An observational study of medication administration errors in old-age psychiatric inpatients CAMILLA HAW, JEAN STUBBS AND GEOFF DICKENS

St. Andrew’s Hospital, Billing Road, Northampton, NN1 5DG, United Kingdom.

Abstract

Background. Relatively little is known about medication administration errors in mental health settings.

Objective. To investigate the frequency and nature of medication administration errors in old-age psychiatry. To assess the acceptability of the observational technique to nurse participants.

Method. Cross-sectional study technique using (i) direct observation, (ii) medication chart review and (iii) incident reports.

Setting. Two elderly long-stay wards in an independent UK psychiatric hospital.

Participants. Nine nurses administering medication at routine medication rounds.

Main outcome measures. Frequency, type and severity of directly observed medication administration errors compared with errors detected by retrospective chart review and incident reports.

Results. Using direct observation 369 errors in 1423 opportunities for errors (25.9%) were detected vs. chart review detected 148 errors and incident reports none. Most errors were of doubtful or minor severity. The pharmacist intervened on four occasions to prevent an error causing patient harm. The commonest errors observed were unauthorized tablet crushing or capsule opening (111/369, 30.1%), omission without a valid reason (100/369, 27.1%) and failure to record administration (87/369, 23.6%). Among the nurses observed, the error rate varied widely from no errors to one error in every two doses administered. Of the seven nurses who completed the post-observation questionnaire, all said they would be willing to be observed again.

Conclusion. Medication administration errors are common and mostly minor. Direct observation is a useful, sensitive method for detecting medication administration errors in psychiatry and detects many more errors than chart review or inci- dent reports. The technique appeared to be acceptable to most of the nursing staff that were observed.

Keywords: administration, adverse drug events, elderly, medication errors, mental health, observation, psychiatry

Medication errors (prescribing, transcribing, dispensing and administration errors) are an important cause of patient mor- bidity and mortality [1]. Medication administration errors are a common sub-type of medication errors and accounted for 34% of errors in one large USA study conducted in medical and surgical units [2]. Observational studies in general hospi- tals have yielded error rates varying between 3.5 and 27% of doses [3–8]. Direct observation detects medication adminis- tration errors at a much higher rate than chart review or inci- dent report review [9]. The observational method has been demonstrated to be valid and reliable [10]. Less research on medication errors has been conducted

in mental health settings, and little is known about the incidence of medication administration errors in psychiatry

[11]. Medication administration to psychiatric inpatients presents different challenges from that to patients in general hospitals. Psychiatric settings might be expected to pose fewer risks to patients, as parenteral drug adminis- tration is uncommon and mainly limited to depot antipsy- chotics used to treat schizophrenia, intravenous vitamin B for patients with alcohol dependence and intra-muscular antipsychotics and benzodiazepines for rapid tranquilliza- tion. Intravenous fluids and blood products are not admi- nistered. On the other hand, many psychiatric patients are extremely vulnerable. They may lack mental capacity to give informed consent to medication, may be non- compliant and even violent. The elderly mentally ill are particularly vulnerable as they may be confused, resist

Address reprint requests to: Dr. Camilla Haw, St. Andrew’s Hospital, Billing Road, Northampton, NN1 5DG, United Kingdom. E-mail: [email protected]

International Journal for Quality in Health Care vol. 19 no. 4 # The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 210

International Journal for Quality in Health Care;Volume 19, Number 4: pp. 210 – 216 10.1093/intqhc/mzm019 Advance Access Publication: 10 June 2007

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medication administration, be physically frail and require complex medication regimes. Review of the literature (by searching Medline, PsycINFO,

CINAHL, BNID and AMED from 1966 onwards) revealed only a handful of studies on medication administration errors in psychiatry, with most based on retrospective chart review or official incident reports [12–14]. We were unable to identify any reports of observational studies in psychiatry, apart from a very small study conducted in a learning disabil- ity group home [15], a study of tablet crushing in residential homes for the elderly [16] and an observational study of medication administration to psychiatric inpatients but this did not report on the frequency of errors [17]. Concerning studies of older persons conducted in general hospitals, we identified an observational study partly conducted in a geria- tric unit [6] and another conducted in an elderly female ward with acute admissions [4]. The aims of the current study were to use the observa-

tional technique in two long-stay old-age psychiatry wards to determine the frequency and nature of medication adminis- tration errors, to study factors associated with errors and to compare observed errors with those detected by chart review and incident report. We also wanted to assess if the observa- tional technique was acceptable to participating nurses.

Methods

Study setting

The study was approved by the Local Research Ethics Committee. It was conducted at St. Andrew’s Hospital, Northampton, a 450-bedded independent charitable hospital providing psychiatric care for patients with a wide range of mental health problems. We studied medication adminis- tration on two long-stay wards for elderly mentally ill patients, a 13-bedded unit for patients with dementia and challenging behaviour (Ward A) and a 21-bedded unit for frail elderly patients with dementia (some patients also had schizophrenia) offering nursing home type care (Ward B). We carried out a semi-structured interview with each patient’s consultant psychiatrist to obtain an ICD-10 clinical diagnosis [18] and details of the patient’s disabilities.

Medication administration

Prescriptions are written on a paper medication chart. It is hospital policy that each time a medication is administered the administering nurse signs the medication chart. If the nurse is not able to administer the medication, they should record an omission code e.g. ‘A’ if the patient is absent, ‘R’ if the patient refuses the medication. Medication administration on Wards A and B is undertaken by one nurse, with the assistance of ‘runners’ who may be nurses or healthcare assistants. The runners take medication to patients who are unable to walk to the medicines trolley. Runners are required to ensure that medication is taken by the patient, i.e. tablets are swallowed.

Details of how participants were recruited

Nursing staff were given information about the aims of the study and invited to participate. Participants were required to give written consent. At the end of the study, participants were invited to complete a questionnaire on how acceptable or otherwise they had found the experience of being observed.

Definition and classification of medication administration errors

We defined a medication administration error as ‘a deviation from a prescriber’s valid prescription or the hospital’s policy in relation to drug administration, including failure to correctly record the administration of a medication’. This definition was derived and adapted from the literature [7, 19, 20] and is one that we have used previously [14]. Omission of a drug for valid clinical reason was not counted as an administration error, provided the nurse recorded an appropriate code on the medication chart indicating that the drug was not given. Administration errors were categorized using the National

Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) taxonomy [21]. Errors were cate- gorized at consensus meetings attended by all three researchers.

Severity of errors

Error severity was rated on the following five-point scale that two of the researchers had previously used in medication error research [22]: Grade 1—errors or omissions of doubtful or negligible importance.

Grade 2—errors or omissions likely to result in minor adverse effects or worsening condition.

Grade 3—errors or omissions likely to result in serious effects or relapse.

Grade 4—errors or omissions likely to result in fatality. Grade X—unratable (due to lack of clinical and other information).

Error severity was agreed by the three researchers at consen- sus meetings.

Method of observing medication administration

J.S. (Head Pharmacist) observed medication administration of regular and as required (prn) drugs given at each of the four routine daily drug rounds. Administration of ‘prn’ drugs and depot preparations given at other times of the day or night was not observed. Details of medications that were adminis- tered were recorded on a standard pro-forma data collection sheet. It was agreed beforehand that if the observer witnessed a ‘near miss’ incident whereby an error was about to be made that was likely to cause patient harm, then she would intervene prior to the medication being administered. For the purposes of the study, such ‘near miss’ events were counted as errors. After the medication round, J.S. examined each patient’s medi- cation chart to check that the correct medication had been

Medication administration errors

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given, to see if any medication had been omitted in error and if any clerical errors had been made.

Administration errors detected by chart review

A second pharmacist (see Acknowledgement) blind to the results of the observational study carried out a retrospective chart review of the recording of medication administration for those drug rounds that were included in the observa- tional study. She recorded the number and type of errors that she was able to detect by chart review.

Administration errors reported using the Hospital’s medication error reporting system

The Hospital policy is that all medication errors should be reported on an incident form that is sent to and collated by the responsible senior nurse manager. We requested details of the number of administration errors reported for Wards A and B for the 3 months before and the 3 months after the study as well as for the study period.

Statistical analysis

Data were analysed using SPSS version 14.0 [23]. The x2 test was used to compare differences between variables and whether or not an error had occurred.

Results

Patient details

Medication administration to 32 patients was observed. Of these, 20 (63%) had organic brain disease and 12 (38%) schizophrenia. Nineteen (59%) patients had more than one diagnosis. Twenty-one (66%) were unable to give informed consent with respect to medication. Thirteen (41%) had swallowing difficulties, 13 (41%) sometimes refused or spat out medication and 15 (47%) had a history of aggression towards nursing staff.

Participants and details of medication rounds observed

Nine out of 12 (75%) nurses approached consented to take part in the study. Observations were conducted over a 2-week period in March 2006 on Ward A and in June and July 2006 on the Ward B. On Ward A five medication rounds at 08.00, 12.00, 18.00 and 22.00 h were observed, giving a total of 20 rounds observed, whereas on Ward B, four rounds each at these times were observed, giving a total of 16 rounds.

Details of medication administered

A total of 1423 opportunities for error were studied (1313 doses were administered, 10 doses were not/could not be

administered for valid clinical reasons and there were 100 omission errors). Most doses were oral (1306; 91.8%). The rest were: topical 59 (4.1%), inhaled 47 (3.3%), ophthalmic 9 (0.6%) and subcutaneous 2 (0.1%).

Details of error numbers, types and severity detected by direct observation

A total of 369 errors were made out of 1423 doses (25.9%). For 20 (1.4%) doses, two errors were made. The types of error observed are given in Table 1. The commonest error types encountered were crushing tablets without the author- ization of the prescriber (28.7%), omission without a valid clinical reason (27.1%), failing to sign the medication chart to record that a drug had been administered (23.6%) and wrong quantity (8.7%). Other types of error were compara- tively rare. Concerning the 111 instances where tablets were crushed or capsules opened without authorization, this was specifically contra-indicated by the drugs’ manufacturers in seven instances (esomeprazole three doses, digoxin two doses, aminophylline modified release one dose and lanso- prazole orodispersible one dose).

