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International Journal of Nursing Practice 2015; 21: 141–146
RESEARCH PAPER
Detecting medication errors: Analysis based on a hospital’s incident reports Marja Härkänen MSc RN PhD Student, Finnish Doctoral Programme in Nursing Sciences, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
Hannele Turunen PhD RN Professor, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Nurse Manager (adjunct), Kuopio University Hospital, Kuopio, Finland
Susanna Saano PhD Pharmacist, Kuopio University Hospital, Kuopio, Finland
Katri Vehviläinen-Julkunen PhD RN Professor, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Nurse Manager (adjunct), Kuopio University Hospital, Kuopio, Finland
Accepted for publication May 2013 Härkänen M, Turunen H, Saano S, Vehviläinen-Julkunen K. International Journal of Nursing Practice 2015; 21: 141–146 Detecting medication errors: Analysis based on a hospital’s incident reports The aim of this paper is to analyse how medication incidents are detected in different phases of the medication process. The study design is a retrospective register study. The material was collected from one university hospital’s web-based incident reporting database in Finland. In 2010, 1617 incident reports were made, 671 of those were medication incidents and analysed in this study. Statistical methods were used to analyse the material. Results were reported using frequencies and percentages. Twenty-one percent of all medication incidents were detected during documenting or reading the documents. One-sixth of medication incidents were detected during medicating the patients, and approximately one-tenth were detected during verifying of the medicines. It is important to learn how to break the chain of medication errors as early as possible. Findings showed that for nurses, the ability to concentrate on documenting and medicating the patient is essential. Key words: hospital, medication errors, nursing, patient safety, register study.
INTRODUCTION Medication is an important part of nurses’ work. At the same time, it represents one of the largest areas for risks in nursing practice. The possibility of an error always
Correspondence: Marja Härkänen, University of Eastern Finland, Department of Nursing Science, P.O. Box 1627, 70211 Kuopio, Finland. Email: [email protected] doi:10.1111/ijn.12227
exists because of the complexity of this multi-professional process.1 Nurses have a dual role in the medication process; they are both producers of errors and defenders against them.2 Thus, it is important to understand nurses’ perspectives on medication errors.3
Background Medication error is defined as a preventable event that might cause or lead to inappropriate medication use or © 2013 Wiley Publishing Asia Pty Ltd
142
M Härkänen et al.
patient harm while the medication is in the control of the health-care professional, patient or consumer.4 In this study, the concept of ‘incident’ refers to the description of both medication errors reaching patients as well as near misses, which are prevented before an error. High medication error rates have been found in previous studies. In the study of Westbrook et al.,5 errors were detected in up to 70% of intravenous medication administrations. Medication errors have been evaluated to be a serious threat to patients’ safety6 and are recognized as causes for patient morbidity and mortality in hospital settings.7 An important factor in improving patient safety in medication processes is to collect and analyse information about errors. In recent years, error-reporting systems have been created to enable health-care professionals to gather data on errors and use the information to identify opportunities for improvement.8 The aim of this paper is to analyse how medication incidents are detected in different phases of the medication process according to information received from hospital’s incident reports.
METHODS Design and data collection The study design is a retrospective register study. The material was collected from a web-based error-reporting database (HaiPro) at one of Finland’s five university hospitals. This hospital has 800 patient beds, and in 2010, there were 226 997 treatment days. Between January and December 2010, there were 1617 incident reports in the hospital’s database, of which 671 were connected to medication and used in this study. All health-care professionals who take part in patient care are able to report incidents on the error-reporting database (HaiPro). The reporting process is easy and fast, and it can be done anonymously on any workstation computer in hospital wards. The database collects information on incidents with web-based forms. This form contains both predefined pickup lists and spaces for free-text descriptions to be used when reporting about incidents.
Data analysis In the data analysis, the information on detecting errors was read from free-text descriptions of incidents. When reading the descriptions of the events, it was noted that the reporter had usually written about detecting the error. They wrote that, for example, ‘.. the error was detected when I went to write the details of administered medicine to patient records..’, or ‘I gave another patient’s drug to this © 2013 Wiley Publishing Asia Pty Ltd
patient. I noticed it during medication administration..’, or ‘..patient noticed that one of his medicines was missing and asked about the medicine..’. The qualitative material was quantified and classified into different categories depending on the contents. The incidences that could not be categorized reliably because of scarce description were classified as ‘not known’. Two experts analysed the material in collaboration (the principal investigator with a nursing background and a hospital pharmacist). The categorizing of incidents was jointly agreed. A consensus was reached for those incidents that were determined differently. The material was processed statistically using spss statistics 19.0 (SPSS Inc., Chicago, IL, USA) for Windows. Cross-tabulation was used when analysing the connection between how errors were detected and the phase of the medication process (stage). Results are reported using frequencies and percentages.
