- Email: [email protected]
Medication events on a tertiary neurology inpatient service
Journal of Clinical Neuroscience 21 (2014) 51–54
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
Medication events on a tertiary neurology inpatient service Lindsy N. Williams ⇑, Cynthia M. Sweeney, Jeffrey W. Britton Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
a r t i c l e
i n f o
Article history: Received 18 October 2012 Accepted 1 April 2013
Keywords: Medication error Neurology Patient safety Quality improvement
a b s t r a c t This study aimed to determine the prevalence and attributes of medication events in a tertiary inpatient neurology setting. These findings were compared with the results of a physician survey designed to assess general knowledge of medication events. We reviewed all medication events reported through an established voluntary event recording system for adult neurology inpatients at a tertiary referral center over a 2 year period. An electronic survey was sent to all neurology residents and hospital staff regarding medication events. One hundred and forty-three medication events were reported, for a rate of 8.6 events per 1000 patient-days. The medication event rate was comparable to published rates on medicine services. There was no evidence of events being more prevalent at the beginning of the academic year or on nights. One hundred and seventeen events (81.8%) reached the patient, but most (92.7%, 108/117) did not result in harm. The most common medication types involved were anticoagulants (24 events, 16.8%), anticonvulsants (17 events, 11.9%), and antibiotics (16 events, 11.2%). Nurses were involved in reporting 133 events (93%), while physicians were involved in reporting 20 events (14%). Physicians completed the survey at a rate of 60.8% (48/79). There were notable differences between physician presumptions as to medication event attributes and actual results. No trend referable to time of year or day was identified, which contrasted with physician beliefs in our survey. Nursing staff reported the majority of events. Ó 2013 Elsevier Ltd. All rights reserved.
1. Introduction The quality and safety of hospital care has come under increased attention in recent years. Preventable adverse events have been recognized as a significant source of morbidity and mortality for patients for over a decade, estimated to contribute up to 98,000 deaths per year in the 1999 Institute of Medicine report, To err is human: building a safe health system.1 Preventable adverse events are particularly common among hospitalized patients, occurring in 2.9–16.6% of admissions.2–7 Medication errors are one of the most common types of preventable adverse events occurring in the hospital setting6 comprising 5.5% of sentinel events reported to the Joint Commission between 2004 and 2011.8 There is considerable variability in the reported rate of medication events in hospitalized patients ranging from 6.52 to 70 events per 1000 patient-days, with this range likely reflecting variability in event detection and reporting methodologies.9–11 Information on the nature and characteristics of medication events on inpatient neurology services is limited. Studies evaluating safety for inpatient neurology services have not specifically focused on medication events, but rather report on all adverse events or on events occurring in the care of a specific diagnosis such as ⇑ Corresponding author. Tel.: +1 507 538 1036; fax: +1 507 266 4419. E-mail address: [email protected] (L.N. Williams). 0967-5868/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jocn.2013.04.012
stroke.12–14 The general knowledge level of medication events amongst medical staff and trainees is also unknown, and published rates of medication events on neurological services are lacking. The objective of this study was to determine the prevalence and attributes of medication events in a tertiary inpatient neurology setting. These findings were compared with the results of a survey designed to assess general knowledge of medication events. 2. Methods 2.1. Study setting The Mayo Clinic neurology inpatient services consist of the general neurology service, cerebrovascular service, epilepsy monitoring unit, and neurological critical care unit. The Mayo Clinic’s hospitals utilize computer prescriber order entry for medication ordering. This study was reviewed and approved by the local Institutional Review Board. 2.2. Reporting system The Mayo Clinic uses a voluntary event tracking system to record patient events. Patient events are defined as unanticipated, unplanned, unscheduled, or undesired occurrences that cause or have the potential for causing personal injury. During the timeframe of this study, events were recorded by paging an ‘‘events
52
L.N. Williams et al. / Journal of Clinical Neuroscience 21 (2014) 51–54
pager,’’ which is staffed by a registered nurse 24 hours a day, with event details documented in a database. Data obtained at the time of the event-reporting included the event date, reporter role (nursing, pharmacy, prescriber, emergency department), shift, event location, department, medication name, error type, contributing factors, step in medication process where event started, event outcome classification, and a brief free-text event description. Event severity was determined at the time of the report and documented by classifying the events on a scale, A-I (Supp. Table 1). Summary and detailed reports were provided to the neurology department for quality control purposes. 2.3. Medication events in neurology patients We reviewed all medication event summary reports for neurology inpatients (patients on the general neurology service, cerebrovascular service, epilepsy monitoring unit, and neurological critical care unit) occurring from 1 January 2009 to 31 December 2010. All medication event detailed reports were reviewed to ensure that the events were for patients admitted to neurological services and for accuracy of entry. The event reporting process remained unchanged during that period of time. Medications involved were classified as antibiotic, anticoagulant, anticonvulsant, antihypertensive, antihyperglycemic, narcotic, or other.
