Incidents et accidents médicamenteux en établissement de santé : une analyse descriptive au sein d'un CHU mère-enfant de 2018 à 2022.

Background: The safety of care provided is based on an analysis of medication incidents and accidents. Objective: The primary objective was to describe medication-related incidents and accidents (I&A) within a university-affiliated hospital. Methods: This retrospective descriptive study was based on data from a 500-bed mother-child university-affiliated hospital. All I&As declared between April 1, 2018, and March 31, 2022, were considered. The analysis included all medication-related I&As that occurred during an admission or in an outpatient setting. Some variables were recoded manually. Descriptive statistical analyses were performed. Results: A total of 23 284 I&As were considered, including 7578 medication-related I&As. Daily averages of 15.9 ± 14.0 I&As and 5.2 ± 0.3 medication-related I&As were reported. There were 22.4 medication-related I&As/1000 inpatient days. The majority of medication-related I&As occurred in surgery (20%, 1530/7578), oncology (19%, 1405/7578), and pediatrics (16%, 1200/7578). Most were associated with incorrect dosing (21%, 1575/7578); infiltration, extravasation, or removed lines (19%, 1405/7578); and omissions (16%, 1205/7578). Physical consequences were reported in 15% (1158/7578) of the medication-related I&As. Conversely, psychological consequences were reported in less than 1% (44/7578) of medication-related I&As. Conclusions: This study provides a comprehensive descriptive profile over a 4-year period. Most of the reported I&As did not lead to consequences for patients. The sharing of ratios promotes comparative analysis with other facilities and can contribute to discussions about risk reduction. A culture of reporting events is present within this health care facility.

Ratios d'incidents et d'accidents totaux et médicamenteux par 1000 jours-présence en établissement de santé au Québec: une étude exploratoire.

Background: Since 2022, it has been mandatory in Québec to report all incidents and accidents (I&As) occurring in health-care facilities. Since 2011, a summary report of these I&As has been published each year. However, it is difficult to compare health facilities given that no denominator is specified and ratios are not calculated. Objective: The primary objective was to calculate the ratios of total I&As and medication-related I&As per 1000 inpatient-days per type of facility for all health-care facilities in Québec. Methods: This retrospective descriptive study was based on data from the period of April 1, 2016, to March 31, 2021. Data were extracted from the National Register of Incidents and Accidents Occurring during the Provision of Health Care and Social Services in Québec (Registre national des incidents et accidents survenus lors de la prestation des soins et services de santé au Québec) and financial reports. The ratios of total I&As/1000 inpatient-days and medication-related I&As/1000 inpatient-days, expressed as the mean ± standard deviation and median [minimum; maximum], were calculated. Results: A total of 85 health-care facilities had usable data, specifically 33 acute-care facilities, 45 long-term care facilities, and 7 rehabilitation facilities. The mean ratio for total I&As/1000 inpatient-days varied from 33 ± 19 to 38 ± 22 in acute-care facilities, from 14 ± 5 to 16 ± 7 in long-term care facilities, and from 99 ± 39 to 147 ± 55 in rehabilitation facilities. The mean ratio for medication-related I&As/1000 inpatient-days varied from 11 ± 7 to 12 ± 7 in acute care facilities, from 3 ± 2 to 4 ± 3 in long-term care facilities, and from 24 ± 10 to 40 ± 21 in rehabilitation facilities. Conclusions: This exploratory study demonstrated the feasibility of calculating I&A ratios from the National Register of Incidents and Accidents Occurring during the Provision of Health Care and Social Services in Québec. These ratios facilitate discussion of the reporting culture of I&As within the health-care system. It is hoped that these ratios will be added to future annual reports from the Québec I&A register.

Two-year audit of compliance in the preparation and administration of medications by nursing staff in a mother-and-child university hospital center.