Ethical considerations The research permit was granted from the study hospital in December 2010, and the statement of Ethical Governance was granted from the University Ethics Board in January 2011. The study is a register study and so did not connect directly to patients. The data do not include patient names or any identifiers. When reporting the study results, there is no information that could reveal persons or hospital units from the population.
RESULTS A total of 671 medication incident reports were analysed. Most incidents (82.6%, n = 554) were reported by registered nurses. Practical nurses reported 6.6% (n = 44), pharmacists 5.4% (n = 36), physicians 2.5% (n = 17), examination personnel 0.7% (n = 5), students 0.7% (n = 5) and other health professionals 1.5% (n = 10) of the incidents. Approximately two-thirds (69.2%, n = 464) of errors reached to the patient; the rest (n = 207) were near misses. The majority of the errors did not cause any harm to patients (65.7%, n = 441). Of the errors, 15.6% (n = 105) were estimated to have caused mild harm, 2.4% (n = 16) moderate harm, 0.3% (n = 2) severe harm to patients and rest (16%, n = 107) were classified in the ‘not known’ class.
Detecting medication errors in different phases of the medication process Medication errors were detected in different ways (Fig. 1) and in different phases of the medication process
Detecting medication errors
143
Not known
146 (21,8 %)
DocumenƟng /reading documents
141 (21,0 %)
MedicaƟng the paƟent
95 (14,2 %)
Verifying medicines
63 (9,4 %)
Dispensing / preparing drugs
50 (7,5 %)
Entry/ transfer to unit
47 (7,0 %)
PaƟent noƟced the error
42 (6,3 %)
PaƟent condiƟon or lab.values
41 (6,1 %)
Detected otherwise
19 (2,8 %)
ShiŌ handover
Number of errors
13 (1,9 %)
Physician round
10 (1,5 %) 4 (0,6 %)
Other person noƟced the error 0
50
100
150
200
Figure 1. Detecting the medication errors (n = 671), (f, %). ( ) number of errors.
(Table 1). Approximately one-fifth (21.0%, n = 141) of the medication errors were detected during documenting or when reading the documents, for example during the handling of prescriptions. The majority of them were documenting (45.4%) or administrating (32.6%) errors. During medicating the patient, 14.2% (n = 95) of errors were detected. About two-thirds (65.3%) of those errors were administration errors, but dispensing errors (21.1%) were also detected. A portion (9.4%, n = 63) of medication errors were detected by verifying of medicines. Those were detected in the final verification before medicating the patients by double-checking or, for example, during verifying the medicines in shift changes. The majority of those errors were dispensing (27.0%) errors. Handling the drugs before administering them is usually one of the final possibilities to avoid a medication error. During the dispensing or the preparing of drug doses, 7.5% (n = 50) of errors were detected.
