediatric, surgery, cardiology, nephrology) Prospective, direct continuous observation 1 year Academic, tertiary care urban hospit in Massachusetts Medic intensive care and coronary care unit Prospective comparison of prescribed medication, dose, and infusion rate with corresponding IV pump data and retrospective anysis of rate deviation error preventability 1 day No. of Patients Results 106 There was one or more in 212 (49%) of 430 doses. Of 249, 7% were in preparation, 36% were in, and 6% were in both. Errors were potentily severe in 1% of doses, potentily moderate in 29% of doses, and potentily minor in 19% of doses. Most were in of bolus doses or preparation processes involving multiple steps. 391 patients with 420 unit admissions and 1490 patient-days 286 patients with 426 medications given via IV pump There were 265 in 483 IV drug preparations and 447 drug s. 67% were deliberate violations, 23% were mistakes, 10% were slips/lapses. Lack of perceived risk and poor role models and technology design for violations; lack of knowledge and complex equipment design for mistakes, slips, and lapses. Staff training and equipment design should be addressed to reduce the rate of IV drug preparation and. Rates per 1000 patient-days for l adverse events, preventable adverse events, and serious were 80.5, 36.2, and 149.7, respectively; 78% of serious involved medications Most (61%) serious occurred during ordering or. Performance included skill-based slips/lapses (53%), knowledge-based mistakes (26%), and rulebased mistakes (5%). 12% of adverse events and 11% of serious were life-threatening One or more error in 285 (67%) of 426 medications; a tot of 389. The most common involved no rate on label (46%), unauthorized medication (16%), patient identification error (13%), and rate deviation error (9%). 3 (8%) of 37 rate deviation were caused by programming mistakes. Most (96%) did not cause patient harm. 36 of 37 rate deviation were unlikely to be prevented by smart pump technology

2 5 Fortescue et Blake et 7 Hicks et 8 Hicks & Becker 9 Hicks et 2004 preventing error using smart pumps without interface and software capabilities Classify types of and identify effective strategies for prevention Identify facilitators and barriers to safe practice implementation frequency, types, severity, causes, and consequences of involving PCA types, causes, and consequences of IV types, severity, causes, and consequences of 725-bed tertiary care academic medic center in Illinois Prospective cohort study 6 weeks 2 large academic medic centers Pediatric medic, surgic, and ICU; neonat ICU Telephone interview/questionnaire 18 acute care hospits in Georgia Retrospective anysis of 5 years (2000-) Primarily hospits in U.S. Retrospective anysis of 5 years ( ) Primarily hospits in U.S. Retrospective anysis of 1 year (2002) 482 hospits in U.S Errors in 5.7% of medication orders. Most (77.8%) were in ordering (12.8% in and 5.8% in transcribing), with 28.4% in dosing, 17.7% in route, and 12.5% in frequency. 19.5% of had potenti for harm. Strategies for prevention of potentily harmful error with highest ratings were ward-based clinic pharmacists (88%), improved communication among hethcare practitioners (86%), and CPOE and clinic decision support (76%) Resistance to change was a major barrier. Administrative leadership support, education, and training were facilitators. 624 (1%) of 9571 reported involved PCA. The most common types of were improper dosage or quantity (38.0%), omission (17.4%), and unauthorized or wrong drug (17.3%). The most common causes of error were distractions (37.8%), inexperienced staff (26.3%), and workload increase (19.7%). 6.5% of involving PCA resulted in harm. The most common types of IV error were omission (28.5%), improper dose or quantity (22.9%), and prescribing error (16.2%). The most common causes of error were performance deficit (48%), procedure or protocol not followed (28%), and transcription inaccurate or omitted (14%). Harm resulted from 2.92% to 5.03% of. Drug shortages, interconnectivity of tubing, and cculation mistakes predispose to harmful IV. The most common types of were omission (25.6%), improper dosage or quantity (25.5%), and prescribing error (18.5%). The most common causes of harmful error were performance deficit (46.6%), procedure or protocol not followed (29.3%), communication (17.7%), and knowledge deficit (17.6%). 1.67% of reported resulted in harm. 2

