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Prakash V.,University of Toronto | Koczmara C.,Institute for Safe Medication Practices Canada | Trip K.,University of Toronto | Stewart J.,Sunnybrook Health science Center | And 3 more authors.
BMJ Quality and Safety | Year: 2014

Background: Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. Objective: The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. Methods The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. Results: Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. Conclusions: Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required. © 2014, BMJ Publishing Group. All rights reserved.

Koczmara C.,Institute for Safe Medication Practices Canada
Dynamics (Pembroke, Ont.) | Year: 2011

In this column, the authors review Amphotericin B incidents reported Although amphotericin B may be less commonly used today because to ISMP Canada. In particular, we focus on incidents reported to have of alternative antifungal agents available, incident reports suggest resulted in patient harm due to mix-ups between the conventional there continues to be a need to alert practitioners to the different (non-lipid)formulation and lipid formulations of amphotericin B. formulations, and to implement system safety strategies.

Koczmara C.,Institute for Safe Medication Practices Canada
Dynamics (Pembroke, Ont.) | Year: 2011

In this article, the authors highlight an incident that involved a mix-up between the oral anticoagulant medication Pradax (dabigatran etexilate) and the antiplatelet medication Plavix (clopidogrel). Because critical care nurses may admit or care for patients who are receiving (or have received) one of these medications, it is important that they be aware of the potential for confusion between these two drug names throughout the medication-use process.

Orser B.A.,University of Toronto | Hyland S.,Institute for Safe Medication Practices Canada | David U.,Institute for Safe Medication Practices Canada | Sheppard I.,Institute for Safe Medication Practices Canada | Wilson C.R.,Queen's University
Canadian Journal of Anesthesia | Year: 2013

Purpose: This article presents a summary of recent advances, including tools and interventions, that are designed to improve drug safety for patients in critical care settings, particularly those undergoing anesthesia and surgery. Principal findings: Medication error remains a leading cause of adverse events among patients undergoing anesthesia. Misidentification of ampoules, vials, and syringes is a common source of error. Systems are now being engineered to reduce the likelihood of medication misidentification through approaches such as revision of standards for labelling of drug ampoules and vials and the development of bar code systems that allow "double checking" or drug verification in the operating room. Also, efforts are being made to improve medication reconciliation, a process for accurately communicating a patient's medication information during transitions from one healthcare setting to another. Finally, the opportunity exists for anesthesiologists to increase awareness about the rising problem of opioid addiction in patients for whom typical doses are initially prescribed for appropriate indications such as postoperative pain. Conclusions: There is a need to improve drug delivery systems in complex critical care environments, particularly the operating room. Anesthesiologists must continue to play a leading role in promoting drug safety in these environments. © 2012 Canadian Anesthesiologists' Society.

Koczmara C.,Institute for Safe Medication Practices Canada | Wade A.W.,Institute for Safe Medication Practices Canada | Skippen P.,Institute for Safe Medication Practices Canada | Campigotto M.J.,Institute for Safe Medication Practices Canada | And 4 more authors.
Dynamics (Pembroke, Ont.) | Year: 2010

Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors.

PubMed | University of Toronto, Womens College Hospital, Womens College Research Institute, Institute for Safe Medication Practices Canada and Toronto Central Community Care Access Center
Type: Journal Article | Journal: American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists | Year: 2016

The published literature on medication reconciliation (MR) interventions, outcomes, and facilitators in ambulatory care settings is reviewed.A scoping review was conducted to characterize ambulatory care-based MR research in terms of study design, elements of interventions, and outcomes examined. English-language articles on comparative studies of MR programs targeting adults in ambulatory care settings were identified using data sources including MEDLINE, PreMEDLINE, EMBASE, and International Pharmaceutical Abstracts. For each study, steps undertaken in the MR process were extracted. The Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy was used to classify types of interventions; taxonomies for reported outcomes and factors facilitating implementation of MR initiatives were developed by the authors.From among 2062 publications screened, 15 were included in the review. In 13 studies, multiple data sources were used to compile a best possible medication history (BPMH); however, the BPMH was shared with external healthcare providers in only 4 studies and with patients in only 5 studies. Most reported MR interventions were classified into two EPOC domains: professional (predominantly educational outreach visits and patient reminders) and organizational (predominantly provider-oriented interventions). Process outcomes were reported in 12 studies, with correct performance of MR being the most commonly evaluated process outcome, and 9 studies identified factors that facilitated MR implementation.Few studies have examined clinical outcomes of MR in ambulatory care settings, with the majority of pertinent reports focusing instead on process outcomes. Facilitators of successful MR interventions have been identified at the patient, staff, and clinic setting levels.

