Background
Methods
Setting
Study design
Data collection
Data analysis
Opportunity for error |
The number of opportunities for error (OE) was the denominator used to determine the MAE rate. An OE was defined as any dose that was prepared and administered to the patient and could be determined as being correct or incorrect by the researcher, or a dose that was due for administration but omitted in error [16]. An administered drug was defined as either the patient consuming the prepared medication or the prepared medication being left by the patient’s bedside for self-administration [16]. Medication doses that were administered unsuccessfully due to the patient being unable to take the dose or subsequent refusal were also considered OEs if the researcher could determine preparation and attempted administration as being correct or incorrect. Each dose was considered to be one OE. |
Medication administration error |
Medication administration errors (MAE) were defined as any deviation or omission from the medication order as stated on the patient’s drug chart [16]. An omission was defined as a dose of medication that had not been administered by the time of the next scheduled dose. This included omission of a dose because the medication was not available on the ward as well as unintentional omissions. Doses omitted according to a doctor’s instructions, or if the patient was not on the ward or refused the medication, were not considered to be OEs. Doses omitted as a result of a nurse’s clinical judgement were also not considered OEs. Administration processes that did not adhere to local hospital policy were not considered MAEs; for example a dose not administered within two hours of the time for which it was prescribed was not considered an MAE if it was otherwise correct. Errors prevented by the observer were included as MAEs although errors prevented by other healthcare professionals working within their usual roles were not. |
Documentation discrepancies |
Discrepancies in documentation (DD) occurred when the documented details of dose administration or omission were different to what happened in practice as observed by the researcher [16]. Documentation was considered for all medication doses due, including omissions. |
Results
Observations and opportunities for error
Prevalence and type of medication administration errors
Pre-ePA (paper only; 428 OEs) | Post-ePA (ePA only; 528 OEs) | Post-ePA (ePA and paper; 597 OEs) | ||||||
---|---|---|---|---|---|---|---|---|
n | Percentage (95% CI) | n | Percentage (95% CI) |
P valuea
| n | Percentage (95% CI) |
P valueb
| |
Total MAEs | 18 | 4.2% (2.3–6.1) | 18 | 3.4 (1.9–5.0) | 0.64 | 24 | 4.0% (2.4–5.6) | 0.99 |
MAEs excluding omission due to unavailability of drug | 12 | 2.8% (1.2–4.4) | 11 | 2.1% (0.9–3.3) | 0.61 | 12 | 2.0% (0.9–3.1) | 0.54 |
Only MAEs due to unavailability of drug | 6 | 1.4% (0.2–2.5) | 7 | 1.3% (0.3–2.3) | 0.86 | 12 | 2.0% (0.9–3.1) | 0.62 |
Paper or ePA prescribing | Error type (definitions based on existing work [30]) | Drug(s) involved in error | Field notes for additional context where relevant |
---|---|---|---|
Pre-ePA (paper) | Wrong dose | 5 mg of morphine sulphate solution administered instead of 2.5 mg | The prescribed dose was “2.5 mg”. The nurse erroneously drew 2.5 ml of 10 mg/5mlsolution instead of 1.25 ml into an oral syringe. The quantity in the syringe was checked by a second nurse and a student nurse was also observing. |
Pre-ePA (paper) | Wrong dose | 312.5 mg of co-amoxiclav liquid administered instead of 625 mg | The nurse originally read the prescribed dose as “625 mg”. Then they read the concentration of co-amoxiclav on the bottle (250 mg/62.5 mg in 5 ml) and concluded that the prescribed dose actually read 62.5 mg as stated on the bottle of co-amoxiclav, not 625 mg. They informed the student nurse that the dose correlates to the smaller of the two numbers stated on the co-amoxiclav bottle (62.5 mg). Therefore 5 ml was prepared, the researcher intervened. |
Pre-ePA (paper) | Wrong dose | 12.5 mg of spironolactone administered instead of 25 mg | The original prescribed dose was 12.5 mg which had then been amended by the prescriber by scoring through the dose and re-writing “25 mg” next to the old dose. The rewritten dose was potentially unclear and interpreted as 12.5 mg. |
Post-ePA (paper) | Unintentional omission | Ramipril 2.5 mg | The nurse did not notice this drug was written on a new drug chart, the administration box was left blank. The paper chart was then transcribed to ePA and the next dose was prescribed for the following morning, so the dose was omitted. |
Post-ePA (ePA) | Wrong dose | 25 mg of metolozone administered instead of 2.5 mg | The nurse prepared five 5 mg tablets instead of cutting one tablet in half. The researcher intervened. The nurse stated that they read the dose specifically as they were not familiar with the drug. They could not see the decimal place on the computer screen and therefore read 25 mg as the dose. |
Post-ePA (ePA) | Wrong form | Venlafaxine 75 mg modified release administered instead of immediate release | The medication administered was the patient’s own, therefore it is likely that the prescription was incorrect although the nurse did not notice this. |
Post-ePA (ePA) | Wrong route | Furosemide 40 mg oral administered instead of intravenous dose | The nurse prepared oral furosemide for administration. The researcher intervened and the nurse stated that they had not noticed the route of administration. |
Post-ePA (ePA) | Wrong route | Atropine 1% eye drops administered in eyes instead of sublingually | The eye drops were being used off-label and prescribed via sublingual route although administered in each eye. The researcher intervened and the nurse stated they had not noticed the additional instructions specifying the route of administration. The researcher informed the nurse after administration to the eye. |