DISCUSSION Study limitations and strengths This study has some potential limitations. Firstly, classification of detecting errors was made based on the incident descriptions. Because of the limited description of the incidents, the ‘not known’ category included 22% of incidents, and this should be taken into account in assessing
the results. Secondly, it is known that only a small number of errors are noticed9,10 and that only a minority of them are reported for many reasons, such as disagreement with definition, reporting effort, fear or administrative response.3,9,11 This is why it is assumed that the material represents only a part of the actual medication errors. However, this is one of the problems with the nature of this field, and we must recognize that we will never know all of the errors. Finally, the generalization of the results has limitations because of the fact that the results were collected over specific time period of 1 year, in one hospital and in one country. Therefore, it is possible that aspects related to culture or time period might have effects on the study results. However, despite the fact that these were potential limitations, our findings are consistent with previous researches in this area and reference other similar findings. The strength of the research is that two experts analysed the material in collaboration, and all categorizing was jointly agreed. Secondly, the sample comprised 1 year information of the medication errors from one hospital. Therefore, the material, including much information on the medication incidences, is more valid. Finally, because previous medication error-reporting studies have not included an analysis on how the errors were detected, in this study, we can present new information about medication errors. © 2013 Wiley Publishing Asia Pty Ltd
0.7 (1) 21.1 (20) 27.0 (17) 16.0 (8) 6.4 (3) 54.8 (23) 2.4 (1) 5.3 (1) 15.4 (2) 0 0 15.1 (22)
20.6 (29) 1.1 (1) 7.9 (5) 16.0 (8) 27.7 (13) 4.8 (2) 7.3 (3) 0 0 22.2 (2) 75.0 (3) 13.0 (19)
0.7 (1) 5.3 (5) 3.2 (2) 12.0 (6) 2.1 (1) 2.4 (1) 2.4 (1) 0 0 0 0 0.7 (1)
0 1.1 (1) 7.9 (5) 4.0 (2) 0 0 0 10.5 (2) 7.7 (1) 0 0 0.7 (1)
0 2.1 (2) 4.8 (3) 6.0 (3) 0 0 0 0 0 0 0 0.7 (1)
0 1.1 (1) 4.8 (3) 6.0 (3) 0 0 2.4 (1) 0 0 0 0 0
0 1.1 (1) 0 2.0 (1) 0 0 0 0 7.7 (1) 0 0 0.7 (1)
Discussion of the results
© 2013 Wiley Publishing Asia Pty Ltd
One data is missing.
32.6 (46) 65.3 (62) 19.0 (12) 20.0 (10) 10.6 (5) 16.7 (6) 65.9 (27) 73.7 (14) 38.5 (5) 33.3 (3) 25.0 (1) 51.4 (75) Documenting/reading documents Medicating the patient Verifying medicines Dispensing/preparing drugs Entry/transfer to unit Patient noticed the error Patient condition or lab values Detected otherwise Shift handover Physician round Other person noticed the error Not known
45.4 (64) 2.1 (2) 25.4 (16) 18.0 (9) 53.2 (25) 21.4 (9) 19.5 (8) 10.5 (2) 30.8 (4) 44.4 (4) 0 17.8 (26)
Other (%, (f )) Order (%, (f )) Storing (%, (f )) Delivery (%, (f )) Preparing (%, (f )) Prescribing (%, (f )) Dispensing (%, (f )) Documenting (%, (f )) Administration (%, (f )) Detecting errors
Table 1 Detecting the medication errors in different phases of the medication process (n = 670)
100 (141) 100 (95) 100 (63) 100 (50) 100 (47) 100 (42) 100 (41) 100 (19) 100 (13) 100 (9) 100 (4) 100 (146)
M Härkänen et al.
Total (%, (f ))
144
The aim of this study was to analyse how medication incidents are detected according to error reports. Most of the reporters were nurses. Physicians reported only 2.5% of the errors. The results are similar to previous studies.9,12 According to the study by Evans et al.,9 major barriers to reporting for physicians were lack of feedback, incident form taking too long to complete and a belief that the incident was too trivial. It is possible that incidents reported by physicians could have produced different information about errors, and it would be important to encourage them to report incidents and adverse events. Only in two cases it was estimated that errors caused severe harm to patients. The results are similar to previous error-reporting studies. Miller et al.12 analysed 1010 reported errors, and none of those were serious. Also, Griffin and Resar13 estimated that 90–95% of reported errors cause no harm to the patient. Nevertheless, in many cases, moderate or mild harm was caused to patients because of the errors, and these should also be prevented. Even though many of the reported errors had no clinical significance, it is important to use the information about them. Many of those might cause serious consequences, and it is important to learn how to break the chain of errors as early as possible. The incidences were most commonly found during documenting or reading the documents, for example during the handling of prescriptions. The importance of focusing on those medication tasks is essential. Also, comparing the written patient records to other documents and lists of medication is extremely important. Clearly written information is needed in clinical practice. Many errors were detected during handling of the drugs, such as medicating the patient and the dispensing or preparing of drug doses. In those situations, administration errors were usually detected. The importance of concentration on the task is especially underscored. Medication administration is considered to be a highly vulnerable stage of medication delivery because of multiple opportunities for incidents.14 Distractions might partly explain the increased risk of errors. Also, a heavy workload, long shifts and fatigue have an influence on personnel’s focus.15 Nurses should have the time and space to operate the medications without external distractions. That is not self-evident in a busy and complex hospital environment. Interruptions during nurses’ drug rounds or during
Detecting medication errors
