Use of Pediatric Injectable Medicines Guidelines and Associated Medication Administration Errors: A Human Reliability Analysis

Abstract

Background: In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs). Objective: The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice ( discrepancies) that contributed to large-magnitude and/or clinically significant MAEs. Methods: Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study. Results: In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs. Conclusion and Relevance: Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.

Evolution of Intravenous Medication Errors and Preventive Systemic Defenses in Hospital Settings—A Narrative Review of Recent Evidence

“…Most of the studies concerned administration (n = 8, 50%) 6,31,[33][34][35]40,41,44 or preparation (n = 6, 38%) 32,33,36,39,41,42 phases. Up to 31% (n = 5) 32,34,38,41,44 of the studies utilized research designs that could be interpreted as proactive risk management, while in our earlier systematic review 19 features of prospective risk management could be identified only in 2 studies (18%). 45,46…”

“…Our systematic search on Medline (Ovid) found 16 articles describing systemic causes of IV MEs published between June 2016 and October 2021 (Supplementary file 2, http://links.lww.com/ JPS/A612). These studies were conducted in the following 6 countries: United States (n = 6), 6,[30][31][32][33][34] United Kingdom (n = 5), [35][36][37][38][39] France (n = 2), 40,41 Canada (n = 1), 42 South Korea (n = 1), 43 and Spain (n = 1). 44 Most of the studies were carried out in a hospital setting without a specification of a specialty area (n = 7), 6,30,31,34,36,37,43 whereas some were conducted in a pediatric hospital setting (n = 3), 35,39,41 hospital pharmacy (n = 2), 32,42 emergency department (n = 1), 33 intensive care unit (ICU) and hematology sterile unit (n = 1), 40 neonatal intensive care unit (NICU) (n = 1), 44 and a simulated pediatric medical facility (n = 1).…”

“…44 Most of the studies were carried out in a hospital setting without a specification of a specialty area (n = 7), 6,30,31,34,36,37,43 whereas some were conducted in a pediatric hospital setting (n = 3), 35,39,41 hospital pharmacy (n = 2), 32,42 emergency department (n = 1), 33 intensive care unit (ICU) and hematology sterile unit (n = 1), 40 neonatal intensive care unit (NICU) (n = 1), 44 and a simulated pediatric medical facility (n = 1). 38 There was a lot of variation between the study designs and research methods; the most used methods were observation (n = 7) 5,6,36,[38][39][40]42 and retrospective analysis of ME reports (n = 2). 30,35 Other methods included a systematic review (n = 1), 34 analysis of IV compatibility data in literature (n = 1), 44 failure mode and effects analysis (FMEA) (n = 1), 32 inductive preliminary hazard analysis (PHA) (n = 1), 41 retrospective analysis of smart pump alert log data (n = 1), 31 retrospective analysis of medical records (n = 1), 43 and structured chart and video review (n = 1).…”

“…An overview of the studies focusing on systemic causes of IV MEs (n = 16). 6,[30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] The studies are categorized according to the MMU process stages they focused on. Two studies (*) were displayed in 2 categories.…”

Developing Strategic Recommendations for Implementing Smart Pumps in Advanced Healthcare Systems to Improve Intravenous Medication Safety

“…information on intravenous medication administration can be a cause of medication errors [23]. Assessing the performance of such guidelines in the hands of 'real' users and subsequently redesigning them to prevent problems might lead to safer medicines administration [24].…”