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Table 1 Types of medication administration error detected by observation (N ¼ 369)

Error type Frequency Percent of total number of errors

Percent of total number of doses

Crushing tablets without authorization

106 28.7 7.4

Omission without valid reason

100 27.1 7.0

Not signing for an administered medication

87 23.6 6.1

Wrong quantity 32 8.7 2.2 Wrong formulation

14 3.8 1.0

Administration of a prescribing error

9 2.4 0.6

Wrong time 7 1.9 0.5 Wrong drug 6 1.6 0.4 Opening capsules without authorization

5 1.4 0.4

Mixing drug with food without authorization

2 0.5 0.1

Unauthorized extra dose

1 0.3 0.1

Total 369 100 25.9

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The severity ratings of the errors detected are given in Table 2. More than two-thirds of errors were of doubtful or negligible significance (Grade 1). Only one error was rated as likely to result in serious effects or relapse. For nearly a quarter of errors, potential severity could not be rated. This was mainly because a nurse had been observed to have cor- rectly administered a dose of medication but had then failed to sign the medication chart. It was therefore possible, but not certain, that another nurse might then have administered a duplicate dose. The pharmacist observer intervened on four occasions to prevent patient harm (two wrong drug

errors, one wrong dose error and one omission error). Analysis of the more severe errors (Grade 2 and 3) showed the commonest error types were omission (N ¼ 13) (e.g. insulin, sodium valproate and carbamazepine), wrong drug (N ¼ 6) (e.g. propranolol given instead of trazodone, que- tiapine given instead of olanzapine) and unauthorized crush- ing (N ¼ 5) (e.g. aminophylline modified-release).

Factors associated with errors

Proportionally fewer errors were made at the 22.00 h medi- cation round than at other rounds (08.00 h 215 errors out of 694 doses, 31.0%; 12.00 h 50/157, 31.8%; 18.00 h 81/345, 23.5%; 22.00 h 23/227, 10.1%, P , 0.0001). A greater proportion of errors involved non-psychotropic

drugs (non-psychotropic errors 258 out of 893 doses (28.9%) vs. psychotropics 111 errors out of 530 doses (20.9%), P ¼ 0.001). A greater proportion of errors involved drugs administered by non-oral routes (non-oral routes, 70 errors in 118 doses (59.3%) vs. oral route, 299 errors in 1305 doses (22.9%), P , 0.0001). Of the 59 doses of topical preparations prescribed, there were 58 errors. In 57 instances, the error involved was omission of a topical preparation without a valid clinical reason. When topical creams and lotions were excluded from the analysis, the difference between errors involving the oral and non-oral routes disappeared. Errors were more often associated with patients with a

diagnosis of organic brain disease than those with functional mental illnesses (253/829, 30.5% vs. 116/594, 19.5%; P , 0.0001) and with those who lacked capacity to consent to medication administration than those with capacity (272/913, 29.8% vs. 97/510, 19.0%; P , 0.0001). Medication errors were also more often associated with patients with swallow- ing difficulties than those without (179/480, 37.3% vs. 190/ 943, 20.1%; P , 0.0001) and with those who were known to regularly spit out or refuse medication than with those who did not (169/540, 31.3% vs. 200/883, 22.7%; P , 0.0001). After excluding those doses of medication where tablets were crushed or capsules opened, errors were still more often associated with patients with swallowing difficulties (110/ 377, 29.2% vs. 117/780, 15%; P , 0.0001) but not with the other patient characteristics. Among the nurses observed, the error ratio (number of

errors made per total doses observed) varied widely from no errors made to one error in every 2.0 doses administered (P , 0.0001). The median error rate was one error in every 6.4 doses administered.

Errors detected by chart review

The independent pharmacist who reviewed the medication charts detected 148 administration errors. The types of errors detected were as follows: 133 omissions, 9 unauthor- ized extra doses, 5 wrong times and 1 administration of a discontinued item. All errors detected by chart review were detected by direct observation but of the 133 omissions detected by chart review, direct observation demonstrated

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Table 2 Severity ratings of medication administration errors (N ¼ 369)

Severity grade of error

Examples Medication administration errors N (%)

Grade 1: Errors or omissions of doubtful or negligible importance

Lactulose 20 ml administered— 30 ml prescribed. Pericyazine 2.5 mg administered at the wrong time.

255 (69.1)

Grade 2: Errors or omissions likely to result in minor adverse effects or worsening of condition

Sinemet 110 administered at the wrong time. Carbamazepine 200 mg administered— 400 mg prescribed

27 (7.3)

Grade 3: Errors or omissions likely to result in serious effects or relapse

Insulin omitted but the nurse recorded administration on the medication chart.

1 (0.3)

Grade 4: Errors or omissions likely to result in fatality

0 (0)

Grade X: Unrateable

Medication was observed to be correctly administered but the nurse failed to record administration on the medication chart.

86 (23.3)

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that 33 of the 133 omissions were in fact clerical errors (the nurse had correctly administered the medication but then failed to record administration on the medication chart).

Errors reported using the Hospital’s medication error reporting system

During the period of the observational study no adminis- tration errors on Wards A or B were reported using the Hospital’s medication error reporting system. No errors were reported in the 3 months before and only one error in the 3 months after the study.

Acceptability of the observational technique reported by participants

Seven (78%) of the nine participants completed the post- observation questionnaire. Five out of seven (71%) thought the observational procedure was well explained prior to com- mencement. None rated the experience of being observed as unpleasant. Two (29%) reported that they felt being observed made it more likely for them to make an error. All seven said they would be willing to be observed while administering medication in the future.

Discussion

In this observational study of medication administration to elderly long-stay psychiatric inpatients, errors were very common, occurring in one in four doses. Most errors were not serious and no patient suffered observable harm as a result of errors, although the pharmacist intervened on four occasions to prevent patient harm. The commonest types of error were unauthorized crushing of tablets or opening cap- sules, omission of medication and failing to sign for medi- cation. More errors were associated with patients with swallowing difficulties, even after crushed doses of medi- cation were excluded from the analysis. The reason for this association is not clear. The error rate varied widely between the nine nurse participants. The observational study detected two and a half times the number of errors than did retro- spective review of the medication charts, whereas none of the errors detected during the observational study were reported using the hospital’s incident report system. In addition, some errors misclassified as unauthorized omis- sions by chart review were shown by the observational study to be failures to sign for administered doses. The observational technique appeared acceptable to most

of the participating nurses. All who completed the post- observation questionnaire stated they would be willing to be observed administering medication in the future, although two reported they felt that being observed made them more prone to make errors. The pharmacist observer had to stand very close to the administering nurse in order to accurately record medicines administration and some nurses commen- ted that this was intrusive. However, an observational study conducted in a general hospital reported no evidence that

the technique made nurses more or less likely to make errors [10]. The participating nurses were aware of the aims of the study and it is possible that this knowledge may have affected their behaviour. The fact that observation was not disguised could have resulted in greater vigilance. Equally, it could have made some nurses anxious and inattentive and thus more prone to make errors. Compared with observational studies conducted in general

hospital settings, our study detected a similar proportion of errors but fewer potentially serious errors [6, 7]. In psychia- try, few drugs are administered parenterally. However, many of the patients in our study were physically frail requiring medication for physical conditions and all were elderly. Serious and fatal medication administration errors are more common in elderly patients [1]. Medicines administration to our patients was particularly difficult as some were confused and uncooperative, could be aggressive and had swallowing difficulties. On the other hand, the patients in our study were long stay and there was a low turnover of nursing staff. Patients’ medication changed little during the study period and yet despite this errors were very common. It would be expected that the error rate on a psychiatric admission ward would be much higher because of the greater turnover of patients and nursing staff and frequent changes to prescrip- tions. There are a number of possible reasons for the large number of process errors detected in our study. The phar- macist observer noted that medication administration fre- quently occurred at patients’ meal times in noisy and sometimes cramped conditions. Thus, the administering nurse had to contend with many potential distractions as well as being under pressure to complete the medication round as swiftly as possible. The ward atmosphere during the night- time medication round was, by contrast, much quieter and less pressured. At the time the study was conducted, there was no standardized refresher training in safe medication practice for nursing staff. In our study, the commonest error type was the unauthor-

ized crushing of tablets (and a few instances of opening cap- sules). Although beyond the scope of this researcher study, the pharmacist observer found no evidence that unauthor- ized tablet crushing was being used to covertly administer medication to patients. In some instances, the crushed medi- cation was then mixed with food. However, we could not find reports of this type of error in other observational studies, apart from one conducted in two units in France, one of which was a geriatric unit [6] and another conducted in an elderly acute admission ward [4]. Tablet crushing and capsule opening were observed to be common in an Australian study of units for the elderly [16]. In our study, crushing was done for two main reasons: for patients with swallowing difficulties and for uncooperative patients, but there were also instances of tablets being crushed for no obvious reason. Surveys of nursing and care staff have reported that tablet crushing is common in residential and nursing homes [24], as is the practice of concealing drugs in food and beverages [25]. Crushing tablets alters the bioavail- ability of some drugs and may have serious consequences for the patient. It may be appropriate but should be

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authorized by the prescriber. A pharmacist may be able to recommend a more appropriate dosage form. Since this study was conducted, staff on one of the wards concerned have set up a multidisciplinary medication administration group to review all patients’ medication regarding adminis- tration problems such as swallowing difficulties. The team includes a pharmacist and a speech and language therapist and aims to ensure medicines are administered in a safe and effective way. The other common error types we encountered were

omission of a medication without a valid clinical reason and failing to sign the medication chart after a medication had been administered. In our study, most of the prescriptions for topical preparations were not being administered. Omission errors have been reported as the commonest type of administration error in observational studies conducted in general hospitals [3–5]. Six wrong drug errors were detected in our study, all rated

as being of grade 2 severity (likely to results in minor adverse effects or worsening of the condition). None of these errors involved drugs of similar sounding names or similar packa- ging. One wrong dose error concerned confusion between two liquid preparations held in bottles of approximately the same size though with different coloured labels. Thus, given that no clear cause for these wrong drug errors was evident, it was not possible to develop strategies to prevent their re-occurrence. Wrong drug errors are an important cause of morbidity and mortality in general hospitals, and in one large USA study, they were the second most common cause of fatal medication errors [1]. Our study has a number of limitations. It took place on

two wards of an independent sector hospital, and thus the findings may not apply to the National Health Service or community settings. However, the patients studied were not atypical of those found in nursing homes for the elderly mentally ill, although some exhibited particularly challenging behaviour and had been referred from NHS hospitals for this reason. We studied medicines administration by a rela- tively small number of nurses and not all nurses approached agreed to participate. These are important limitations, and because of the small number of nurses observed, we were unable to report on whether errors were associated with par- ticular nurse characteristics. A study conducted in a paedia- tric hospital reported that error rates were higher for student nurses and nurses who did not regularly work on the unit [8]. All the nurses in our study were permanent staff on the wards concerned.

