Evidence based practice on reducing medication error Analysis

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Received: 20 January 2020
Revised: 9 April 2020
Accepted: 10 April 2020
DOI: 10.1111/jep.13407
ORIGINAL PAPER
Intervention study for the reduction of medication errors in
elderly trauma patients

María de los Angeles
Parro Martín Hospital Pharmacy Specialist1
|
María Muñoz García Doctor of Pharmacy, Hospital Pharmacy Specialist1
|
Eva Delgado Silveira Doctor of Pharmacy, Hospital Pharmacy Specialist1 |

Sagrario Martín-Aragón Alvarez
Doctor of Pharmacy, Professor2 |
Teresa Bermejo Vicedo Doctor of Pharmacy, Hospital Pharmacy Specialist1
1
Servicio de Farmacia, Hospital Universitario
Ramón y Cajal, Madrid, Spain
2
Departamento de Farmacología,
Farmacognosia y Botánica, Facultad de
Farmacia, Universidad Complutense, Madrid,
Spain
Correspondence

M. Angeles
Parro Martín, Servicio de Farmacia,
Hospital Universitario Ramón y Cajal, 28034
Madrid, Spain.
Email: [email protected]
Abstract
Objective: To analyse the impact of a set of measures designed by a working group
to reduce medication errors (MEs) during the care transition of elderly trauma
patients. The secondary objectives were to classify MEs and determine their location.
Methods: A 43-month pre-post prospective intervention study in a university hospital. A working group was set up in the Trauma Service. A pharmacist analysed the
pharmacotherapeutic processes of all patients admitted to the Trauma Service in different healthcare locations from Monday to Friday. To detect MEs, the pharmacist
reviewed this process at the following points: reconciliation, prescription, validation,
dispensing, and administration records. Errors were classified according to the Ruiz
Jarabo classification. Subsequently, the working group designed a set of measures
that were implemented with the incorporation into the Acute Care Team and the
intervention of a pharmacist. Data on MEs were again collected in a postimplementation phase.
Results: There was a statistically significant reduction in MEs between phases. A total
of 132 (31.3%) patients experienced MEs during the pre-implementation phase and
75 (16.2%) during the post-implementation phase. Among the measures
implemented, the incorporation of the pharmacist to the team, as well as training sessions and design of medication protocols. During the pre-implementation and postimplementation phases, the ME rates were respectively as follows: reconciliation
31.6% (172) vs 14.8% (91); prescription 7.7% (79) vs 1.9% (23); dispensing 1% (10) vs
0.3% (3); administration record 0.4% (4) vs 0.0% (0); and validation 0.3% (3) vs 0.1%
(1). There were significant reductions in reconciliation, prescription, and dispensing
errors. The majority of the MEs occurred in the Trauma Service.
Conclusions: The implementation of specific measures by a Multidisciplinary Safety
Group reduced MEs in the care transition of elderly trauma patients, particularly
those MEs that occurred during reconciliation. The greatest reduction in MEs
occurred in the Trauma Service.
160
© 2020 John Wiley & Sons, Ltd.
wileyonlinelibrary.com/journal/jep
J Eval Clin Pract. 2021;27:160–166.
161
PARRO MARTÍN ET AL.
KEYWORDS
medication error, pharmaceutical care, pharmaceutical intervention, safety group,
traumatology
1
|
I N T RO DU CT I O N
2
|
MATERIAL AND METHOD
Medication errors (MEs) are the most frequent cause of adverse
A 43-month pre-post intervention study (April 2015-November 2018)
events, which result in patient injury and even death, and involve sig-
conducted in a university hospital.
