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The possibility of patient involvement in prevention of medication error
KONT-16; No. of Pages 6 kontakt xxx (2014) e1–e6
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Original research article
The possibility of patient involvement in prevention of medication error Iva Brabcová a,*, Sylva Bártlová a, Valérie Tóthová a, Radka Prokešová b a
University of South Bohemia in České Budějovice, Faculty of Health and Social Studies, Department of Nursing and Midwifery, Czech Republic b University of South Bohemia in České Budějovice, Faculty of Health and Social Studies, Department of Law, Management and Economics, Czech Republic
article info
abstract
Article history:
Medication errors are the most frequent cause of patient harm. The new view of the role of
Received 11 March 2014
the patient as a partner in his/her safe care can help reduce the risk of serious errors and
Accepted 13 May 2014
omissions by health workers. In the context of sociological investigation, the level of patient
Available online xxx
involvement in the medication process in checking the accuracy of the medication administered and informing healthcare professionals about all the medication taken and possible
Keywords:
allergies, has been researched. The selective file of patients admitted to the hospital,
Patient
corresponded with the patient composition in the Czech Republic in terms of regions,
Errors
gender and age. These features were intended to be representative. The research file
Medication process
consisted of 514 patients hospitalized at the hospital inpatient wards for at least 3 days.
Prevention
The research results show that patients carry out medication control very superficially. They
Safety
trust the nursing staff and do not check medication accuracy. More than half of the
Education
respondents (56.2%) do not check the medication and do not ask the nurse about its name. It is puzzling and alarming that almost one-third of patients (26.3%) would not draw the attention of a doctor or nurse to the administration of wrong or unusual medication! In contrast, most patients do inform a doctor about medication already being taken (87.5%), and possible allergies (86.0%), and so the active involvement of patients in risk prevention is a possible solution. Patients should be encouraged to be vigilant and alert health professionals about errors that, in their opinion, have happened or could happen during the treatment process. # 2014 Published by Elsevier Urban & Partner Sp. z o.o. on behalf of Faculty of Health and Social Studies of University of South Bohemia in České Budějovice.
* Corresponding author at: University of South Bohemia in České Budějovice, Faculty of Health and Social Studies, Department of Nursing and Midwifery, 26 U Výstaviště, 370 05 České Budějovice, Czech Republic. E-mail address: [email protected] (I. Brabcová). http://dx.doi.org/10.1016/j.kontakt.2014.05.003 1212-4117/# 2014 Published by Elsevier Urban & Partner Sp. z o.o. on behalf of Faculty of Health and Social Studies of University of South Bohemia in České Budějovice.
Please cite this article in press as: Brabcová, I., et al., The possibility of patient involvement in prevention of medication error. Kontakt (2014), http://dx.doi.org/10.1016/j.kontakt.2014.05.003
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Introduction The occurrence of errors in nursing and medical care is a global issue. The research studies ‘‘Crossing the Quality Chasm: A New Health System for the 21st Century’’ [1] and ‘‘To Err Is Human: Building a Safer Health System’’ [2] have shown that the misconduct of medical personnel affects approximately 5% of hospitalized patients. It is estimated that in the member states of the European Union (including the Czech Republic) the errors of members of the medical team affect between 8 and 12% of hospitalized patients [3]. Medication errors are the most common cause of patient harm; it is one of the most serious errors, which often ends with irreversible damage to the health status of the patients affected. Elderly patients who are suffering from a number of diseases are primarily at risk of medication errors, and furthermore, these patients use more drugs which may mutually interact. The economic and staffing situation of a number of hospitals that have a shortage of doctors and nurses, or who are at risk of budget loss, present another issue. According to AHRQ [4] 2–7% of all hospitalized patients are damaged during the medication process. Anderson and Townsend [5] reported that every year 1.5 million Americans are injured in some way due to medication errors by health professionals and that the costs of such errors amount to $3.5 trillion. An English study [6] showed that the health of every tenth hospitalized patient in the UK is damaged by the large number of errors occurring during the medication process. According to a German study [7], errors in medication affect the health of 40,000 Germans every year and 12,000 incidents are followed by legal action. From these reports, it is clear that the traditional management of safe health care is failing! A new look at the role of the patient as a partner in his/her safe health care can help reduce the risk of serious errors and omissions in medical and nursing care. Patients and their families should be encouraged and motivated by healthcare professionals to actively participate in the process of assuring the safety of the care provided. We were interested in finding out whether patients are actively involved in the medication process, in checking the accuracy of the medication administered and in informing healthcare professionals about the medication being used and possible allergies.
Czech Republic in terms of region, gender and age. These features were intended to be representative. The research file consisted of 514 patients admitted at the hospital inpatient wards for at least 3 days. In terms of gender, the file includes 242 (47.1%) male patients and 272 (52.9%) female patients, which corresponds to the analogous composition of patients admitted to the hospitals in the country. In terms of relative frequency, there was no file deviation from the population file. Age and gender are represented in the sample as percentages as given in Table 1. Compared to the age breakdown of the basic file, the deviation does not exceed 1.0% (Table 1). It can be concluded that the results are representative of the various age groups of hospitalized patients in the Czech Republic. The regional classification of the respondents used for the breakdown by regions of the Czech Republic, has been in force since 2001. When compared to the layout of the basic file, the maximal deviation is 0.4%. It can be concluded that the research results are representative of the various gender, age and region groups of hospitalized patients in the Czech Republic (Table 2). The preliminary analysis of the acquired data showed that out of the given aspects, which can describe and characterize the file, the basic demographic indicators best certify their desired differentiating function, namely the characteristics of gender, age and regional affiliation. Other characteristics of the selective file of hospitalized patients do not meet the requirements of representativeness, but they do enable its description through other features, which include education, marital status, occupation, type of hospital and characteristic features of hospitalization. In terms of education, the selective
Table 1 – Composition of the research file by gender and age. Age
18–29 years 30–39 years 40–49 years 50–59 years 60 and more
Men
Women
A
%
Deviation
A
%
Deviation
23 31 29 34 125
4.5 6.0 5.6 6.6 24.3
0.0 +0.2 0.4 0.8 +0.9
30 34 38 38 132
5.8 7.0 6.8 6.6 26.7
0.0 0.4 +0.6 +0.8 1.0
Source: [8]
Table 2 – Composition of the selective file by regions.
