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Rapid Responses: Rapid Responses published:
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Engineered Solutions to Prevent Drug Errors
- Joseph J Carter, Peter J. Young, Charles Barsted (17 March 2009)
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Re: Engineered Solutions to Prevent Drug Errors
- Phillip J. Colquitt (21 March 2009)
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Self report may lead to underestimation of “wrong dose” medication errors
- Panagiotis Kiekkas, Panagiotis Kiekkas, Diamanto Aretha, Mary Karga, and Menelaos Karanikolas (26 March 2009)
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Error rates reported are likely to be an underestimate of the true incidence of errors
- K Taxis, Bryony D. Franklin and Nick Barber (27 March 2009)
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Meaningless numbers
- John Larkin (10 May 2009)
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Automatic identification and GS1 standards can reduce risk of medical errors
- Roger Lamb (26 May 2009)
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Joseph J Carter, Consultant in Anaesthesia and Intensive care Queen Elizabeth Hospital, Kings Lynn, PE30 4ET, Peter J. Young, Charles Barsted
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We commend the authors on their important work. Medication errors are a clearly both a common and potentially preventable cause of patient injury and death. The authors’ conclusions that error reporting systems and routine checks must be introduced in order to reduce risk are correct, however, this alone is insufficient. The evidence for this is obvious insofar as, these checks and reporting systems are already in place, yet the errors continue to occur. It is imperative that where possible we prevent the occurrence of these errors. In some situations this can be achieved through engineered solutions. Where wrong route errors are implicated, engineered solutions are already available which prevent the possibility of these occurring. The main issue with many of the wrong route errors is the ubiquitous nature of the luer connector on medical devices. We would like to highlight an example of an engineered solution already in place in our hospital which prevents the unintentional administration of local anaesthetic intended for epidural delivery into intravenous cannulae. This is a tragic and common occurrence that has already been raised by the National Patient Safety Agency[1] and exposed by the press[2]. By providing clinicians with a modification of the current epidural infusion systems wrong route drug errors, either of drugs intended for epidural use being given intravenously, or, of intravenous drugs being delivered to the epidural space are prevented. The system is modified such that the local anaesthetic bag is irreversibly bonded to an infusion system which is then continuous with the epidural filter and only has a connector for attachment to an epidural catheter. There is no cross- compatibility of these two systems and therefore no potential for error. Similar engineered solutions have been successfully introduced for other medical applications[3] and other solutions are being developed[4,5]. As the paper highlights, errors of drug administration are multifactorial. Engineered solutions will provide an important adjunct to prevent some of these errors. Wherever possible, preventing the possibility of errors is the desirable solution. References 1. National Patient Safety Agency Patient Safety Alert NPSA/2007/21 2. Mayra Cabrera 'unlawfully killed' by epidural blunder in hospital The Times accessed on 13th March 2009 http://www.timesonline.co.uk/tol/life_and_style/health/article3314183.ece 3. Evans LA, Young PJ. Preventing iatrogenic air embolism in the intensive care unit. Med Device Technol. 2007;18(3):36-7 4. Ramai Santhirapala, Ajay Arora, Joseph J. Carter, Peter J. Young. A Non Interchangeable Connector System (NICS) for Central Venous Catheters (Abstract) Critical Care Medicine December 2008 supplement 5. Joseph J. Carter, Ajay Arora, Ramai Santhirapala, Peter J. Young. Safer Arterial Access: Preventing Accidental Arterial Injection (Abstract). Critical Care Medicine December 2008 supplement Competing interests: None declared |
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Phillip J. Colquitt, Technicain/RN Independent comment
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It is doctors who have often asked me to make a connection between two tubes which need joining, yet which have no dedicated connector. It happens not infrequently. Health care workers seem to reject help. The inferior metal Luer predates current plastics technology by the best part of a century, yet is still proudly advertised by sphygmomanometer makers as a selling point for their manual devices used in indirect measurement of blood pressure. It is doctors and nurses who want the older inferior technology - they are the uninformed consumer driving the market. Competing interests: None declared |
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Panagiotis Kiekkas, RN, PhD Dept of Anaesthesiology and Critical Care Medicine, Patras University Hospital, Rion 26500, Greece, Panagiotis Kiekkas, Diamanto Aretha, Mary Karga, and Menelaos Karanikolas
