Drug Handling in a Paediatric Intensive Care Unit – Can Errors be Prevented by a Three-Step Intervention?

D. Niemann; A. Bertsche; D. Meyrath; S. Oelsner; A. L. Ewen; B. Pickardt; T. Henhapl; G. Hoffmann; J. Meyburg; T. Bertsche

doi:10.1055/s-0033-1364030

Klin Padiatr 2014; 226(02): 62-67
DOI: 10.1055/s-0033-1364030

Original Article

Drug Handling in a Paediatric Intensive Care Unit – Can Errors be Prevented by a Three-Step Intervention?

Arzneimittelanwendung auf einer pädiatrischen Intensivstation – können Fehler durch eine dreistufige Intervention reduziert werden?

D. Niemann

¹Department of Clinical Pharmacy, University of Leipzig, Leipzig, Germany

²Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany

,

A. Bertsche

³Hospital for Children and Adolescents, Centre for Pediatric Research, University of Leipzig, Leipzig, Germany

⁴University Children's Hospital, University of Heidelberg, Heidelberg, Germany

,

D. Meyrath

²Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany

,

S. Oelsner

²Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany

,

A. L. Ewen

²Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany

,

B. Pickardt

²Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany

,

T. Henhapl

⁴University Children's Hospital, University of Heidelberg, Heidelberg, Germany

,

G. Hoffmann

⁴University Children's Hospital, University of Heidelberg, Heidelberg, Germany

,

J. Meyburg

⁴University Children's Hospital, University of Heidelberg, Heidelberg, Germany

,

T. Bertsche

¹Department of Clinical Pharmacy, University of Leipzig, Leipzig, Germany

²Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany

› Institutsangaben

Abstract

Background:

Drug handling in paediatric intensive care units (PICU) is prone to medication errors. We aimed to identify type and prevalence of those errors and to assess preventative interventions.

Methods:

Prospective intervention study investigating a 3-step intervention for preventing errors in drug handling in a 10-bed PICU of a university hospital. Nurses’ drug handling was monitored in daily routine to identify the number of patients affected by errors and overall prevalence and types of errors in drug handling. We implemented a comprehensive intervention consisting of an information handout, a training course, and a 76-page reference book tailored to reduce the prevalence.

Results:

The prevalence of errors in drug handling decreased from 83% (555 errors/668 processes) to 63% (554/883; p<0.001) after the intervention. The number of affected patients remained unchanged (95% vs. 89%, p=0.370). Peroral (PO) drugs (1.33 errors/process) were more error-prone than intravenous (IV) drugs (0.64), despite being used less frequently (27% vs. 73% of all processes, p<0.001). The interventions decreased the prevalence to 0.77 errors/process (p<0.001) in PO and to 0.52 in IV drugs (p=0.025).

Conclusion:

Errors in drug handling were alarmingly frequent. PO drugs were frequently subject to errors, even though being used less frequently. The implementation of a comprehensive intervention succeeded in reducing the prevalence of errors. Yet further refinements are necessary to decrease also the number of affected patients.

Zusammenfassung

Hintergrund:

Die Arzneimittelanwendung auf pädiatrischen Intensivstationen (ITS) ist anfällig für Medikationsfehler. Ziel der Studie war es, Art und Prävalenz solcher Fehler zu identifizieren und präventive Maßnahmen zu untersuchen.

Methode:

Prospektive Interventionsstudie mit einer 3-stufigen Intervention zur Prävention von Fehlern bei der Arzneimittelanwendung auf einer pädiatrischen ITS (10 Betten) eines Universitätsklinikums. Das Pflegepersonal wurde bei der täglichen Arzneimittelanwendung beobachtet, um die Anzahl von Patienten mit fehlerhafter Arzneimittelanwendung sowie die Prävalenz und Art der Fehler zu identifizieren. Zur Prävention wurde eine 3-stufige Intervention bestehend aus einem Informationshandout, einer Schulung sowie einem 76-seitigen Nachschlagehandbuch entwickelt.

Ergebnisse:

Die Fehlerprävalenz bei der Arzneimittelanwendung nahm von 83% (555 Fehler in 668 Prozessen) auf 63% (554/883; p<0.001) nach der Intervention ab. Die Anzahl der Patienten mit mindestens einem Fehler blieb unverändert (95% vs. 89%, p=0.370). Perorale (PO) Arzneimittel (1.33 Fehler/Prozess) waren fehleranfälliger als intravenöse (IV) Arzneimittel (0.64), obwohl sie seltener angewendet wurden (27% vs. 73% von allen Prozessen, p<0.001). Die Intervention reduzierte die Prävalenz auf 0.77 Fehler/Prozess (p<0.001) bei PO und auf 0.52 bei IV Arzneimitteln (p=0.025).

Schlussfolgerung:

Fehler bei der Arzneimittelanwendung auf einer pädiatrischen ITS sind alarmierend häufig. PO Arzneimittel sind besonders fehleranfällig, obwohl sie seltener angewendet werden. Die Implementierung einer 3-stufigen Intervention reduzierte die Prävalenz der Fehler. Eine Weiterentwicklung ist jedoch notwendig, um auch die Anzahl der betroffenen Patienten zu reduzieren.