OBJECTIVE: Audits are essential for reviewing and improving the medication-use process. Identifying areas for improvement can limit the risk of errors when preparing and administering drugs. Pediatric centers face specific challenges in ensuring the safety of the medication-use process. The objective of this study was to observe and compare compliance with criteria for the preparation and administration of medications by nurses in a mother-and-child university hospital center over two consecutive years. METHODS: This observational cross-sectional study was conducted in a Canadian mother-and-child university hospital center. Audits were conducted over a 1-month period in 16 and 18 nursing care sectors in 2021 and 2022, respectively. The standardized audit evaluated compliance with prespecified criteria related to the preparation and administration of medication by nursing staff (77 criteria for 2021 and 82 criteria for 2022). The auditors comprised nurses and a pharmacist trained by the research team. Compliance was compared between years and assessed through a chi-square test. RESULTS: The audit consisted of 522 observations in 2021 and 448 observations in 2022. Overall compliance was 76% in 2021 and 66% in 2022. The compliance rate by criterion ranged from 16% to 100%. In 2021 and 2022, 51 (84%) and 52 (87%) of the criteria, respectively, had compliance rates of more than 75%, and 12 (20%) and eight (13%), respectively, had 100% compliance. There were statistically significant decreases in compliance for nine of the 39 criteria for preparation of medications, notably prior hand hygiene (91%% vs. 84%, p = 0.002), and for six of the 17 criteria for administration of medications, including mentioning possible adverse effects to the patient (41% vs- 30%, p = 0.008). CONCLUSION: In this study, compliance was over 75% for most of the criteria. However, for a few criteria, we observed a decrease in compliance from 2021 to 2022. Various hypotheses are proposed to explain these decreases, such as the COVID-19 pandemic.

Design and Development of an Escape Game as a Knowledge Transfer Tool in Preparation for an Accreditation Visit in a Health Care Facility.

Background: Knowledge transfer helps health care staff to be competent, well informed, and up to date. It also contributes to adherence to standards and best practices. Objectives: To design, implement, and evaluate an escape game based on a selection of Accreditation Canada required organizational practices (ROPs). Methods: This prospective descriptive study involved nurses and pharmacists in a health care centre. An escape game based on 6 ROPs was designed. The game was played by teams of participants in a patient room within the centre, with each game lasting 25 minutes. Participants' satisfaction with various aspects of their experience was assessed. Results: A total of 200 people (52 teams) participated in the escape game. About half of the teams (n = 28) completed the game within the allotted time (average completion time 20 minutes, 53 seconds; standard deviation [SD] 2 minutes, 45 seconds). On average, 1.32 (SD 0.88) clues were provided to successful teams and 1.88 (SD 0.95) to unsuccessful teams. Participants were very satisfied with their experience. However, members of unsuccessful teams had significantly lower agreement that the escape game was relevant to their practice and that it was an effective method of communication. Conclusions: An escape game based on a selection of ROPs was successfully implemented as part of the hospital's preparation for an accreditation visit. Use of an escape game as a knowledge transfer tool was appreciated by the staff.

Contexte: La transmission des connaissances aide le personnel de la santé à être compétent, bien informé et à jour. Elle contribue également au respect des normes et des meilleures pratiques. Objectifs: Concevoir, mettre en œuvre et évaluer un jeu d'évasion basé sur une sélection de pratiques organisationnelles requises (POR) d'Agrément Canada. Méthodes: Des infirmiers et des pharmaciens d'un centre de santé ont participé à cette étude prospective descriptive. Un jeu d'évasion basé sur 6 POR a été conçu. Des équipes de participants y ont joué dans une chambre de patient au sein du centre, chaque partie durant 25 minutes. La satisfaction des participants à l'égard de divers aspects de leur expérience a été évaluée. Résultats: Au total, 200 personnes (52 équipes) y ont participé. Environ la moitié des équipes (n = 28) ont terminé le jeu dans le temps imparti (temps moyen d'achèvement 20 minutes, 53 secondes ; écart type [ET] 2 minutes, 45 secondes). En moyenne, 1,32 indice (ET 0,88) a été remis aux équipes qui l'ont réussi et 1,88 (ET 0,95) aux équipes qui ont échoué. Les participants étaient très satisfaits de leur expérience. Cependant, les membres des équipes ayant échoué étaient significativement moins d'accord sur le fait que le jeu d'évasion était pertinent pour l'exercice de leur profession et qu'il s'agissait d'une méthode de communication efficace. Conclusions: Un jeu d'évasion basé sur une sélection de POR a été mis en place avec succès dans le cadre de la préparation de l'hôpital à une visite d'agrément. L'utilisation d'un jeu d'évasion comme outil de transmission des connaissances a été reçue de manière positive par le personnel.