nificant health costs. There are no error-free systems and therefore
The MHSG was formed by different representatives of the
the fundamental objective of clinical safety is to minimize the risks
Traumatology, Anaesthesia, Geriatrics, and Pharmacy Services. The
and likelihood of errors, thereby enabling processes to be conducted
group comprised one traumatologist, one geriatrician, two anaesthetists,
correctly.1
three pharmacists, two nursing supervisors (traumatology and orthog-
The retrospective ENEAS study conducted with 5624 patients
eriatrics), and one nurse. At the first official meeting of the group (April
admitted to 24 Spanish public hospitals. It found that of the total
2015) it was decided to hold meetings on a monthly basis. One of the
number of adverse events, 37.4% were related to medication. Of
objectives of this group was to define strategies to prevent MEs in the
these, 34.8% were avoidable.2 Several Spanish studies have found a
hospital. Thus, we had to determine the real situation of patients and
prevalence of MEs of between 7% and 22%, suggesting that they are
their treatment during the different care transitions in order to be able
a highly relevant problem, particularly because almost 50% of them
to define and implement measures to improve the safety of the entire
are preventable.3 In recent years, initiatives have been developed to
pharmacotherapeutic process.
improve patient safety in Spain by the Ministry of Health, Social Services and Equality, Autonomous Communities, scientific societies, and
other institutions.4 However, as is the case of the United States and
other countries, the degree of implementation in Spain remains low.5
2.1 | Sample size and locations in patient care
transition
The recommendations of the Quality Plan of the National Health System and the World Health Organization (WHO) include the creation
For the calculation of the sample size, expressed as lines of treatment
of Multidisciplinary Working Groups within each specialty.6 The active
to evaluation, the prevalence of reconciliation errors of 50% calcu-
involvement of the pharmacist within these groups is crucial to
lated in a previous study carried out in our centre will be considered
improve the safety of all the processes in medication use systems.4
as a reference value.12 The sample size calculation was made
The benefits of pharmaceutical intervention have been verified in dif-
accepting an alpha risk of 0.05 and a beta risk of 0.20 in a bilateral
ferent studies, which have demonstrated acceptance rates of 39.0%
contrast. Taking into account 10% losses, the number of treatment
to 91.6% in relation to prescribers accepting the pharmacists’ recom-
lines required to detect a difference ≥0.025 at each point in the pro-
mendations.7 A review of 36 studies analysing the impact of pharma-
cess was 427, assuming that the prevalence of errors after the imple-
cists’ activity on hospitalized patients has suggested that their
mentation of improvement measures could decrease to 40%.
incorporation into the Acute Care Team resulted in improved care
with no evidence of harm.8,9
The GSMH decided the locations and points of the process
according to the errors detected.
The implementation of prevention strategies can be facilitated by
The MHSG decided to analyse three locations during patient
determining at which points in the medication use process the highest
care transition: the Emergency Department (ED), the Reanimation
rates of MEs occur. The WHO has established effective AE preven-
and Post-Anaesthesia Unit (RPAU), and the Traumatology Hospitali-
tion measures, such as medication reconciliation in care transitions.10
zation Unit. In addition, we decided to assess the medication use
In addition, it has been estimated that 50% of surgical patients
process at the following points: reconciliation, prescription, valida-
11
This aspect, together with
tion, dispensing, and administration records. All MEs were analysed if
the great complexity and severity of patients treated in Orthopaedic
their rate was more than 2% at each point of use. The sample size
Surgery and Trauma Services, has led to a significant increase in
was obtained based on a study conducted previously in the same
adverse events, many of which are very severe.1 In order to analyse
centre.
take some type of chronic medication.
these adverse events and reduce MEs, we decided to create a Multidisciplinary Safety Group in the Trauma Service of our hospital.
The main objective of this study is to analyse the impact of a set
of measures designed by a Multidisciplinary Hospital Safety Group
2.2 | Medical errors according to the process
analysed
(MHSG) to reduce MEs during the care transition of elderly trauma
patients. The secondary objectives are to classify errors and deter-
All the patients admitted to the Traumatology Service were selected.
mine their location.
Patients admitted to other Services were excluded.
162
PARRO MARTÍN ET AL.
