Barker et al. (2002) Van Den Bemt et al. (2002) Tissot et al. (2003)

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1 Prevalence and Causes of Wrong Time Medication Administration Errors at Tertiary Care Hospital Karachi, Pakistan When categorized, the Medication administration error can relate to: Wrong Time Wrong Patient Wrong Drug Wrong Dose Wrong Route Dose administered >60 minutes before or after scheduled time (Fitz Henry, 2007; Tissot 2003; Barker 2002; Allan and Barker Administration of a drug at least 60 minutes earlier or later than prescribed. 1990) (Bemt et al,2007) Author: Ms Salimah Taufiq Lead Clinical Nurse Analyst Aga Khan University Hospital, Pakistan 1 2 Wrong time medication administration error (WTMAE) is a high riskto patient safety WTMAEs are under-reported Accurate recording of WTMAE is a great challenge for nurses with manual administration record. Use of technology to recognize and highlight medication administration errors Purpose of this study was to investigate the prevalence of WTMAEs via electronic medication administration record (emar) and to explore the contributing factors. WTMAE is becoming great threat to patient s safety, leading to severe harm, fatal consequences including death. It is the second largest category of medication error reported worldwide as per National Patient Safety Agency report EVIDENCE Different Fitzhenry Hughes and observational et Blegen al, (2007) (2008) reported and highlighted chart wide review disparity that studies medication in conducted wrong administration time error United rates error State ranging of included America from (USA) Cullen 0.5% to reported (1995) concluded 35.7%. He wrong recommended time that error voluntary future ranging incident study from on 10% reporting medication to 42% system at administration several does healthcare not help in up to 11% of wrong time error and most of them were under reported due to processes identification of accurate prevalence. This can lead to significant bias. institutions. to manual determine process (Balas classification of 2004; medication Barker of medication administration. 2002; Colen errors 2003; based Grasso on 2003; timing Prot criticality. 2005) Author Setting Method WT error Calabrese et al. 5 ICU of USA hospitals Observation 13.9% (2001) Barker et al. (2002) Van Den Bemt et al. (2002) Tissot et al. (2003) Balas, Scott and Rogers (2004) Fitzhenry et al. (2007) Van Den Bemt et al. (2007) 18 healthcare facilities randomly selected Observation 43% 2 ICU of Dutch hospitals Disguised- Observation Geriatric and Cardiovascular Surgery Unit All inpatient and critical care units Adult critical care units Five units from five different day care and living units 11.6 % Observation 26% Questionnaire 33.6% Retrospective chart audits Observation 16.9% Buckley et al. (2007) PICU Observation 26.7% 3% WT error reported from total of 25.4% drug administration errors. DeYoung et al. (2009) Szczepura, Wild and Nelson (2011) Medical ICU Observation 7.5% after BCMA implementation 13 care homes Central Data System 45% 5 6 1

2 OBJECTIVES OF WTMAE METHODOLOGY Investigate the prevalence Evaluate contributing factors Recognize reliability of technology in identifying discrepancy of wrong time medication administration errors versus voluntary incident reporting Comparison between WTMAE identified thru e-mar system and voluntary incident reporting (IR) system A descriptive comparative study design with quantitative research approach Data gathered from e-mar system and electronic IR system Convenience universal sampling of all prescribed doses for 90 days in 5 in-patient locations (adult medical, adult surgical, pediatric, intensive care unit and coronary care unit) Comparative study to identify the incidence of WTMAE reported thru IR system and WTMAE identified by e-mar data 7 8 RESULTS Total 250,213 doses were observed out of which 231,380 doses were administered and 18,833 doses were not administered or doses missed. Administered doses (n= 231,380) were further analyzed 83% On-time administration (n=191,994) 17% Wrong time administration (n=39,386) DOSES PRESCRIBED Total 250,213 doses were observed out of which 231,380 doses were administered and 18,833 doses were not administered or doses missed 250, ,380 Highest percentage of WTMAE were during night shift. Contributing factors for WTMAE 50 reasons for late administration 9 reasons for early administration. Prescribed Doses Administered Dose Closed/omited Doses 17,603 1,230 Niether Administered Nor closed 9 10 BREAK-UP OF PRESCRIBED DOSES Administered doses (n= 231,380) were further analyzed 83% On-time administration (n=191,994) 17%Wrong time administration (n=39,386) 100% 83% PERCENTAGE OF ON-TIME AND WT ADMINISTRATION BY SHIFT Total doses administered Ontime Doses 81.88% 85.54% On-time Administration Wrong time Doses 78.78% Wrong Time Administration Morning Shift 96,682 (100%) 79,160 (81.8%) 17,522 (18.1%) Evening shift 99,426 (100%) 85,047 (85.5%) 14,379 (14.4%) Night Shift 35,272 (100%) 27,787 (78.7%) 7,485 (21.2%) 17% 18.12% 14.46% 21.22% Total Doses Administered Ontime Doses WTMAE Morning Shift Evening Shift Night Shift