3 10 Lesar 11 Parshuram et 12 Wheeler, Carter, et 13 Phillips et 2001 Quantify and characterize prescribing involving route of rate of error in IV infusion preparation Evuate the effect of expressing drug concentration as a ratio (1:1000) vs. mass (1 mg/ml) on potenti types, causes, and patient demographics in fat medication reported to FDA Prospective review of medication orders, then entry into database for subsequent anysis 42 months 631-bed tertiary care teaching hospit in NY Direct observation Non-clinic setting Randomized, controlled, blinded tri Simulation (non-clinic setting) Hypothetic 5-yr-old pediatric patient in anaphylaxis Review of case reports 6 years ( ) Hospits, ambulatory care settings, patient homes in U.S. 862 clinicly- significant involving route in 2.1 million orders. The most common types of error were wrong route of (39.2%) and prescribing the same or similar medications concurrently by two routes (21.1%). The most common characteristic contributing to route was the routine use of a drug by multiple routes (75.8%). The most common type of error resulting in adverse patient effects involved excessive pharmacologic effects (52%). The most common type of drug involved in route was cardiovascular (23.5%). Errors were detected in 4.9% of drug volume cculations, 2.5% of rounding cculations, and 1.6% of volume measurements. Concentration were found in 34.7% of infusion preparations. Concentration were associated with fewer infusions prepared in the previous week, increased number of years of profession experience, use of a concentrated stock solution, and preparation of sml dose volumes. Large were associated with few hours of sleep in the previous 24 hours, use of a concentrated solution, and preparation of sml infusion doses. Cculator use reduced in dose volume cculations. Participants with >10 yr experience were more likely than those with less experience to make at least one error in rounding cculations. Cculation error rate was significantly higher with ratio (86%) than mass (21%). Hypothetic dose given was 213 μg higher than target dose with use of ratio than mass, and time to administer hypothetic dose was significantly longer with ratio (122 sec) than mass (61 sec). 9.8% of medication error reports involved fatities. Patients >60 years of age were the largest age group with fat (48.6%). The most common types of error were improper dose (40.9%), wrong drug (16.2%), and wrong route (9.7%). The most common causes of error were performance deficit (29.8%), miscommunication (15.8%), and knowledge deficit (14.2%). 3

4 14 Kilbridge et 15 Gheb et 16 Kaush et Prot et 18 Herff et Compare rates and types of ADEs at the two hospits using a computerized surveillance system To characterize the incidence, types, and consequences of Evuate rates and types of medication, potenti ADEs, and ADEs, and the potenti impact of prevention strategies Quantify the incidence and types of and identify associated factors Evuate frequency of serious error involving nitrous oxide during Review of potenti ADEs identified by computerized surveillance system and voluntary reporting 8 months Two tertiary care hospits (one university and the other community) in North Carolina Not specified Meta-anysis of 32 medication error studies using spontaneous reporting, review of medication orders or charts, or observation 2 months to 5 years Primarily hospits in U.S. or Canada Pediatric Prospective cohort study 36 days Two urban academic hospits in Massachusetts Pediatric Prospective direct observation 12 months Four clinic units in a pediatric hospit in France Pediatric intensive care, neonat intensive care, pediatric nephrology, and gener pediatric Retrospective review of lay literature 2 years 33,206 The rate of ADEs per 100 admissions was 4.4 at the university hospit and 6.2 at the community hospit. The rates of druginduced hypoglycemia, anticoagulant-related events, and antibiotic-associated C. difficile colitis were significantly higher at the community hospit than the university hospit. Compared with voluntary reporting, the surveillance system detected ADEs at a rate 3.6 times higher at the university hospit and 12.3 times higher at the community hospit patient-days Error rate varied widely due to differences in definition of error and study methodology. Dosing error was the most common type of error. Antibiotics and sedatives were the most common medications involved. Not addressed in most studies. No patient harm was reported in most studies because were detected and corrected. The magnitude of the problem of in pediatric patients remains to be determined. The rate of, potenti ADEs, and ADEs among 10,778 medication orders was 5.7%, 1.1%, and 0.24%, respectively. Most (28%) and potenti ADEs (34%) were dosing. More than hf involved the IV route. Five (19%) of 26 ADEs were preventable. Ward-based clinic pharmacists and CPOE could have prevented most potenti ADEs. The rate of potenti ADEs was higher in neonates than other pediatric age groups and in the neonat ICU compared with neonates in other wards. 336 The error rate was 27%. The most common types of error were wrong time (36%), wrong route (19%), and wrong dose (15%). Addition management procedures significantly increased the risk of error. No were lifethreatening. IV drugs were associated with fewer than other types of drugs. Administration by a temporary nurse instead of a registered full-time nurse increased the risk for error. 6 fat cases were identified out of an estimated 11 million anesthesia cases in the three countries. All 6 cases were attributed to misconnection of the nitrous oxide tank with the oxygen supply. It was not possible to cculate an error rate

5 19 Hsieh et 2004 gener anesthesia Identify the frequency and causes of drug lergy ert overrides and frequency with which they lead to preventable ADEs Germany, Austria, and Switzerland 3 obstetric cases, 1 trauma case, 1 outpatient surgery case, and 1 case involving cardiopulmonary bypass during surgery Chart review for tot population and a stratified random subset of lergy erts chosen based on prior experience 3 months 709-bed academic hospit in Massachusetts with CPOE and drug lergy checking capability Subset with overridden lergy erts involving sulfur-containing diuretics, narcotics, and l other drug classes combined 1150, including stratified random subset of 320 because the estimate of anesthesia cases was not reliable. Allergy erts were overridden in 80% of orders in 1150 patients, with 90% triggered by a non-exact match between drug ordered and drug on lergy list. The most common drug classes associated with l 1150 overridden erts were narcotics (39%) and cephosporins (21%). The most common reasons for 1150 ert overrides were physician aware/will monitor (55%), patient does not have lergy/tolerates drug (33%), and patient ready taking drug (10%). Nineteen (6%) of subset of 320 patients experienced ADEs due to overridden lergy erts, including 9 ADEs that were serious. None of the ADEs was considered preventable. The investigators recommended increasing the specificity of the ert capability to improve its clinic usefulness (e.g., differentiate between drug lergies and sensitivities/intolerances; make erts interruptive for only true lergies). 5