Conclusion

The observational technique can usefully be applied in psy- chiatry, although informed consent must be obtained from nurse participants. Medication administration errors in our study were very common, although fortunately most were not serious. The fact that the error rate varied widely between nurses and also the absence of annual refresher courses in medicines administration at our hospital suggests

some form of regular standardized training might impact on the error rate. We plan to repeat the study at a later date once training has taken place to see if practice has improved. However, a recent systematic review found little research on the efficacy of nursing educational interventions in reducing medication administration errors [26]. In a ran- domized controlled trial, the use of dedicated medication nurses who had undergone brief review training in safe medication use did not result in a reduction in medication administration errors compared with the control group [27]. The reporting of errors using incident reports needs to be encouraged, although several authors have highlighted the many reasons why staff are reluctant to report errors [28, 29].

Acknowledgement

Our thanks to Caroline Cahill for reporting on medication errors detected by chart review.

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Accepted for publication 13 April 2007

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3/15/20, 1)56 PMThe medication process in a psychiatric hospital: are errors a potential threat to patient safety?

Page 1 of 17https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775703/

Risk Manag Healthc Policy. 2013; 6: 23–31.

Published online 2013 Sep 9. doi: 10.2147/RMHP.S47723

PMCID: PMC3775703

PMID: 24049464

The medication process in a psychiatric hospital: are errors a potential threat to patient safety? Ann Lykkegaard Soerensen, Marianne Lisby, Lars Peter Nielsen, Birgitte Klindt Poulsen, and Jan Mainz

Faculty of Social Sciences and of Health Sciences, Aalborg University, Aalborg, Denmark

Department of Nursing, University College of Northern Denmark, Aalborg, Denmark

Research Centre of Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark

Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark

Aalborg Psychiatric University Hospital, Aalborg, Denmark

Department for Health Services Research, University of Southern Denmark, Denmark

Correspondence: Ann Lykkegaard Soerensen, Aalborg University, Danish Center for Healthcare Improvements,

Fibigerstraede 11, 9220 Aalborg Oest, Denmark, Tel +45 99 40 27 22, Email [email protected]

Copyright © 2013 Soerensen et al, publisher and licensee Dove Medical Press Ltd

The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of

the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly

attributed.

Abstract

Purpose

To investigate the frequency, type, and potential severity of errors in several stages of the medication process in an inpatient psychiatric setting.

Methods

A cross-sectional study using three methods for detecting errors: (1) direct observation; (2) unannounced control visits in the wards collecting dispensed drugs; and (3) chart reviews. All errors, except errors in discharge summaries, were assessed for potential consequences by two clinical pharmacologists.

Setting

Three psychiatric wards with adult patients at Aalborg University Hospital, Denmark, from January 2010–April 2010.

1,2 3 4 4 5,6

1

2

3

4

5

6

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The observational unit

The individual handling of medication (prescribing, dispensing, and administering).

Results

In total, 189 errors were detected in 1,082 opportunities for error (17%) of which 84/998 (8%) were assessed as potentially harmful. The frequency of errors was: prescribing, 10/189 (5%); dispensing, 18/189 (10%); administration, 142/189 (75%); and discharge summaries, 19/189 (10%). The most common errors were omission of pro re nata dosing regime in computerized physician order entry, omission of dose, lack of identity control, and omission of drug.

Conclusion

Errors throughout the medication process are common in psychiatric wards to an extent which resembles error rates in somatic care. Despite a substantial proportion of errors with potential to harm patients, very few errors were considered potentially fatal. Medical staff needs greater awareness of medication safety and guidelines related to the medication process. Many errors in this study might potentially be prevented by nursing staff when handling medication and observing patients for effect and side effects of medication. The nurses’ role in psychiatric medication safety should be further explored as nurses appear to be in the unique position to intercept errors before they reach the patient.

Keywords: medication safety, mental health disorders, medication errors, psychiatry

Introduction

Adverse drug events (ADEs) and medication errors (MEs) are recognized as an important quality and patient safety problem in modern hospital settings, causing harm as well as avoidable morbidity and mortality.1–5

There is limited evidence about these issues in psychiatric settings. Only a few studies on ADEs and MEs in psychiatric hospital settings exist. Four of these studies addressed prescribing errors and two studies addressed administration errors.6–11

Results from three of the studies investigating prescribing errors displayed a rate of decision-making errors which ranged from 12.5%–23.7% and a rate of documentation (clerical) errors, which ranged from 76.3%–84.5%.7–9 The fourth study, aimed at describing errors in the prescribing phase, was based on reports about pharmacists’ interventions.6 In the two studies which focused on administration errors, one study was based on self-reporting by nurses and did not report any rate of error. The other study was an observational study of administration errors in elderly psychiatric inpatients where administration errors were detected in 25.9% of all opportunities for error.10,11 Some studies have investigated several stages in the medication process, but these studies were primarily based on data collected from self-reporting of medication errors and chart reviews.12–15 These studies measured their outcomes using different methods and denominators which makes it difficult to conduct comparisons. However, it is recognized that direct observation is the most valid method when

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collecting data in the dispensing stage and the administration stage.16 It is highly important to apply reliable methods when investigating frequency and character of errors in the medication process to produce valid and precise information.16,17

To our knowledge, there are no studies in psychiatric hospital settings which focus on errors in more stages of the medication process, including discharge summaries, by applying the most sensitive methods of detection. A precise estimate of frequency, type, and potential severity of errors is needed to choose relevant interventions to reduce errors in the medication process. Therefore, the objective of this study was to investigate the frequency, type, and potential severity of errors in several stages of the medication process in an inpatient psychiatric setting.

Materials and methods

The medication process can be divided into prescribing, dispensing, administering, and monitoring.18

Furthermore, the prescription stage of the medication process can be divided into a decision-making process and a clerical process. The decision-making process concerns the physician’s choice of drug, dose, and form of administration.18 The stage of monitoring the patient for effects and side effects was not included in the study.

An error was defined as “a planned action which failed to achieve the desired consequences.”19 This means that all deviations from guidelines were considered errors; subsequently, two clinical pharmacologists evaluated all errors for potential severity, thereby separating harmless errors from errors with the potential to harm patients.

Describing proportions of errors requires a defined denominator.20

“Opportunities for error”, defined as opportunities for active errors (omissions, mistakes, and/or conscious or unconscious rule violations), was the denominator used to calculate the proportion of errors in this study. The denominator is established by multiplying the number of handled medications with the number of requirements in the guidelines to be followed. The proportion of errors was the sum of actual errors divided by the total number of opportunities for errors.

Design

The study was designed as a descriptive, cross-sectional study of errors in the medication process and potential harm. Data was collected using three methods: direct observation; unannounced visits to the wards to collect dispensed drugs for identification; and chart review. The study population included in- hospital patients aged 18 or above (n = 67), nurses and nurses’ assistants dispensing and administering drugs, and physicians prescribing drugs, but the observational unit was the individual handling of medication (prescribing, dispensing, and administering). It is common in Denmark that each ward has its own stock ward system where nurses dispense drugs. The term “dispensing” refers to nurses identifying the drugs prescribed and dispensing it to medication cups. Subsequently, the nurses will administer the medications to patients. The hospital pharmacy staff undertakes monitoring the use, needs, and reordering of drugs as well as giving advice for the individual wards. In this study, regular and pro re nata (PRN) prescriptions were included, apart from discharge summaries in which PRN prescriptions were excluded. The choice of excluding PRN prescriptions in discharge summaries was

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made because physicians often forget or are not aware that a PRN drug deliberately not prescribed in the discharge summary must be discontinued in the computerized physician order entry (CPOE). Including this as an error type would give a distorted impression of the prevalence of errors in discharge summaries. PRN prescriptions are prescriptions not scheduled to be administered at predetermined times of the day but to be used “when needed.” Errors in discharge summaries were not evaluated for potential severity, due to practical reasons. Included drug forms were tablets, capsules, mixture, suppositories, and injections.

Study site

This study was conducted in three psychiatric wards at Aalborg University Hospital, Denmark, from January 2010 to April 2010. Physicians were responsible for prescribing drugs and nurses or nurses’ assistants were responsible for dispensing and administering medication. There was no administration of drugs scheduled in the night shift. Drug prescriptions were documented in a CPOE system.

Methods for collecting data

All comparisons of observations to the CPOE were conducted by one of the authors (ALS).

Observational method

Data were collected on the wards using direct observation. The observer spent two day shifts (8 hours) and one evening shift (8 hours) on each ward, observing the nurse or nursing assistant responsible for dispensing and administering drugs. The observations covered six rounds of dispensing and administering drugs in each of the three wards. The caregiver responsible for the entire medication administration in the ward was aware of the study purpose but had no knowledge about which actions were observed and registered. The observations of dispensed and administered drugs were registered on a structured paper form and subsequently compared with prescriptions in the CPOE. Due to the tradition and rules of observing the patients’ consumption of medication in psychiatric nursing, it was possible to register all administered medication. Any discrepancies between the observed and the prescribed medication in the CPOE were classified as errors, according to the criteria outlined in Table S1.

Unannounced visit to the ward

The unannounced visit to the ward was conducted approximately 3 weeks after the observational study. The dispensed medication was collected from the medication storage room before administration. The medicine collected from the medication storage room was subsequently compared to the CPOE. Any discrepancies between the identified drugs and the prescriptions in the CPOE were classified as errors, according to the criteria outlined in Table S1.

Chart review

The CPOE and discharge summaries were retrospectively screened for errors. It was assessed whether drug prescriptions were in accordance with the criteria outlined in Table S1. If a patient was sampled more than once, only new or altered prescriptions were screened for errors. Discharge summaries were

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also screened to identify errors, ie, discrepancies between eligible prescriptions in the CPOE and the discharge summaries, according to the criteria outlined in Table S1.

Potential clinical consequences

All registered errors in the observational study, screening of the CPOE (errors in discharge summaries excluded), and the unannounced visits to the wards to collect dispensed drugs were assessed for potential clinical consequences. The assessment was conducted independently by two senior clinical pharmacologists using a four-scale system: potentially fatal; potentially serious; potentially significant; and potentially nonsignificant.5 The four-scale classification system can be found in Table S2.

Statistics

All data were analyzed using Stata/IC 10.0 (StataCorp, College Station, TX, USA). Frequencies were described as percentages. The kappa test was used to evaluate the interrater variation in the clinical pharmacologists’ assessment of potential clinical consequences where appropriate. The statistical significance level was set at 0.05.

Ethics

Approval of the study was obtained from the Danish Data Protection Agency. The investigator was ethically obliged to intervene in the case of observing an error. If the investigator had to intervene, it was registered as an error.

Results

Patients

The study included 67 eligible patients (24 men [36%] and 43 women [64%]) with a mean age of 46 years (20–79 years). The most common reason for admission was schizophrenia and other psychotic disorders (22/67;33%), followed by bipolar disorders (11/67;16%).

