User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in-situ simulation study

Background: User-testing and subsequent modification of clinical guidelines increases health professionals’ information retrieval and comprehension. No study has investigated whether this results in safer care.

Objective: To compare the frequency of medication errors when administering an intravenous medicine using the current NHS Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing.

Method: Single-blind, randomised parallel group in-situ simulation. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing. Direct observation was used to time the simulation and identify errors. Participant confidence was measured using a validated instrument. The primary outcome was the percentage of simulations with at least one moderate-severe IMG-related error, with error severity classified by an expert panel.

Results: In total, 133 participants were randomised to current guidelines and 140 to user-tested guidelines. Fewer moderate-severe IMG-related errors occurred with the user-tested guidelines (n=68, 49%) compared with current guidelines (n=79, 59%), but this difference was not statistically significant (risk ratio: 0.82; 95% confidence interval: 0.66-1.02). Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines (n=67, 48%) compared with current guidelines (n=26, 20%) (risk ratio: 2.46; 95% confidence interval: 1.68-3.60). Median simulation completion time was 1.6 minutes (95% confidence interval 0.2-3.0) less with the user-tested guidelines. Participants who used user-tested guidelines reported greater confidence.

Conclusion: User-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, whilst increasing staff confidence.