Surveillance des substances contrôlées en établissements de santé : une contribution à la gestion de la crise des opioïdes au Canada.

BACKGROUND: The use of controlled substances, especially opioids, is a public health concern. Canada is the country with the second greatest opioid use in the world. The use of these substances is associated with problems of misuse, as evidenced by North America's opioid crisis. OBJECTIVES: To describe and analyze usage patterns for controlled substances in a health care facility from 2003/04 to 2017/18, and to propose a tool for monitoring the use of controlled substances in this setting. METHOD: In this retrospective descriptive study, usage data for all controlled substances were extracted from the institution's supply management software for the period April 1, 2003, to March 31, 2018. The data are presented according to the Anatomical Therapeutic Chemical classification in terms of number of Defined Daily Doses (DDD) per 1000 inpatient-days, using the DDD values proposed by the World Health Organization. Only descriptive statistics were determined. RESULTS: During the last 15 years, use of controlled substances at the study facility dropped by 43% (min. 739 and max. 1292 DDD/1000 inpatient-days per year). From 2003/04 to 2017/18, the main therapeutic classes consumed (in decreasing order) were opioids, hypnotics and sedatives, anxiolytics, and general anesthetics. The main opioid molecules consumed in 2017/18 were hydromorphone and injectable morphine. CONCLUSIONS: This retrospective descriptive study showed a decrease in the consumption of controlled substances in the study facility from 2003/04 to 2017/18. It also demonstrated the feasibility of developing a tool for monitoring the use of controlled substances in a health care facility. This approach could be implemented at a larger scale to foster comparisons between facilities.

Conformité du circuit du médicament dans les unités de soins et les cliniques externes : étude observationnelle transversale au sein d'un établissement universitaire de 500 lits.

BACKGROUND: In the hospital setting, the medication-use system is complex, having more than 50 steps. To assess the compliance of the study organization's medication-use system with established criteria, an annual audit process was developed. OBJECTIVES: The primary objective was to describe the compliance of certain steps in the medication-use system (mainly medication management) in care units and outpatient clinics of a mother and child university hospital centre. The secondary objective was to compare the current results with those of previous audits. METHODS: This cross-sectional descriptive observational study was carried out in summer 2018 in patient care units (n = 34) and outpatient clinics (n = 28) of the study hospital. Data were collected according to an audit matrix. RESULTS: In 2018, the rate of compliance with audit criteria varied between 32% and 100% for the patient care units. Relative to the previous year, the compliance rate remained unchanged for 30 criteria and worsened for 4 criteria. For 35% of the criteria (12/34), compliance was greater than 85%. In 2018, the rate of compliance with audit criteria varied between 0% and 100% for the outpatient clinics. The compliance rate increased for one criterion, remained unchanged for 21 criteria, and worsened for 2 criteria. For 32% of the criteria (9/28), compliance was more than 85%. Thirty-five recommendations were made to the pharmacy and nursing care committee, and a personalized report was sent to managers. CONCLUSIONS: This cross-sectional descriptive observational study reports the degree to which the medication-use system complies with medication management criteria, mainly in patient care units and outpatients' clinics. This original approach from the Pharmacy Department led to the formulation of 35 recommendations to the pharmacy and nursing care committee, which helped to improve the safety of the medication-use system in patient care units and outpatient clinics.

Utilisation des jeux d'évasion en santé : une revue de littérature.