patient, 92.7% (108/117) did not result in harm, 6.8% (8/117) may have resulted in temporary harm and 0.9% (1/117) may have contributed to permanent harm to a patient. In terms of steps in the medication use process, most events (77, 53.8%) occurred during the administration step. Two events had two or more steps listed (Fig. 1). Common error types included medication omission (27, 18.9%), and wrong medication dose (26, 18.2%). Four events had more than one error type listed (Fig. 2). Over 40 different causes for medication events were described. Twenty-four events were recorded as having multiple causes, while the cause was listed as ‘‘unknown’’ in 16. Dispensing issues (related to the medication being sent at an incorrect time, dose or form from pharmacy) accounted for 21 (14.7%) events. Other common causes included those due to ‘‘equipment’’ (18, 12.6%) and communication problems (15, 10.5%; Table 1). The most common medication class involved was anticoagulants with 24 events (16.8%). The distribution of event number by medication class is shown in Fig. 3. When examining the characteristics of events for specific drug classes, we noted several trends. Of anticoagulation events, the majority were associated with various steps involving our institutional heparin nomogram process (16, 66.7%). Half of the antibiotic events (8/16) were labeled omissions. None of the 16 antibiotic events required intervention. Half of the narcotic events (6/12) were due to wrong medication dose.
2.4. Physician survey An electronic survey was sent to all neurology residents and hospital staff regarding medication events as part of a quality improvement project (Supp. Table 2). The responses to the questions were recorded and reported back anonymously. 2.5. Statistical analysis Statistical analysis was performed using SAS version 9.2 (SAS Institute, Inc., Cary, NC, USA). The Wilcoxon rank sum test was used to compare event rates. Weekday and weekend comparison was done with the rate:ratio test function on R package to compare two independent Poisson rates. A p value of less than 0.05 was considered statistically significant. 3. Results One hundred and forty-three medication events were reported over 16,563 patient-days, for a rate of 8.6 events per 1,000 patientdays. The majority of events (133/143 or 93%) were reported by nursing staff. Twenty events (14%) were co-reported by a prescriber. There were no events with a prescriber as the sole reporter. There was no statistically significant difference in the number of events per 1000 patient-days between the first academic quarter (July, August, September; mean 7.16, standard deviation 4.76) and last academic quarter (mean 8.13, standard deviation 4.24; p = 0.63 on Wilcoxon rank sum test). Reported events were more common during day (59) and evening (55) shifts as compared to the night shift (20). We were unable to determine the shift for nine events. In terms of day of the week, Mondays had the largest number of events (25 events) and Thursdays had the least (17 events). There was no statistically significant difference in number of events per 1000 patient-days between the weekend and weekdays (9.39 versus 8.34, respectively; p = 0.57). Of the 143 reported events, 117 (81.8%) reached the patient and 26 (18.2%) were recorded as ‘‘near-misses.’’ The most commonly reported event severity (78 events, 54.5%) was C (i.e. an event that reached the patient but did not require additional monitoring, intervention, or result in harm). Of the events that reached the
3.1. Survey results On the physician survey, 21 of the 33 residents (63.6%) and 27 of the 46 faculty physicians (58.7%) responded. Not all participants completed every question on the survey. Several differences were noted between physician presumptions about medication events and the results of our review of the event data. Most physicians (25/43; 58%) predicted that events would be more common over the weekend when hand-offs are more common than the week day; our data showed no statistically significant difference between weekend and weekday event rates. Night shift (17/44,
Ordering/prescribing 16 events (11.2%)
Profiling/Dispensing 28 events (19.6%)
Administration 77 events (53.8%)
Fig. 1. Diagram showing at which step in medication administration the error occurred. Not shown are 25 events listed as ‘‘other.’’
