Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis
Author(s)
Type
Journal Article
Abstract
Background:
In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs).
Objective:
The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice (discrepancies) that contributed to large-magnitude and/or clinically significant MAEs.
Methods:
Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study.
Results:
In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs.
Conclusion and Relevance:
Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.
In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs).
Objective:
The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice (discrepancies) that contributed to large-magnitude and/or clinically significant MAEs.
Methods:
Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study.
Results:
In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs.
Conclusion and Relevance:
Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.
Date Issued
2021-11-01
Date Acceptance
2021-02-12
Citation
Annals of Pharmacotherapy, 2021, 55 (11), pp.1333-1340
ISSN
1060-0280
Publisher
SAGE Publications
Start Page
1333
End Page
1340
Journal / Book Title
Annals of Pharmacotherapy
Volume
55
Issue
11
Copyright Statement
© The Author(s) 2021. This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
License URL
Sponsor
National Institute for Health Research
Identifier
https://journals.sagepub.com/doi/10.1177/1060028021999647
Grant Number
n/a
Subjects
Science & Technology
Life Sciences & Biomedicine
Pharmacology & Pharmacy
administration
intravenous
guidelines as topic
medication errors
nurses
patient safety
practice guidelines as topic
HEALTH RECORD USABILITY
SETTINGS
CARE
administration
guidelines as topic
intravenous
medication errors
nurses
patient safety
practice guidelines as topic
Administration, Intravenous
Child
Humans
Medication Errors
Pharmaceutical Preparations
Reproducibility of Results
Resuscitation
Pharmacology & Pharmacy
1115 Pharmacology and Pharmaceutical Sciences
Publication Status
Published
Date Publish Online
2021-03-01