Materials and methods The research was based on the technique of structured interviews between an interviewer and a respondent. The data were collected through the survey network INRES. 216 interviewers from the Czech Republic were involved in the survey. The interviewers were well instructed before commencement of the research. Statistical data processing was carried out using the statistical analysis programme SASD social data, version 1.4.10. 1st degree of sorting and 2nd degree classification table were processed. The degree of dependence of the selected features was based on the x2 test and other criteria (depending on the nature of characters). The sample of patients admitted to hospital was designed so that its structure corresponded with the patient composition in the
Region
A
%
Deviation
Capital city of Prague Central Bohemia region South Bohemia region Plzeň region Karlovy Vary region Ústí region Liberec region Hradec Králové region Pardubice region Highlands region Region of South Moravia Olomouc region Zlín region Moravia–Silesia region
47 65 33 27 15 48 24 24 24 28 58 31 29 61
9.1 12.6 6.4 5.3 2.9 9.3 4.7 4.7 4.7 5.4 11.3 6.0 5.6 11.9
0.4 +0.4 +0.2 +0.1 0.2 +0.2 0.2 0.2 0.1 +0.3 +0.2 0.1 0.3 0.2
Source: [8]
Please cite this article in press as: Brabcová, I., et al., The possibility of patient involvement in prevention of medication error. Kontakt (2014), http://dx.doi.org/10.1016/j.kontakt.2014.05.003
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file is mostly represented by patients with apprenticeships and secondary education. In terms of marital status, the selective file is mostly represented by married patients (51.6%). In terms of occupation, the selective file is represented by retired (36.8%) and employed patients (35.4%). Other listed features characterize the selective file from the perspective of hospitalization: patients were mostly hospitalized in the regional, university and county hospitals. In terms of hospital admission, patients are divided into two approximately equally sized files; those admitted on an emergency basis and those whose admission was planned. The number of hospitalizations is another characteristic observed in the research of hospitalized patients affecting as it does, knowledge of the hospital environment and extent of experience with it. The largest proportion of patients (48.2%) stated that they had undergone three or more hospitalizations, the least (21.4%) were those who stated the current hospital stay as their first hospitalization ever. The research also focused on the length of patient hospitalization on the day of their interview. The research included only the patients whose length of stay was at least three days. The feature was defined as connected; respondents reported the actual number of days of hospitalization on the day of the interview. The average length of hospitalization was 7.8 days. Patients were subsequently divided into three basic groups and patients who had been on the day of the interview hospitalized from 3 to 5 days, composed the largest group of patients in terms of hospitalization length (52.1%). Respondents were informed about the research objectives and familiarized with the interviewer sheet in advance. Participation of respondents in the research was voluntary and based on informed consent. The actual investigation did not include any controversial ethical issues. Refusal to answer individual questions did not exceed the level of statistical significance. The above characteristics of the selective files do not meet the representativeness (education, marital status, occupation, type of hospital and the characteristics of the patient in terms of hospitalization) and are within the mathematical-statistical analysis tested for their correlation with other characters. A statistically significant correlation can be interpreted in view of the fact that they do not meet the requirements of representativeness, only as a tendency.
Results The way medication is dealt with, is one of the main risks of the nursing process, and a large part of the research focus was given to this area which was fed by five items. The questions focused on whether the patient look at what medications they are taking, whether they inform health professionals about the medicines they are currently taking, as well as allergies to drugs they suffer from. The first question (Do you assure the accuracy of drugs that are administered to you?) was given to ascertain whether the patient checks the drugs that are administered to him/her. More than half (52%) patients stated that they partially or completely follow the accuracy of drugs that are administered to them: a substantial part (41.6%) state that they do not follow
Table 3 – Control of administered drugs by patient (n = 512). Feature Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Absolute frequency
Relative frequency (%)
128 138 18
25.0 27.0 3.5
128 85 15 512
25.0 16.6 2.9 100.0
Histogram
the accuracy of drugs and trust the nursing staff. Only a small proportion (6.4%) of patients takes a neutral stand on this question. The analysis carried out on the basis of seconddegree classification did not identify statistically significant differences in the breakdown by socio-demographic groups. This means that the distribution of answers is similar for all of them (Table 3). The second question (Do you look at each given medication and ask the nurse about its name during medication administration?) examined the extent to which the patient monitors the accuracy of the administered drugs. Patients follow the drug administration rather superficially. A smaller portion (38.0%) of them always or usually checks the given medication and possibly asks the nurse about its name, the majority (56.2%) does not do so and usually does not check the administered drugs in this way or not at all. Only 5.8% of respondents take a neutral stand in this case. No statistically significant differences were revealed in the responses of each group of patients. We can conclude that these various groups are behaving similarly (Table 4). In connection with the drug handling, it also examined patients behaviour when they believe that they have been given wrong medication. The question was: ‘‘Did you inform a doctor or nurse if you had received a different kind of medication or if the medication that you were normally given, had not been administered?’’ The distribution of answers to this question is quite variable. The largest proportion of patients (40.5%) reported that they informed a doctor or nurse in the event of administration of a wrong drug or a not usual drug. Another 26.3% of patients reported that they had certainly not done so, the remaining 33.3% of patients stated that the situation had
Table 4 – Control (following) of the accuracy of patient medication and request for the name of medication (n = 514). Feature Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Absolute frequency
Relative frequency (%)
78 117 16
15.2 22.8 3.1
165 124 14 514
32.1 24.1 2.7 100.0
Histogram
Please cite this article in press as: Brabcová, I., et al., The possibility of patient involvement in prevention of medication error. Kontakt (2014), http://dx.doi.org/10.1016/j.kontakt.2014.05.003
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Table 5 – Informing doctor (nurse) by patient in the absence or administration of wrong drug (n = 514).
