The Impact of Dedicated Medication Nurses Upon the Rate of Medication Administration Errors: A Randomized, Controlled Trial
Cedars-Sinai Health System in Los Angeles, CA, and The Ohio State University Hospital in Columbus, OH
Investigators: Nancy Lynn Greengold, MD, MBA (PI), Rita Shane, PharmD, Linda Burnes-Bolton, DrPH, RN, and Philip Schneider, RPh, MS
The goal of this study was to determine whether the provision of a dedicated, specially trained medication nurse will reduce the number of medication administration errors in the hospital setting. A prospective, randomized study was performed by a multi-disciplinary team of physicians, pharmacists, and nurses of the Cedars-Sinai Health System in Los Angeles, CA, and The Ohio State University Hospital in Columbus, OH.
At both institutions combined, medication nurses had a total error rate of 15.7% compared with 14.9% for general nurses (P<.84). Comparing institutions, the total error rate for medication nurses at Hospital B was significantly higher, 19.7%, than it was at Hospital A, 11.2% (P<.04). At Hospital A, there was a significantly lower error rate for medication nurses than for general nurses in the surgical units, (P<.01), yet no significant differences in total errors comparing nurse types in the medical units.
The medication nurses at both study institutions combined had an 11.2% medication error rate, compared with the general nurses who had a 6.9% medication error rate, a difference that was not statistically significant, using the sign test. Analyses of rates for unit types were essentially the same as for total errors except that the higher rates for medication nurses at Hospital B were significant at P<.01. Comparisons between sites showed the same pattern as for total errors.
The most common medication error types were: administration technique (6.4%), dose preparation (1.4%), omission of drug (0.9%), and incorrect dosage given (0.8%). Dosage form errors (.1%), route errors (.6%), IV rate errors (.2%), and unauthorized drug errors (.1%) were all uncommon.
The medication nurses at both study institutions combined had a 4.9% process variation error rate, compared with the general nurses who had an 8.4% process variation error rate, a difference that was not statistically significant, using the sign test. The overall pattern of results differed somewhat from that seen for total errors and medication errors. For the Hospital A surgical units, the medication nurse had a lower rate of process variation errors than the general nurses (P<.10), which did not reach statistical significance. At Hospital B, in the mixed medical/surgical units, the medication nurses had a significantly lower rate of process variation errors than the general nurses (P<.01). There were no statistically significant differences found when comparing Hospital A and Hospital B medication nurse process variation error rates (4.4% and 5.2%, respectively) and when comparing the general nurse process variation error rates (7.4% and 9.2%, respectively). The analysis of process variation errors is limited by the relatively low number of these errors recorded by the observers and the variation in recording these errors from one observer to another. The most common process variation errors were: failure to check patient wristband identification (4.0%) and unlabeled medication (1.8%).
This randomized trial suggests that use of a dedicated medication nurse does not reduce medication error rates. However, subgroup analysis indicates that a medication nurse might be useful in some settings. The differences in findings at the 2 institutions and their differences in medication use processes reinforce the concept that medical errors are usually related to systems design issues. At one institution, nurses had to obtain most of the medications from automated dispensing machines, whereas at another they obtained them from patient-specific cassettes.
Two abstracts have been submitted for publications in Archives of Internal Medicine thus far.
This study attempts to develop an understanding of the nature and mechanisms of errors in Emergency Departments (ED). Building on the scope of previous research that addressed the type and scope of errors in ED, this research team will answer "why" and "how" those errors occur. The information gained through this process will improve basic understanding of how errors occur in the ED. An immediately applicable outcome will be an extension of existing frameworks for analysis of critical events. This study is conducted at the University of Florida and the University of Michigan.The Surgeons Checklist
University of Virginia Health System Department of Surgery
Investigators: R. Scott Jones, MD, FACS (PI), J. Forrest Calland, MD, Reid B. Adams, MD, Don Detmer, MD, Viktor Bovbjerg, PhD, Stephanie Guerlain, PhD, and Owen Seely
Based on the successful utility of checklists developed in aviation and anesthesia practices, the investigators of this study developed and evaluated an intra-operative safety checklist to reduce the frequency of procedural variance, adverse events, and errors in the operating room. A protocol for performance of laparoscopic cholecystectomy (the surgical removal of the gall bladder with the aid of a tiny camera) was developed through review of current surgical practices and focus groups conducted among expert clinicians and tested by comparing videotaped cases of two randomized groups of physicians. The study was conducted at the University of Virginia Health System Department of Surgery.
Checklist use led to a significant improvement in the frequency with which surgical teams utilized a pre-procedure briefing (p=0.001) and the likelihood that intra-operative coordination of flow was rated as having "met" criteria (on a scale of poor, below, meets) (p=0.029), but decreased the team members' satisfaction with communication (p=.036) as compared to the control group. Review of 299 post-case questionnaires revealed group situational awareness was not significantly better among checklist participants (p=0.055). Furthermore, there was not a significant difference between intervention or control group surgeons technical proficiency (p=0.193).
A procedural checklist improved briefing skills and intra-operative coordination of flow but decreased teams' satisfaction with communication. The checklist failed to improve situational awareness and technical proficiency. Team communication may be enhanced with supplemental training or debriefing of the operative team.