medication administration are common. In the study by Biron et al.,16 a total of 6.3 work interruptions per hour were observed during medication administration. In the study by Palese et al.,17 interruptions were discovered during every third drug given. Interruptions interfere with working memory and cause lack of focus as well as creating feelings of stress and frustration.18 One major way of avoiding the problem should be through creating a calm atmosphere for working in every phase of the medication process. Space for dispensing medications should be separate without extra noise or distractions. The administration of medicines should be implemented without additional interruptions. Verifying the drugs before administration revealed many errors in this study, mostly dispensing errors. Sheu et al.19 found that the most common way of noticing the error was through double-checking the medication. However, there is also evidence that double-checking is not always effective and did not reveal all errors.20 Still, a double-checking policy should be encouraged when possible, at least when handling high-alert medications and in blood transfusions.19 Verifying should be a normal practice in a medication processes. Rushing or lack of understanding should not be a reason for not verifying effectively, or at all. There is currently no complete method of reducing all medication errors. Many improvements have already been made. There is evidence that using technology, such as barcode checks, could improve staff awareness and also reduce errors.21 Interventions such as unit dose dispensing systems, wearing ‘no interruptions’ vests by nurses during medication administration or creating no-interruption zones can be useful and helpful for reducing errors. Safety awareness of staff is highly important. Every error detected before reaching the patient is worthy of improvement. Individuals can do much for diminishing the risk of error but not without the support of systems. Still, in the future, there is a need to obtain more information about medication errors and their causes. Web-based reporting systems can give important information about incidents, and the information should not only be collected but also used for developing safer practices. In this study, it was found that the reporting practices should be developed so that more exact information can be found from reports. The ‘not known’ classification does not give the needed information. However, the limitations of incident reports exist, and different detection methods identified different errors and adverse events.22
145
Thus, also using a different method to complete the information of the phenomenon can be recommended.23
CONCLUSION In this study, we analysed how medication errors were detected in different phases of the medication process using the medication error reports. The critical factors of medication errors and phases of medication processes were detected. It is essential that nurses could increase concentration on medication processes. The nursing management and leadership should guarantee them the needed resources and possibilities to work without interruptions in order to implement safer medication practices.
ACKNOWLEDGEMENTS This research has been supported by the strategic funding of the University of Eastern Finland (Attractive and Safe Hospital study—project led by Professor Katri Vehviläinen-Julkunen) and by the Finnish Doctoral Programme in Nursing Science.
REFERENCES 1 Schelbred A-B, Nord R. Nurses’ experiences of drug administration errors. Journal of Advanced Nursing 2007; 60: 317–324. 2 Barker KN, Flynn EA, Pepper GA. Observation method of detecting medication errors. American Journal of HealthSystem Pharmacy 2002; 59: 2314–2316. 3 Wakefield BJ, Uden-Holdman T, Wakefield DS. Development and validation of the medication administration error reporting survey. Advances in Patient Safety 2005; 4: 475– 488. 4 The National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors, 2013. Available from URL: http://www.nccmerp.org/ aboutMedErrors.html. Accessed 8 April 2013. 5 Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Quality and Safety 2011; 20: 1027–1034. 6 Joolaee S, Hajibabaee F, Peyrovi H, Haghani H, Bahrani N. The relationship between incidence and report of medication errors and working conditions. International Nursing Review 2011; 58: 37–44. 7 Mansour M, James V, Edgley A. Investigating the safety of medication administration in adult critical care setting. Nursing in Critical Care 2012; 17: 189–197. 8 Savage SW, Schneider PJ, Pederson GA. Utility of an online medication-error-reporting system. American Journal of Health-System Pharmacy 2005; 62: 2265–2271. © 2013 Wiley Publishing Asia Pty Ltd
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9 Evans SM, Berry JG, Smith BJ et al. Attitudes and barriers to incident reporting: A collaborative hospital study. Quality and Safety in Health Care 2006; 15: 39–43. 10 van den Bemt PMLA, Robertz R, De Jong AL, van Roon EN, Leufkens HGM. Drug administration errors in an institution for individuals with intellectual disability: An observational study. Journal of Intellectual Disability Research 2007; 51: 528–536. 11 McBride-Henry K, Foureur M. Medication administration errors: Understanding the issues. Australian Journal of Advanced Nursing 2006; 23: 33–41. 12 Miller MR, Clark JS, Lehmann CU. Computer based medication error reporting: Insight and implications. Quality and Safety in Health Care 2006; 15: 208–213. 13 Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse events (Second edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare improvement, 2009. Available from URL: http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ IHIGlobalTriggerToolWhitePaper.aspx. Accessed 8 April 2013. 14 Wulff K, Cummings GG, Marck P, Yurtseven O. Medication administration technologies and patient safety: A mixed-method systematic review. Journal of Advanced Nursing 2011; 67: 2080–2095. 15 Hewitt P. Nurses’ perceptions of the causes of medications errors: An integrative literature review. Medsurg Nursing 2010; 19: 159–167.