Table 7 – Informing the health professionals about allergies the patient suffer from (n = 514).
Feature
Feature
Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Absolute frequency
Relative frequency (%)
92 116 37
17.9 22.6 7.2
74 61 134 514
14.4 11.9 26.1 100.0
Histogram
Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Table 6 – Informing the health professionals about take drugs by the patient (n = 514). Feature Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Absolute frequency
Relative frequency (%)
381 69 13
74.1 13.4 2.5
21 6 24 514
4.1 1.2 4.7 100.0
Histogram
nothing to do with them or took a neutral stand. No statistically significant differences were revealed in the opinions of each group of patients responding to this question (Table 5). The issue of whether patients truthfully and fully inform healthcare professionals about all medications they are currently taking, and any allergies or reactions to certain drugs, also falls into safe drug management. The question to respondents was: ‘‘Have you informed healthcare professionals about all the medications you are currently taking?’’ The vast majority of patients (87.5%) reported that they always or usually informed health professionals about all medication they were taking. Only 5.3% of patient do not do so, others took a neutral stand point. We can conclude that the risk of patients not informing health professionals about the medication they take, is minimal. Since the applied testing criteria did not identify statistically significant differences in the behaviour of patients, we can be conclude that all patient groups are equally responsible in this area (Table 6). The last feature which was used to identify patient behaviour in connection with dealing with drugs, examined whether
Absolute frequency
Relative frequency (%)
372 70 17
72.4 13.6 3.3
10 11 34 514
1.9 2.1 6.6 100.0
Histogram
patients inform health professionals about allergies and reactions to certain drugs they have (‘‘Have you informed health professionals of all allergies to certain drugs you suffer from?’’). As in the previous case, the majority of patients (86.0%) inform health professionals about allergies and reactions to certain drugs they suffer from. 4.0% of patients only do not do so, others took a neutral stand point. Even in this feature, the tested context was not identified as important. This means that different groups of patients, classified according to sociodemographic characteristics, behave similarly and there is not much of a safety risk in this case (Table 7). The comparison of different behavioural patterns in the way of dealing with drugs, characterized by the above features, was due to the use of mean value measures performed again on the reduced file. This means that the extreme scale items (‘‘cannot answer’’, ‘‘except’’) were filtered out and only the file which took a stand point in the first five items of the scale (‘‘absolutely yes’’, ‘‘probably yes’’, ‘‘difficult to decide’’, ‘‘somewhat disagree’’ and ‘‘not at all’’), was evaluated. The comparison of the features characterizing the dealing with drugs suggests that the smallest risk lies in the patients reporting of allergies and reactions to medications and in reports of drugs that they take. In contrast, one cannot rely on the control of administered drugs by patients, as their behaviour when giving information about medications they use, and allergies and reactions to them is characterized by the highest homogeneity; the variability of their behaviour in the case of these items is the smallest (Table 8).
Discussion Medication is a series of complex steps that includes drug prescription by the doctor, correct identification of the prescribed drug, the preparation, administration of medication
Table 8 – Behaviour of patients in the prevention of medication errors. Item Reporting on allergy to drugs Reporting on used drugs Reporting on administration of another drug Checking of drug administration accuracy Control of administered drugs
n
Mo
Me
Å x
s2
s
480 490 380 499 500
1 1 2 2 4
0 0 2 2 4
1.371 1.372 2.726 2.802 3.28
0.704 0.691 2.036 2.211 2.102
0.839 0.831 1.427 1.487 1.45
Å n, number of observations; Mo, mode; Me, median; x; arithmetic mean; s2, variance; s, standard deviation.
Please cite this article in press as: Brabcová, I., et al., The possibility of patient involvement in prevention of medication error. Kontakt (2014), http://dx.doi.org/10.1016/j.kontakt.2014.05.003
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by a nurse, and the subsequent monitoring of the drug effects and potential complications. Error may occur at any point in this process. An incomplete history, erroneous or incomplete prescription, inadequate patient identification, poor team communication, equipment failure (infusion pumps, dispensers), ignoring the fatigue of personnel and last but not least a lack of patient education rank among the common causes of medication errors. A number of international studies [9–11] point to the fact that patients may protect themselves against error by medical health professionals. However, the condition of change is a shift from traditional (passive) patient attitude to the care provided, to acceptance of an active role as a partner to physician (nurse) in ensuring safety of care. We were interested in whether patients check the given drugs and whether they ask a nurse for the name of the drug. More than a half of patients (52.0%) reported that they partially or fully check drugs which are administered to them. On the contrary a substantial part (41.6%) of respondents state that they do not follow the accuracy of drugs and trust nursing staff (Table 3). Patients check drugs administered rather superficially; only 38.0% of them always or usually check the given medication and possibly ask a nurse about its name. The majority (56.2%) of respondents reported that they do not check the drugs administered by a nurse (Table 4). From the above results we can conclude that physicians and nurses cannot rely on the control of drugs given performed by patients. According to Anderson and Townsend [5] patients should be alert to potential medical errors carried out by health professionals and actively ask for the information that is in their interests. Also in our research, the respondents were asked about their behaviour when they believed that they had been given the wrong medication. The responses to the question were highly variable. The largest proportion of patients (40.5%) reported that they informed a doctor or a nurse in the event of wrong drug or no drug administration. On the contrary, less than a third (26.3%) stated that they would not do so (Table 5). The interest and willingness of patients to highlight potential errors of doctors and nurses can greatly affect health professionals themselves. According to Davis et al. [12] when the patients were educated in safe practices by health professionals and encouraged to report any discrepancies, the ability and willingness of patients to draw health