Key words

drug administration - medication error - paediatric intensive care unit - intervention study - healthcare quality assurance

Schlüsselwörter

Arzneimittelanwendung - Medikationsfehler - pädiatrische Intensivstation - Interventionsstudie - Qualitätssicherung

Volltext

Referenzen

References
1 Barber N, Taxis K. Incidence and severity of intravenous drug errors in a German hospital. Eur J Clin Pharmacol 2004; 59: 815-817
2 Bates DW. Preventing medication errors: A summary. Am J Health Syst Pharm 2007; 64 (14 Supplement 9) S3-S9
3 Berdot S, Sabatier B, Gillaizeau F et al. Evaluation of drug administration errors in a teaching hospital. BMC Health Serv Res 2012; 12: 60
4 Bertsche T, Niemann D, Mayer Y et al. Prioritising the prevention of medication handling errors. Pharm World Sci 2008; 30: 907-915
5 Bertsche T, Bertsche A, Krieg EM et al. Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents. Qual Saf Health Care 2010; 19: e26-(1–5)
6 Bertsche T, Pfaff J, Schiller P et al. Prevention of adverse drug reactions in intensive care patients by personal intervention based on an electronic clinical decision support system. Intensive Care Med 2010; 36: 665-672
7 Cornish P. “Avoid the crush”: hazards of medication administration in patients with dysphagia or a feeding tube. CMAJ 2005; 172: 871-872
8 Dabliz R, Levine S. Medication Safety in Neonates. Am J Perinatol 2011; 29: 49-56
9 Davis L, Ware R, McCann D et al. Evaluation of contextual influences on the medication administration practice of paediatric nurses. J Adv Nurs 2009; 65: 1293-1299
10 Endacott R. The continuing imperative to measure workload in ICU: impact on patient safety and staff well-being. Intensive Care Med 2012; 38: 1415-1417
11 Elganzouri ES, Standish CA, Androwich I. Medication Administration Time Study (MATS): nursing staff performance of medication administration. J Nurs Adm 2009; 39: 204-210
12 Franke HA, Woods DM, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care Med 2009; 10: 85-90
13 Ghaleb MA, Barber N, Franklin BD et al. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child 2010; 95: 113-118
14 Hiemisch A, Kiess W, Brähler E. Mental Job Strain in an University Children’s Hospital – A Study on Stress Experience and the Resulting Employee Health. Klin Padiatr 2011; 223: 236-241
15 Huebner J, Rack-Hoch AI, Pear A et al. Pilot Project of an Pediatric Antibiotic Stewardshio Initiative at the Hauner Children’s Hospital. Klin Padiatr 2013; 225: 223-229
16 Koren G, Haslam RH. Pediatric medication errors: predicting and preventing tenfold disasters. J Clin Pharmacol 1994; 34: 1043-1045
17 McDonnell C, Hum S, Frndova H et al. Pharmacotherapy in pediatric critical illness: a prospective observational study. Paediatr Drugs 2009; 11: 323-331
18 Merry AF, Anderson BJ. Medication errors – new approaches to prevention. Pediatr Anesth 2011; 21: 743-753
19 Pardoe P. Psychological support for nurses on paediatric intensive care units. Nurs Child Young People 2011; 23: 27-29
20 Parshuram CS, To T, Seto W et al. Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ 2008; 178: 42-48
21 Prandstretter C, Tamesberger M, Wagner O et al. Medical prescriptions to premature and newborn infants in an Austrian Neonatal Intensive Care Unit. Klin Padiatr 2009; 221: 312-317
22 Prot S. Drug administration errors and their determinants in pediatric in-patients. Int J Qual Health Care 2005; 17: 381-389
23 Schneider MP, Cotting J, Pannatier A. Evaluation of nurses’ errors associated in the preparation and administration of medication in a pediatric intensive care unit. Pharm World Sci 1998; 20: 178-182
24 Terrin G, Passariello A, De Curtis M et al. Ranitidine is Associated With Infections, Necrotizing Enterocolitis, and Fatal Outcome in Newborns. Pediatrics 2011; 129: e40-e45
25 Tzimenatos L, Bond GR. Severe injury or death in young children from therapeutic errors: a summary of 238 cases from the American Association of Poison Control Centers. Clin Toxicol 2009; 47: 348-354
26 Uppal N, Yasseen B, Seto W et al. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ 2011; 183: E246-E248
27 Westbrook JI, Woods A, Rob MI et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010; 170: 683-690
28 Wetherton AR, Corey TS, Buchino JJ et al. Fatal intravenous injection of potassium in hospitalized patients. Am J Forensic Med Pathol 2003; 24: 128-131
29 Wetter J, Gohlke S, Stutte S et al. Pediatric Hyperglycemic Hyperosmolar Coma Diabeticum: Diagnostic Evaluation and Therapeutic Concept. Klin Padiatr 2012; 224: 26-31
30 Williams NT. Medication administration through enteral feeding tubes. Am J Health Syst Pharm 2008; 65: 2347-2357