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We read with great interest the multinational study by Valentin et al[1], which assessed the frequency, characteristics and factors contributing to parenteral drug administration errors in Intensive Care Units (ICUs). The authors acknowledge that, due to under-reporting, underestimation of the true error frequency is a limitation of the incident self reporting method, which was used in their study. Direct observation is considered the most efficient and accurate method for detecting medication errors[2] and has been used for medication error detection in five ICU studies[3-7]. Wrong dose was observed and included among the three more frequent error types in all five direct observation studies, while administration time and dose omission errors were observed in four and three of these studies respectively, and were included among the three more frequent error types in only two of these five studies. In contrast, the study by Valentin et al[1], which was based on error self-reporting found that the frequency of “wrong dose” errors was much lower compared to the frequency of administration time errors and dose omission errors. Could the discrepancy between the findings of the Valentin study1 and those of the five direct observation studies[3-7] be attributed to under-reporting of “wrong dose” medication errors? We believe that there are at least two plausible reasons why different types of medication error may not be equally reported when self reporting is used: First, staff must become aware of an error in order to report it and, compared to administration time and dose omission errors, which can be detected through reviewing of ICU daily charts, dose errors are much less likely to be noticed. Second, well-described bias of self reporting include social desirability bias and self-esteem bias; according to them, respondents tend to reply in a manner either viewed favorably by important others or being consistent with their self-esteem perceptions respectively[8]. Wrong dose has been primarily attributed to individual deficiencies (especially of nurses), such as inadequate mathematical skills or medication knowledge, limited experience and failure to follow policies (i.e. properly checking drugs)[9]. In contrast, administration time and dose omission errors have generally been associated with organizational deficiencies, mainly increased workload (which was also identified as a factor contributing to errors in the study by Valentin et al[1]). Due to the subconscious tendency of being socially agreeable and protecting self-esteem, it seems reasonable to expect that self reporting individuals would more likely under-report types of medication error which have been associated with personal deficiencies. Although findings derived from multicenter studies are highly generalizable, the importance of data collection bias should not be overlooked. The hypothesis that “wrong dose” errors are under-reported when error detection is based on self-report can be tested by studies designed specifically for comparing the frequency of different error types detected by direct observation vs. self reporting. Underestimation of dose errors, if real and confirmed by additional studies, could have important ramifications, because it would lead to erroneous conclusions about medication error epidemiology and contributing factors, and could therefore become the basis for ill-conceived, ineffective preventive interventions. References 1. Valentin A. Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 2009;338:b814. 2. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled- nursing facilities. Am J Health-Syst Pharm 2002;59:436-46. 3. Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Tavakoli Ardakani M. Errors in preparation and administration if intravenous medications in the intensive care unit of a teaching hospital: an observational study. Aust Crit Care 2008;21:110-6. 4. Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med 2006;34:415-25. 5. Tissot E, Cornette C, Demoly P, Jacquet M, Barale F, Capellier G. Medication errors at the administration stage in an intensive care unit. Intensive Care Med 1999;25:353-9. 6. Van den Bemt PM, Fijn R, van der Voort PHJ, Gossen AA, Egberts TCG, Brouwers JRBJ. Frequency and determinants of drug administration errors in the intensive care unit. Crit Care Med 2002;30:846-50. 7. Calabrese AD, Erstad BL, Brandl K, Barletta JF, Kane SL, Sherman DS. Medication administration errors in adult patients in the ICU. Intensive Care Med 2001;27:1592-8. 8. Waltz CF, Strickland OL, Lenz ER. Measurement in Nursing and Health Research: Third Edition. New York, NY: Springer Publishing Company, Inc, 2005. 9. O’Shea E. Factors contributing to medication errors: a literature review. J Clin Nurs 1999;8:496-504. Competing interests: None declared |
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K Taxis, Assistant Professor of Pharmacotherapy and Pharmaceutical Care 9713BV Groningen, Bryony D. Franklin and Nick Barber
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We note with interest this extensive study on errors in administration of parenteral drugs in intensive care units (1). However, we would recommend caution in interpreting the findings of this study. The error rates reported are likely to be an underestimate of the true incidence of errors. This is for two reasons. First, errors were identified using self-reporting by hospital staff. Studies suggest that only about 1 in 100 prescribing errors (2) and 1 in 1000 administration errors (3) are reported using established incident reporting systems. While the approach used in this study, encouraging staff to report all errors identified during a very short, focussed period, is likely to have resulted in higher reporting rates, the error rates identified are still likely to be a significant under-estimate of the true error rates. The error rate in the present study, calculated as percentage of all doses given, is 7%. This is substantially lower than the parenteral medication error rates of 18%-173% found in other studies in the ICU setting and other wards using the “gold standard” method