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L.N. Williams et al. / Journal of Clinical Neuroscience 21 (2014) 51–54
wrong patient 3% variation in standard operating procedure 3%
Anticonvulsant 12% duplication 5% omission 18%
antibiotic 11%
other 39%
other 22%
anticoagulant 17%
wrong dose 18% narcotic 8%
unauthorized medication 15%
insulin 5%
antihypertensive 8%
Fig. 3. Pie chart showing the medication type involved in medication events by percentage.
wrong time 16% Fig. 2. Pie chart showing the error type involved in medication events by percentage.
Table 1 List of medication event causes reported and number of events associated with that cause Cause
Number of events
Other Dispensed incorrectly IV related Unknown Communication issue Medication profile not checked Computer entry or processing error Order misread Label misread/not read Nomogramà Ordered incorrectly Sensory overload Packaged incorrect Variation in SOP Charting Look alike/sound alike Allergy Verbal order
23 21 18 16 15 13 11 10 7 7 7 7 6 3 2 2 1 1
IV = intravenous, SOP = standard operating procedure. ‘‘Other’’ indicates that it could not fit into a specific category of cause and was not further detailed in the event report. à Nomogram refers to an error occurring during the use of the institutional heparin nomogram.
38.6%) and day shift (17/44, 38.6%) were predicted to be the most common timeframes for medication events; the night shift had the lowest reported number of events in our study. Physicians predicted that medication events would be most common during the first academic quarter (34/44, 77.2%); however our results showed no difference in event rate based on quarter. Physicians surveyed were correct in predicting that the most common medication class involved in medication events would be anticoagulants (20/45, 44.4%). The majority of physicians surveyed (43/46, 93.5%) were correct in predicting that physicians would most likely report less than 20% of reported medication events.
4. Discussion The observed rate of 8.6 medication events per 1000 patientdays is consistent with the 9.7 preventable adverse drug events or potential adverse drug events per 1000 patient-days on medical
units noted in Cullen et al.’s 1997 study.10 The vast majority of reported events were rated at C, meaning they did not require intervention or additional monitoring, with no further consequences to the patient. One key finding of this study was that the majority of events were reported by nursing staff (93%). Prescribers were listed as reporters in 14% of events, but prescribers were never the sole reporter. These results are similar to the findings in other studies reviewing the culture of event reporting.13,15,16 On our physician survey, physicians appeared aware of this tendency. There are likely multiple factors contributing to this. This suggests a stronger culture of reporting among non-physicians, and nurses in particular, at our institution. This phenomenon also likely relates to the place in the medication use process sequence held by each discipline. Physicians are primarily involved in the early steps of the medication use process (ordering and prescribing), where an error is more likely to be caught by the pharmacist and nurse before it reaches a patient. Such ‘‘near misses’’ are likely underreported. In contrast, the nurse administering the medication is the final step, making it the point in which events are most likely to be labeled as occurring. In addition, other medication event types involving the physician, such as those related to optimal medication selection and medical judgment, may remain elusive and undetected by real-time medication event reporting processes. Such event types may also remain inapparent to nursing staff, which is the discipline with the strongest culture of reporting. Physicians may also culturally be less likely to report on other physicians, which would affect these rates.17 There have been reports of a ‘‘July effect’’ with increased rates of medical errors in the literature.18,19 The July effect refers to an increased likelihood of patient care events occurring during the earliest months of postgraduate medical training. Our physician survey illustrates some level of belief in this phenomenon. However, our data show that events were no more common in the first academic quarter of the year than the final quarter. This is similar to findings in Lesar et al.’s 1997 study reviewing prescribing errors in a teaching hospital, where there was no significant difference in prescribing error rates between June and July for a 9 year period.11 However, as reporting by prescribers is relatively low in our study, we may not be capturing the full effect from the influx of new trainees in the first academic quarter. There is also a preconceived notion (reflected in our physician survey results) that more events occur during weekends, which was also not seen in our study. There was no significant difference between the numbers of events occurring on the weekends versus weekdays. In addition, fewer
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medication events were reported during the night shift, presumably due to the lower rates of medications administered during this time period. Not surprisingly, many of the medications involved in reported events are commonly used in the management of neurological patients including anticoagulants and antiepileptics. The majority of anticoagulant events were associated with heparin intravenous drips. As this medication therapy requires frequent blood draws and dose adjustments, there are many potential steps that could lead to a medication event. As this is a high risk medication, it is a good target to focus on in quality improvement measures. When reviewing medication event type, there was no predominant type of event seen. Reported causes for medication events were even more varied. These findings illustrate the heterogenous nature of medication events, which presents challenges to targeting areas for improvement. This is a retrospective study on medication events on inpatient neurology services. This study was limited to the information previously provided through a voluntary reporting system and likely does not represent all medication events that occurred, particularly those that did not reach patients, as discussed above.20 Another limitation is that severity was determined by a nurse at the time the event was reported, when outcome of the event may have still been uncertain. The study is based out of a tertiary academic hospital and may not be representative of all hospital environments. However, we feel that it provides an overview of medication event characteristics, as well as event reporting patterns on inpatient neurology services.