professionals' attention to potential errors increased. The question remains as to what extent doctors and nurses want to engage the patient in the process of assuring safe care! According to a Swiss study which addressed the issue of medication errors, 77% of respondents (cancer patients) believed that patients can help reduce the risk medication error by health professionals. At the same time, in the patients' opinion the health professionals are not interested in letting patients enter into assuring safe care. A quarter of patients reported that they were not encouraged by health professionals to actively seek and report medical errors during hospitalization [13]. In the Spanish study [14], only one out of five doctors stated that it is good to involve patients in the process of providing care. The above researches suggest that doctors and nurses are often reluctant to engage the patient in safety procedures. The patients query about the quality of care can be interpreted as an act of mistrust towards them. In contrast, in research by Schwappach et al. [15], although nurses claimed that inclusion of patients in safe care is
e5
difficult, the patients appreciated their efforts and felt safer by being involved in the safety procedures. Also in the study by Schwappach [16], most of the health professionals positively evaluated the queries on safe care. However, it was easier for them to accept a patient alert on medication errors than on the lack of hand hygiene. The fact that the hand hygiene of health professionals and patients is a very sensitive issue, was confirmed by the research of Davis et al. [11]. The vast majority of the questioned patients reported inflammation of wounds to the staff, but only a half of them were willing to alert the physician or nurse to the fact that they had not washed their hands before the procedure. Currently, the patient role in assuring safe care is changing. Patients are instructed and motivated to be attentive and alert health professionals on any possible errors that in their opinion have happened or may happen. The patients get involved in their own care when they are invited by the health professionals to do so [9] when they are encouraged to ask questions about their medication in order to make sure that they know everything and are clear about its purpose. This is to be responsible for their contribution to treatment, which seems a reasonable and a useful measure. However, if implemented on all occasions, it could be very time-demanding for health professionals. To what extent health professionals accept and support any patient influence on his/her security is influenced by their own attitude towards the issue, workload and patient illness, education, social status and ethnicity [10]. According to Dvořáček [17] there are 38,889 patients hospitalized in the Czech Republic each year because of the adverse effects of drugs: in 889 of them it leads to death. We were interested whether respondents truthfully and fully informed health professionals about all the medications they were taking at that time, and whether there were any allergies or reactions to certain drugs. A pleasant finding is the fact that the vast majority of patients inform health professionals about all the medication (87.5%), which are currently taking, and any potential allergies (86.0%), see Tables 6 and 7. A comparison of the features describing the safe care way of dealing with drugs suggests that the smallest risks lie in the patient's report of allergies and reactions to medications and reports of drugs that patients are taking (Table 8).
Conclusion The Czech health sector suffers from underfunding, a lack of qualified personnel, and the inefficiency of the system. These rank among the risk factors that increase the probability of medical errors. The solution is to change the traditional passive role of the patient in the system of provided care. Active involvement of patients in ensuring their own safe care, can contribute significantly to reducing the risk of medical errors. Research demonstrates that it is not possible to rely on the control of administered drugs by patients. A substantial part (41.6%) of respondents state that they do not follow the accuracy of drugs and trust nursing staff. More than a half of the respondents (56.2%) do not check the medication and do not ask the nurse about its name and 40.5% of patients would not inform a doctor or nurse when given the wrong or no medication. Most
Please cite this article in press as: Brabcová, I., et al., The possibility of patient involvement in prevention of medication error. Kontakt (2014), http://dx.doi.org/10.1016/j.kontakt.2014.05.003
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patients get involved in safety procedures through reporting of medication (87.5%), and reporting of potential allergies (86.0%). The above data show the need for education of patients about the possible involvement in safety procedures when care is being provided. In prevention of medication errors, patients should know the name of the medication that is prescribed to them, the purpose for its prescription, how to use the medication, how often, in what dose and what side effects may appear. If patients are actively involved in ensuring their own safety, the medical and nursing processes automatically change and become safer [18]. Mutual education is necessary. Health professionals should be trained how to respond to patient queries. Doctors and nurses must learn to tolerate patient queries. It is necessary to remember that patients have limited ability to assess the level of care and detect a fault by health professionals. However, it is desirable to be involved in the care control, even with the risk of mistaken and misleading alerts on health professionals misconduct! Strengthening the role of patient organizations is the way to increase the active participation of patients in risk prevention. At a national level, it would be appropriate to establish a state institute which would follow the quality of the hospitals, using an internet error database. This would allow patients to select of the bestquality facilities and for hospitals themselves, it would assist in choosing their specialization.
Conflict of interest The authors declare that the study has no conflict of interest and in the process it has complied with ethical aspects of research. The research plan was approved by the Ethical Committee of ZSF JU in České Budějovice. The management of the hospitals involved agreed with the research. The respondents were informed about the purpose of the research and agreed to be included in the research file.
Acknowledgements The research was conducted with the support of the Internal Grant Agency of the Ministry of Health of the Czech Republic within the project reg. no. NT 14133 with the title ‘‘Increasing of nursing care safety’’.
references
[1] Crossing the quality chasm: a new health system for the 21st Century. Washington, DC, USA: National Academies Press; 2001.
