JBI Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settingsBest Practice 14(4) 2010 | 1

Evidence-based information sheets for health professionals

Recommendations• Individualorpatientdosesystemsshouldbeinplacewithinthehospital,ratherthanstockbasedmedicationsystems.(Grade B)

• Medicationadministrationshouldtakeplaceasclosetothepatientaspossibleeitherfromatrolleyorbedsidelocker. (Grade B)

• Includingthepatientmorefullyinthemedicationadministrationprocessthroughselfadministrationorinvolvementinthecheckingprocesshassomepotentialforreducingerrors. (Grade B)

• Reductionofmedicationadministrationerrorsmaybeachievedthroughaconsiderationofnurses'perceptionsofexternalfactorsincludingstructuresthatareinplaceformedicationadministrationandtheorganisationofcarewithinacute,hospitalbasedsettings.(Grade A)

• Reductionofmedicationerrorsmaybeachievedthroughaconsiderationofnurses'perceptionsofinternalfactorsincludingpersonalcharacteristicsandrelationshipsthatexistaroundmedicationadministrationprocessesinacutehospitalbasedsettings.(Grade A)

• Patientsshouldbeencouragedandincludedinthemedicationadministrationprocessthroughverbalandnon-verbalcommunication.Nursesshouldlistentopatientsconcernsandalsoprovidewritteninformationonthedrugadministrationprocessanddrugsbeingadministered.(Grade B)

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

Best Practice 14(4) 2010 | 1

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

ThisinformationsheetfirstpublishedastheJoannaBriggsInstitute. Rolesandsystemsforroutinemedicationadministrationtopreventmedicationerrorsinhospital-basedacutecaresettings

Best Practice:evidence-basedinformationsheetsforhealthprofessionals.2010;14(4):1-4

Information SourceThisBestPracticeinformationsheethasbeenderivedfromasystematicreviewpublishedin2010inJBILibraryofSystematicReviews.Thefulltextofthesystematicreviewreport2isavailablefromtheJoannaBriggsInstitute (www.joannabriggs.edu.au)

BackgroundMedicationerrorsoccurworldwideandinmanyhealthcaresettings.Thenumberofsucherrorsis,onthewhole,unknown,asmanyincidentsareneverdiscovered,acknowledgedorreported.Ithasbeensuggestedthatupto10timesmoreerrorsarecommittedthanreported.3Levelsofmedicationadministrationerrors(MAEs)havebeenreportedasaccountingfor38%ofalladversedrugeventsandhavebeencalculatedasoccurringin3-8%ofalladministrations.4,5Unlikeothererrorsthatoccurearlierinthemedicationchain,whichareoftenintercepted,suchaswithprescribing,only2%ofadministrationerrorsaredetected.Theprocessforroutinemedicationadministrationhasanumberoffactorswhichhavebeenidentifiedascontributingtoerrors:mathematicalskills,knowledgeofmedications,thequalityoftheprescription,lengthofexperience,shiftpatterns,workloadandstaffinglevels,medicationdeliverysystems,single-nurseadministration,policiesandproceduresanddistractionsandinterruptions.6 Acutecarehospitalsettingsbringadditionalconcernsforroutinemedicationadministration,particularlyincreasingpressuresonstaff,increasingnumberofdrugs,polypharmacy,increasinglysimilarsoundingdrugnames,increasedthroughputofpatients,rangesofillnessesandtreatments,agreatervarietyofadministrationroutesandpressuresoftimetocompleteadministration“rounds”.

Grades of RecommendationTheseGradesofRecommendationhavebeenbasedontheJBI-developed2006 Grades of Effectiveness1

Grade A StrongsupportthatmeritsapplicationGrade B Moderatesupportthatwarrantsconsideration

ofapplicationGrade C Notsupported

JBI Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings2 | Best Practice 14(4) 2010

ObjectivesThepurposeofthisBestPracticeInformationSheetistopresentthebestavailableevidenceforrolesandsystemsforroutinemedicationadministrationtopreventmedicationerrorsinhospital-basedacutecaresettings.

Quality of the research Sevenquantitative(surveytype)studiesandthreequalitativestudiesexaminednursesperceptionsofcausesofmedicationadministrationerror.Onlyonequalitativestudyexploredthepatient’sperceptionsofmedicationadministrationanderrors.Twostudiesofselfadministrationofmedicineswereincludedinthereview.OneRCTand5evaluationstudiesexaminedtherolesandsystemsformedicationadministration.

