Identify gaps between local and international measures to avoid administration error on 1-year review in United Christian Hospital, Hong Kong
Author(s)
Lap Fung Tsang*
ABSTRACT
Many medication errors could be avoided if administration was more closely linked with structured monitoring. The contributory factors to administration errors occurred in one recent year were reviewed and identified contributory factors to errors as six domains of administration principles according to the report from the Quality and Safety website. The current measures including guidelines, policy, and practices to prevent the administration errors identified in the previous step were searched from the United Christian Hospital (UCH) homepage. Meanwhile, the international measures suggested in literature were identified to address the administration errors identified. 41 cases were identified as medication errors related to administration error events, with total twenty contributory factors identified according to the incident report which identified five contributory factors as common causes. Measures to prevent interruption of medication round and measures to improve individual knowledge and skills, and personal responsebility were suggested to fill the gaps. The medication administration errors should be avoided through both education reinforcing programme and preventive interventions of distraction or interruption to the procedure after comparing the existing measures to the suggested measures from literature. This study was so important to improve the current measures to prevent medication administration errors.
Many medication errors could be avoided if administration was more closely linked with structured monitoring. The contributory factors to administration errors occurred in one recent year were reviewed and identified contributory factors to errors as six domains of administration principles according to the report from the Quality and Safety website. The current measures including guidelines, policy, and practices to prevent the administration errors identified in the previous step were searched from the United Christian Hospital (UCH) homepage. Meanwhile, the international measures suggested in literature were identified to address the administration errors identified. 41 cases were identified as medication errors related to administration error events, with total twenty contributory factors identified according to the incident report which identified five contributory factors as common causes. Measures to prevent interruption of medication round and measures to improve individual knowledge and skills, and personal responsebility were suggested to fill the gaps. The medication administration errors should be avoided through both education reinforcing programme and preventive interventions of distraction or interruption to the procedure after comparing the existing measures to the suggested measures from literature. This study was so important to improve the current measures to prevent medication administration errors.
Cite this paper
Tsang, L. (2013) Identify gaps between local and international measures to avoid administration error on 1-year review in United Christian Hospital, Hong Kong. Open Journal of Nursing, 3, 13-20. doi: 10.4236/ojn.2013.38A003.
Tsang, L. (2013) Identify gaps between local and international measures to avoid administration error on 1-year review in United Christian Hospital, Hong Kong. Open Journal of Nursing, 3, 13-20. doi: 10.4236/ojn.2013.38A003.
References
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http://dx.doi.org/10.1111/j.1365-2834.2012.01329.x [13] Yoder, M. and Schadewald, D. (2012) The Effect of a safe zone on nurse distractions, interruptions,
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http://dx.doi.org/10.1177/0193945912453687 [14] Miranda, S. (2011) Back to basics, medication safety at the bedside a nursing administrator’s
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http://dx.doi.org/10.1046/j.1365-2648.2003.02922.x [18] Bullock, S. and Manias, E. (2002) The educational preparation of undergraduate nursing students in
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errors. Journal of Emergency Nursing, 37, 141-147.
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in Australian hospitals: A literature review. Contemporary Nurse, 31, 176-189.
http://dx.doi.org/10.5172/conu.673.31.2.176 [21] Alsulami, Z., Conroy, S. and Choonara, I. (2012) Double checking the administration of medicines:
what is the evidence? A systematic review. Archives of Disease in Childhood, 97, 833-837.
http://dx.doi.org/10.1136/archdischild-2011-301093 [22] David, U. (2003) Medication safety alerts. JCPH, 56, 167-169.
[1] Reason, J. (1990) Human error. Cambridge University Press, Cambridge.
http://dx.doi.org/10.1017/CBO9781139062367 [2] Gibson, T. (2001) Nurses and medication error: A discursive reading of the literature. Nursing Inquiry, 8,
108-117. http://dx.doi.org/10.1046/j.1440-1800.2001.00098.x [3] HAHO Medication Safety Committee (2012) HA Guidelines on Medication Management—Prescribing,
Dispensing
and Administration (Administration Guidelines).
http://uchweb5/Pharm/Guidelines/HAHO%20and%20Medication%20Safety
%20Committee/HA%20Guidelines%
20on%20Medication%20Management-Prescribing,Dispensing%20and%20Administration.pdf [4] Self-Assessment Guide for Medication Safety (2005) Hospital Authority.