[2] Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC, USA: National Academies Press; 2000. 287p. [3] MZČR. Metodika sledování nežádoucích událostí ve zdravotnických zařízeních lůžkové péče. Věstník Ministerstva zdravotnictví České republiky. Částka 8. 2012;20–7. Available from: http://www.mzcr.cz/Legislativa/ dokumenty/vestnik-c8/2012_6865_2510_11.html [accessed 2013-05-27]. [4] Patient Safety Practices Rated by Strength of Evidence. Addendum to Summary. AHRQ Publication No. 01-E057b. Rockville, MD: Agency for Healthcare Research and Quality; 2001. Available from: http://www.ahrq.gov/clinic/ptsafety/ addend.htm. [5] Anderson P, Townsend T. Medication errors: don't let them happen to you. Am Nurse Today 2010;5(3):23–8. [6] Karnon JD, Dean JT, Bath P, Hutchinson A, Oakley J, Thomas N, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. Saf Sci 2007;45(4):523–39. [7] Breckenkamp J, Wiskow Ch, Laaser U. Progress on quality management in the German health system – a long and winding road. Health Res Policy Syst 2007;5(7.). [8] Hospitalizovaní v nemocnicích ČR v roce 2011. Praha: Ústav zdravotnických informací a statistiky; 2012. [9] Schwappach DL, Frank O, Davis RE. A vignette study to examine health care professionals' attitudes towards patient involvement in error prevention. J Eval Clin Pract 2013;19:840–8. [10] Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc 2010;85(1): 53–62. [11] Davis RE, Sevdalis N, Vincent CA. Patient involvement in patient safety: how willing are patients to participate? BMJ Qual Saf 2011;20:108–14. [12] Davis RE, Koutantji M, Vincent CA. How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study. Qual Saf Health Care 2008;17:90–6. [13] Schwappach DLB, Wernli M. Chemotherapy patients' perceptions of drug administration safety. J Clin Oncol 2010;28:2896–901. [14] Mira JJ, Guilabert M, Pérez-Jover V, Lorenzo S. Barriers for an effective communication around clinical decision-making: an analysis of the gaps between doctors' and patients' point of view. Health Expect 2012;1–14. [15] Schwappach DLB, Hochreutener MA, Wernli M. Oncology nurses' perceptions about involving patients in the prevention of chemotherapy administration errors. Oncol Nurs Forum 2010;37(2):E84–91. [16] Schwappach DLB. Frequency of and predictors for patientreported medical and medication errors in Switzerland. Swiss Med Wkly 2012;141(w13262):1–8. [17] Dvořáček L. Dosavadní zkušenosti z kontrol historické preskripce léků na recept. Klin Farmakol Farm 2008;22 (4):31–6. [18] Involving patients in improving safety. London: The Health Foundation; 2013.
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Original research article
The possibility of patient involvement in prevention of medication error Iva Brabcová a,*, Sylva Bártlová a, Valérie Tóthová a, Radka Prokešová b a
University of South Bohemia in České Budějovice, Faculty of Health and Social Studies, Department of Nursing and Midwifery, Czech Republic b University of South Bohemia in České Budějovice, Faculty of Health and Social Studies, Department of Law, Management and Economics, Czech Republic
article info
abstract
Article history:
Medication errors are the most frequent cause of patient harm. The new view of the role of
Received 11 March 2014
the patient as a partner in his/her safe care can help reduce the risk of serious errors and
Accepted 13 May 2014
omissions by health workers. In the context of sociological investigation, the level of patient
Available online xxx
involvement in the medication process in checking the accuracy of the medication administered and informing healthcare professionals about all the medication taken and possible
Keywords:
allergies, has been researched. The selective file of patients admitted to the hospital,
Patient
corresponded with the patient composition in the Czech Republic in terms of regions,
Errors
gender and age. These features were intended to be representative. The research file
Medication process
consisted of 514 patients hospitalized at the hospital inpatient wards for at least 3 days.
Prevention
The research results show that patients carry out medication control very superficially. They
Safety
trust the nursing staff and do not check medication accuracy. More than half of the
Education
respondents (56.2%) do not check the medication and do not ask the nurse about its name. It is puzzling and alarming that almost one-third of patients (26.3%) would not draw the attention of a doctor or nurse to the administration of wrong or unusual medication! In contrast, most patients do inform a doctor about medication already being taken (87.5%), and possible allergies (86.0%), and so the active involvement of patients in risk prevention is a possible solution. Patients should be encouraged to be vigilant and alert health professionals about errors that, in their opinion, have happened or could happen during the treatment process. # 2014 Published by Elsevier Urban & Partner Sp. z o.o. on behalf of Faculty of Health and Social Studies of University of South Bohemia in České Budějovice.
* Corresponding author at: University of South Bohemia in České Budějovice, Faculty of Health and Social Studies, Department of Nursing and Midwifery, 26 U Výstaviště, 370 05 České Budějovice, Czech Republic. E-mail address: [email protected] (I. Brabcová). http://dx.doi.org/10.1016/j.kontakt.2014.05.003 1212-4117/# 2014 Published by Elsevier Urban & Partner Sp. z o.o. on behalf of Faculty of Health and Social Studies of University of South Bohemia in České Budějovice.
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Introduction The occurrence of errors in nursing and medical care is a global issue. The research studies ‘‘Crossing the Quality Chasm: A New Health System for the 21st Century’’ [1] and ‘‘To Err Is Human: Building a Safer Health System’’ [2] have shown that the misconduct of medical personnel affects approximately 5% of hospitalized patients. It is estimated that in the member states of the European Union (including the Czech Republic) the errors of members of the medical team affect between 8 and 12% of hospitalized patients [3]. Medication errors are the most common cause of patient harm; it is one of the most serious errors, which often ends with irreversible damage to the health status of the patients affected. Elderly patients who are suffering from a number of diseases are primarily at risk of medication errors, and furthermore, these patients use more drugs which may mutually interact. The economic and staffing situation of a number of hospitals that have a shortage of doctors and nurses, or who are at risk of budget loss, present another issue. According to AHRQ [4] 2–7% of all hospitalized patients are damaged during the medication process. Anderson and Townsend [5] reported that every year 1.5 million Americans are injured in some way due to medication errors by health professionals and that the costs of such errors amount to $3.5 trillion. An English study [6] showed that the health of every tenth hospitalized patient in the UK is damaged by the large number of errors occurring during the medication process. According to a German study [7], errors in medication affect the health of 40,000 Germans every year and 12,000 incidents are followed by legal action. From these reports, it is clear that the traditional management of safe health care is failing! A new look at the role of the patient as a partner in his/her safe health care can help reduce the risk of serious errors and omissions in medical and nursing care. Patients and their families should be encouraged and motivated by healthcare professionals to actively participate in the process of assuring the safety of the care provided. We were interested in finding out whether patients are actively involved in the medication process, in checking the accuracy of the medication administered and in informing healthcare professionals about the medication being used and possible allergies.