Fields A.,Cancer Care | Fields A.,University of Alberta | Cheng R.,Institute for Safe Medication Practices Canada | Easty A.,University of Toronto
Journal of Oncology Pharmacy Practice | Year: 2014

Background: This exploratory study was launched following a critical chemotherapy medication incident to thoroughly and proactively examine the current processes for ordering, preparing, labeling, verifying, administering, and documenting ambulatory intravenous chemotherapy in Canada, and to identify factors that may contribute to preventable adverse drug events. Methods: Field observations in six Canadian cancer centers to identify end-to-end processes in clinic, pharmacy, and treatment areas; analysis of processes to identify risks. Results: Three types of previously locally unrecognized potential chemotherapy preparation errors in Canadian oncology pharmacies were uncovered, all of which are undetectable if they occur. Although the frequency of these errors is unknown, their impact is potentially catastrophic. Interpretation: Dispensing errors in high-risk intravenous preparation have been studied in the past, but it is unlikely that these studies have detected these errors because of the inherent limitations of the detection methods used. Research on preparation errors using more sensitive methods is therefore urgently needed to establish the extent to which pharmacy preparation practices may be error-prone, and to allow reliable evaluation of the impact of mitigation strategies. Widespread practice changes in Canadian oncology pharmacies are necessary, and are currently underway. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

PubMed | University of Toronto and Institute for Safe Medication Practices Canada
Type: Journal Article | Journal: Ontario health technology assessment series | Year: 2015

Research conducted in earlier phases of this study prospectively identified a number of concerns related to the safe administration of multiple intravenous (IV) infusions in Ontario hospitals.To investigate the potential prevalence of practices or policies that may contribute to the patient safety risks identified in Phase 1b of this study.Sixty-four survey responses were analyzed from clinical units where multiple IV infusions may occur (e.g., adult intensive care units). Survey questions were organized according to the topics identified in Phase 1b as potential contributors to patient harm (e.g., labelling practices, patient transfer practices, secondary infusion policies).Survey results indicated suboptimal practices and policies in some clinical units, and variability in a number of infusion practices. Key areas of concern included the following: use of primary IV tubing without back check valves when administering secondary infusions, administration of secondary infusions with/as high-alert continuous IV medications, potential confusion about how IV tubing should be labelled to reflect replacement date and time, interruptions to IV therapy due to IV pump and/or tubing changes when patients are transferred between clinical units, coadministration of continuous or intermittent infusions on central venous pressure monitoring ports, variability in respondents awareness of the infusion pumps bolus capabilities.Due to the limited sample size, survey responses may not be representative of infusion practices across Ontario. Answers to some questions indicated that the intent of the questions might have been misunderstood. Due to a design error, 1 question about bolus administration methods was not shown to as many respondents as appropriate.The Ontario survey revealed variability in IV infusion practice across the province and potential opportunities to improve safety.

PubMed | University of Toronto and Institute for Safe Medication Practices Canada
Type: Journal Article | Journal: Ontario health technology assessment series | Year: 2015

Administering multiple intravenous (IV) infusions to a single patient via infusion pump occurs routinely in health care, but there has been little empirical research examining the risks associated with this practice or ways to mitigate those risks.To identify the risks associated with multiple IV infusions and assess the impact of interventions on nurses ability to safely administer them.Forty nurses completed infusion-related tasks in a simulated adult intensive care unit, with and without interventions (i.e., repeated-measures design).Errors were observed in completing common tasks associated with the administration of multiple IV infusions, including the following (all values from baseline, which was current practice): setting up and programming multiple primary continuous IV infusions (e.g., 11.7% programming errors)identifying IV infusions (e.g., 7.7% line-tracing errors)managing dead volume (e.g., 96.0% flush rate errors following IV syringe dose administration)setting up a secondary intermittent IV infusion (e.g., 11.3% secondary clamp errors)administering an IV pump bolus (e.g., 11.5% programming errors)Of 10 interventions tested, 6 (1 practice, 3 technology, and 2 educational) significantly decreased or even eliminated errors compared to baseline.The simulation of an adult intensive care unit at 1 hospital limited the ability to generalize results. The study results were representative of nurses who received training in the interventions but had little experience using them. The longitudinal effects of the interventions were not studied.Administering and managing multiple IV infusions is a complex and risk-prone activity. However, when a patient requires multiple IV infusions, targeted interventions can reduce identified risks. A combination of standardized practice, technology improvements, and targeted education is required.

White R.E.,University of Toronto | Trbovich P.L.,University of Toronto | Easty A.C.,University of Toronto | Hyland S.,Institute for Safe Medication Practices Canada
Quality and Safety in Health Care | Year: 2010

Objective: To determine what components of a checklist contribute to effective detection of medication errors at the bedside. Design: High-fidelity simulation study of outpatient chemotherapy administration. Setting Usability laboratory. Participants Nurses from an outpatient chemotherapy unit, who used two different checklists to identify four categories of medication administration errors. Main outcome measures: Rates of specified types of errors related to medication administration. Results As few as 0% and as many as 90% of each type of error were detected. Error detection varied as a function of error type and checklist used. Specific stepby-step instructions were more effective than abstract general reminders in helping nurses to detect errors. Adding a specific instruction to check the patient's identification improved error detection in this category by 65 percentage points. Matching the sequence of items on the checklist with nurses' workflow had a positive impact on the ease of use and efficiency of the checklist. Conclusions: Checklists designed with explicit step-bystep instructions are useful for detecting specific errors when a care provider is required to perform a long series of mechanistic tasks under a high cognitive load. Further research is needed to determine how best to assist clinicians in switching between mechanistic tasks and abstract clinical problem solving.

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