http://uchweb5/Pharm/Guidelines/HAHO%20and%20Medication%20Safety%20
Committee/Self%20Assessment%20Guide%20for%20Medication%20Safety.pdf [5] Drug Allergy Reference Card (2011) Kowloon East Cluster.
http://uch.home/pharm/usefulinfo/AllergyRefCard.pdf [6] HAHO Medication Safety Committee (2008) Safety Solutions on Look-Alike Sound-Alike Medications.
http://uchweb5/Pharm/Guidelines/HAHO%20and%20Medication%20Safety%20Committee/Safety%
20Solutions%20on%20Look-alike%20Sound-alike%20Medications.pdf [7] Joanna Briggs Institute (2010) Evidence-based information sheets for health professionals. Best
Practice, 14, 1-4. [8] Tang, F.I., Sheu, S.J. and Yu, S. (2007) Nurses relate the contributing factors involved in medication
errors. Journal of Clinical Nursing, 16, 447-457.
http://dx.doi.org/10.1111/j.1365-2702.2005.01540.x [9] Biron, A.D., Lavoie-Tremblay, M. and Loiselle, C.G. (2009) Characteristics of work interruptions
during medication administration. Journal of Nursing Scholarship, 41, 330-336.
http://dx.doi.org/10.1111/j.1547-5069.2009.01300.x [10] Westbrook, J.I., Woods, A. and Rob, M.I. (2010) Association of interruptions with an increased risk
and severity of medication administration errors. Archives of Internal Medicine, 170, 683-690.
http://dx.doi.org/10.1001/archinternmed.2010.65 [11] Kliger, J., Blegen, M.A. and Gootee, D. (2009) Empowering frontline nurses: A structured intervention
enables nurses to improve medication administration accuracy. The Joint Commission Journal on Quality
and Patient Safety, 35, 604-612. [12] Tomietto, M., Sartor, A. and Mazzozoli, E. (2012) Paradoxical effects of a hospital-based,
multi-intervention programme aimed at reducing medication round interruptions. Journal of Nursing
Management, 20, 335-343.
http://dx.doi.org/10.1111/j.1365-2834.2012.01329.x [13] Yoder, M. and Schadewald, D. (2012) The Effect of a safe zone on nurse distractions, interruptions,
and medication administration errors. Western Journal of Nursing Research, 34, 1068-1069.
http://dx.doi.org/10.1177/0193945912453687 [14] Miranda, S. (2011) Back to basics, medication safety at the bedside a nursing administrator’s
perspective. Penn Nursing, 66, 6-10. [15] Aiken, L.H., Clarke, S.P., Cheung, R.B., et al. (2003) Educational levels of hospital nurses
and surgical patient mortality. JAMA, 290, 1617-1623.
http://dx.doi.org/10.1001/jama.290.12.1617 [16] Kendall-Raynor, P. (2010) Training assessment will address medication and care concerns.
Nursing Standard, 24, 7. [17] King, R. (2004) Nurses’ perceptions of their pharmacological educational needs. Journal of Advanced
Nursing, 45, 392-400.
http://dx.doi.org/10.1046/j.1365-2648.2003.02922.x [18] Bullock, S. and Manias, E. (2002) The educational preparation of undergraduate nursing students in
pharmacology: A survey of lecturers’ perceptions and experiences. Journal of Advanced Nursing, 40, 7-16.
http://dx.doi.org/10.1046/j.1365-2648.2002.02335.x [19] Blank, F.S.J., Tobin, J. and Macomber, S. (2011) A “Back to Basics” approach to reduce ED medication
errors. Journal of Emergency Nursing, 37, 141-147.
http://dx.doi.org/10.1016/j.jen.2009.11.026 [20] Evans, J. (2009) Prevalence, risk factors, consequences and strategies for reducing medication errors
in Australian hospitals: A literature review. Contemporary Nurse, 31, 176-189.
http://dx.doi.org/10.5172/conu.673.31.2.176 [21] Alsulami, Z., Conroy, S. and Choonara, I. (2012) Double checking the administration of medicines:
what is the evidence? A systematic review. Archives of Disease in Childhood, 97, 833-837.
http://dx.doi.org/10.1136/archdischild-2011-301093 [22] David, U. (2003) Medication safety alerts. JCPH, 56, 167-169.