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16 Biron AD, Lavoie-Tremblay N, Loiselle CG. Characteristics of work interruptions during medication administration. Journal of Nursing Scholarship 2009; 41: 330–336. 17 Palese A, Sartor A, Costaperaria G, Bresadola V. Interruptions during nurses’ drug rounds in surgical wards: Observational study. Journal of Nursing Management 2009; 17: 185–192. 18 Bennet J, Dawoud D, Maben J. Effects of interruptions to nurses during medication administration. Nursing Management 2010; 16: 22–23. 19 Sheu S-J, Wie I-L, Chen C-H, Yu S, Tang F-I. Using snowball sampling method with nurses to understand medication administration errors. Journal of Clinical Nursing 2008; 18: 559–569. 20 Armitage G. The risks of double checking. Nursing Management 2009; 16: 30–35. 21 Wild D, Szczepura A, Nelson S. New barcode checks help reduce drug round errors in care homes. Nursing Management 2011; 18: 26–30. 22 Naessens JM, Campbell CR, Huddleston JM et al. A comparison of hospital adverse events identified by three widely used detection methods. International Journal for Quality in Health Care 2009; 21: 301–307. 23 Olsen S, Neale G, Schwab K et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: Incident reporting, pharmacist surveillance and local real-time record review may all have a place. Quality and Safety in Health Care 2007; 16: 40–44.
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International Journal of Nursing Practice 2015; 21: 141–146
RESEARCH PAPER
Detecting medication errors: Analysis based on a hospital’s incident reports Marja Härkänen MSc RN PhD Student, Finnish Doctoral Programme in Nursing Sciences, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
Hannele Turunen PhD RN Professor, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Nurse Manager (adjunct), Kuopio University Hospital, Kuopio, Finland
Susanna Saano PhD Pharmacist, Kuopio University Hospital, Kuopio, Finland
Katri Vehviläinen-Julkunen PhD RN Professor, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Nurse Manager (adjunct), Kuopio University Hospital, Kuopio, Finland
Accepted for publication May 2013 Härkänen M, Turunen H, Saano S, Vehviläinen-Julkunen K. International Journal of Nursing Practice 2015; 21: 141–146 Detecting medication errors: Analysis based on a hospital’s incident reports The aim of this paper is to analyse how medication incidents are detected in different phases of the medication process. The study design is a retrospective register study. The material was collected from one university hospital’s web-based incident reporting database in Finland. In 2010, 1617 incident reports were made, 671 of those were medication incidents and analysed in this study. Statistical methods were used to analyse the material. Results were reported using frequencies and percentages. Twenty-one percent of all medication incidents were detected during documenting or reading the documents. One-sixth of medication incidents were detected during medicating the patients, and approximately one-tenth were detected during verifying of the medicines. It is important to learn how to break the chain of medication errors as early as possible. Findings showed that for nurses, the ability to concentrate on documenting and medicating the patient is essential. Key words: hospital, medication errors, nursing, patient safety, register study.
INTRODUCTION Medication is an important part of nurses’ work. At the same time, it represents one of the largest areas for risks in nursing practice. The possibility of an error always
Correspondence: Marja Härkänen, University of Eastern Finland, Department of Nursing Science, P.O. Box 1627, 70211 Kuopio, Finland. Email: [email protected] doi:10.1111/ijn.12227
exists because of the complexity of this multi-professional process.1 Nurses have a dual role in the medication process; they are both producers of errors and defenders against them.2 Thus, it is important to understand nurses’ perspectives on medication errors.3
Background Medication error is defined as a preventable event that might cause or lead to inappropriate medication use or © 2013 Wiley Publishing Asia Pty Ltd
142
M Härkänen et al.