Conflict of interest/disclosure The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
Appendix A. Supplementary Material Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.jocn.2013.04.012.
References 1. Kohn LT, Corigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000. 2. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care study. Med J Aust 1995;163:458–71. 3. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261–71. 4. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678–86. 5. Forster AJ, Asmis TR, Clark HD, et al. Ottawa Hospital Patient Safety study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ 2004;170:1235–40. 6. de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216–23. 7. Soop M, Fryksmark U, Koster M, et al. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Int J Qual Health Care 2009;21:285–91. 8. Summary Data of Sentinel Events Reviewed by The Joint Commission.. [accessed 9.04.12]. 9. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors Quality Chasm Series. Washington, DC: The National Academies Press; 2007. 10. Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997;25:1289–97. 11. Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med 1997;157:1569–76. 12. Holloway RG, Tuttle D, Baird T, et al. The safety of hospital stroke care. Neurology 2007;68:550–5. 13. Frank S, Holloway R. Medical errors on an inpatient neurology service. Neurology 2003;61:254–7. 14. Daud-Gallotti R, Dutilh Novaes HM, Lorenzi MC, et al. Adverse events and death in stroke patients admitted to the emergency department of a tertiary university hospital. Eur J Emerg Med 2005;12:63–71. 15. Milch CE, Salem DN, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med 2006;21:165–70. 16. Rowin EJ, Lucier D, Pauker SG, et al. Does error and adverse event reporting by physicians and nurses differ? Jt Comm J Qual Patient Saf 2008;34:537–45. 17. Kingston MJ, Evans SM, Smith BJ, et al. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust 2004;181:36–9. 18. Young JQ, Ranji SR, Wachter RM, et al. ‘‘July effect’’: impact of the academic year-end changeover on patient outcomes: a systematic review. Ann Intern Med 2011;155:309–15. 19. Phillips DP, Barker GE. A July spike in fatal medication errors: a possible effect of new medical residents. J Gen Intern Med 2010;25:774–9. 20. Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002;59:436–46.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
Medication events on a tertiary neurology inpatient service Lindsy N. Williams ⇑, Cynthia M. Sweeney, Jeffrey W. Britton Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
a r t i c l e
i n f o
Article history: Received 18 October 2012 Accepted 1 April 2013
Keywords: Medication error Neurology Patient safety Quality improvement
a b s t r a c t This study aimed to determine the prevalence and attributes of medication events in a tertiary inpatient neurology setting. These findings were compared with the results of a physician survey designed to assess general knowledge of medication events. We reviewed all medication events reported through an established voluntary event recording system for adult neurology inpatients at a tertiary referral center over a 2 year period. An electronic survey was sent to all neurology residents and hospital staff regarding medication events. One hundred and forty-three medication events were reported, for a rate of 8.6 events per 1000 patient-days. The medication event rate was comparable to published rates on medicine services. There was no evidence of events being more prevalent at the beginning of the academic year or on nights. One hundred and seventeen events (81.8%) reached the patient, but most (92.7%, 108/117) did not result in harm. The most common medication types involved were anticoagulants (24 events, 16.8%), anticonvulsants (17 events, 11.9%), and antibiotics (16 events, 11.2%). Nurses were involved in reporting 133 events (93%), while physicians were involved in reporting 20 events (14%). Physicians completed the survey at a rate of 60.8% (48/79). There were notable differences between physician presumptions as to medication event attributes and actual results. No trend referable to time of year or day was identified, which contrasted with physician beliefs in our survey. Nursing staff reported the majority of events. Ó 2013 Elsevier Ltd. All rights reserved.