In the pre-implementation phase, the pharmacist reviewed all the
The types of RE, PE, and VE were classified according to the Ruiz
pharmacotherapeutic processes of patients admitted to the Trauma
Jarabo classification.13 The errors at the various points in the process
Service. The data were collected according to the different locations
were analysed independently, so that an error detected in one process
and points of the process. The dependent variable was ME. The MEs
could not influence the subsequent analysis of another process.
were classified according to the process in which they occurred:
The independent variables were the age and sex of the selected
patients.
• Reconciliation
the
The pharmacist in charge prepared a report on the errors found in
pharmacotherapeutic history to detect REs. Thus, the patient or
the pre-implementation phase, which were classified according to the
family member/caregiver was interviewed to obtain data on
point of the process and the location in which they occurred.
error
(RE):
the
pharmacist
prepared
chronic medication and compared this data with the medications
The results of the pre-implementation phase were analysed over
prescribed by the doctor. In addition, the pharmacist reviewed
the course of several meetings by the MHSG, which drew up a set of
the Primary Care viewer (HORUS) and the Specialized Care clini-
measures to be implemented in a subsequent phase.
cal reports (CAJAL). Any discrepancy not justified by the doctor
After the implementation of the measures and a 3-month wash-
was considered to be an RE. The prevalence of REs was calcu-
out period, we repeated the systematic data collection process
lated by dividing the number of REs by the total number of lines
described above (post-implementation phase).
In July 2015, approval for the study was obtained from the hospi-
of reconciled medicines.
• Prescribing error (PE): the pharmacist reviewed the treatment pre-
tal’s Drug Research Ethics Committee.
scribed by the doctor using the Electronic Assisted Prescribing program for the selected patients. A failure in the prescribing process
that resulted in an incorrect instruction about one or more of the
3
|
RE SU LT S
regular features of a prescription was considered to be a
PE. Regular characteristics included appropriate medication (with
We reviewed the data of 886 patients, of whom 207 (23.4%) had
correct indication, duration, and without contraindications or rele-
experienced ME. We also analysed 9976 medication lines. The mean
vant interactions), dose, frequency, and route of administration.
age of patients who had experienced ME (60.4% women) was 79.5
The prevalence of PEs was calculated by dividing PEs by the total
± 14 years.
number of lines of prescribed medicines.
In the pre- and post-implementation phases, 31.3% (132) and
• Validation error (VE): a review was conducted of the validation
16.2% (75) of patients had experienced an ME, respectively. After the
process of the treatments prescribed using the Electronic Assisted
agreed measures had been implemented, there was a decrease in MEs
Prescribing for the selected patients. Cases in which the prescrip-
from 5.7% to 2.2% (P < .001). tion, dose, frequency, and route of administration of a medicine After the results of the pre-implementation phase had been were not appropriate and which had not been corrected by a phar- analysed, the MHSG proposed the following improvement measures: macist during the validation process were considered to be VEs. The prevalence of VEs was calculated by dividing the number of VEs by the total number of lines of validated medicines. • Dispensing error (DE): over a period of 1 week, the pharmacist determined whether the prescribed and validated medication had been dispensed correctly. Thus, the pharmacist reviewed the contents of the boxes of the medication unit dose trolley from the Trauma Service prepared by the Auxiliary Nursing Care Technicians (ANCT) of the Pharmacy Service. Any discrepancy between the drug prescription (type, quantity, and dose) and the medicine 1. The incorporation of a pharmacist in the multidisciplinary team during the medication reconciliation process at the time of admitting the patients to the ED and the Traumatology Unit. 2. The review and dissemination of the medication reconciliation process at hospital admission and discharge. 3. The implementation of a training session in the Trauma Service for doctors and the ANCTs of the Pharmacy Service. 