BACKGROUND: Many different teaching strategies are used to promote learning in an academic or professional environment. Among these can be noted the emergence of simulation, based on the concept of escape games. OBJECTIVE: To identify methodologies relating to the use, design, and implementation of escape games in health care. DATA SOURCES: The Pubmed, Embase, and CINAHL databases were searched up to December 3, 2018. STUDY SELECTION: All studies focusing on the design or development of escape games in the health care field (published in English or French) were included. DATA EXTRACTION: For each study, the country, target population, design, development, method of evaluation, and results were extracted for analysis. DATA SYNTHESIS: Seven poster abstracts and 9 published articles were included. Twelve escape games were developed in the United States. They were used in medicine (n = 5), pharmacy (n = 4), nursing (n = 4) and other fields (n = 3), mainly within academic teaching contexts (n = 12) but also in professional settings (n = 4). Their goals were to improve knowledge (n = 8), to increase participants' interest and motivation regarding a specific topic (n = 2), and to improve cohesion and communication within a team (n = 2). Ten of the escape games described in the articles were based on a clinical scenario. Ten of the research teams held debriefings with participants, and one did not; 5 articles did not report information about debriefing. CONCLUSIONS: Few data exist concerning the use of escape games in the health care setting, and it is too early to judge the efficiency of this approach to learning. However, growing interest justifies systematic monitoring of the literature to follow the evolution of such strategies and to better understand their place in health care education.

Compliance with Recommended Practices for Management of Controlled Substances in a Health Care Facility and Corrective Actions.

BACKGROUND: Pharmacists are required to maintain a secure inventory of medications and to ensure proper, safe, and diversion-free dispensing practices. OBJECTIVES: The primary objectives of this study were to determine compliance with recommended practices for the management of controlled substances in a mother-child teaching hospital and to identify actions to improve compliance. The secondary objective was to identify steps in the drug pathway for controlled substances and associated failure modes in the study hospital. METHODS: This descriptive cross-sectional study used a framework developed by the California Hospital Association (CHA) to assess compliance with recommended practices for the management of controlled substances in hospitals. For each criterion, a research assistant observed practices within the pharmacy, on patient care units, at outpatient care clinics, and in operating and delivery rooms. The level of compliance was recorded as compliant, partially compliant, or noncompliant. An Ishikawa diagram was developed to illustrate steps in the drug pathway and associated failure modes related to the use of controlled substances in the study hospital. RESULTS: The pathway for controlled substances at the study hospital was compliant for 56 (49.6%) of the 113 CHA criteria, partially compliant for 27 (23.9%) of the criteria, and noncompliant for 24 (21.2%) of the criteria; the remaining 6 (5.3%) criteria were not applicable. This practice evaluation highlighted 22 corrective actions, 12 (55%) that could be implemented in the short term, 8 (36%) suitable for implementation in the medium term, and 2 (9%) suitable for both the short and medium term. A total of 57 potential failure modes related to the use of controlled substances were identified. CONCLUSIONS: The pathway for controlled substances at the study hospital was compliant with almost half of the CHA criteria, and 22 corrective actions were identified. Pharmacists, physicians, and nurses should be mobilized to optimize the use of controlled substances throughout the drug-use process.

CONTEXTE: Les pharmaciens sont responsables de maintenir à jour les réserves de médicaments et doivent faire en sorte que les pratiques de distribution soient adéquates, sûres et exemptes de détournement. OBJECTIFS: Les objectifs principaux de la présente étude consistaient à déterminer le degré de conformité aux pratiques de gestion des substances contrôlées, recommandées dans un hôpital universitaire mère-enfant, et de trouver des mesures pour améliorer leur degré de conformité. L'objectif secondaire visait à recenser les étapes que suivent les substances contrôlées dans le circuit des médicaments et les modes de défaillance qui y sont associés dans l'hôpital à l'étude. MÉTHODES: La présente étude descriptive et transversale s'appuyait sur un cadre mis au point par la California Hospital Association (CHA), qui sert à évaluer le degré de conformité aux recommandations relatives aux pratiques de gestion des substances contrôlées dans les hôpitaux. Pour chaque critère, un assistant de recherche observait les pratiques dans le service de pharmacie, les unités de soins, les cliniques de consultation externe et les salles d'opération ou les salles d'accouchement. Il évaluait le degré de conformité à l'aide d'un des qualificatifs suivants : conforme, partiellement conforme ou non conforme. Un diagramme d'Ishikawa a été conçu pour illustrer les étapes du circuit des médicaments et les modes de défaillance associés à l'utilisation de substances contrôlées dans l'hôpital à l'étude. RÉSULTATS: Le circuit des substances contrôlées à l'hôpital où se déroulait l'étude était conforme à 56 (49,6 %) des 113 critères de la CHA, partiellement conforme à 27 (23,9 %) critères et non conforme à 24 (21,2 %) critères; les 6 (5,3 %) critères restants n'étaient pas applicables. Cette évaluation des pratiques a mis en évidence 22 actions correctives, dont 12 (55 %) pouvaient être mises en place à court terme, 8 (36 %) à moyen terme et 2 (9 %) à court ou à moyen terme. Les investigateurs ont repéré 57 modes de défaillance potentiels liés à l'utilisation de substances contrôlées. CONCLUSIONS: L'analyse du circuit des substances contrôlées à l'hôpital où se déroulait l'étude a révélé que près de la moitié des critères de la CHA étaient conformes, et 22 actions correctives ont été proposées. Les pharmaciens, médecins et infirmières devraient participer à l'optimisation de l'utilisation des substances contrôlées dans l'ensemble du processus de distribution des médicaments.