Frequency of errors

A total of 189 errors were detected in 1,082 (17%) opportunities for errors. The frequency of errors in the different stages of the medication process is shown in Table 1. The majority of errors were detected in the administration stage with errors in 142/340 (42%) opportunities for error. This was followed by discharge summaries with errors in 19/84 (23%) opportunities for error. Nine (47%) errors in discharge summaries were due to eligible prescriptions in the CPOE, which were not prescribed in the discharge summary.

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Table 1

Frequency of errors in the different stages of the medication process

Prescribing, CPOE n/N (%)

Dispensing, observational study n/N (%)

Dispensing, unannounced visit n/N (%)

Administration n/N (%)

Discharge summaries n/N (%)

10/267 (4) 9/324 (3) 9/67 (13) 142/340 (42) 19/84 (23)

Notes: N , the total number of opportunities of errors in each stage (prescription and doses); n, the total number of detected errors in each stage of the medication process. The difference in number of dispensed medications and number of administered medications in the observational study was due to incidents where staff had administered medicine without the investigators’ presence.

Abbreviation: CPOE, computerized physician order entry.

The intention behind investigating the dispensing stage using two methods was to examine the validity of the results obtained in the observational study. There were errors in 9/324 (3%) opportunities for error of the dispensed drugs in the observational study and in (9/67) 13% of the dispensed drugs in the unannounced control visit of which the majority was associated with one nurse assistant. Fewest errors were detected in the prescribing stage.

Frequency of error types

The identified errors were distributed by error types which are shown in Table 2. The most frequent error types were lack of identity control (135/142; 95%) and concordance with drug prescription (10/142; 7%). The error type lack of identity control occurs when the patients’ identity is not established before administering drugs. The clinical guideline states that the person administering the drugs must identify the patient by having the patient say his full name and Social Security number, or by using the obligatory wristband to identify the patient. The error type concordance with drug prescription occurs if already-dispensed drugs are delegated to another staff member; this person must compare the drugs to be administered with the prescriptions in the CPOE. Error types in the administration stage could be mutually dependent. This occurred with the following error types: “lack of identity control;” “wrong time;” and “lack of correct labeling.” The dependency arises because each of the aforementioned error types affects all doses which were delivered to the patient in that particular incidence. Analysis of these error types showed that “lack of identity control” occurred in 49 of 137 (36%) deliveries. “Wrong time” occurred in four of 137 (3%) deliveries. Finally, “Lack of correct labeling” occurred in three of 137 (3%) deliveries.

total total total

total total

total

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Table 2

Frequency of error types in the different stages of the medication process

Stage in medication process

Total number of doses or prescriptions affected with at least one error in each stage of the medication process (N)

Total number of error types in each stage (n/N)

Prescribing, CPOE

N = 10

 Drug name 0

  Drug prescription

2/10

  Omission of PRN dosing in CPOE

8/10

Dispensing, observational study

N = 9

 Drug prescription

0

 Omission of dose

3/9

 Wrong dose 1/9

 Unordered dose 0

 Contamination 1/9

 Lack of correct labeling

4/9

Dispensing, unannounced control visit

N = 9

 Drug prescription

0

 Omission of dose

6/9

 Wrong dose 2/9

 Unordered dose 1/9

Administration N = 142

 Omission of dose

0

a

b

c

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Open in a separate window

Notes:

One dose or prescription affected by an error could be associated with more than one error type; drug prescription: means one or more errors (including omissions) in strength per unit, route of

administration, form of administration, dose, frequency of administration, signature, date, duration of treatment (only antibiotics was included in this study); omission of PRN dosing regime in CPOE: means one or more errors (including omissions) in strength per

unit, route of administration, form of administration, dose, frequency of administration, signature, date, duration of treatment; lack of correct labeling: means that all drugs administered to patients must be marked with the patient’s full

identity; wrong time: means the drugs were administered ±60 minutes off the scheduled time; lack of identity control: means that the patient’s identity has not been established by having the patient state

full name and Social Security number or using the obligatory wristband; concordance with drug prescription: means that when dispensed drugs are delegated to another staff member,

this person must compare the drugs to be administered with the prescriptions in the CPOE.

Abbreviations: CPOE, computerized physician order entry; PRN, pro re nata.

Assessment of potential clinical consequences

The assessment of the potential clinical consequences was carried out in a worse-case scenario, meaning that whenever the clinical pharmacologists disagreed on the severity of an error, the most severe assessment was included in the analysis. Results from the assessment are displayed in Table 3; definitions are outlined in Table S2. The inter-rater agreement (measured by the test statistic kappa) for errors in prescribing, dispensing, and administration varied from good to perfect (0.54; 0.75; 0.82; and 1.0, respectively).21

a

b

c

d

e

f

g

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Table 3

Categories of potential clinical consequences of errors in the medication process

Nonsignificant n (%)

Significant n (%)

Serious n (%)

Fatal n (%)

Interrater variation

Prescribing, CPOE 0 4 (40) 4 (40) 2 (20) κ = 1,0

Dispensing, observational study, n (%)

0 6 (66) 3 (33) 0 κ = 0.82

Dispensing, unannounced visit, n (%)

4 (44) 5 (56) 0 0 κ = 0.75

Administration, n (%) 29 (20) 38 (27) 73 (51) 2 (1) κ = 0.54

Notes:

Kappa test for interrater agreement; the highlighted areas represent errors with the potential to harm patients.

Abbreviation: CPOE, computerized physician order entry.

The pharmacologists assessed 84/998 (8%) errors as potentially serious or potentially fatal. The number of opportunities for error in this part of the study was reduced to 998 because assessment of potential clinical consequences did not include errors in discharge summaries. The four potentially fatal errors were related to the error types: “omission of PRN dosing regime” (n = 2) and “lack of identity control” (n = 2). There were errors in 142/340 (42%) of all opportunities for errors in the administration stage, and it was assessed that 75/142 (53%) of these errors had the potential to harm patients.

Drug categories and errors

Errors with the potential to harm patients were most often associated with drugs related to the patients’ psychiatric condition (Table 4). The drug category most often associated with these errors was psycholeptics. The type of drug most often involved in potential harmful errors was atypical antipsychotics, followed by anxiolytic-sedative drugs and mood stabilizers. The errors assessed to be potentially fatal were related to prescribing and administration of medication and were associated with analgesics (opioids) (n = 2) and psycholeptics (atypical antipsychotics) (n = 2). Nonpsychiatric drugs associated with potential harmful errors constituted 7/77 (9%). The majority of these errors were anti- inflammatory and antirheumatic drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs).

a

a

a

a

a

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Table 4

Categories of drugs involved in errors with potential to harm patients

Drug category Prescribing Dispensing (observational and unannounced control visit)

Administration

N Nervous system

 N02 Analgesics 2 0 0

 N03 Antiepileptics 0 0 9

 N05 Psycholeptics

  – Atypical antipsychotics 3 3 20

  – Typical antipsychotics 0 1 9

  – Anxiolytic-sedative 1 0 17

  – Other 0 0 3

 N06 Psychoanaleptics

  – Mood stabilizers 0 0 9

 N07 Other nervous system drug 0 1

M Musculoskeletal system

 M01 Anti-inflammatory and antirheumatic products

6

H Systemic hormonal preparations, excluding sex hormones and insulins

 H03 Thyroid therapy 1

Notes: Drugs are categorized according to the Anatomic Therapeutic Chemical (ATC) Classification System (World Health Organization Collaborating Centre for Drugs Statistics Methodology [WHOCC]).

In this table, the observational and unannounced control visit in the dispensing stage have been collapsed.

Discussion

There were errors in almost one-fifth of all handlings of medication of which the vast majority occurred in the administration stage. The main type of errors was lack of identity control. The prevalence of potentially harmful errors was 8%, of which 0.3% errors were considered potentially fatal. The potentially fatal errors involved drugs from the categories of analgesics and psycholeptics. A few other studies in psychiatry have examined administration errors and identified the error types mismatching between medication and patient and wrong patient. One study found mismatching

a

a

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between medication and patient to occur with the second highest frequency; whereas, the second study found wrong patient to constitute 4/108 (3.7%) of all administration errors.10,14 These results emphasize the importance of systematically identifying patients to secure the right medication for the right patient. We found that administration errors constituted 142/340 (42%) of all errors, which is in contrast to a USA study of several stages in the medication process, which demonstrated that 10% of all medication errors were identified in the administration stage.15 This disparity is most likely due to variation in error types. In an observational study of administration errors in elderly psychiatric patients, errors were identified in 369/1423 (25.9%) of opportunities for error. However, this result is not entirely comparable, because the aforementioned study did not include the error type lack of identity control or any of the related error types, such as wrong patient or mismatching between medication and patient.

The severity of administration errors in psychiatric settings has been assessed less severe when compared to administration errors in somatic hospital settings.11,15 However, this study assessed more than one-half of all administration errors to be potentially serious. Many hospitals have introduced wristbands as a means to control patients’ identity, including the psychiatric hospital where our study was carried out. In a study of how and whether nurses identify patients in a psychiatric hospital setting, it was found that the use of wristbands was erratic and influenced by a psychiatric nursing culture rooted in the belief that (good) nurses know who the patients are.22 The inconsistency in using the patient’s wristband for identification has also been addressed in somatic settings, and it has been shown in simulation tests that as many as 61% of nurses do not discover an unexpected identity error.23,24 This raises a question about how and when nursing culture plays a role in patient safety and whether this brings advantages or barriers. Nurses are involved in many errors, but nurses also prevent many errors from happening.25 It needs to be considered that nurses are the professionals spending most time with the patients and, therefore, function as gatekeepers, where they can prevent errors and harm from reaching the patient. Nurses are coordinating several aspects of care to patients, including the care delivered by other health care professionals, and this is a major contribution to patient safety.26

Errors in discharge summaries constituted 10% (19/189) of all errors detected in the study. It is not possible to compare these results directly to other studies due to definitions and categorizations; however, earlier studies of errors in discharge summaries in general hospital settings have found discrepancies in 2%–76% of the prescribed drugs.5,27,28

It has been asserted that surgery and psychiatry are associated with the highest rate of dispensing errors and, therefore, it appears reasonable to consider psychiatry a high-risk specialty, in regards to dispensing errors.29 We investigated dispensing errors using observation and unannounced control visit, which showed a difference in results. When using observation and unannounced control visit to identify dispensing errors the rate of errors was 9/324 (3%) and 9/67 (13%), respectively. The difference in identified errors is caused by dependency in data, which arises due to the few nurses and nurses’ assistants involved in dispensing and administering medication. When pooling the results from the dispensing stage, the error rate was 18/391 (5%). This result is supported by other studies not depending on unit dose systems which found error rates <1% and up to 5%.5,29,30 The most common error type in the dispensing stage was omitted dose, which is in accordance with a previous study using similar methods of error detecting but in a general hospital setting.5

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In this present study, the clinical pharmacologists assessed three errors in the dispensing stage to be potentially serious, and no errors were assessed as potentially fatal. To our knowledge, there are no other studies in psychiatry where observed dispensing errors have been assessed for severity.