Czech Republic in terms of region, gender and age. These features were intended to be representative. The research file consisted of 514 patients admitted at the hospital inpatient wards for at least 3 days. In terms of gender, the file includes 242 (47.1%) male patients and 272 (52.9%) female patients, which corresponds to the analogous composition of patients admitted to the hospitals in the country. In terms of relative frequency, there was no file deviation from the population file. Age and gender are represented in the sample as percentages as given in Table 1. Compared to the age breakdown of the basic file, the deviation does not exceed 1.0% (Table 1). It can be concluded that the results are representative of the various age groups of hospitalized patients in the Czech Republic. The regional classification of the respondents used for the breakdown by regions of the Czech Republic, has been in force since 2001. When compared to the layout of the basic file, the maximal deviation is 0.4%. It can be concluded that the research results are representative of the various gender, age and region groups of hospitalized patients in the Czech Republic (Table 2). The preliminary analysis of the acquired data showed that out of the given aspects, which can describe and characterize the file, the basic demographic indicators best certify their desired differentiating function, namely the characteristics of gender, age and regional affiliation. Other characteristics of the selective file of hospitalized patients do not meet the requirements of representativeness, but they do enable its description through other features, which include education, marital status, occupation, type of hospital and characteristic features of hospitalization. In terms of education, the selective
Table 1 – Composition of the research file by gender and age. Age
18–29 years 30–39 years 40–49 years 50–59 years 60 and more
Men
Women
A
%
Deviation
A
%
Deviation
23 31 29 34 125
4.5 6.0 5.6 6.6 24.3
0.0 +0.2 0.4 0.8 +0.9
30 34 38 38 132
5.8 7.0 6.8 6.6 26.7
0.0 0.4 +0.6 +0.8 1.0
Source: [8]
Table 2 – Composition of the selective file by regions.
Materials and methods The research was based on the technique of structured interviews between an interviewer and a respondent. The data were collected through the survey network INRES. 216 interviewers from the Czech Republic were involved in the survey. The interviewers were well instructed before commencement of the research. Statistical data processing was carried out using the statistical analysis programme SASD social data, version 1.4.10. 1st degree of sorting and 2nd degree classification table were processed. The degree of dependence of the selected features was based on the x2 test and other criteria (depending on the nature of characters). The sample of patients admitted to hospital was designed so that its structure corresponded with the patient composition in the
Region
A
%
Deviation
Capital city of Prague Central Bohemia region South Bohemia region Plzeň region Karlovy Vary region Ústí region Liberec region Hradec Králové region Pardubice region Highlands region Region of South Moravia Olomouc region Zlín region Moravia–Silesia region
47 65 33 27 15 48 24 24 24 28 58 31 29 61
9.1 12.6 6.4 5.3 2.9 9.3 4.7 4.7 4.7 5.4 11.3 6.0 5.6 11.9
0.4 +0.4 +0.2 +0.1 0.2 +0.2 0.2 0.2 0.1 +0.3 +0.2 0.1 0.3 0.2
Source: [8]
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file is mostly represented by patients with apprenticeships and secondary education. In terms of marital status, the selective file is mostly represented by married patients (51.6%). In terms of occupation, the selective file is represented by retired (36.8%) and employed patients (35.4%). Other listed features characterize the selective file from the perspective of hospitalization: patients were mostly hospitalized in the regional, university and county hospitals. In terms of hospital admission, patients are divided into two approximately equally sized files; those admitted on an emergency basis and those whose admission was planned. The number of hospitalizations is another characteristic observed in the research of hospitalized patients affecting as it does, knowledge of the hospital environment and extent of experience with it. The largest proportion of patients (48.2%) stated that they had undergone three or more hospitalizations, the least (21.4%) were those who stated the current hospital stay as their first hospitalization ever. The research also focused on the length of patient hospitalization on the day of their interview. The research included only the patients whose length of stay was at least three days. The feature was defined as connected; respondents reported the actual number of days of hospitalization on the day of the interview. The average length of hospitalization was 7.8 days. Patients were subsequently divided into three basic groups and patients who had been on the day of the interview hospitalized from 3 to 5 days, composed the largest group of patients in terms of hospitalization length (52.1%). Respondents were informed about the research objectives and familiarized with the interviewer sheet in advance. Participation of respondents in the research was voluntary and based on informed consent. The actual investigation did not include any controversial ethical issues. Refusal to answer individual questions did not exceed the level of statistical significance. The above characteristics of the selective files do not meet the representativeness (education, marital status, occupation, type of hospital and the characteristics of the patient in terms of hospitalization) and are within the mathematical-statistical analysis tested for their correlation with other characters. A statistically significant correlation can be interpreted in view of the fact that they do not meet the requirements of representativeness, only as a tendency.