patient harm while the medication is in the control of the health-care professional, patient or consumer.4 In this study, the concept of ‘incident’ refers to the description of both medication errors reaching patients as well as near misses, which are prevented before an error. High medication error rates have been found in previous studies. In the study of Westbrook et al.,5 errors were detected in up to 70% of intravenous medication administrations. Medication errors have been evaluated to be a serious threat to patients’ safety6 and are recognized as causes for patient morbidity and mortality in hospital settings.7 An important factor in improving patient safety in medication processes is to collect and analyse information about errors. In recent years, error-reporting systems have been created to enable health-care professionals to gather data on errors and use the information to identify opportunities for improvement.8 The aim of this paper is to analyse how medication incidents are detected in different phases of the medication process according to information received from hospital’s incident reports.
METHODS Design and data collection The study design is a retrospective register study. The material was collected from a web-based error-reporting database (HaiPro) at one of Finland’s five university hospitals. This hospital has 800 patient beds, and in 2010, there were 226 997 treatment days. Between January and December 2010, there were 1617 incident reports in the hospital’s database, of which 671 were connected to medication and used in this study. All health-care professionals who take part in patient care are able to report incidents on the error-reporting database (HaiPro). The reporting process is easy and fast, and it can be done anonymously on any workstation computer in hospital wards. The database collects information on incidents with web-based forms. This form contains both predefined pickup lists and spaces for free-text descriptions to be used when reporting about incidents.
Data analysis In the data analysis, the information on detecting errors was read from free-text descriptions of incidents. When reading the descriptions of the events, it was noted that the reporter had usually written about detecting the error. They wrote that, for example, ‘.. the error was detected when I went to write the details of administered medicine to patient records..’, or ‘I gave another patient’s drug to this © 2013 Wiley Publishing Asia Pty Ltd
patient. I noticed it during medication administration..’, or ‘..patient noticed that one of his medicines was missing and asked about the medicine..’. The qualitative material was quantified and classified into different categories depending on the contents. The incidences that could not be categorized reliably because of scarce description were classified as ‘not known’. Two experts analysed the material in collaboration (the principal investigator with a nursing background and a hospital pharmacist). The categorizing of incidents was jointly agreed. A consensus was reached for those incidents that were determined differently. The material was processed statistically using spss statistics 19.0 (SPSS Inc., Chicago, IL, USA) for Windows. Cross-tabulation was used when analysing the connection between how errors were detected and the phase of the medication process (stage). Results are reported using frequencies and percentages.
Ethical considerations The research permit was granted from the study hospital in December 2010, and the statement of Ethical Governance was granted from the University Ethics Board in January 2011. The study is a register study and so did not connect directly to patients. The data do not include patient names or any identifiers. When reporting the study results, there is no information that could reveal persons or hospital units from the population.
RESULTS A total of 671 medication incident reports were analysed. Most incidents (82.6%, n = 554) were reported by registered nurses. Practical nurses reported 6.6% (n = 44), pharmacists 5.4% (n = 36), physicians 2.5% (n = 17), examination personnel 0.7% (n = 5), students 0.7% (n = 5) and other health professionals 1.5% (n = 10) of the incidents. Approximately two-thirds (69.2%, n = 464) of errors reached to the patient; the rest (n = 207) were near misses. The majority of the errors did not cause any harm to patients (65.7%, n = 441). Of the errors, 15.6% (n = 105) were estimated to have caused mild harm, 2.4% (n = 16) moderate harm, 0.3% (n = 2) severe harm to patients and rest (16%, n = 107) were classified in the ‘not known’ class.
Detecting medication errors in different phases of the medication process Medication errors were detected in different ways (Fig. 1) and in different phases of the medication process
Detecting medication errors
143
Not known
146 (21,8 %)
DocumenƟng /reading documents
141 (21,0 %)
MedicaƟng the paƟent
95 (14,2 %)
Verifying medicines
63 (9,4 %)
Dispensing / preparing drugs
50 (7,5 %)
Entry/ transfer to unit
47 (7,0 %)
PaƟent noƟced the error
42 (6,3 %)
PaƟent condiƟon or lab.values
41 (6,1 %)
Detected otherwise
19 (2,8 %)
ShiŌ handover
Number of errors
13 (1,9 %)
Physician round
10 (1,5 %) 4 (0,6 %)
Other person noƟced the error 0
50
100
150
200
Figure 1. Detecting the medication errors (n = 671), (f, %). ( ) number of errors.
