Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.

Objective The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Conclusions Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.

Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy.

BACKGROUND: Insulin is a high-risk medicine which may cause significant patient harm or death when given incorrectly. A 10-fold error in administered insulin dose commonly occurs when the abbreviation 'u' is used for 'units' and subsequently misinterpreted as a 'zero.' METHOD: A multidisciplinary working party was convened and mapped insulin prescribing, dispensing and administration. All inpatient orders above 25 units for short-acting insulin and 50 units for other insulin require validation by an additional source. Educational strategies to support adherence to the guideline and product-labelling alerts were developed. RESULTS: Implementation occurred in August 2008 across the three hospital sites. In 90 weeks after implementation, there were 150 patients identified in which 200 high doses of insulin were prescribed (>25 units for short-acting insulin and 50 units for other insulin). There were eight instances where high doses of insulin were prescribed in error but were detected and rectified through the new validation process. There were 12 dosing errors that occurred, including two 10-fold dosing errors. In contrast, seven major errors resulting in excessive insulin administration were identified over a 2-year period prior to the introduction of the insulin high-dose validation system. CONCLUSION: A structured validation process was successful in reducing incorrect prescription and administration of high-dose insulin and has reduced the risk of associated fatalities or significant patient harm. Consideration should be given to adopting this process in any setting where insulin is prescribed and administered.

Intravenous potassium chloride prescribing and administration practices in Victoria: an observational study.

OBJECTIVE: To identify current prescribing and administration practices in relation to intravenous potassium chloride (IV KCl). DESIGN AND SETTING: A prospective multicentre assessment of IV KCl prescribing and administration at six public hospitals (three large metropolitan hospitals, a smaller metropolitan specialty hospital, and two rural hospitals) in Victoria between August and December 2006. Data were collected for either a 4-week period or for 200 IV KCl orders, whichever occurred first, in clinical areas where concentrated KCl ampoules were available. MAIN OUTCOME MEASURES: Number and type of IV KCl prescriptions and dose administrations; method of preparation and administration of each dose. RESULTS: A total of 888 prescriptions and 1088 administrations were assessed across the six hospitals. There were 69 different types of orders for IV KCl, varying in either concentration or volume. KCl ampoules were used in 59% of all administrations of IV KCl. In instances where the prescription matched an available premixed IV KCl infusion, the premix was used on 89% of occasions. CONCLUSIONS: There is significant variability in the prescribing and administration of IV KCl in these Victorian hospitals. New formulations of premixed IV KCl infusions may enable the removal of ampoules from patient care areas. The medical profession can play a major role in driving the adoption of consistent practice and supporting and leading this important safety initiative.

Taking aim at infusion confusion.

A comprehensive multidisciplinary approach was used to improve drug infusion safety in an acute care hospital in Melbourne, Australia. This project aimed to reduce the potential for drug infusion-related error, improve drug infusion safety for patients, and encourage incident reporting to inform and guide continuous quality improvement projects. The project applied a systems approach to medication safety, using redesign strategies such as continuous quality improvement (plan, do, study, and act) and re-engineering. Key safety design concepts such as standardization, simplification, and forcing functions were also used.