1. Introduction The quality and safety of hospital care has come under increased attention in recent years. Preventable adverse events have been recognized as a significant source of morbidity and mortality for patients for over a decade, estimated to contribute up to 98,000 deaths per year in the 1999 Institute of Medicine report, To err is human: building a safe health system.1 Preventable adverse events are particularly common among hospitalized patients, occurring in 2.9–16.6% of admissions.2–7 Medication errors are one of the most common types of preventable adverse events occurring in the hospital setting6 comprising 5.5% of sentinel events reported to the Joint Commission between 2004 and 2011.8 There is considerable variability in the reported rate of medication events in hospitalized patients ranging from 6.52 to 70 events per 1000 patient-days, with this range likely reflecting variability in event detection and reporting methodologies.9–11 Information on the nature and characteristics of medication events on inpatient neurology services is limited. Studies evaluating safety for inpatient neurology services have not specifically focused on medication events, but rather report on all adverse events or on events occurring in the care of a specific diagnosis such as ⇑ Corresponding author. Tel.: +1 507 538 1036; fax: +1 507 266 4419. E-mail address: [email protected] (L.N. Williams). 0967-5868/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jocn.2013.04.012
stroke.12–14 The general knowledge level of medication events amongst medical staff and trainees is also unknown, and published rates of medication events on neurological services are lacking. The objective of this study was to determine the prevalence and attributes of medication events in a tertiary inpatient neurology setting. These findings were compared with the results of a survey designed to assess general knowledge of medication events. 2. Methods 2.1. Study setting The Mayo Clinic neurology inpatient services consist of the general neurology service, cerebrovascular service, epilepsy monitoring unit, and neurological critical care unit. The Mayo Clinic’s hospitals utilize computer prescriber order entry for medication ordering. This study was reviewed and approved by the local Institutional Review Board. 2.2. Reporting system The Mayo Clinic uses a voluntary event tracking system to record patient events. Patient events are defined as unanticipated, unplanned, unscheduled, or undesired occurrences that cause or have the potential for causing personal injury. During the timeframe of this study, events were recorded by paging an ‘‘events
52
L.N. Williams et al. / Journal of Clinical Neuroscience 21 (2014) 51–54
pager,’’ which is staffed by a registered nurse 24 hours a day, with event details documented in a database. Data obtained at the time of the event-reporting included the event date, reporter role (nursing, pharmacy, prescriber, emergency department), shift, event location, department, medication name, error type, contributing factors, step in medication process where event started, event outcome classification, and a brief free-text event description. Event severity was determined at the time of the report and documented by classifying the events on a scale, A-I (Supp. Table 1). Summary and detailed reports were provided to the neurology department for quality control purposes. 2.3. Medication events in neurology patients We reviewed all medication event summary reports for neurology inpatients (patients on the general neurology service, cerebrovascular service, epilepsy monitoring unit, and neurological critical care unit) occurring from 1 January 2009 to 31 December 2010. All medication event detailed reports were reviewed to ensure that the events were for patients admitted to neurological services and for accuracy of entry. The event reporting process remained unchanged during that period of time. Medications involved were classified as antibiotic, anticoagulant, anticonvulsant, antihypertensive, antihyperglycemic, narcotic, or other.