3 ON-TIME & WRONG TIME ADMINISTRATION (BY LOCATION) Ontime Administration WT Administration Intensive Care Unit (ICU) n=29272; 87% n= 4216; 13% Pediatric Unit (D0) n=33587; 84% n= 6548; 16% Coronary Care Unit (CCU) n= 1899; 83% n= 9093; 17% Surgical Unit (B1) n=61670; 83% n=12866; 17% Medical Unit (C2) n=58372; 81% n=13821; 19% Ontime Doses Wrong time Doses 83% 81% 84% 83% 87% ANALYSIS OF WRONG TIME ADMINISTRATION Total WTMAE (n=39,386; 17%) were further analyzed Late administration errors n= 36,818; 15.90% Early administration errors n=2,568; 1.10% 6% Late Administraion 17% 19% 16% 17% 13% 94% Early Administration Surgical Unit (B1) Medical Unit (C2) Pediatric Unit (D0) Coronary Care Unit (CCU) Intensive Care Unit (ICU) TOP THREE REASONS FOR EARLY ADMINISTRATION ERROR 0.50% TOP FIVE REASONS FOR LATE ADMINISTRATION ERROR 3.40% 0.33% 0.35% 1.95% 1.83% 1.02% 1.33% Pre meal, drug require to administered empty stomach, etc (n=1398) "Dot and Comma" instead of actual reason in comments column (n=783) Inappropriate/ unjustified reasons mentioned in comments column (n=818) Delayed dispensation from pharmacy (n=4523) Busy with other critical task in patient care (n=4257) Forgotten to mark the administration (n=2365) Nurse enter Dot and Comma instead of actual reason (n=7889) Inappropriate / unjustify reasons, such as given, already given, given on time, etc (n=3101) WTMAE COMPARATIVE IR versus e-mar Discrepancy of WTMAE identified from two separate data base Incident Report versus Electronic Medication Administration Record This study provided a reliable method using technology to obtain the number of WTMAE. Previous studies were based on observation and chart review method. CONCLUSION WTMAE are under reported through voluntary reporting system (IR) as study data evidence shows that frequency of WTMAE is much high when data is obtained from e-mar system

4 RECOMMENDATIONS LIMITATIONS Enforcement of on-time documentation policy Close monitoring and dissemination of on-time and wrong time administration record to relevant stakeholders Encourage staff to report wrong time administration in a structured format for proper categorization of causes and discourage use of free text option Improve medication dispensation process Improve nurse-patient ratio and ensure good working environment to reduce errors Not enough literature is available on study conducted through e-mar. Work-load, working environment and long working hours were some of the variables which influenced the study WAY FORWARD ACKNOWLEDGMENT Findings of this research can be utilized to improve reporting of WTMAE and system gaps. Hence ensure patient safety and quality care. Various other reasons were identified and can be further evaluated through a separate study for improvements. Dr. Peter Bath, Reader in Health Informatics University of Sheffield, UK. Khadija Pir Muhammad, Director Nursing Dr. Zafar Nazir, Medical Director Mr. Chris Handley, Chief Information Officer Mr. Bazal Nasir, Project Manager - Electronic Health Records Mr. Hamza Akram, Manager AV & LRC Ms Nida Hussain, Manager CMS and IMSes Ms. Khairunnisa Ismail, Sr. Management Executive Hospital Operation. Mr. Jahangir Rathore, Sr. Administrative Officer, EHR Project Ms Saba Akber, Quality Coordinator REFERENCES Allan, E.L. and Barker, K.N. (1990) Fundamentals of medication error research. American Journal of Hospital Pharmacy [Online], 47 (3), [Accessed 5 January 2011] Balas, M.C., Scott, L.D. and Rogers, A.E. (2004) The prevalence and nature of errors reported by hospital staff nurses. Applied Nursing Research [Online] 17 (4), [Accessed 20 November 2010] Bates, D.W., Cullen, D.J., Laird, N, et al (1995) Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention The Journal of the American Medical Association [online] 274 (1) Barker, K., Flynn, E., and Pepper, G. (2002). Observation method of detecting medication errors. American Journal of Health-System Pharmacy. 59 (1) Bemt, V.D., Robertz, R., DeJong, A.L., et al (2007) Drug administration errors in an institution for individuals with intellectual disability: an observational study Journal of Intellectual Disability Research, 51(7), Colen, H.B, Neef. C. and Schuring, R.W. (2003) Identification and Verification of Critical Performance Dimensions: Phase I of the Systematic Process Redesign of Drug Distribution. Pharmacy World Science, 25(3): REFERENCES FitzHenry, F., Peterson, J.F., Arrieta, M., et al. (2007). Medication Administration Discrepancies Persist Despite Electronic Ordering. Journal of the American Medical Informatics Association [Online], 14 (6), [Accessed 24 October 2010] Hughes, G. R. and Blegen, A.M. (2008) Patient Safety and Quality: an Evidence based handbook for Nurses [Online] [Accessed 20 December 2011] National Patient Safety Agency Report (2007) Safety in Doses Improving the use of medicines in the NHS. [Online], 24 February 2010] Prot, S., Fontan, J.E., Alberti, C., et al. (2005). Drug administration errors and their determinants in pediatric in-patients. Internal Journal of Quality Health Care [Online] 17(5), Tissot, E., Cornette, C., Limat, S., et al. (2003) Observational study of potential risk factors of medication administration errors. Pharmacy World Science 25(6):

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