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ADC-FNN Online First, published on April 5, 2012 as 10.1136/fetalneonatal-2011-300989 Original article

The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care Indra Chedoe,1 Harry Molendijk,2 Wobbe Hospes,1 Edwin R Van den Heuvel,3 Katja Taxis4 1Department

of Clinical Pharmacy, Isala Clinics, Zwolle, The Netherlands 2Princess Amalia Department of Pediatrics, Isala Clinics, Zwolle, The Netherlands 3Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands 4 Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands Correspondence to Katja Taxis, Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Ant Deusinglaan 1, 9713AV Groningen, The Netherlands; [email protected] Received 6 September 2011 Accepted 10 February 2012

ABSTRACT Objective To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU). Design Prospective study with a preintervention and postintervention measurement using direct observation. Setting NICU in a tertiary hospital in the Netherlands. Intervention A multifaceted educational intervention including teaching and self-study. Main outcome measures The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts. Results The incidence of errors decreased from 49% (43–54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25–36%). Preintervention, 0.3% (0–2%) medications contained severe errors, 26% (21–31%) moderate and 23% (18–28%) minor errors; postintervention, none 0% (0–2%) was severe, 23% (18–28%) moderate and 8% (5–12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29–0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)). Conclusions The multifaceted educational intervention seemed to have contributed to a signifi cant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.

INTRODUCTION Pharmacotherapy in the neonatal intensive care unit (NICU) is complex. There is a lack of evidence for the use of a lot of medications in neonates. Dosing has to be individualised based on age, gestational age, weight with or without body surface area. Changes in weight and length, maturation of the enzyme system and renal function require frequent adaption of medication dosages and administration intervals. Furthermore, there is only a limited range of licensed medication available in appropriate dosage forms. Consequently, the process of prescribing, dispensing, preparation and administration of medicines to neonates involves frequent calculations and dilutions of medicines presenting a large number of opportunities for error. What is more, small errors may have serious consequences in this very vulnerable patient group.1–4

What is already known on this topic ▶



Medication preparation and administration errors occur frequently in adult intensive care units and possibly also in neonatal intensive care units. Lack of knowledge of practical procedures and deviations from guidelines were frequent causes of medication preparation and administration errors.

What this study adds ▶



About one in four administered doses was associated with a potentially clinically relevant medication preparation or administration error in neonatal intensive care. A multifaceted educational intervention seemed to contribute in reducing the overall frequency of errors, but other measures are needed to improve medication safety further.

The incidence and nature of medication errors in the NICU have been reviewed.1 A US-based study4 found an overall rate of 6% medication errors using a combination of chart review and voluntary reporting for data collection. But so far, few studies investigated in depth the process of drug preparation and administration in the neonatal intensive care setting using the ‘gold standard’ of direct observation. 5 Two studies using observation methods, one from the USA and one from Malaysia, showed error rates of 20%6 and 31%, 7 respectively. Another observation-based study on paediatric patients from the UK reported medication administration error rates of around 15% for the two NICUs.8 The majority of other studies1 9 reported much lower error rates using different types of incident-reporting methods. But incident reporting is known for under-reporting.10 Related studies on administration errors in adult intensive care units11 and intravenous medication errors12 showed that preparation and administration of medication is one of the most risky steps in the whole medication management process. Lack of knowledge of practical procedures, deviations from guidelines (violations) and nurses’ experience were shown to be frequent causes of

Copyright ArticleH,author 2012. Produced by BMJ Publishing Group Ltd (& RCPCH) underF1licence. Chedoe I, Molendijk Hospes W,(or et al.their Arch Disemployer) Child Fetal Neonatal Ed (2012). doi:10.1136/fetalneonatal-2011-300989 of F7

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Original article medication preparation and administration errors.13–16 This would suggest that educational interventions could be useful to improve medication safety, but this has not been studied extensively. In adult intensive care, simulation-based teaching successfully reduced medication administration errors, whereas no error reduction was observed when the same material was presented in a traditional-style lecture.17 In paediatric patients, a combination of written material, lectures and practical teaching sessions was successful in reducing medication administration errors.18 In NICU patients, the study from Malaysia7 investigated the impact of an educational programme consisting of lectures and educational posters on medication administration errors. Errors in correct time of medication administration could be reduced from 31% to 15% and adherence to follow procedures such as correct documentation and labelling medication could be improved. But clinical significance of the errors was not studied. Similar studies from the USA or Europe carried out in the NICU setting seem absent. Therefore, we investigated the effect of a multifaceted educational intervention on the incidence and clinical importance of medication preparation and administration errors in a NICU in a tertiary hospital in the Netherlands.