patient, 92.7% (108/117) did not result in harm, 6.8% (8/117) may have resulted in temporary harm and 0.9% (1/117) may have contributed to permanent harm to a patient. In terms of steps in the medication use process, most events (77, 53.8%) occurred during the administration step. Two events had two or more steps listed (Fig. 1). Common error types included medication omission (27, 18.9%), and wrong medication dose (26, 18.2%). Four events had more than one error type listed (Fig. 2). Over 40 different causes for medication events were described. Twenty-four events were recorded as having multiple causes, while the cause was listed as ‘‘unknown’’ in 16. Dispensing issues (related to the medication being sent at an incorrect time, dose or form from pharmacy) accounted for 21 (14.7%) events. Other common causes included those due to ‘‘equipment’’ (18, 12.6%) and communication problems (15, 10.5%; Table 1). The most common medication class involved was anticoagulants with 24 events (16.8%). The distribution of event number by medication class is shown in Fig. 3. When examining the characteristics of events for specific drug classes, we noted several trends. Of anticoagulation events, the majority were associated with various steps involving our institutional heparin nomogram process (16, 66.7%). Half of the antibiotic events (8/16) were labeled omissions. None of the 16 antibiotic events required intervention. Half of the narcotic events (6/12) were due to wrong medication dose.
2.4. Physician survey An electronic survey was sent to all neurology residents and hospital staff regarding medication events as part of a quality improvement project (Supp. Table 2). The responses to the questions were recorded and reported back anonymously. 2.5. Statistical analysis Statistical analysis was performed using SAS version 9.2 (SAS Institute, Inc., Cary, NC, USA). The Wilcoxon rank sum test was used to compare event rates. Weekday and weekend comparison was done with the rate:ratio test function on R package to compare two independent Poisson rates. A p value of less than 0.05 was considered statistically significant. 3. Results One hundred and forty-three medication events were reported over 16,563 patient-days, for a rate of 8.6 events per 1,000 patientdays. The majority of events (133/143 or 93%) were reported by nursing staff. Twenty events (14%) were co-reported by a prescriber. There were no events with a prescriber as the sole reporter. There was no statistically significant difference in the number of events per 1000 patient-days between the first academic quarter (July, August, September; mean 7.16, standard deviation 4.76) and last academic quarter (mean 8.13, standard deviation 4.24; p = 0.63 on Wilcoxon rank sum test). Reported events were more common during day (59) and evening (55) shifts as compared to the night shift (20). We were unable to determine the shift for nine events. In terms of day of the week, Mondays had the largest number of events (25 events) and Thursdays had the least (17 events). There was no statistically significant difference in number of events per 1000 patient-days between the weekend and weekdays (9.39 versus 8.34, respectively; p = 0.57). Of the 143 reported events, 117 (81.8%) reached the patient and 26 (18.2%) were recorded as ‘‘near-misses.’’ The most commonly reported event severity (78 events, 54.5%) was C (i.e. an event that reached the patient but did not require additional monitoring, intervention, or result in harm). Of the events that reached the
3.1. Survey results On the physician survey, 21 of the 33 residents (63.6%) and 27 of the 46 faculty physicians (58.7%) responded. Not all participants completed every question on the survey. Several differences were noted between physician presumptions about medication events and the results of our review of the event data. Most physicians (25/43; 58%) predicted that events would be more common over the weekend when hand-offs are more common than the week day; our data showed no statistically significant difference between weekend and weekday event rates. Night shift (17/44,
Ordering/prescribing 16 events (11.2%)
Profiling/Dispensing 28 events (19.6%)
Administration 77 events (53.8%)
Fig. 1. Diagram showing at which step in medication administration the error occurred. Not shown are 25 events listed as ‘‘other.’’
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L.N. Williams et al. / Journal of Clinical Neuroscience 21 (2014) 51–54
wrong patient 3% variation in standard operating procedure 3%
Anticonvulsant 12% duplication 5% omission 18%
antibiotic 11%
other 39%
other 22%
anticoagulant 17%
wrong dose 18% narcotic 8%
unauthorized medication 15%
insulin 5%
antihypertensive 8%
Fig. 3. Pie chart showing the medication type involved in medication events by percentage.
wrong time 16% Fig. 2. Pie chart showing the error type involved in medication events by percentage.
Table 1 List of medication event causes reported and number of events associated with that cause Cause
Number of events
Other Dispensed incorrectly IV related Unknown Communication issue Medication profile not checked Computer entry or processing error Order misread Label misread/not read Nomogramà Ordered incorrectly Sensory overload Packaged incorrect Variation in SOP Charting Look alike/sound alike Allergy Verbal order
23 21 18 16 15 13 11 10 7 7 7 7 6 3 2 2 1 1
IV = intravenous, SOP = standard operating procedure. ‘‘Other’’ indicates that it could not fit into a specific category of cause and was not further detailed in the event report. à Nomogram refers to an error occurring during the use of the institutional heparin nomogram.