in this field, observation of actual administration using independent observers (4-6). Second, the authors only assessed five specific types of error. Other potentially common administration errors associated with parenteral medication including the use of the wrong diluent, incompatibility errors and wrong administration rate errors, appear to have been excluded. Conducting regression analyses based on a potentially small sub-set of reported errors is therefore likely to be flawed. We were also surprised that no information was presented about the role of pharmacists in the units studied. It is routine practice to include a pharmacist as part of the critical care team in many of the countries included in the study. It has been shown that pharmacist involvement reduces adverse events due to prescribing errors in the critical care setting (7) and having a pharmacist involved with the multi- disciplinary team is likely to also be associated with reduced administration errors. We would advocate the method of using independent observers collecting data on actual practice (5;8;9) to understand the true incidence and causes of administration errors in this setting. Furthermore, to identify the true impact of interventions such as electronic prescribing or the provision of parenteral medication by the pharmacy department, completely different approaches, such as controlled studies, are needed. Bryony Dean Franklin Professor of Medication Safety and Director, Centre for Medication and Service Quality, Imperial College Healthcare NHS Trust / The School of Pharmacy, University of London Katja Taxis Assistant Professor of Pharmacotherapy and Clinical Pharmacy, Department of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care, University of Groningen, The Netherlands Nick Barber Professor of the Practice of Pharmacy, The School of Pharmacy, University of London Reference List (1) Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 2009; 338:b814. (2) Franklin BD, Vincent C, Schachter M, Barber N. Prescribing errors - an overview of research methods. Drug Saf 2005; 28(10):891-900. (3) Allan Flynn E, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled nursing facilities. Am J Health-Syst Pharm 2002; 59:436-446. (4) Han PY, Coombes ID, Green B. Factors predictive of intravenous fluid administration errors in Australian surgical care wards. Qual Saf Health Care 2005; 14(3):179-184. (5) Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ 2003; 326:684-687. (6) O'Hare MCB, Gallagher T, Shields MD. Errors in the administration of intravenous drugs. BMJ 1995; 310:1536-1537. (7) Leape LL, Cullen DJ, Dempsay Clapp M, Burdick E, Demonaco HJ, Ives Erickson J et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 282(3):267-270. (8) Franklin BD, O'Grady K, Donyai P, Jacklin A, Barber N. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and- after study. Qual Saf Health Care 2007; 16(4):279-284. (9) Dean B, Barber N. Validity and reliability of observational methods for studying medication administration errors. Am J Health-Syst Pharm 2001; 58:54-59. Competing interests: None declared |
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John Larkin, consultant Victoria Infirmary G42 9TY
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Franklin et al's rapid response to Valentin et al's paper shows unhappiness with the low error estimation at 7%. They quote self- reportings only pick up "1 in 100 prescribing errors and 1 in 1000 administration errors". Are they suggesting the true incidence of errors is between 700% and 7000%? Of course the estimates will be wrong. All such estimates are wrong and...it doesn't matter. We don't need to know the incidence to know we have to do something to decrease it. A gardener watching greenfly attack his roses doesn't need to calculate the percentage of roses which will be affected before he takes steps to prevent it. And don't say we need baseline figures (hey, why not use Franklin's quoted 18-173% as a precise starting point?). You still don't believe me. Read the conclusion to Valentin's paper, the result of all of their efforts. Put any figure instead of the percentage they measured (other than zero) and the conclusion would be written in exactly the same way. JL Competing interests: None declared |
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Roger Lamb, GS1 UK Healthcare Business Manager WC1V 7QH
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I was interested to note the conclusions of this report that parenteral medication errors at the administration stage are common and a serious safety problem in intensive care units. I fully support the observation that with the increasing complexity of care in critically ill patients organisational factors such as error reporting systems and routine checks can reduce the risk for such errors. The GS1 System of standards, recommended by DH, used in automatic unique identification (such as bar coding) is just such a system. It has been shown in “Coding for Success” (DH Feb 2007) that dispensing and administration errors are significantly reduced by AIDC (Automatic Identification and Data Capture). GS1 standards are currently being ratified by NHS ISB and over 200 hospitals in England have now joined up for GS1 UK membership since the NHS Connecting for Health programme on AIDC began 2 years ago. This has enabled better control of medicines manufacturing, repackaging and over- labelling procedures in hospitals and facilitated tracing systems for surgical instrument decontamination. Working with the NPSA the GS1 System is now also being used to enable automatic positive patient identification at the bedside. Competing interests: None declared |
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