4. The addition of protocols and alerts to the Electronic Assisted Prescribing program. that the ANCT had placed in the patients' boxes was considered to be a DE. In addition, a review was conducted of the medication Tables 1 and 2 summarize the medication lines, MEs, and percent- replenishment of the Emergency Department's (ED) automatic dis- age of MEs by location and point of use, indicating the most frequent pensing system. The prevalence of DE was calculated by dividing type of error at each point. the number of DEs by the total number of medicines dispensed. In the post-implementation phase, there was a 50% decrease in • Administration record error (ARE): the pharmacist reviewed all REs (P < .001). In total, 68.1% (62) of the recommendations made by administration record sheets completed by the nursing staff from the pharmacist were accepted. In addition, the number of REs Monday to Friday. Any discrepancy (type, dose, time) between the decreased by 57.2% and 27.7% in the Traumatology Unit and the ED, administration records and interviews with the nurses in charge of respectively. There were striking improvements in the type of RE the patients were considered to be AREs. The prevalence of AREs “omission of a medicine.” was calculated by dividing the number of AREs by the total number of medicines administered. In the post-implementation phase, there was a 75.3% decrease in PEs (P < .001). There were decreases of 83.3% in the ED, 163 PARRO MARTÍN ET AL. TABLE 1 Number of MEs by location and point of use of the medication process Number of lines with Total number MEs in the of lines revised in the PRE phase PRE phase % of MEs in Most frequent type the PRE of ME in the PRE phase phase Total number of lines revised in the POST phase Number of lines with MEs in the POST phase % of MEs in the POST Most frequent type of phase ME in the POST phase Reconciliation Emergency 119 department 24 20.2 Omission of a medication (58.3%) 184 27 14.6 Omission of a medication (74.1%) Trauma unit 425 148 34.8 Omission of a medication (79.1%) 430 64 14.9 Omission of a medication (67.2%) Total RE 544 172 31.6 Omission of a medication (76.2%) 614 91 14.8 Omission of a medication (69.2%) Emergency 162 department 12 7.4 Incorrect administration, frequency (33.3%) 331 2 0.6 Incorrect pharmaceutical form (100.0%) RPAU 433 37 8.6 Incorrect administration, frequency (54.1%) 444 12 2.7 Incorrect treatment duration: longer duration (58.3%) Trauma unit 431 30 7.0 Incorrect administration, frequency (46.7%) 451 9 1.9 Others: indication in remarks undated (88.9%) Total PE 1026 79 7.7 Incorrect administration, frequency (48.1%) 1226 23 1.9 Others: indication in remarks undated (34.8%) Prescription Abbreviations: MEs, medication errors; PE, prescription errors; POST, post-implementation; PRE, pre-implementation; RE, reconciliation errors; RPAU, Reanimation and Post-Anaesthesia Unit. 70.0% in the Traumatology Unit, and 67.6% in the RPAU. We use of different MEs in the studies, as well as the use of different defi- draw attention to the marked improvements in the type of PE nitions, scenarios, and methodologies.15 “frequency of incorrect administration” in the RPAU and the Traumatology Unit. The following discussion addresses each point of use of the medication process affected by MEs. In the pre-implementation phase, the number of DEs, VEs, and AREs detected was less than 2%. In the post-implementation phase, there was a statistically significant decrease in DEs, but not in VEs 4.1 | Reconciliation or AREs. One of the implemented measures was the incorporation of the pharmacist within the multidisciplinary team in the reconciliation 4 | DISCUSSION process during patient admission. A systematic review by Cheema et al16 found an association between active interventions by phar- Strategic plans to improve patient safety include the creation of Multi- macists such as medication reconciliation, personalized patient disciplinary Safety Groups. Although there is an increasing number of counselling, and the provision of telephone consultations to deliver studies on such groups, no data are available concerning their direct patient care after hospital discharge and a reduction in medication results.6 The present study showed that the incorporation of an discrepancies compared to standard care. MHSG in the Trauma Service led to a statistically significant reduction The most frequent errors were REs. They comprised 68.1% of in MEs from 5.7% to 2.2%. In addition, the number of patients who the total MEs analysed (pre- and post-implementation phases), underwent had experienced MEs decreased from 31.3% to 16.2%. This interven- a statistically significant 50% decrease after the implementation of tion was widely accepted by the traumatology service and by the cen- the measures. In addition, 68.1% of the recommendations made by the tre, actively participating in the objective of said intervention. pharmacist were accepted. Franco et al17 and Pascual et al18 found It is currently estimated that the prevalence of MEs ranges from 14 discrepancies in medication reconciliation ranging from 42.0% to Although several studies have documented the inci- 48.0% of trauma patients. However, Moriel et al19 found higher values in dence of adverse events and MEs in Trauma Services, there were vari- trauma patients (71.4%). These results are similar to those found in the ations in the reported frequencies.1,14 These variations are due to the present study (75.9%). The difference between our results and those of 2% to 75%. 164 PARRO MARTÍN ET AL. TABLE 2 Number of MEs by location and point of use of the medication process Total number of lines revised in the PRE phase Number of lines with MEs in the PRE phase % of MEs in the PRE phase Most frequent type of ME in the PRE phase Total number of lines revised in the POST phase Number of lines with MEs in the POST phase % of MEs in the POST phase Most frequent type of ME in the POST phase Validation Emergency department 207 0 0.0 NA 217 1 0.50 Incorrect pharmaceutical form (100.0%) RPAU 435 2 0.5 Incorrect pharmaceutical form (100.0%) 434 0 0.0 NA Trauma unit 438 1 0.2 Incorrect pharmaceutical form (100.0%) 427 0 0.0 NA Total VE 1080 3 0.3 Incorrect pharmaceutical form (100.0%) 1078 1 0.1 Incorrect pharmaceutical form (100.0%) Dispensing Trauma unit 449 8 1.8 Omission of a medication (100.0%) 571 0 0.0 NA Emergency department 628 2 0.3 Omission of a medication (50.0%) and Others: a medication that is not prescribed appears in the box (50.0%) 530 3 0.5 Others: a medication that is not prescribed appears in the box (66.6%) Total DE 1077 10 1.0 Omission of a medication (60.0%) 1101 3 0.3 Others: a medication that is not prescribed appears in the box (66.6%) Administration record Emergency department 215 0 0.0 NA 287 0 0.0 NA RPAU 267 4 1.5 The administration record sheet is not signed by the nurse in charge (100.0%) 435 0 0.0 NA Trauma unit 501 0 0.0 NA 525 0 0.0 NA The administration record sheet is not signed by the nurse in charge (100.0%) 1247 0 0.0 NA Total ARE 983 4 0.4 Abbreviations: ARE, administration record errors; DE, dispensing errors; MEs, medication errors; NA, not applicable; PRE, pre-implementation; POST, post-implementation; RPAU, Reanimation and Post-Anaesthesia Unit; VE, validation errors. other authors may be due to the higher mean age of the population in the unable to find any studies that have analysed MEs in different loca- present study. tions during care transition. The most common type of RE was “medication omission.” This result is similar to those obtained in studies conducted in an Internal Medicine Service20,21 and in an Intermediate Care 4.2 | Prescription Service.22 These studies found “medication omission” rates of 60.0%. One of the improvement measures implemented by the MHSG was to Regarding location, after the implementation of measures in the improve prescriber training. Several authors have shown an associa- Emergency Department, RE rate was 14.6%, which was similar to that tion between training in the prescription of specific medicines and observed in the Traumatology Unit (14.9%). To date, we have been decreases in PEs.23,24 In addition, two of the improvement measures 165 PARRO MARTÍN ET AL. were related to the Electronic Assisted Prescribing program: the prevalence of DEs of between 1.0% and 2.2%.29,31 These results are incorporation in the program of guidelines on the prescription of spe- similar to those found in the present study. cific medicines and on groups of patients; and the creation of new In the pre-implementation phase, the most frequent type of DE pharmacotherapeutic protocols. Several studies have shown an asso- was “omission of medication,” whereas in the post-implementation ciation between prescription guidelines and decreases in PEs.25,26 phase it was “Others: a medication that is not prescribed appears in The implementation of these measures led to a significant reduction the box.” The literature suggests that the three most frequent types of DE are “omission,” “different