The Québec NTBC Study.

In this chapter we describe the current Quebec NTBC Study protocol. Quebec's unique characteristics have influenced the development of the protocol, including a high prevalence of hepatorenal tyrosinemia (HT1), universal newborn screening for HT1, availability of treatment with nitisinone (NTBC) and special diet, a large territory, where HT1 treatment is coordinated by a small number of centers. Screened newborns are seen within 3 weeks of birth. Patients with liver dysfunction (prolonged prothrombin time and/or international normalized ratio (INR) provide sensitive, rapidly available indicators) are treated by NTBC and special diet. The specific diagnosis is confirmed by diagnostic testing for succinylacetone (SA) in plasma and urine samples obtained before treatment. After an initial period of frequent surveillance, stable patients are followed every 3 months by assay of plasma amino acids and NTBC and plasma and urine SA. Abdominal ultrasound is done every 6 months. Patients have an annual visit to the coordinating center that includes multidisciplinary evaluations in metabolic genetics, hepatology, imaging (for abdominal ultrasound and magnetic resonance imaging) and other specialties as necessary. If hepatocellular carcinoma is suspected by imaging and/or because of progressive elevation of alphafetoprotein, liver transplantation is discussed. To date, no patient in whom treatment was started before 1 month of age has developed hepatocellular carcinoma, after surveillance for up to 20 years in some. This patient group is the largest in the world that has been treated rapidly following newborn screening. The protocol continues to evolve to adapt to the challenges of long term surveillance.

Medication errors room: a simulation to assess the medical, nursing and pharmacy staffs' ability to identify errors related to the medication-use system.

RATIONALE, AIMS AND OBJECTIVES: The medication-use system in hospitals is very complex. To improve the health professionals' awareness of the risks of errors related to the medication-use system, a simulation of medication errors was created. The main objective was to assess the medical, nursing and pharmacy staffs' ability to identify errors related to the medication-use system using a simulation. The secondary objective was to assess their level of satisfaction. METHOD: This descriptive cross-sectional study was conducted in a 500-bed mother-and-child university hospital. A multidisciplinary group set up 30 situations and replicated a patient room and a care unit pharmacy. All hospital staff, including nurses, physicians, pharmacists and pharmacy technicians, was invited. Participants had to detect if a situation contained an error and fill out a response grid. They also answered a satisfaction survey. RESULTS: The simulation was held during 100 hours. A total of 230 professionals visited the simulation, 207 handed in a response grid and 136 answered the satisfaction survey. The participants' overall rate of correct answers was 67.5% ± 13.3% (4073/6036). Among the least detected errors were situations involving a Y-site infusion incompatibility, an oral syringe preparation and the patient's identification. Participants mainly considered the simulation as effective in identifying incorrect practices (132/136, 97.8%) and relevant to their practice (129/136, 95.6%). Most of them (114/136; 84.4%) intended to change their practices in view of their exposure to the simulation. CONCLUSIONS: We implemented a realistic medication-use system errors simulation in a mother-child hospital, with a wide audience. This simulation was an effective, relevant and innovative tool to raise the health care professionals' awareness of critical processes.

Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center.

PURPOSE: To evaluate how nursing staff felt about the impact of automated dispensing cabinets (ADCs) on the safe delivery of health care and workplace ergonomics. To identify the main issues involved in the use of this technology and to describe the corrective measures implemented. METHODS: Cross-sectional descriptive study with quantitative and qualitative components. A questionnaire that consisted of 33 statements about ADC was distributed from May 24 to June 3, 2011. RESULTS: A total of 172 (46%) of 375 nurses completed the questionnaire. Nursing staff considered the introduction of ADC made their work easier (level of agreement of 90%), helped to safely provide patients with care (91%), and helped to reduce medication incidents/accidents (81%). Nursing staff was particularly satisfied by the narcotic drugs management with the ADCs. Nursing staff were not satisfied with the additional delays in the preparation and administration of a medication dose and the inability to prevent a medication from being administered when stopped on the medication administration record (48%). CONCLUSION: The nursing staff members were satisfied with the use of ADC and believed it made their work easier, promoted safe patient care, and were perceived to reduce medication incidents/accidents.

Nursing perception of the impact of medication carts on patient safety and ergonomics in a teaching health care center.

OBJECTIVES: In our Quebec (Canada) University Hospital Center, 68 medication carts have been implemented as part of a nationally funded project on drug distribution technologies. There are limited data published about the impact of medication carts in point-of-care units. Our main objective was to assess nursing staff's perception and satisfaction of medication carts on patient safety and ergonomics. METHOD: Quantitative and qualitative cross-sectional study. Data were gathered from a printed questionnaire administered to nurses and an organized focus group composed of nurses and pharmacists. RESULTS: A total of 195 nurses completed the questionnaire. Eighty percent of the nurses agreed that medication carts made health care staff's work easier and 64% agreed that it helped to reduce medication incidents/accidents. Only 27% and 43% agreed that carts' location reduces the risk of patients' interruptions and colleagues' interruptions, respectively. A total of 17 suggestions were extracted from the focus group (n = 7 nurses; n = 3 pharmacist) and will be implemented in the next year. CONCLUSIONS: This descriptive study confirms the positive perception and satisfaction of nurses exposed to medication carts. However, interruptions are a major concern and source of dissatisfaction. The focus group has revealed many issues which will be improved.

[Not Available]. / Utilisation de lignes directrices dans le cadre de l'implantation de cabinets automatisés décentralisés en établissement de santé

CONTEXT: Few data are available on the use and consequences of decentralized automated dispensing cabinets (ADCs) in institutional settings. METHOD: This descriptive study examined compliance with published guidelines on the implementation of decentralized ADCs. The primary objective was to evaluate overall compliance, as well as compliance with specific steps in the medication cycle. The study was carried out at the Centre hospitalier universitaire (CHU) Sainte-Justine, a 500-bed mother-and-child hospital. The 2008 guidelines of the Institute for Safe Medication Practices (US) concerning the safe use of decentralized ADCs and the associated self-assessment tool (2009) were used to evaluate compliance at 30 days and at 120 days after implementation. RESULTS: From November 2009 to April 2010, 7 decentralized ADCs were brought into service at the CHU Sainte-Justine. Overall compliance with published guidelines increased from 66% to 74% between January and April 2010. For each process related to the safe use of the ADCs, the criteria were briefly described, along with the non-compliance components related to technological or organizational aspects of implementation. For each component for which practice was noncompliant with guidelines, the actions required to modify the equipment (i.e., technological aspects) were determined and conveyed to the manufacturer; similarly, modes of use requiring modification (i.e., organizational aspects) were determined and conveyed to the institution. CONCLUSION: This study has described the compliance of practices at the CHU Sainte-Justine with published guidelines of the Institute for Safe Medication Practices. The use of published guidelines can help to guide both the technological and organizational aspects of implementing decentralized ADCs. [Publisher's translation].