Outcomes measures

PerceptionsofmedicationadministrationerrorNurses perceptions of causes of medication administration error

Quantitative evidence for nurses perceptions of medication administration errorsAlargesurveyofnursesintheUSsoughttoidentifynursesperceptionsofcausesofmedicationadministrationerror.Thehighestscorewasforinterruptionstonurseswhileadministeringmedicationsandprescriptionsfrommedicalstaffnotbeingclearorlegiblewere2ndand3rd.Anotherstudyreportedtranscriptionerrors(usuallyreferstothetransferofaprescriptionontoamedicationadministrationrecord(MAR))asperceivedmosthighlyinrespectoferrors(73.6%ofrespondents),followedbydistractions(56.3%)andlegibility(49.3%).Thelowestthreescoreditemswereallrelatedtothedrugsorpharmacy–incorrectlyfilled(10.4%),mislabelled(11.1%),orlookalikemedications(11.8%).Factorsrelatedtoindividualnursefactorssuchasmiscalculations(34%)andfailuretofollowprocedure/policy(17.4%)weremidwayinthelevelofresponses.

QualitativeevidencefornursesperceptionsofmedicationadministrationerrorsThreequalitativestudieswereincludedinthesystematicreview.ThesynthesisoffindingsfromthesethreestudieshighlightedthattherewereExternalandInternalfactorsthatwereperceivedascontributingtomedicationadministrationerrors.

External factorsExternalfactorsconsistedofavarietyofcategoriesrelatedtothe:useofpolicies,protocolsandguidance,contextandorganisationofcareandrolesofpeoplewithinthesystem.Nursesviewedpolicytypeguidanceasbeingbothvaluable,forexamplewhendoublecheckingpickeduppotentialerrorsorunhelpfulwhenitwasn’tspecificenoughaboutparticularmedications.Perceptionsarereportedthatinterruptionstothemedicationroundcontributedtoerror,asdidnotbeingorganisedinplanningworktoensurethatinterruptionswereminimised.Teamworkbetweenprofessionalswasnotedbynursesasadverselyaffectingthemedicationadministrationprocess.Communicationchannelsbetweendifferentprofessionalswasoftenviewedasineffectiveandcouldimpactonmedicationerrors.Therolethatprescribers(inthiscasemedicalstaff)playwasidentifiedasinfluential,specificallythemannerinwhichordersarewritten(particularlylegibility)andchangescommunicatedtonurses.Nursesalsoperceivedthatthepatient/clientshould,wherepossible,haveanactiveparticipatoryroleasthiscouldreduceerrorrates.Therewasaperceptionthatnursesperceivedthemonitoringandfollowupprocessforerrorsaspunitiveandthatmanagersoftenplacestaffinunsafesituationswhichmaybothinhibitreportingandincreasetherisksassociatedwithmedicationerrors.

Definition of terms Forthepurposesofthisinformationsheetthefollowingdefinitionswereused:

Medication error-“anypreventableeventthatmaycauseorleadtoinappropriatemedicationuseorpatientharmwhilethemedicationisincontrolofhealthprofessional,patientorconsumer”.7

Routine medication administration-isthatwhichisnormallycarriedoutbynursesatspecifiedtimeintervalsinhospitalwardsandunits.

JBI Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settingsBest Practice 14(4) 2010 | 3

Internal factorsInternalfactorsconsistedof:interpersonalskillsandrelationships,individualknowledgeandskills,personalresponsibility.Onestudyreportedhownursessawthemselvesasresponsibleformedicationerrorsandhowtheoverlayofcontextualfactorssuchasnightshiftsincreasedthisperception.Tiredness,stress,lackofconfidenceinchallengingdoctors,concentration,complacencyandeventhepersonalityofthenursecouldbeconsideredinternalfactors.Therewasalsoaperceptionthathavinggoodinterpersonalskillsinnursescanimpactonmedicationadministrationandthiscaninfluenceteamworkwithmedicalstaffandpharmacists.Thiscanalsoincreasethesupportavailableforthosewhoareinexperiencedandwhoneedacontextthatissupportiveattheoutset.Levelofknowledgewasalsoseentobeafactorthatimpactedonmedicationerrors.Themoreknowledgethelesslikelyerrorswouldbemade.

Qualitativeevidenceforpatient’sperceptionsofmedicationadministrationanderrorsOnlyonequalitativestudywasidentifiedonpatientperceptions.Fromtheperspectiveofthepatientinacutecaresettingsitappearedthattheircontributiontoerrorreductioncouldbevaluable.Patientsshould,whereverpossible,beencouragedandincludedinthemedicationadministrationprocessthroughverbalandnon-verbalcommunication.Patientshighlightedhownursesmaynotlistentotheirconcerns,maybelievethenurseknowsbestand,forthemselves,beunawareofthemedicationadministrationprocessintheacutesetting.