(Table 1). Approximately one-fifth (21.0%, n = 141) of the medication errors were detected during documenting or when reading the documents, for example during the handling of prescriptions. The majority of them were documenting (45.4%) or administrating (32.6%) errors. During medicating the patient, 14.2% (n = 95) of errors were detected. About two-thirds (65.3%) of those errors were administration errors, but dispensing errors (21.1%) were also detected. A portion (9.4%, n = 63) of medication errors were detected by verifying of medicines. Those were detected in the final verification before medicating the patients by double-checking or, for example, during verifying the medicines in shift changes. The majority of those errors were dispensing (27.0%) errors. Handling the drugs before administering them is usually one of the final possibilities to avoid a medication error. During the dispensing or the preparing of drug doses, 7.5% (n = 50) of errors were detected.
DISCUSSION Study limitations and strengths This study has some potential limitations. Firstly, classification of detecting errors was made based on the incident descriptions. Because of the limited description of the incidents, the ‘not known’ category included 22% of incidents, and this should be taken into account in assessing
the results. Secondly, it is known that only a small number of errors are noticed9,10 and that only a minority of them are reported for many reasons, such as disagreement with definition, reporting effort, fear or administrative response.3,9,11 This is why it is assumed that the material represents only a part of the actual medication errors. However, this is one of the problems with the nature of this field, and we must recognize that we will never know all of the errors. Finally, the generalization of the results has limitations because of the fact that the results were collected over specific time period of 1 year, in one hospital and in one country. Therefore, it is possible that aspects related to culture or time period might have effects on the study results. However, despite the fact that these were potential limitations, our findings are consistent with previous researches in this area and reference other similar findings. The strength of the research is that two experts analysed the material in collaboration, and all categorizing was jointly agreed. Secondly, the sample comprised 1 year information of the medication errors from one hospital. Therefore, the material, including much information on the medication incidences, is more valid. Finally, because previous medication error-reporting studies have not included an analysis on how the errors were detected, in this study, we can present new information about medication errors. © 2013 Wiley Publishing Asia Pty Ltd
0.7 (1) 21.1 (20) 27.0 (17) 16.0 (8) 6.4 (3) 54.8 (23) 2.4 (1) 5.3 (1) 15.4 (2) 0 0 15.1 (22)
20.6 (29) 1.1 (1) 7.9 (5) 16.0 (8) 27.7 (13) 4.8 (2) 7.3 (3) 0 0 22.2 (2) 75.0 (3) 13.0 (19)
0.7 (1) 5.3 (5) 3.2 (2) 12.0 (6) 2.1 (1) 2.4 (1) 2.4 (1) 0 0 0 0 0.7 (1)
0 1.1 (1) 7.9 (5) 4.0 (2) 0 0 0 10.5 (2) 7.7 (1) 0 0 0.7 (1)
0 2.1 (2) 4.8 (3) 6.0 (3) 0 0 0 0 0 0 0 0.7 (1)
0 1.1 (1) 4.8 (3) 6.0 (3) 0 0 2.4 (1) 0 0 0 0 0
0 1.1 (1) 0 2.0 (1) 0 0 0 0 7.7 (1) 0 0 0.7 (1)
Discussion of the results
© 2013 Wiley Publishing Asia Pty Ltd
One data is missing.
32.6 (46) 65.3 (62) 19.0 (12) 20.0 (10) 10.6 (5) 16.7 (6) 65.9 (27) 73.7 (14) 38.5 (5) 33.3 (3) 25.0 (1) 51.4 (75) Documenting/reading documents Medicating the patient Verifying medicines Dispensing/preparing drugs Entry/transfer to unit Patient noticed the error Patient condition or lab values Detected otherwise Shift handover Physician round Other person noticed the error Not known
45.4 (64) 2.1 (2) 25.4 (16) 18.0 (9) 53.2 (25) 21.4 (9) 19.5 (8) 10.5 (2) 30.8 (4) 44.4 (4) 0 17.8 (26)
Other (%, (f )) Order (%, (f )) Storing (%, (f )) Delivery (%, (f )) Preparing (%, (f )) Prescribing (%, (f )) Dispensing (%, (f )) Documenting (%, (f )) Administration (%, (f )) Detecting errors
Table 1 Detecting the medication errors in different phases of the medication process (n = 670)
100 (141) 100 (95) 100 (63) 100 (50) 100 (47) 100 (42) 100 (41) 100 (19) 100 (13) 100 (9) 100 (4) 100 (146)
M Härkänen et al.