There were few prescription errors, but the prescription stage represented one-half of the potential fatal errors. Most of the prescribing errors were of the type “lack of PRN regime,” which is a type of prescription error that nurses are capable of intercepting. On the other hand, it also places nurses in a situation where they possibly make independent decisions as to whether a PRN medication is appropriate. The use of PRN medication is often solely the nurses’ decision and, perhaps, due to a lack of research into the use of PRN medication as an intervention in mental health care, the practice varies considerably.31

Strengths and weaknesses in the study

The majority of studies on medication errors and psychopharmacotherapy have been conducted in general hospital settings, and very few studies include a psychiatric population. Thus, this study is an important contribution to the current knowledge, as it focuses on errors in several stages of the medication process by applying the most sensitive method to each stage in a psychiatric hospital setting. There were 67 patients included in the study, which is a relatively small sample and a potential weakness in the study. Observation as a method of detecting errors is considered a valid and well-tested method; in this study, we sought to substantiate the validity of observing for errors with the unannounced control visit.17,32 The difference in errors identified by observation and the unannounced control visit is solely due to the dependency in data caused by the few nurses and nurses’ assistants participating in the study. In this study, dispensing of drugs was done by nurses and nurses’ assistants, which might complicate comparisons with other hospitals and settings where hospital pharmacies undertake the dispensing of drugs. It appears the study has a good internal validity, but the study was carried out in a single university hospital, thus producing a limited external validity. However, it is evident that psychiatric university hospitals – in comparison with somatic hospitals – are equally challenged in improving the quality of the medication process.

Conclusion

Errors were found in almost one-fifth of all handlings of medication, and a proportion of these errors had the potential to harm patients. In this study, the majority of errors involved psycholeptics, but potential fatal errors also involved analgesics. Most errors were found in the administration stage, and studies suggest that both nursing culture as well as an irregular practice regarding the patient’s identity wristband could be a risk factor for not checking the patient’s identity. This could lead to the error type “wrong patient.” It might be beneficial to address nursing culture as well as awareness of existing clinical guidelines. Further studies are needed to investigate how and whether nurses influence medication safety for in-hospital psychiatric patients and how nurses can improve the quality of medication and medication safety for psychiatric patients.

Supplementary tables

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Table S1

Criteria and definitions for error types

Stage in medication process

Definition Error types

Prescribing Unambiguous prescription

Omission of drug name, drug formulation, route, dose, dosing regime, date, signature, length of treatment time where required

Dispensing Dispensed medication is concordant with prescribed drug in electronic medication chart

Wrong drug, unordered dose, omission of dose, wrong dose, wrong drug formulation, contamination (ie, touching tablets without gloves), control of prescription (ie, controlling that only prescribed drugs are dispensed), ambiguous labeling of medication

Administering The right medication to the right patient in the right way and at the right time

Wrong: dose, administration technique, route, time (±60 minutes), unordered drug, unordered dose, omission of dose, lack of identity control, wrong patient (one or more medications administered to the wrong patient), contamination, concordance with drug prescription

Discharge summaries

Eligible prescriptions in medical record are identical to prescriptions in discharge summaries

Discrepancy in: drug name, drug formulation, route, dose, regime, omission of drug, unordered drug

Note: Adapted with permission from Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care. 2005.

Abbreviation: CPOE, computerized physician order entry.

Table S2

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Definition of potential clinical consequences

Category Definition Definition of keywords

Potentially fatal

Errors judged to imply a potential clinical risk for causing the death of the patient

Fatal refers to errors that could lead to the death of the patient

Potentially serious

Errors judged to imply a potential clinical risk of injuring the patient

Injury includes errors that would require active treatment to restore the health of the patient. A potentially serious error would lead to either permanent or temporary disability

Potentially significant

Errors judged to imply a potential clinical risk of being “inconvenient” for the patient – without causing any harm or injury

“Inconvenient” refers to unpleasant consequences of wrong dose/drug omission of dose/drug that could lead to pain, dizziness. It also refers to any monitoring of the patient, such as extra blood test, measurement of blood pressure

Potentially nonsignificant

Errors judged to be without any potential clinical risk for the patient

Without clinical risk refers to errors that did not lead to any injury or inconvenience for the patient

Notes: The highlighted areas represent errors with the potential to harm patients. Adapted with permission from Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care. 2005.

Reference

1. Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care. 2005;17(1):15–22. [PubMed] [Google Scholar]

Footnotes Disclosure

The authors report no conflicts of interest in this work.

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...تاثیر آموزش خانواده محور بر میسان تبعیت

Preventive Care in Nursing & Midwifery Journal 2018; 8(2): 1-8

Factors associated with medication errors in the psychiatric ward of Razi Hospital in Tabriz: Perspectives of nurses

Abdi M1 , Piri Sh2 , Mohammadian R2 , Asadi Aghajeri M2 , khademi E3 *

1Department of Intensive Care, School of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran

2MSc. Department of Nursing, Maragheh Branch, Islamic Azad University, Maragheh, Iran 3MSc. Dept. Nursing, Maragheh Branch, Islamic Azad University, Maragheh, Iran

*Corresponding Author: Dept. Nursing, Maragheh Branch, Islamic Azad University, Maragheh, Iran

Email: [email protected]

Received: 7 Jan 2019 Accepted: 11 Aug 2019

Abstract

Background: Medication errors are considered to be the most significant safety threatening factors for the patients in hospital, to which many factors contribute. Objectives: This study was conducted to determine the role of associated factors in the incidence of medication errors in the psychiatric ward of Razi Hospital in Tabriz from the perspectives of nurses in 2017. Methods: In this descriptive cross-sectional study, we selected 150 nurses working in the psychiatric ward of Razi Hospital in Tabriz through random sampling method. The data collection instrument included a demographic and researcher-made questionnaire to assess the effective factors in the incidence of medication errors according to the perspectives of nurses. The data were imported into SPSS version 20 and analyzed via ANOVA and Chi-square tests. Results: In this study, 95(63.3%) women and 55(36.7%) men with the mean age of 34.4±0.66 participated. The highest mean score for the causes of medication errors was related to the professional errors made by nurses (33.93±2.61) and the structure of the psychiatric ward (27.96±5.8). The change in Kardex during the transfer of the patient to other wards was the most significant cause of errors with a mean of 4.35±5.53. The mean score of medication errors was significantly different with that of the level of education, age, work experience, and employment types. However, it was not significantly different with that of gender, marital status, nurse job position, and shift work rotation. Conclusion: Considering the incidence of the most common medication errors in the field of nursing careers and structure of psychiatric ward, we recommend that nurse managers increase the skills of medication administration through holding training courses and improve the physical conditions of the ward. Keywords: medication errors, nurses, psychiatric ward Introduction Providing patient safety is one of the most important tasks of healthcare -medical complexes. Today, patient safety in the delivery service system is a key concept and is regarded as one of the important indicators of control quality of health services [1]. Factors such as wrong injection, falls, burns, and errors in invasive procedures threaten patients’ safety, among which

medication errors are the most important factors [2]. Medication errors are defined as deviations from the proper conduct of the treatment process, which may occur in administration, preparation, delivery, use, or distribution of drugs. Administering drugs to patients is one of the main tasks of nurses and the most important part of care processes. Proper administration of drugs to patients requires high level of knowledge and

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accuracy on the part of nurses [3]. Today, various types of medicine are used in the field of health and treatment of patients, all of which may have harmful effects on the health of individuals despite their beneficial effects. Thus, nurses should be aware of the importance of correctly recognizing and administering drugs to prevent possible complications due to medication errors [4]. According to a survey conducted in England in 2018, more than 2 million people are injured each year due to medication errors, and of which about 100,000 die in hospitals [5]. According to previous studies, the cost of medication side effects was estimated to be nearly $ 300 million in 2018 [6]. However, it is difficult to estimate accurate statistics in the third world and developing countries due to the lack of proper registration and reports [7]. Watanabe et al. showed that 30% of the injured patients due to medication errors are impaired for more than 6 months or even lose their lives [8]. In this regard, psychiatric drugs are very sensitive, and if administered incorrectly, they poison the patient very early. A majority of medicines for patients with psychological problems are taken orally, and due to drug similarities, the risk of wrong administration is high [10]. The structure of the psychiatric ward, the lack of co-operation of mental patients in treatments, the poisoning dose close with the therapeutic dose in mood- stabilizing, antipsychotic, and depression drugs necessitate nurses' attention when administering the drug [11,12]. Ferrera et al. mentioned that more than half of the medication errors could be prevented, and observing the precise principles of drugs medication could reduce the incidence of errors [13]. The reason for the incidence of medication errors is not limited to one aspect and must be controlled in all aspects [14]. There are several factors involved in the incidence of medication errors; however, in previous studies, the cause of medication errors has been differently reported. For instance, Jones et al. have reported that the most common cause of medication errors made by nurses is the lack of compliance with the five rights of medication administration (the right patient, the right drug, the right dose, the right route, and the right time) [15]. However, Sarvadikar et al. (2010) stated that most of the

errors occurred in the process of administering drugs to the patients [16]. A study by Cottney et al in 2014 suggested that medication errors of the psychiatric ward is more likely to occur due to insufficient knowledge and skills of nurses in terms of the right dose, time, and medication [12]. Yakubi et al. and Mashhala et al. reported factors such as the burden on nurses, the lack of readability of drug orders in patient's file or medication card, doctors’ bad handwriting, the similarity in the form and packages of drugs, fatigue due to overwork, anxiety and stress resulted from work, noise of the ward settings, and nurses’ dissatisfaction with the amount of salary and benefits as the most important causes of medication errors [17,18]. In summary, the main causes of the incidence of nurses’ medication errors are workplaces, drug companies, and nurse management. Each study has presented a cause for the error in a different way, and the number of studies that comprehensively examine these factors is small. It seems that there has not been a study in Iran to examine the medication errors of the psychiatric ward. In the present study, considering the complications of drugs for patients, heavy economic costs for individuals and society due to medication errors, the role of each member in the drug supply chain in the incidence of medication errors, and the sensitivity of drugs in the psychiatric ward, we aim to determine the associated factors in the incidence of medication errors in the psychiatric ward of Razi Hospital in Tabriz from the perspective of nurses. We hope that the results of this study can help identify the causes of the incidence of medication errors and provide a solution to reduce their incidence and complications in patients and decrease the cost of treatment and the duration of hospitalization. Methods This descriptive cross-sectional study was carried out using random sampling method based on a random table of numbers in the first half of 2017. One hundred fifty nurses working in the psychiatric ward of Razi psychiatric hospital participated in the present study. The main population of the study included 280 nurses. To estimate the minimum sample size at 95% confidence level, with a 90% test power and the