RolesandsystemsformedicationadministrationIndividualised and Unit dose medication systemsUnit or patient dose systems Onestudyhighlightedthepotentialthatunitorpatientdosesystemscanhaveonreducingmisseddosesasagainstadministrationfromawardstock(imprestsystem).Fourhospitalswithsimilarwardswereutilised;threeusedtheimprestsystem,onetheunitdosesystem.Acrossthethreehospitalsusingtheimprest(stockbasedsystem)5.7%oftotaldoseswereidentifiedasmissed.Intheonehospitalusingunitdoseapproach4.1%oftotaldoseswereidentifiedasmissed(p<0.005).

Unit supply/bedside system Inonestudyacomparisonofatrolleybasedwardstocksystemwithaunitsupplysystemwheremedicationswereplacedinalockedbedsidedrawerwasundertakenonamedicalandsurgicalwardandwhilstonlyasmallnumberofnursesparticipated,showedanoverallreductioninerrorsfrom62.8%withthewardstocksystemto39.2%(p=0.00005)fortheunitsupply/bedsidesysteminthemedicalwardandfrom46.2%to25%(p=0.00005)inthesurgicalward.Themajorityoftheseerrorswereaccountedforbyminortimingerrors.Whentimingerrorswereremovedtherateswere8.5%forwardstocksysteminthemedicalwardto1.2%fortheunitsupply/bedsidesystemandfrom13.4%to3.6%inthesurgicalward(p=0.00005).

Trolley vs fixed ward bay administrationInonesmallstudymedicationerrors(primarilyadministrationerrors)werecomparedina30bedsurgicalwardwhichhadanaturaldivisionwherebyhalfofthewardhaddrugadministrationviaatrolleyandtheotherhalffixedwardbaydistributionpointsthatcouldserveuptosixpatients.Twodispensingerrorswereobservedand20administrationerrors.Thetrolleysystemhadanerrorrateof2.6%,thewardbaysystemanerrorrateof9.2%(p=0.034).

Ward bay vs bedsideOnestudycomparedwardbayadministrationwithbedsideadministrationfromthepatient’slocker.Errorsusingthebedsidesystemwere7%vsWardBayerrors16.4%(p=0.02).Errorrateswheninjectionswereremovedfromtheresultswerethatbedsideadministrationremainedat7%,wardbayincreasedto17.6%(p=0.02).

Self administration of medicinesOnlytwostudiesonselfadministrationinacutecarewereidentifiedthatsoughttomeasureerrorrates.OnesmallstudytoevaluatetheeffectivenessofanSelfMedicationProgramme(SMP)ona26bedsmedicalandsurgicalunitfoundnopatientinitiatedmedicationerrorswiththeSMPbutanincreaseinnurseinitiatederrors(from1to2).Thesecondstudycomparedaco-operativecarecentrewith“traditionalnursingunits”withinthesamemedicalcentre.Co-operativecareaccountedfor19.4%ofdischarges,10.3%ofpatientdaysbutonly4.6%ofallmedicationerrors.Amedicationerrorrateof3.6per1000dischargesinco-operativecarewasidentifiedoveraretrospective4yearperiodwhereastraditionalnursingunitshad17.8errorsper1000discharges.80errorsoccurredin261,443medicationordersinco-operativecare(3.06per10,000orders)vs1643errorsin4,094,352orders(4.01per10.000orders)intraditionalnursingunits.50%oferrorsinco-operativecarewereattributedtonursingstaff.

JBI Roles and systems for routine medication administration to prevent medication errors in hospital-based acute care settings4 | Best Practice 14(4) 2010

AcknowledgmentsThisBestPracticeinformationsheetwasdevelopedbyTheJoannaBriggsInstitute.

References1. 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.

“The procedures described in Best Practice must only be used by people who have appropriate expertise in the field to which the procedure relates. The applicability of any information must be established before relying on it. While care has been taken to ensure that this edition of Best Practice summarises available research and expert consensus, any loss, damage, cost, expense or liability suffered or incurred as a result of reliance on these procedures (whether arising in contract, negligence or otherwise) is, to the extent permitted by law, excluded”.

TheJoannaBriggsInstitute TheUniversityofAdelaide SouthAustralia5005 AUSTRALIAwww.joannabriggs.edu.au

©TheJoannaBriggsInstitute2011ph: +61883034880 fax:+61883034881 email:jbi@adelaide.edu.au

Publishedby BlackwellPublishing

Use individual or patientsystems for medicationadministration

Include patients in themedication administrationprocess

Consider nurses’perceptions of structuresand relationships aroundmedication administrationprocess

Use bedside locker formedication administration

YesNo

Risk of medication errors

Prevention ofmedication errors

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

ThisBest Practiceinformationsheetpresentsthebestavailableevidenceonthistopic.Implicationsforpracticearemadewithanexpectationthathealthprofessionalswillutilisethisevidencewithconsiderationoftheircontext,theirclient’spreferenceandtheirclinicaljudgement.8

Evidence-based Practiceevidence,context,clientpreference

judgement