38.6%) and day shift (17/44, 38.6%) were predicted to be the most common timeframes for medication events; the night shift had the lowest reported number of events in our study. Physicians predicted that medication events would be most common during the first academic quarter (34/44, 77.2%); however our results showed no difference in event rate based on quarter. Physicians surveyed were correct in predicting that the most common medication class involved in medication events would be anticoagulants (20/45, 44.4%). The majority of physicians surveyed (43/46, 93.5%) were correct in predicting that physicians would most likely report less than 20% of reported medication events.
4. Discussion The observed rate of 8.6 medication events per 1000 patientdays is consistent with the 9.7 preventable adverse drug events or potential adverse drug events per 1000 patient-days on medical
units noted in Cullen et al.’s 1997 study.10 The vast majority of reported events were rated at C, meaning they did not require intervention or additional monitoring, with no further consequences to the patient. One key finding of this study was that the majority of events were reported by nursing staff (93%). Prescribers were listed as reporters in 14% of events, but prescribers were never the sole reporter. These results are similar to the findings in other studies reviewing the culture of event reporting.13,15,16 On our physician survey, physicians appeared aware of this tendency. There are likely multiple factors contributing to this. This suggests a stronger culture of reporting among non-physicians, and nurses in particular, at our institution. This phenomenon also likely relates to the place in the medication use process sequence held by each discipline. Physicians are primarily involved in the early steps of the medication use process (ordering and prescribing), where an error is more likely to be caught by the pharmacist and nurse before it reaches a patient. Such ‘‘near misses’’ are likely underreported. In contrast, the nurse administering the medication is the final step, making it the point in which events are most likely to be labeled as occurring. In addition, other medication event types involving the physician, such as those related to optimal medication selection and medical judgment, may remain elusive and undetected by real-time medication event reporting processes. Such event types may also remain inapparent to nursing staff, which is the discipline with the strongest culture of reporting. Physicians may also culturally be less likely to report on other physicians, which would affect these rates.17 There have been reports of a ‘‘July effect’’ with increased rates of medical errors in the literature.18,19 The July effect refers to an increased likelihood of patient care events occurring during the earliest months of postgraduate medical training. Our physician survey illustrates some level of belief in this phenomenon. However, our data show that events were no more common in the first academic quarter of the year than the final quarter. This is similar to findings in Lesar et al.’s 1997 study reviewing prescribing errors in a teaching hospital, where there was no significant difference in prescribing error rates between June and July for a 9 year period.11 However, as reporting by prescribers is relatively low in our study, we may not be capturing the full effect from the influx of new trainees in the first academic quarter. There is also a preconceived notion (reflected in our physician survey results) that more events occur during weekends, which was also not seen in our study. There was no significant difference between the numbers of events occurring on the weekends versus weekdays. In addition, fewer
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medication events were reported during the night shift, presumably due to the lower rates of medications administered during this time period. Not surprisingly, many of the medications involved in reported events are commonly used in the management of neurological patients including anticoagulants and antiepileptics. The majority of anticoagulant events were associated with heparin intravenous drips. As this medication therapy requires frequent blood draws and dose adjustments, there are many potential steps that could lead to a medication event. As this is a high risk medication, it is a good target to focus on in quality improvement measures. When reviewing medication event type, there was no predominant type of event seen. Reported causes for medication events were even more varied. These findings illustrate the heterogenous nature of medication events, which presents challenges to targeting areas for improvement. This is a retrospective study on medication events on inpatient neurology services. This study was limited to the information previously provided through a voluntary reporting system and likely does not represent all medication events that occurred, particularly those that did not reach patients, as discussed above.20 Another limitation is that severity was determined by a nurse at the time the event was reported, when outcome of the event may have still been uncertain. The study is based out of a tertiary academic hospital and may not be representative of all hospital environments. However, we feel that it provides an overview of medication event characteristics, as well as event reporting patterns on inpatient neurology services.
Conflict of interest/disclosure The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
Appendix A. Supplementary Material Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.jocn.2013.04.012.
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