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Preventive Care in Nursing & Midwifery Journal (PCNM) 2018; 8(2)

mean incidence of medication errors as at least =0.18 using the formula

(d=1/96), the final sample size included 141 participants. To prevent sample loss, 165 people were invited to participate in the study. During the research, 15 people refused to continue, and the study was done using 150 people. The data was collected in morning, noon, and night shifts. The inclusion criteria in this study were having more than one year of work experience in hospital, undergraduate and postgraduate studies, and lack of mental and physical illness. Nurses who had less than one year of work experience or were reluctant to participate in the study were excluded. In order to ensure the confidentiality of information, it was announced to the participants that writing name and surname is optional. This study was approved by the Ethics Committee of Maragheh University of Medical Sciences with number 5/13/15/12378 and Iranian code of IR.MARAGHEHPHC.REC.1396.26. After obtaining informed consent from the patients, compliance with the ethical issues according to the Helsinki Treaty, and compliance with the conditions of inclusion criteria, the questionnaires were completed. A demographic and researcher-made questionnaire was used to assess the factors affecting the incidence of medication errors according to the perspective of nurses, which were designed after studying different texts [19,20]. The questionnaire consists of 31 questions and five areas in which questions 1 to 10 are related to nursing

professional errors, 11 to 18 to the conditions of the ward and the attendance of patients, 19 to 22 to doctors’ errors, 23 to 24 to the errors of drug companies, and 25 to 31 to the management process errors. The scoring procedure of the questionnaire was considered as a 5-point Likert spectrum that included very low, low, moderate, high, and very high with the scores of 1 to 5. The least acquired score is 31, and the maximum is 155. Higher scores in one area indicate the importance of that area. The face and content validity of this questionnaire was verified by ten faculty members and nursing experts. To determine the reliability, split-half method and the correlation coefficient calculation were used in two parts of the questionnaire, for which correlation coefficient was found to be 81%. The data were imported into SPSS version 21 software, and then the data normalization was determined using Kolmogorov-Smirnov test. To analyze the data, descriptive statistical indices were employed. Besides, to compare the socio- demographic characteristics with the probability of medication errors, statistical analysis of variance and Chi-square were used. Results In this study, 95 (63.3%) women and 55 (36.7%) male participated. The mean age of the participants was 34.4±0.69 years. The mean total score of medication errors was 106.25±9.28. The highest mean score for nurses' professional errors was 33.93±2.61, and factors associated with the ward was 27.96 ± 5.8 (Table 1).

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Table 1: The frequency of effective factors in the incidence of medication errors from the

perspective of nurses in the psychiatric ward of Razi Hospital in Tabriz

P Value M± SD N (%) Demographic Factors

586/0p=* 81/106 ± 97/7 55 (7/36) Female

Gender 69/105 ± 01/10 (3/63)95 Male

001/ 0p<* 75/109 ± 53/9 (3/83)125 Bachelor of Science

Education Level 92/88 ± 52/7 (7/16)25 Master of Science

209/0p=* 94/106 ± 68/8 (7/46)70 Single

Marital Status 60/105 ± 81/9 (3/53)80 Married

837/0p=* 27/106 ± 45/9 (7/96)145 Nurse

Job Position 01/105 ± 45/9 (3/3)5 Head Nurse

284/0p=* 60/105 ± 03/5 (30)45 Fixed Shift

Work Shift 38/106 ± 58/10 (70)105 Rotational

04/0p=** 12/106 ± 34/10 (3/63)95 25-35

Age 101± 18/7 (30)45 35-45 98± 16/3 (7/6)10 45-50

01/0p=** 40/106 ± 84/9 (7/76)115 10>

Work Experience 60/98 ± 31/6 (7/16)25 10-20 99± 16/3 (7/6)10 20<

021/0p=**

75/107 ± 85/18 (3/13)20 Draft

Recruitment Status

33/106 ± 77/6 (10)15 Hiring 76/104 ± 27/7 (50)75 Contractual 42/96 ± 4/6 (3/13)20 Official Trial

50/92 ± 66/2 (3/13)20 Official *Chi-square ** one way ANOVA

The most important cause of nursing professional errors was related to non-compliance with the eight rights of medication errors with a mean of 3.70±0.97. In the factors related to the ward, the most important reason was the change of Kardex when the patient was transferred to other wards with a mean of 4.53±5.58. Regarding the factors related to nursing management, the most leading cause was inappropriate work shift layout of nurses with the mean of 3/53+1/02. The

association between the mean score of medication errors and other socio-demographics of participants is shown in Table 2. There was a significant difference between the mean score of medication errors and that of the level of education, age, increase in work experience, and type of employment (p<0.05). However, there was no significant difference between medication errors and sex, marital status, and nurses’ job position and work shift rotation (p<0.05).

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Table 2: Comparison of the mean score of medication errors with individual-social factors

N um

ber

Field Questions Very

Low Low Moderate High Very High M± SD N (%) N (%) N (%) N (%) N (%)

1 N ursing professional errors

Lack of sufficient knowledge about medicine 0(0) 50(3/33) 45 (30) 35 (3/23) 20 (3/13) 03/1±16/3 2 Indifference of nurses to their profession 0(0) 25(7/16) 60 (40) 50 (3/33) 15 (10) 87/0±36/3 3 Low salary and economic problem 0(0) 25(7/16) 55 (7/36) 70 (7/46) 0(0) 73/0±30/3 4 Nurses’ family challenges 0(0) 30(20) 45 (30) 50 (3/33) (7/16) 25 99/0±46/3 5 Nurses’ psychological challenges 0(0) 20 (313) 65 (3/43) 35 (3/23) 30(20) 96/0±50/3 6 Much workload 0(0) 15 (10) 45 (30) 75 (50) 15(10) 80/0±60/3 7 Failure to comply with 8 rights of medication administration 0(0) 25 (7/16) 25 (7/16) 70 (7/46) 30(20) 97/0±70/3 8 Error in the rate of drug infusion 5 (3/3) 35 (3/23) 50 (3/33) 50 (3/33) 10 (7/6) 97/0±16/3 9 Forgetting medication administration in due time 10 (7/6) 15 (10) 55 (7/36) 60 (40) 10 (7/6) 97/0±30/3

10 Failure to properly transfer physician’s orders to Kardex 0(0) 30 (20) 45 (30) 65 (3/43) 10 (7/6) 87/0±36/3

61/2±93/33 11 Conditions of the w

ard and the attendance of patients

Lack of appropriate drug information (DI) resources in the wards 0(0) 40 (7/26) 45 (30) 50 (3/33) 15 (10) 96/0±26/3

12 The physical conditions of the ward in terms of light, ventilation, temperature,... 0(0) 20 (3/13) 70 (7/46) 50 (3/33) 10 (7/6) 79/0±33/3

13 Noise and crowded setting of the ward 0(0) 20 (3/13) 60 (40) 55 (7/36) 15 (10) 84/0±43/3 14 Placement of the drugs on the shelves 0(0) 25 (7/16) 50 (3/33) 50 (3/33) 25 (7/16) 96/0±50/3 15 The large variety of drugs in the ward 0(0) 10 (7/6) 80 (3/53) 45 (30) 15 (10) 76/0±43/3 16 Attendance of patient’s companions in the ward 0(0) 40 (7/26) 60 (40) 35 (3/23) 15 (10) 93/0±16/3 17 Patients and companions, inappropriate behavior 0(0) 20 (3/13) 70 (7/46) 55 (7/36) 5 (3/3) 73/0±30/3

18 Change of Kardex when transferring the patient to other wards 0(0) 35 (3/23) 30 (20) 60 (40) 25 (7/16) 58/5±53/4

8/5±96/27 19

D octors’ errors

Giving instructions on the phone by doctors 0(0) 15 (10) 65 (3/43) 60 (40) 10 (7/6) 76/0±43/3 20 Illegibility of doctor’s handwriting 0(0) 25 (7/16) 65 (3/43) 45 (30) 15 (10) 87/0±33/3 21 Error in prescribing drugs 0(0) 35 (3/23) 35 (3/23) 60 (40) 20 (3/13) 99/0±43/3 22

Failure to comply with the appropriate time for prescribing the drugs by doctor

0(0) 35 (1/24) 45 (31) 45 (31) 20 (8/13) 99/0±34/3 7/1±54/13

23 Error s of drug com

p anies

Inappropriate forms and naming of drugs 0(0) 25 (7/16) 55 (7/36) 50 (3/33) 20 (3/13) 92/0±43/3

24 Pharmaceutical similarities in terms of form, name and ... 5 (3/3) 20 (3/13) 50 (3/33) 55 (7/36) 20 (3/13) 99/0±43/3

15/1±86/6 25

M anagem

ent process errors

Inappropriate relationship of nurses with ward authorities 0(0) 30 (20) 50 (3/33) 65 (3/43) 5 (3/3) 82/0±30/3 26 The existence of occupational discrimination 0(0) 10 (7/6) 70 (7/46) 65 (3/43) 5 (3/3) 66/0±43/3 27 Lack of recording and error reporting systems 0(0) 25 (7/16) 65 (3/43) 50 (3/33) 10 (7/6) 82/0±30/3 28 The inappropriate layout of nurses’ work shift 0(0) 25 (7/16) 55 (7/36) 35 (3/23) 35 (3/23) 02/1±53/3 29 Shortage of nurses in proportion to the number of patients 0(0) 20 (3/13) 65 (3/43) 45 (30) 20 (3/13) 88/0±43/3 30 Lack of supervising care processes by ward authorities 5 (3/3) 10 (7/6) 55 (7/36) 65 (3/43) 15 (10) 88/0±50/3

31 The presence of a large number of serious patients in the ward 0(0) 20 (3/13) 55 (7/36) 60 (40) 15 (10) 84/0±46/3

64/2±96/23 Mean total score of medication errors 28/9±25/106

Discussion In this study, the role of effective factors in the incidence of nurses' medication errors was examined. We found that the most medication errors were related to Kardex change when the patient was transferred to other wards as well as non –compliance with the 8 rights of medication administration which is related to nursing field and disorder of the ward. Katney et al., in a prospective observational study entitled “survey of medical errors in urban psychiatric hospital”, reported that the most common medication errors were amnesia in giving correct amount of drug (37%), incorrect method (18%), incorrect form (12%) and incorrect times (9%) in British hospitals [12]. In fact, this study points to nurses'

failure to properly check drug and non- compliance with the 8 rights of medication administration, which are consistent with the results of the present study. The strength of this study was its observational survey of 4177 Pharmaceutical cares by nurses and the report of 139 errors. Although the observational study can be very objective to examine the care, it may unconsciously remind the caregiver of the observer, increase the quality of his/her work, and cause a bias in the research. Therefore, elimination of these confounding factors must be carefully done, while Katney et al. did not point out how to remove this bias. Sorensen et al. (2013), in a cross-sectional observational study entitled” medication errors in