Total (%, (f ))
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The aim of this study was to analyse how medication incidents are detected according to error reports. Most of the reporters were nurses. Physicians reported only 2.5% of the errors. The results are similar to previous studies.9,12 According to the study by Evans et al.,9 major barriers to reporting for physicians were lack of feedback, incident form taking too long to complete and a belief that the incident was too trivial. It is possible that incidents reported by physicians could have produced different information about errors, and it would be important to encourage them to report incidents and adverse events. Only in two cases it was estimated that errors caused severe harm to patients. The results are similar to previous error-reporting studies. Miller et al.12 analysed 1010 reported errors, and none of those were serious. Also, Griffin and Resar13 estimated that 90–95% of reported errors cause no harm to the patient. Nevertheless, in many cases, moderate or mild harm was caused to patients because of the errors, and these should also be prevented. Even though many of the reported errors had no clinical significance, it is important to use the information about them. Many of those might cause serious consequences, and it is important to learn how to break the chain of errors as early as possible. The incidences were most commonly found during documenting or reading the documents, for example during the handling of prescriptions. The importance of focusing on those medication tasks is essential. Also, comparing the written patient records to other documents and lists of medication is extremely important. Clearly written information is needed in clinical practice. Many errors were detected during handling of the drugs, such as medicating the patient and the dispensing or preparing of drug doses. In those situations, administration errors were usually detected. The importance of concentration on the task is especially underscored. Medication administration is considered to be a highly vulnerable stage of medication delivery because of multiple opportunities for incidents.14 Distractions might partly explain the increased risk of errors. Also, a heavy workload, long shifts and fatigue have an influence on personnel’s focus.15 Nurses should have the time and space to operate the medications without external distractions. That is not self-evident in a busy and complex hospital environment. Interruptions during nurses’ drug rounds or during
Detecting medication errors
medication administration are common. In the study by Biron et al.,16 a total of 6.3 work interruptions per hour were observed during medication administration. In the study by Palese et al.,17 interruptions were discovered during every third drug given. Interruptions interfere with working memory and cause lack of focus as well as creating feelings of stress and frustration.18 One major way of avoiding the problem should be through creating a calm atmosphere for working in every phase of the medication process. Space for dispensing medications should be separate without extra noise or distractions. The administration of medicines should be implemented without additional interruptions. Verifying the drugs before administration revealed many errors in this study, mostly dispensing errors. Sheu et al.19 found that the most common way of noticing the error was through double-checking the medication. However, there is also evidence that double-checking is not always effective and did not reveal all errors.20 Still, a double-checking policy should be encouraged when possible, at least when handling high-alert medications and in blood transfusions.19 Verifying should be a normal practice in a medication processes. Rushing or lack of understanding should not be a reason for not verifying effectively, or at all. There is currently no complete method of reducing all medication errors. Many improvements have already been made. There is evidence that using technology, such as barcode checks, could improve staff awareness and also reduce errors.21 Interventions such as unit dose dispensing systems, wearing ‘no interruptions’ vests by nurses during medication administration or creating no-interruption zones can be useful and helpful for reducing errors. Safety awareness of staff is highly important. Every error detected before reaching the patient is worthy of improvement. Individuals can do much for diminishing the risk of error but not without the support of systems. Still, in the future, there is a need to obtain more information about medication errors and their causes. Web-based reporting systems can give important information about incidents, and the information should not only be collected but also used for developing safer practices. In this study, it was found that the reporting practices should be developed so that more exact information can be found from reports. The ‘not known’ classification does not give the needed information. However, the limitations of incident reports exist, and different detection methods identified different errors and adverse events.22
145
Thus, also using a different method to complete the information of the phenomenon can be recommended.23
CONCLUSION In this study, we analysed how medication errors were detected in different phases of the medication process using the medication error reports. The critical factors of medication errors and phases of medication processes were detected. It is essential that nurses could increase concentration on medication processes. The nursing management and leadership should guarantee them the needed resources and possibilities to work without interruptions in order to implement safer medication practices.
ACKNOWLEDGEMENTS This research has been supported by the strategic funding of the University of Eastern Finland (Attractive and Safe Hospital study—project led by Professor Katri Vehviläinen-Julkunen) and by the Finnish Doctoral Programme in Nursing Science.
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