PATIENTS AND METHODS Setting The study was conducted in a 14-bed NICU in a tertiary hospital in the Netherlands. Patients were admitted from 25 weeks postconceptional age. Medical management of patients was performed by neonatologists, residents and fellows. They rounded each morning on the patients. The majority of decisions were made during this time. Computerised physician order entry was not available in the NICU during the study period. Doctors prescribed the medication in the medical notes and nurses transcribed the orders onto the medication administration records. They prepared the medication using guidelines available on the ward. There was no separate preparation room; medication was prepared on the ward on a dedicated bench. Several commonly used medications were stocked on the ward. The remainder of the medications was dispensed for individual patients daily from the central pharmacy. Other clinical pharmacy services included prescription review (about

Table 1

twice a week) and participation in medical (teaching) rounds (about once a week).

Study design This was a prospective study with a preintervention and postintervention measurement using direct observation.

Intervention The intervention was an educational programme consisting of five theoretical teaching session (1 h each, repeated about four times to reach all nurses), one individual practical teaching session for each nurse lasting about 30 min covering the preparation and administration of all commonly on the ward used medication and a short-guided tour around the pharmacy department. The theoretical programme was repeated three times between March 2006 and May 2008. Teaching included calculation, reconstitution, compatibilities, administration rate and aseptic technique of drug preparation and administration. The content of the programme was based on an analysis of the preintervention data. The programme was developed and implemented by a clinical pharmacist responsible for the NICU in cooperation with a multidisciplinary team including neonatologists and nurses specialised in neonatology and infection control. Teaching aids included a PowerPoint presentation, a video presentation, both also available on the hospital’s intranet as well as a poster with important recommendations for safe preparation and administration which was placed in the preparation area. Furthermore, during the intervention period, all guidelines outlining drug preparation and administration were updated and available on the ward.

Data collection Data for the preintervention period were collected in February 2006 and for the postintervention period in June 2008. To obtain a representative set of medication errors, data were collected for 10 consecutive days in each period for 24 h per day. Four pharmacy students, two per period, used the observation method.19 Before data collection, all four pharmacy students were carefully trained by the experienced clinical pharmacist (IC) about the preparation and administration of all medication

Classification of preparation and administration errors

Preparation errors

Definition

Wrong medication Wrong dose Not dissolved Not mixed Other Administration errors Wrong medication Omission Wrong time

Another medication used than prescribed More than 10% difference from prescription by, for example, withdrawal of wrong volume Medication powder visibly not dissolved Not or not enough mixed after bringing two or more solvents or liquids together or not mixing of suspensions before use Other preparation errors, not mentioned above

Wrong administration rate

Expired shelf-life Incompatibilities/intravenous lines not flushed Other

F2 of F7

Administration of another medication than prescribed Medication not administered More than 75 min difference from prescribed time (wrong time because of lack of venous access or absence of patient were not included) Not according to guidelines. Bolus intravenous injections administered in less than 20 s. Previous research has shown that administration in less than 20 s was considered clinically significant (Taxis et al14) Usually, it is not feasible for small volumes (35 weeks) 4 Weight 1 (500–1000 g) 4 2 (1000–2000 g) 13 3 (>2000 g) 3 Patients total 20 Number of observed nurses 49 Medication characteristics (number of observations) Preparation 1: One step: withdrawal of required amount 122 from already prepared stock solution 2: Multiple step: preparation of stock 51 solution and withdrawal of required amount 3: Multiple step: withdrawal of required amount 39 from stock/ampoule and dilution 4: Multiple step: preparation of stock 7 solution, withdrawal of required amount and dilution 5: One step: withdrawal of required amount from 79 ready-to-use preparation (multiple use) 6: One step: withdrawal from ready-to-use 13 ampoule (single use) Administration Intravenous bolus 111 Infusions 131 Oral, rectal, pulmonal 69

Postintervention

p Value (Pearson’s χ² test)

0.66 14 8 0.09 14 6 2 0.60 7 11 4 22 31