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the psychiatric ward” and after observing 1082 cases drug administration, reported 189 errors. The most common medication errors were nurses' professional skills in administrating medication (75%), wrong prescription (10%), error in prescribing discharge (10%), and illegibility and incomprehensibility of physicians’ prescription (5%). The most common medication errors in this study are related to nurses' skills, which is consistent with the present study. This study has not paid attention to the various aspects of nursing care during medication such as conditions of the ward, mental status of nurses, and other individual and social factors. The volume of care review is lower than that of other observational studies. Due to the use of different instruments in checking medication errors, the mean score of medication errors was not comparable in various studies. Julaei et al. (2016), in a cross-sectional study, using a population of 300 nurses working in hospitals affiliated with Tehran University of Medical Sciences, reported that the most common types of medication errors were drug administration later or earlier than the due time, failure to take necessary measures before administering drugs, which agrees with findings of the present study [22]. The strength of this study was using a high volume of samples and studying the conditions of work environment via an independent questionnaire. The difference between this study and the presentt study was in the use of the type of medication errors-checking instruments. Julia et al. used a researcher-made questionnaire to examine the medication errors related to nurses' professional performance, and other areas of errors were not addressed. For example, in the present study, one of the biggest medication errors happened due to the physical conditions of the ward, while but Julaei et al. reported that the conditions of the nurses' work environment were favorable for pharmaceutical care [22]. Besides, Julaei et al. did not address the physical conditions of the ward, the placement of medicines in the pharmacist, the presence of companions in the ward, and noises, which could be the reason for the differences between the two studies. Jones et al., in a cross-sectional study, reported that the most common cause of the incidence of medication errors from the perspective of the nurses was non-compliance with five rights of

medication administration (the right patient, the right medication, the right dose, the right method, and the right time), which is consistent with the present study [24]. The similarity between the study of Jones et al. and the present study was in the sample size and error analysis from the perspective of nurses. This study has used five rights of medication administration to examine errors, while, in the present study, eight rights of medication administration (the right patient, the right medication, the right dose, the right route, the right time, the right administration, the right recording and the right patient response to medication) were used, which is a newer form of this law. Mi-Ae You et al., (2015) in a cross- sectional study of 312 nurses in three South Korean hospitals, noted that most of the incidences of medication errors were due to the shortage of nurses in a work shift. Mi-Ae You used a 29-item questionnaire focused more on drug similarities, and little attention was paid to nursing management, medical errors, and conditions of the ward. Moreover, there was no proper distinction among the causes of medication errors. However, the present study analyzed the role of other factors in nursing errors via dividing the nurses' medication errors into five areas. In the present study, there was a significant difference between the mean score of medication errors and the increase in education level, age, work experience, and type of employment, while no significant difference was found between the mean score of medication errors and that of sex, marital status, nursing job position, and work shift rotation. Shouhani et al, using a sample of 120 nurses, found that the mean score of medication errors was not associated with an increase in educational level, work-related experience , gender, marital status, and age, all of are consistent with the present study except for age factor [23]. However, Yaghoubi et al, using 127 nurses of Zahedan hospital, showed that the probability of making errors by nurses with work shift rotation is more than the one in others, which is in contrast with the present study [17]. In their study, the minimum working experience was three months, and this could be the reason for the difference in the results the two studies. Nursing Professional errors and physical conditions of the ward play a major role in nursing staff's medication errors. Considering the

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incidence of medication errors in cases such as Kardex change when transferring patients to other wards, failure to comply with eight rights of medication administration, overwork, psychological challenges of nurses, job discriminations, and lack of supervision on care processes by ward authorities, we suggest that job training, in the form of continuous educational courses, should be offered to nurses to increase their knowledge and performance and to nurse managers for more effective planning. Due to the existence of errors such as the placement of drugs on the shelves and the noise and crowded environment of the ward, hospital administrators are recommended to improve the physical conditions of the workplace. Based on the possibility of an error due to similarities of form and verbal of drugs, it would be more effective to design a system to check the similarity of drugs before issuing a license in food and drug administration. Finally, hospital administrators need to oversee doctors’ handwriting and the way of writing a prescription. One of the limitations of this study was its use of only one hospital for sampling due to the lack of other psychiatric hospitals in Tabriz. Another limitation was the lack of comparisons between psychiatric wards and special, surgery, and emergency wards due to the specificity of the psychiatric hospital. Some of the medication errors were due to the delayed response of medications due to the carelessness of pharmaceutical companies in manufacturing medicines, and there were not enough facilities and opportunities to study these issues in the research. Another limitation was the use of self- reports as the data collection tool. Acknowledgments The authors appreciate the staff of the psychiatric wards of Razi Hospital in Tabriz, who participated in this study despite their heavy work loads. We also express our special thanks to the authorities of Tabriz University of Medical Sciences, Maragheh Medical Sciences, and Maragheh Islamic Azad University, who provided the basis of this study.

Conflict of interest The authors of this article declare that there is no conflict of interest in writing this article.

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13. Ferrah N, Lovell JJ, Ibrahim JE. Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents. J Am Geriatr Soc. 2017; 65(2): 433-42. 14. Ruiz ME, Suñol MM, Miguélez JR, et al. Medication errors in a neonatal unit: One of the main adverse events. An Pediatr (Barc). 2016; 84(4): 211-17. 15. Jones JH, Treiber L. When the 5 rights go wrong: medication errors from the nursing perspective. J Nurs Care Qual. 2010; 25(3): 240- 47. 16. Sarvadikar A, Prescott G, Williams D. Attitudes to reporting medication error among differing healthcare professionals. Eur J Clin Pharmacol. 2010; 66(8): 843-53. 17. Yaghoobi M NA, CHarkhat Gorgich EAH, Salehinya H. Nurses’ Perspectives Of The Types And Causes Of Medication Errors. Iran J Nurs. 2015; 28(93,94): 1-10. 18. Mosahneh A, Ahmadi B, Akbarisari A, Rahimi Foroshani A. Assessing the Causes of Medication Errors from the Nurses' Viewpoints of Hospitals at Abadan City in 2013. J Hospital. 2016; 15(3): 41-51. 19. Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH. Nurses relate the contributing factors involved in

medication errors. J Clin Nurs. 2007; 16(3): 447- 57. 20. Hosseinzadeh M, Ezate Aghajari P, Mahdavi N. Reasons of Nurses' Medication Errors and Persepectives of Nurses on Barriers of Error Reporting. Hayat. 2012; 18(2): 66-75. 21. Soerensen AL, Lisby M, Nielsen LP, Poulsen BK, Mainz J. The medication process in a psychiatric hospital: are errors a potential threat to patient safety? Risk Manag Healthc Policy. 2013; 6: 23-31. 22. Joolaee S, Shali M, Hooshmand A, Rahimi S, Haghani H. The relationship between medication errors and nurses' work environment. Med Surg Nurs J. 2016; 4(4): 27-34. 23. Shohani M, Tavan H. Factors affecting medication errors from the perspective of nursing staff. J Clin Diagn Res. 2018; 12 (3): IC01-IC04. 24. Jones JH, Treiber L. When the 5 rights go wrong: medication errors from the nursing perspective. J Nurs Care Qual. 2010; 25(3): 240- 47. 25. You MA, Choe MH, Park GO, Kim SH, Son YJ. Perceptions regarding medication administration errors among hospital staff nurses of South Korea. Int J Qual Health Care. 2015; 27(4): 276-83.

Realizing E-Prescribing’s Potential to Reduce Outpatient Psychiatric Medication Errors Matthew E. Hirschtritt, M.D., M.P.H., Steven Chan, M.D., M.B.A., Wilson O. Ly, Pharm.D., M.Sc.

Preliminary evidence from observational and cohort studies suggests that replacement of paper- and phone-based med- ication prescriptions with electronic prescribing systems in am- bulatory settings is associated with decreased medication errors. However, problems from traditional prescribing also occur with e-prescribing (such as incorrect medication dose and instructions or wrong patient), as do some new problems (a confusing user interface leading to prescribing the wrong

medication). The authors present four steps for reducing medication errorsin outpatient psychiatric settings: continuing to implement e-prescribing, streamlining user interfaces, im- proving interoperability among various e-prescribing and re- tail pharmacy systems, and using education and advocacy to achieve these goals.

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Medication errors in outpatient settings are relatively com- mon and may lead to significant clinical harm (1). Studies to quantify medication errors specifically among psychiatric populations have been limited to the inpatient setting (2). However, medication errors in the outpatient psychiatric set- ting are especially pertinent given that, among adults with any mental health condition, care is delivered over seven times more frequently in outpatient settings than in inpatient settings (25.4% versus 3.4%) (3). Furthermore, with prescribers us- ing various medical record systems, outpatient settings pose unique challenges in care coordination and opportunities for medication errors.

Taking the wrong medication or taking the intended medication at the wrong strength or frequency can harm patients—sometimes threatening their lives. Moreover, in the outpatient psychiatric setting, where a solid therapeutic alliance is an essential aspect of the patient-physician relation- ship, even errors that do not lead to physical harm can have lasting, negative impact on subsequent care (1). Specifically, patients may perceive these errors as representative of phy- sician negligence and may thereby be less likely to trust their physician in subsequent treatment decisions. Therefore, it is imperative that outpatient psychiatric prescribers make an ongoing, concerted effort to reduce risk of medication errors.

Among the many potential causes of medication errors— from prescribers (incomplete or inaccurate scripts), retail pharmacies (such as filling of incorrect medication or switch- ing medications between patients), and the patients them- selves (continuing to take a discontinued medication, for example)—one that has received increased attention is the outpatient prescription. Until recently, all outpatient scripts

were handwritten and faxed to the pharmacy by the physi- cian’s office, presented by the patient to the pharmacy, or called in to the pharmacy by the prescriber (or a clinic rep- resentative). Integration of electronic health records (EHRs) with e-prescribing capacity was anticipated to drastically reduce errors attributable to illegible handwriting, lost paper scripts, and incomplete or inaccurate instructions (4).

