Environmental Safety and Quality Risks

Jheeta S, Franklin BD. The impact of a hospital electronic prescribing and medication administration system on medication administration safety: an observational study. BMC Health Serv Res. 2017 Aug 9;17(1):547. doi: 10.1186/s12913-017-2462-2. PMID: 28793906; PMCID: PMC5549345.

In this article the author expresses concern about the use of electronic prescribing and administration (ePA) systems in the UK. According to the author in this article, although ePA has been established in the United States (US) for some years to improve patient safety by reducing medication errors, its uptake in the United Kingdom (UK) has been slower. The author refers to how most studies explore the impact of introducing ePA have focused on prescribing rather than medication administration. Other studies report the impact of bar-code medication administration technology, but the findings are not applicable to ePA systems where bar-coding is not utilized. According to the author, a key advantage of ePA is that it can potentially ensure inclusion of essential information that may be omitted on paper, and wrong dose errors caused by unclear handwriting are eliminated. The author refers to statistically significant increase in documentation discrepancies after ePA was largely due to new working practices and nurses not revising documentation as needed. Therefore, the author concludes to improve medication administration safety, ePA systems should be designed to reflect actual working practices rather than stated policy.

Yoon, S., & Sohng, K. (2021). Factors causing medication errors in an electronic reporting system. Nursing open, 8(6), 3251–3260. https://doi.org/10.1002/nop2.1038

In this article, the authors refer to 805 near misses and adverse events reported to the hospital's electronic reporting system between January 2014 and December 2018. According to the article, between 2014 and December 2018 there were 173 adverse events reported and 632 near misses. Both were happening during the dispensing stage and medication administration. According to the article, nurses with 1-9 years’ experience were report of medication errors were relatively low. Whereas, during a direct nurse supervision, they have detected 65% less medication errors than the ones that were not directly supervised. According to the article, medication is the most common medical error in developed and developing countries. Medication errors are a common medical error and compromise the quality of medical systems by increasing hospitalization and medical costs. Therefore, healthcare workers must detect errors that occur regularly and learn how to report patient safety incidents. Nurses perform the last stage of medication administration and play a central role in medication error reporting. While nurses may make medication errors during clinical practice, they are also on the frontline of preventing these errors.

Pereira, R. A., de Souza, F. B., Rigobello, M. C. G., Pereira, J. R., da Costa, L. R. M., & Gimenes, F. R. E. (2020). The quality improvement program reduces errors in oral medication preparation and administration through feeding tubes. BMJ open quality, 9(1), e000882. https://doi.org/10.1136/bmjoq-2019-000882

In this article, the author addresses the importance of preventing medication errors during oral medication preparation and administration. According to the article, patients with nasogastric/ nasoenteric tube (NGT/NET) are at increased risk of adverse outcomes than anyone else. The author explains how healthcare systems used a collaborative approach based on Plan-Do-Study-Act (PDSA) cycle and provides feedback during multidisciplinary meetings. They carried out an experimental study to compare outcome measures before and after the execution of the integrated quality program to improve oral medication preparation and administration through NGT/NET. As a result, good practice guidance for oral medication preparation and administration through NGT/NET was developed and implemented at the hospital sites to improve the result of the study. According to the article, development was made in some area such as: crushing enteric-coated tablets and mixing drugs during medication preparation and triturating pharmaceutical form of modified action. Worsening was observed though in the following measures: crush compressed to a fine and consistent powder and feeding tube obstruction.