Projects per year
Abstract
Background: In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs). Objective: The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice (discrepancies) that contributed to large-magnitude and/or clinically significant MAEs. Methods: Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study. Results: In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs. Conclusion and Relevance: Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.
| Original language | English |
|---|---|
| Pages (from-to) | 1333-1340 |
| Number of pages | 8 |
| Journal | Annals of Pharmacotherapy |
| Volume | 55 |
| Issue number | 11 |
| Early online date | 1 Mar 2021 |
| DOIs | |
| Publication status | Published - 1 Nov 2021 |
Funding
This article presents independent research funded by the National Institute for Health Research (NIHR), the NIHR Imperial Patient Safety Translational Research Centre, and the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College in partnership with Public Health England (PHE). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, PHE, or the Department of Health and Social Care. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: MDJ was funded by a National Institute for Health Research (NIHR), Transitional Research Fellowship for this research project (Grant number TRF-2017-10-006). NA received funding from the Resuscitation Council (UK), which partially funded elements of the simulations and data extraction, with the majority of the funding received from the NIHR Imperial Patient Safety Translational Research Centre. Infrastructure support was provided by the NIHR Imperial Biomedical Research Centre (BRC). BDF is also supported by the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London in partnership with Public Health England (PHE). The views expressed are those of the authors and not necessarily those of the NHS, PHE, the NIHR, or the Department of Health and Social Care. We would like to thank all clinical staff who participated in the simulations. We would also like to thank Carol Jackson and Amanda Skirrow (Royal United Hospitals Bath NHS Foundation Trust) for their invaluable assistance in checking the face validity of our hierarchical task analysis. It is our hope that the enthusiasm and extraordinary open-mindedness of our dedicated and deeply competent colleagues demonstrated in making this study possible will lead to safer systems and innovations in pediatric medication safety. This study was funded by the NIHR Imperial Patient Safety Translational Research Centre, with infrastructure support from the NIHR Imperial Biomedical Research Centre. Support was also received from the Resuscitation Council (UK). MDJ was funded by a National Institute for Health Research (NIHR) Transitional Research Fellowship for this research project. We would like to thank all clinical staff who participated in the simulations. We would also like to thank Carol Jackson and Amanda Skirrow (Royal United Hospitals Bath NHS Foundation Trust) for their invaluable assistance in checking the face validity of our hierarchical task analysis. It is our hope that the enthusiasm and extraordinary open-mindedness of our dedicated and deeply competent colleagues demonstrated in making this study possible will lead to safer systems and innovations in pediatric medication safety. This study was funded by the NIHR Imperial Patient Safety Translational Research Centre, with infrastructure support from the NIHR Imperial Biomedical Research Centre. Support was also received from the Resuscitation Council (UK). MDJ was funded by a National Institute for Health Research (NIHR) Transitional Research Fellowship for this research project. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: MDJ was funded by a National Institute for Health Research (NIHR), Transitional Research Fellowship for this research project (Grant number TRF-2017-10-006). NA received funding from the Resuscitation Council (UK), which partially funded elements of the simulations and data extraction, with the majority of the funding received from the NIHR Imperial Patient Safety Translational Research Centre. Infrastructure support was provided by the NIHR Imperial Biomedical Research Centre (BRC). BDF is also supported by the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London in partnership with Public Health England (PHE). The views expressed are those of the authors and not necessarily those of the NHS, PHE, the NIHR, or the Department of Health and Social Care.
| Funders | Funder number |
|---|---|
| National Institute for Health Research | TRF-2017-10-006 |
Keywords
- administration, intravenous
- Guidelines as Topic
- medication errors
- nurses
- patient safety
- Practice Guidelines as Topic
ASJC Scopus subject areas
- Pharmacy
- Pediatrics
- Emergency
- Fundamentals and skills
- Health Informatics
- Drug guides
- Pediatrics, Perinatology, and Child Health
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Dive into the research topics of 'Use of Pediatric Injectable Medicines Guidelines and Associated Medication Administration Errors: a human reliability analysis'. Together they form a unique fingerprint.Projects
- 1 Finished
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Can Systematic User Testing of the National NHS Injectable Medicines Guide Improve Patient Safety
Jones, M. (PI)
National Institute for Health Research
1/01/18 → 31/12/19
Project: Central government, health and local authorities
Datasets
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Dataset for "Use of paediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis"
Jones, M. (Creator), Clarke, J. (Creator), Feather, C. (Creator), Franklin, B. D. (Creator), Sinha, R. (Creator), Maconochie, I. (Creator), Darzi, A. (Creator) & Appelbaum, N. (Creator), University of Bath, 24 Feb 2021
DOI: 10.15125/BATH-00906
Dataset