With the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the U.S. government began a series of incentive programs to accelerate imple- mentation of e-prescribing (4). The MMA instituted financial incentives to Medicare prescribers who adopted e-prescribing tools; this program was subsequently reinforced by the Medicare Improvements for Patients and Providers Act, or the “eRx incentive,” beginning in 2008 and was succeeded by the Meaningful Use program in 2011. Partially due to these incentive programs, rates of e-prescribing have dramatically increased; in 2015, approximately 1.41 billion e-prescriptions were sent, which represents a 300% increase since 2010 (5). Results from observational and cohort studies suggest that certain types of outpatient medication errors are reduced with e-prescribing; for instance, within three months of im- plementing an e-prescribing system among 20 primary care providers, medication error rates dropped to 6%, markedly lower than average error rates associated with paper-based prescribing (6).

Unfortunately, despite its many advantages, e-prescribing has not eliminated outpatient medication errors. In fact, e-prescribing has reduced some types of errors and created new ones. With e-prescribing, physicians may still omit cru- cial aspects of an order (dose or strength), prescribe the

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wrong medication, continue medications they no longer in- tend the patient to take, and prescribe the same medication multiple times with different instructions (7). Reasons for such oversight range from the growing complexity of medication regimens to fatigue from an abundance of on-screen auto- mated alerts. Prescriber reliance on e-prescribing reduces opportunities to interact with pharmacy staff, a crucial step in conveying complex instructions. Despite pharmacy-based initiatives to maintain accurate medication profiles by set- ting expiration dates for unused prescriptions, Internet-based refill systems may still contain duplicate medications and outdated instructions.

In addition, whereas communication between inpatient pharmacists and prescribers may have improved in recent years with team-based rounds and live digital chats, outpatient pharmacists continue to have difficulty communicating ef- fectively with prescribers to clarify prescriptions. Community pharmacists still resort to using fax and voice mail messages to achieve clarity on orders, drug interactions, and duplications. Although e-prescribing is helpful in improving the efficiency of health care delivery, medication errors continue to affect patient safety (8).

Medication errors are especially concerning among those seeking psychiatric care, given frequent co-occurring gen- eral medical and psychiatric illnesses, which amplify the potential dangers of medication errors. Here, we propose multiple initiatives that could reduce risk of outpatient medi- cation errors in psychiatric settings in the era of e-prescribing, and we conclude with suggestions for achieving these goals.

Accelerate Implementation of E-Prescribing in Outpatient Psychiatric Settings

Despite the shortcomings of e-prescribing in the ambulatory setting, a growing literature indicates that e-prescribing may reduce the overall rate of medication errors. However, the current structure of outpatient psychiatric practice poses unique challenges to widespread implementation. Most outpatient psychiatry is delivered in non–clinic-affiliated, private practice settings, where an e-prescribing system may be perceived as too expensive, cumbersome, and complex to warrant its use. Furthermore, in a 2012 survey (9) of U.S. outpatient psy- chiatrists, 26% of respondents reported either not using or not feeling comfortable using electronic devices for clinical tasks, including e-prescribing. Therefore, any effort to in- crease the use of e-prescribing systems needs to account for up-front and maintenance costs as well as the technological literacy of the prescriber.

Address Design Flaws in E-Prescribing Systems

In contrast to the sleek, streamlined design of many popular consumer social apps (Facebook, Instagram, etc.), e-prescribing interfaces are often cluttered, text heavy, and redundant. Many systems include complex field-based entry formats, which re- quire careful attention to detail to prevent erroneous entry

or omission of important information. Possible solutions in- clude replacing prompts with clear graphical user interfaces, integrating required drop-down menus (for route of admin- istration and units of strength), and autocompleting a medi- cation’s administered amount (calculated by the frequency and number of days prescribed). Revision of automated error alerts, such as pop-up boxes to guide and confirm potentially harmful medication interactions or abnormally high medica- tion strengths, may also prevent these types of errors. However, these automated alerts need to be balanced against “pop-up fatigue” in which prescribers may habituate to and ignore frequent computer-generated warnings.

Likewise, e-prescribing systems should integrate design features to simplify medication reconciliation (matching what the patient is currently taking against the medical record), such as including the computerized medication list in the “plan” part of the note template. Maintaining accurate, com- puterized medication lists is a prerequisite for facilitating cross-talk between e-prescribing and retail pharmacy systems; a rigorous, collaborative initiative may be required to improve the quality of outpatient medication reconciliation.

A detailed analysis of system- and user-specific medication errors related to the use of e-prescribing has been presented elsewhere (7). Here, the study of human factors—that is, un- derstanding interactions between humans and technology—can improve e-prescribing systems. For instance, a human-factors design approach would systematically assess prescriber and pharmacist current practices, needs, and priorities; e-prescribing system capacities; and the areas of mismatch between the two.

Improve Interoperability Among Proprietary E-Prescribing Systems

Patients often seek care from multiple clinicians who may use e-prescribing systems that fail to communicate with each other. This fragmented system of care increases the risk of medication duplication and coadministration of various med- ications. In this context, Pandolfe et al. (10) proposed to augment health information exchanges (HIEs) to include a “patient-adjudicated” medication list. This list can be man- aged through a centralized, digital medication database that maintains an accurate list of the patient’s medications. Within this digital ecosystem, prescribers, hospitals, phar- macies, and the patients themselves could view and mod- ify the list on an ongoing basis. This HIE functionality, if implemented, would improve transparency between various e-prescribing systems for a given patient and reduce harm- ful drug-drug interactions. Patients who have limited facility with or access to technologies, at the very least, should be encouraged to select one pharmacy instead of having cus- tomer profiles with several retail chains. If possible, patients with specialty care needs, such as comorbid psychiatric and medical conditions, should work closely with community pharmacists specialized in these fields (for example, pharma- cists with HIV-focused practices for patients with comorbid HIV and a psychiatric disorder).

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Improve Interoperability of E-Prescribing Systems and Retail Pharmacy Electronic Systems

Although prescribers can confirm that an e-script has been transmitted to and even received by an external pharmacy, they currently cannot view the patient’s list of medications or the number of refills remaining. Kaiser Permanente and the Veterans Health Administration system are two integrated health systems that integrate prescriber and pharmacy records; however, these systems are challenging to replicate among independent and often competing entities. Solutions include enabling prescribers to view the most current list of medi- cations for a patient in their retail pharmacy’s system (and vice versa), allowing for real-time chat between prescribers and pharmacists (reducing the need for time-consuming phone calls), and allowing for e-discontinuation (thus ensuring that medications are stopped).

Likewise, most e-prescribing systems do not allow for e-prescription of controlled substances (EPCS), such as psy- chostimulants (schedule II) and benzodiazepines and hyp- notics (schedule IV), which are commonly used in outpatient psychiatric practice. Although the Drug Enforcement Ad- ministration issued a ruling in 2010 that allows for EPCS, stringent security mandates have limited implementation even among those who use e-prescribing tools.

Implementation: Advocacy, Education, and Further Considerations

Implementation of these changes in outpatient psychiatric settings will require targeted incentive and penalty programs, like those initiated by the Centers for Medicare and Medicaid, and tied to insurance payments. Effective advocacy can push the government to enact changes that will pressure the behav- ioral health care industry to adopt bidirectional e-prescriptions and enhanced pharmacy-provider communication. In addition, all stakeholders—patients, payers, prescribers, and pharmacists— will need to advocate for these changes. Once changes are enacted, outcomes can be measured before and after imple- mentation by comparing the number of medication orders, number of communication errors, medication adverse effects, physician and pharmacist call volume, and administrative burden.

Education for providers around technological literacy and e-prescribing implementation can further bolster demand and advocacy. Such educational efforts should start during residency training. However, the Accreditation Council for Graduate Medical Education has not established general psychiatry milestones that explicitly address clinical informatics (including e-prescription) or bidirectional pharmacy-to- prescriber communication skills. Inculcating such skills may prevent safety mishaps when transmitting e-prescriptions.

Notwithstanding the potential benefits of e-prescribing in outpatient psychiatric settings, several limitations persist. First and foremost, evidence supporting the benefits of e-prescribing specifically in outpatient psychiatric settings is

limited; outpatient studies have so far been restricted to non- psychiatric settings. Therefore, we advise gradual and careful implementation of e-prescribing systems in outpatient psy- chiatric settings on a case-by-case basis. Second, increased interoperability among e-prescribing systems may reveal too much private information to patients’ psychiatric and non- psychiatric providers. Although these improved lines of communication may reduce medication errors (duplicate medications, harmful drug-drug interactions), some patients may perceive an all-inclusive e-prescription system as an invasion of privacy for exposing their psychiatric care to their nonpsychiatric medical providers. A potential solution consists of adding a layer of security in the record in regard to psychotropic medications, akin to “break-the-glass” digi- tal firewalls embedded in many EHRs. Third, it is unclear whether expansion of state-run prescription drug monitor- ing programs (PDMPs), which currently track only con- trolled substances, would confer similar benefits to those of an interoperable e-prescription system. However, reliance on a PDMP would require cross-referencing an external database, leaving room for yet another source of communi- cation error and increasing pharmacist and prescriber bur- den. Fourth, up-front costs of e-prescribing implementation prevent many practices, especially small groups and solo practitioners, from using these systems. State and federal mandates to use e-prescribing systems should be accompa- nied by financial incentives or assistance to overcome this barrier to entry.

Well-designed, controlled studies comparing e-prescribing with traditional prescription practices in outpatient psy- chiatric settings will provide useful information about the benefits and limits of these emerging technologies. How- ever, preliminary evidence from inpatient and nonpsychiatric outpatient settings already demonstrates that e-prescribing is associated with decreased medication error rates. By grad- ually replacing paper- and phone-based medication prescrip- tions with more robust, better designed e-prescribing systems for psychiatry, we may address medication safety issues, med- ication adverse events, pharmacy-prescriber communication problems, and administrative burdens.

AUTHOR AND ARTICLE INFORMATION

Dr. Hirschtritt is with the Department of Psychiatry and Dr. Ly is with the Department of Medical Education, University of California, San Francisco (UCSF), San Francisco. Dr. Chan is with the Clinical Informatics Fellow- ship Program in the UCSF Division of Hospital Medicine. Dror Ben-Zeev, Ph.D., is editor of this column. Send correspondence to Dr. Hirschtritt (e-mail: [email protected]).

Dr. Chan reports joint funding from the American Psychiatric Association/ Substance Abuse and Mental Health Services Administration, as well as support from the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality. This work was supported in part by grant R25-MH060482 from the National Institute of Mental Health to Dr. Hirschtritt.

Dr. Chan reports receipt of compensation by North American Center for Continuing Medical Education, LLC, and Guidewell Innovation. The other authors report no financial relationships with commercial interests.

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Received June 14, 2017; revision received August 17, 2017; accepted September 28, 2017; published online December 15, 2017.

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