Results The way medication is dealt with, is one of the main risks of the nursing process, and a large part of the research focus was given to this area which was fed by five items. The questions focused on whether the patient look at what medications they are taking, whether they inform health professionals about the medicines they are currently taking, as well as allergies to drugs they suffer from. The first question (Do you assure the accuracy of drugs that are administered to you?) was given to ascertain whether the patient checks the drugs that are administered to him/her. More than half (52%) patients stated that they partially or completely follow the accuracy of drugs that are administered to them: a substantial part (41.6%) state that they do not follow
Table 3 – Control of administered drugs by patient (n = 512). Feature Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Absolute frequency
Relative frequency (%)
128 138 18
25.0 27.0 3.5
128 85 15 512
25.0 16.6 2.9 100.0
Histogram
the accuracy of drugs and trust the nursing staff. Only a small proportion (6.4%) of patients takes a neutral stand on this question. The analysis carried out on the basis of seconddegree classification did not identify statistically significant differences in the breakdown by socio-demographic groups. This means that the distribution of answers is similar for all of them (Table 3). The second question (Do you look at each given medication and ask the nurse about its name during medication administration?) examined the extent to which the patient monitors the accuracy of the administered drugs. Patients follow the drug administration rather superficially. A smaller portion (38.0%) of them always or usually checks the given medication and possibly asks the nurse about its name, the majority (56.2%) does not do so and usually does not check the administered drugs in this way or not at all. Only 5.8% of respondents take a neutral stand in this case. No statistically significant differences were revealed in the responses of each group of patients. We can conclude that these various groups are behaving similarly (Table 4). In connection with the drug handling, it also examined patients behaviour when they believe that they have been given wrong medication. The question was: ‘‘Did you inform a doctor or nurse if you had received a different kind of medication or if the medication that you were normally given, had not been administered?’’ The distribution of answers to this question is quite variable. The largest proportion of patients (40.5%) reported that they informed a doctor or nurse in the event of administration of a wrong drug or a not usual drug. Another 26.3% of patients reported that they had certainly not done so, the remaining 33.3% of patients stated that the situation had
Table 4 – Control (following) of the accuracy of patient medication and request for the name of medication (n = 514). Feature Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Absolute frequency
Relative frequency (%)
78 117 16
15.2 22.8 3.1
165 124 14 514
32.1 24.1 2.7 100.0
Histogram
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Table 5 – Informing doctor (nurse) by patient in the absence or administration of wrong drug (n = 514).
Table 7 – Informing the health professionals about allergies the patient suffer from (n = 514).
Feature
Feature
Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Absolute frequency
Relative frequency (%)
92 116 37
17.9 22.6 7.2
74 61 134 514
14.4 11.9 26.1 100.0
Histogram
Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Table 6 – Informing the health professionals about take drugs by the patient (n = 514). Feature Entirely yes Probably yes Difficult to decide Probably not Not at all No answer Total
Absolute frequency
Relative frequency (%)
381 69 13
74.1 13.4 2.5
21 6 24 514
4.1 1.2 4.7 100.0
Histogram
nothing to do with them or took a neutral stand. No statistically significant differences were revealed in the opinions of each group of patients responding to this question (Table 5). The issue of whether patients truthfully and fully inform healthcare professionals about all medications they are currently taking, and any allergies or reactions to certain drugs, also falls into safe drug management. The question to respondents was: ‘‘Have you informed healthcare professionals about all the medications you are currently taking?’’ The vast majority of patients (87.5%) reported that they always or usually informed health professionals about all medication they were taking. Only 5.3% of patient do not do so, others took a neutral stand point. We can conclude that the risk of patients not informing health professionals about the medication they take, is minimal. Since the applied testing criteria did not identify statistically significant differences in the behaviour of patients, we can be conclude that all patient groups are equally responsible in this area (Table 6). The last feature which was used to identify patient behaviour in connection with dealing with drugs, examined whether
Absolute frequency
Relative frequency (%)
372 70 17
72.4 13.6 3.3
10 11 34 514
1.9 2.1 6.6 100.0
Histogram
patients inform health professionals about allergies and reactions to certain drugs they have (‘‘Have you informed health professionals of all allergies to certain drugs you suffer from?’’). As in the previous case, the majority of patients (86.0%) inform health professionals about allergies and reactions to certain drugs they suffer from. 4.0% of patients only do not do so, others took a neutral stand point. Even in this feature, the tested context was not identified as important. This means that different groups of patients, classified according to sociodemographic characteristics, behave similarly and there is not much of a safety risk in this case (Table 7). The comparison of different behavioural patterns in the way of dealing with drugs, characterized by the above features, was due to the use of mean value measures performed again on the reduced file. This means that the extreme scale items (‘‘cannot answer’’, ‘‘except’’) were filtered out and only the file which took a stand point in the first five items of the scale (‘‘absolutely yes’’, ‘‘probably yes’’, ‘‘difficult to decide’’, ‘‘somewhat disagree’’ and ‘‘not at all’’), was evaluated. The comparison of the features characterizing the dealing with drugs suggests that the smallest risk lies in the patients reporting of allergies and reactions to medications and in reports of drugs that they take. In contrast, one cannot rely on the control of administered drugs by patients, as their behaviour when giving information about medications they use, and allergies and reactions to them is characterized by the highest homogeneity; the variability of their behaviour in the case of these items is the smallest (Table 8).
Discussion Medication is a series of complex steps that includes drug prescription by the doctor, correct identification of the prescribed drug, the preparation, administration of medication
Table 8 – Behaviour of patients in the prevention of medication errors. Item Reporting on allergy to drugs Reporting on used drugs Reporting on administration of another drug Checking of drug administration accuracy Control of administered drugs
n
Mo
Me
Å x
s2
s
480 490 380 499 500
1 1 2 2 4
0 0 2 2 4
1.371 1.372 2.726 2.802 3.28
0.704 0.691 2.036 2.211 2.102
0.839 0.831 1.427 1.487 1.45
Å n, number of observations; Mo, mode; Me, median; x; arithmetic mean; s2, variance; s, standard deviation.