amount of medicines in the dispensing in PEs from 7.7% to 1.9%. Vélez Díaz Pallarés et al27 reported PE rates of 9.1% in trauma box” and “different dosage of the medicinal product.”30,31 patients, while García-Ramos et al28 found PE rates of 10.1% in internal medicine patients. Both these rates are similar to those found in 4.5 the present study. | Administration record In the pre-implementation phase, the most frequent type of PE was “incorrect administration frequency,” which was practically elimi- The majority of published studies have analysed administration errors nated in the post-implementation phase. This result was thought to by use of the direct observation method (ie, the presence of an be due to the implementation of protocols in the Electronic Assisted observer at the time of administration).31 However, we checked that Prescribing program, which includes frequency of administration. the medication administration record was correct and unambiguous Vélez et al27 found that “incorrect dose” is the most frequent PE after each shift of medication administration. We were unable to find followed by “incorrect frequency” in trauma patients, while García- any study that exclusively addressed administration records, with the found that the most frequent PE is “incorrect dose” in exception of the study by Vicente et al32. These authors found an 28 Ramos et al internal medicine patients. ARE rate of 48.0%, which is a very high percentage in comparison to Regarding location, after the implementation of measures, there was a 2.7% decrease in PEs in the RPAU, a 1.9% decrease in the the rate we observed. This difference is probably due to the use of different methodologies.32 Traumatology Unit, and a 0.6% decrease in the ED. After the measures One of the limitations of the present study is related to the use of were implemented, there were similar decreases in PEs in all locations the pre-post research method. Thus, we cannot ensure that the of care transition with values ranging between 70.0% and 80.0%. changes observed were due to the intervention itself or to uncontrolled factors. In addition, the pre- and post-intervention samples are not strictly comparable due to the fact that they were obtained at 4.3 | Validation different times of the year (pre: June-October 2016; post: JanuaryApril 2018) and that different health professionals conducted the Delgado et al29 used the same Electronic Assisted Prescribing soft- healthcare activities. Therefore, the results may have been influenced ware used in the present study. These authors found a prevalence of by these factors. VEs of 0.1%, which is similar to the results of both phases of the pre- Despite these limitations, we suggest that the incorporation of sent study (ie, 0.3% and 0.1%, respectively).29 Other authors have the MHSG in the Trauma Service of our hospital improved the safety found prevalences of between 2.0% and 27.0%: however, some stud- of patients admitted to this service, given that there was a striking 30 It is difficult to decrease in the number of MEs at all points in the medication process compare the prevalence of VEs, depending on the methodology, asso- analysed. This intervention has been well accepted by the centre, in ciate the validation and transcription errors, or those of prescription fact the GSMH is still active today and is one of the most important and validation. Furthermore, almost none of these studies included error notification routes. The incorporation of the pharmacist in the 15,29,31 multidisciplinary team was shown to be an effective measure in the ies have found that VEs comprise 10.0% of all MEs. definitions of the types of error. The only type of VE we observed was “wrong pharmaceutical reduction of REs at hospital admission. form.” Pastó Cardona et al31 found that the most frequent type of VE is “omission” followed by “wrong dose.” Vélez et al15 reported OR CID similar results. Differences in the types of VE observed are due to María de los Angeles Parro Martín the way in which the processes were defined, leading to them being 8841-9364 https://orcid.org/0000-0001- classified in different ways. RE FE RE NCE S 4.4 | Dispensing The percentage of DEs was low because several of the measures to reduce DEs described in the literature had already been implemented in our hospital. These DEs comprised 3.4% of all MEs analysed (preand post-implementation phase). Several studies have shown a 1. 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