In the photo (from left to right): UVA Surgical Technology and Safety Laboratory Investigators
Standing: R. Scott Jones, MD, Reid Adams, MD, and Don Brown, Ph.D. Seated: J. Forrest Calland, MD, and Stephanie Guerlain, Ph.D.
Publications
Calland JF, Guerlain S, Adams RB, Tribble CG, Foley E, Chekan E. A Systems Approach to Surgical Safety. Surgical Endoscopy - In print.
Calland JF, Adams RB, Benjamin DK Jr, OConnor MJ, Chandrasekhara V, Guerlain S, Jones RS. Thirty-Day Postoperative Death Rate at an Academic Medical Center. Annals of Surgery 2002; 235 (5):690-698.
Calland JF, Tanaka K, Foley E, Bovbjerg VE, Markey DW, Blome S, Minasi JS, Hanks JB, Moore MM, Young JS, Jones RS, Schirmer BD, Adams RB. Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Annals of Surgery 2001; 233 (5):704-15
Calland JF, Adams RB, Deprince K, Foley EF, Powell SM. Genetic syndromes and genetic tests in colorectal cancer. Seminars in Gastrointestinal Disease. 2000; 11(4):207-218.
Presentations
Calland JF, Guerlain S, Turrentine B (2002) Three years of investigation in peri-operative patient safety: what have we learned? Virginia Chapter of the American Society for Healthcare Risk Management. Roanoke, Virginia.
Calland JF, Guerlain S, Adams RB, & Jones RS. (2002) Three years of investigation in peri-operative patient safety: what have we learned? Virginians Improving Patient Care and Safety Conference, Safe Health Care: Collaborating on Best Practices. Richmond, Virginia.
Calland, JF, Guerlain, S, & Adams, RB. (2002) The Surgeon's Checklist: Measuring Situation Awareness During Laparoscopic Surgery. NPSF Annenberg IV Conference, Patient Safety: Let's Get Practical -- Plenary Sessions. Indianapolis, IN.
Calland, J.F., Guerlain, S. Jones, S.A., Bovbjerg, V.E. & Adams, R.B. (2002) Cognitive Engineering in Surgery: Studying Whole-Team Performance in the Operating Room and Measuring Cognitive Skills in Laparoscopic Surgeons. American College of Surgeons.
Guerlain, S., Shin, T., Guo, T., & Calland, J.F. (2002) Team performance data capture and analysis system. Proceedings of the 46th Annual Meeting of the Human Factors and Ergonomics Society.
Guerlain, S., Shin, T., Guo, T., Adams, R., & Calland, J.F. (2002) Multimedia data collection for analysis of team performance. Proceedings of the 46th Annual Meeting of the Human Factors and Ergonomics Society.
Chekan E.G.; Mitchell B.A., Poole G.R., Luniewski, M., Green, B., Mersch, T., Calland, J.F., and Guerlain, S. (2002). A CD-Rom-based laparoscopic surgery video training simulator. Conference of the Virginia Chapter of the American College of Surgeons.
Calland, J.F., Guerlain, S. Guo, H. Krishnamurthi, S. Scott Jones R.S., and Adams, R. (2002). Comparing Situation Awareness Across Team Members. Proceedings of the IEEE Conference on Systems, Man, and Cybernetics.
Calland, JF, Jones, RS., Adams, RB., Guerlain, S., Benjamin, DE., & Jones, RS. (2001) Thirty-day Mortality: a Study of 7,379 Operations. The Southern Surgical Association, The Homestead, Hot Springs, VA.
Calland JF.( 2001) Error Reduction During Laparoscopic Cholecystectomy. The American College of Surgeons Clinical Congress - Plenary Sessions. New Orleans, La.
Calland JF. (2001) Team Communication During Operative Procedures. NPSF Annenberg III Conference, Let's Talk: Communicating Risk and Safety in Healthcare -- Plenary Sessions. St. Paul, MN.
Guerlain, SA, Calland, J.F., Thompson, M., and LeBeau, K. (2001). The Effect of a Standardized Data Collection Form on the Examination and Diagnosis of Patients with Abdominal Pain. Proceedings of the 45th Annual Meeting of the Human Factors and Ergonomics Society. pp. 1284-1288.
Posters
Calland JF, Benjamin DE, Seward C, Simpson D, Hanks JB, Simpson V, & Adams, RB. Standardization of Family History Data Collection by Surgeons in an Academic Medical Center. The Association of Academic Surgeons -- Poster Session, 2001. Milwaukee, WI.
Calland JF, Seward C, Simpson D, Hanks JB, Simpson V, Adams RB. Adequacy of Family History Data Collection by Surgeons in an Academic Medical Center. The American College of Surgeons Clinical Congress -- Poster Session, 2001. New Orleans, LA.
Calland, JF, Guerlain, S, Benjamin, D, Seely, O, Adams, RB. Opinions of Virginia Surgeons and Primary Care Physicians Toward Issues of Patient Safety. Southeastern Surgical Congress -- Scientific Poster Session, 2001. New Orleans, LA.
Calland, JF, Foley, E, Guerlain, S, Adams, RB. A Systems Approach to Surgical Safety: Procedural Checklists and Automated Data Collection. American College of Surgeons -- Scientific Poster Session, 2000. Chicago, IL.
Calland, JF and Guerlain, S. Patient Safety Initiatives at UVA. University of Maryland -- Department of Anesthesiology Research Lab Meeting. 2000. Baltimore, MD.