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by a nurse, and the subsequent monitoring of the drug effects and potential complications. Error may occur at any point in this process. An incomplete history, erroneous or incomplete prescription, inadequate patient identification, poor team communication, equipment failure (infusion pumps, dispensers), ignoring the fatigue of personnel and last but not least a lack of patient education rank among the common causes of medication errors. A number of international studies [9–11] point to the fact that patients may protect themselves against error by medical health professionals. However, the condition of change is a shift from traditional (passive) patient attitude to the care provided, to acceptance of an active role as a partner to physician (nurse) in ensuring safety of care. We were interested in whether patients check the given drugs and whether they ask a nurse for the name of the drug. More than a half of patients (52.0%) reported that they partially or fully check drugs which are administered to them. On the contrary a substantial part (41.6%) of respondents state that they do not follow the accuracy of drugs and trust nursing staff (Table 3). Patients check drugs administered rather superficially; only 38.0% of them always or usually check the given medication and possibly ask a nurse about its name. The majority (56.2%) of respondents reported that they do not check the drugs administered by a nurse (Table 4). From the above results we can conclude that physicians and nurses cannot rely on the control of drugs given performed by patients. According to Anderson and Townsend [5] patients should be alert to potential medical errors carried out by health professionals and actively ask for the information that is in their interests. Also in our research, the respondents were asked about their behaviour when they believed that they had been given the wrong medication. The responses to the question were highly variable. The largest proportion of patients (40.5%) reported that they informed a doctor or a nurse in the event of wrong drug or no drug administration. On the contrary, less than a third (26.3%) stated that they would not do so (Table 5). The interest and willingness of patients to highlight potential errors of doctors and nurses can greatly affect health professionals themselves. According to Davis et al. [12] when the patients were educated in safe practices by health professionals and encouraged to report any discrepancies, the ability and willingness of patients to draw health professionals' attention to potential errors increased. The question remains as to what extent doctors and nurses want to engage the patient in the process of assuring safe care! According to a Swiss study which addressed the issue of medication errors, 77% of respondents (cancer patients) believed that patients can help reduce the risk medication error by health professionals. At the same time, in the patients' opinion the health professionals are not interested in letting patients enter into assuring safe care. A quarter of patients reported that they were not encouraged by health professionals to actively seek and report medical errors during hospitalization [13]. In the Spanish study [14], only one out of five doctors stated that it is good to involve patients in the process of providing care. The above researches suggest that doctors and nurses are often reluctant to engage the patient in safety procedures. The patients query about the quality of care can be interpreted as an act of mistrust towards them. In contrast, in research by Schwappach et al. [15], although nurses claimed that inclusion of patients in safe care is
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difficult, the patients appreciated their efforts and felt safer by being involved in the safety procedures. Also in the study by Schwappach [16], most of the health professionals positively evaluated the queries on safe care. However, it was easier for them to accept a patient alert on medication errors than on the lack of hand hygiene. The fact that the hand hygiene of health professionals and patients is a very sensitive issue, was confirmed by the research of Davis et al. [11]. The vast majority of the questioned patients reported inflammation of wounds to the staff, but only a half of them were willing to alert the physician or nurse to the fact that they had not washed their hands before the procedure. Currently, the patient role in assuring safe care is changing. Patients are instructed and motivated to be attentive and alert health professionals on any possible errors that in their opinion have happened or may happen. The patients get involved in their own care when they are invited by the health professionals to do so [9] when they are encouraged to ask questions about their medication in order to make sure that they know everything and are clear about its purpose. This is to be responsible for their contribution to treatment, which seems a reasonable and a useful measure. However, if implemented on all occasions, it could be very time-demanding for health professionals. To what extent health professionals accept and support any patient influence on his/her security is influenced by their own attitude towards the issue, workload and patient illness, education, social status and ethnicity [10]. According to Dvořáček [17] there are 38,889 patients hospitalized in the Czech Republic each year because of the adverse effects of drugs: in 889 of them it leads to death. We were interested whether respondents truthfully and fully informed health professionals about all the medications they were taking at that time, and whether there were any allergies or reactions to certain drugs. A pleasant finding is the fact that the vast majority of patients inform health professionals about all the medication (87.5%), which are currently taking, and any potential allergies (86.0%), see Tables 6 and 7. A comparison of the features describing the safe care way of dealing with drugs suggests that the smallest risks lie in the patient's report of allergies and reactions to medications and reports of drugs that patients are taking (Table 8).
Conclusion The Czech health sector suffers from underfunding, a lack of qualified personnel, and the inefficiency of the system. These rank among the risk factors that increase the probability of medical errors. The solution is to change the traditional passive role of the patient in the system of provided care. Active involvement of patients in ensuring their own safe care, can contribute significantly to reducing the risk of medical errors. Research demonstrates that it is not possible to rely on the control of administered drugs by patients. A substantial part (41.6%) of respondents state that they do not follow the accuracy of drugs and trust nursing staff. More than a half of the respondents (56.2%) do not check the medication and do not ask the nurse about its name and 40.5% of patients would not inform a doctor or nurse when given the wrong or no medication. Most
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patients get involved in safety procedures through reporting of medication (87.5%), and reporting of potential allergies (86.0%). The above data show the need for education of patients about the possible involvement in safety procedures when care is being provided. In prevention of medication errors, patients should know the name of the medication that is prescribed to them, the purpose for its prescription, how to use the medication, how often, in what dose and what side effects may appear. If patients are actively involved in ensuring their own safety, the medical and nursing processes automatically change and become safer [18]. Mutual education is necessary. Health professionals should be trained how to respond to patient queries. Doctors and nurses must learn to tolerate patient queries. It is necessary to remember that patients have limited ability to assess the level of care and detect a fault by health professionals. However, it is desirable to be involved in the care control, even with the risk of mistaken and misleading alerts on health professionals misconduct! Strengthening the role of patient organizations is the way to increase the active participation of patients in risk prevention. At a national level, it would be appropriate to establish a state institute which would follow the quality of the hospitals, using an internet error database. This would allow patients to select of the bestquality facilities and for hospitals themselves, it would assist in choosing their specialization.
Conflict of interest The authors declare that the study has no conflict of interest and in the process it has complied with ethical aspects of research. The research plan was approved by the Ethical Committee of ZSF JU in České Budějovice. The management of the hospitals involved agreed with the research. The respondents were informed about the purpose of the research and agreed to be included in the research file.
Acknowledgements The research was conducted with the support of the Internal Grant Agency of the Ministry of Health of the Czech Republic within the project reg. no. NT 14133 with the title ‘‘Increasing of nursing care safety’’.
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