Background This paper presents Part 1 of a two-part literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care to update a previous national report on medication safety conducted in 2002. This first part of the review examines the extent and causes of medication incidents and adverse drug events in acute care. Methods A literature search was conducted to identify Australian studies, published from 2002 to 2008, on the extent and causes of medication incidents and adverse drug events in acute care. Results Studies published since 2002 continue to suggest approximately 2%-3% of Australian hospital admissions are medication-related. Results of incident reporting from hospitals show that incidents associated with medication remain the second most common type of incident after falls. Omission or overdose of medication is the most frequent type of medication incident reported. Studies conducted on prescribing of renally excreted medications suggest that there are high rates of prescribing errors in patients requiring monitoring and medication dose adjustment. Research published since 2002 provides a much stronger Australian research base about the factors contributing to medication errors. Team, task, environmental, individual and patient factors have all been found to contribute to error. Conclusions Medication-related hospital admissions remain a significant problem in the Australian healthcare system. It can be estimated that 190,000 medication-related hospital admissions occur per year in Australia, with estimated costs of $660 million. Medication incidents remain the second most common type of incident reported in Australian hospitals. A number of different systems factors contribute to the occurrence of medication errors in the Australian setting.

Medication safety in acute care in Australia: where are we now? (part 1)

Background: The General Level Framework (GLF) is a tool for evaluating pharmacists' performance, providing tailored feedback and training, and guiding professional development. Aim: To ascertain the changes in pharmacists' workplace performance over time using the GLF and to describe pharmacists' views on the baseline evaluation process. Method: The UK GLF was mapped against Australian pharmacy competency standards and practice guidelines. 61 of the 92 competencies from the Queensland Health version of the GLF representing core professional activities of Australian pharmacists were analysed. Trained evaluators used the adapted GLF to observe pharmacists from 18 Queensland public hospitals in their workplace (baseline and repeat) and rate the frequency with which competencies were completed to a defined standard. The evaluators then provided pharmacists with tailored feedback, encouraged self-problem solving, and identified and addressed their training needs. Pharmacists' views of the baseline evaluation process was assessed using a 7-point rating scale. Results: 66 pharmacists from 18 Queensland hospitals underwent the evaluation. At baseline, pharmacists had a median of 3 (1 to 10) years hospital experience. A median of 14 (5 to 22) months lapsed between baseline and repeat observations. Of the 61 competencies analysed, 35 (57%) competencies showed a significant improvement from baseline to repeat observations (p ≤ 0.05). Competencies that improved significantly from baseline included: aspects of medication history taking; medication management; identification, documentation and resolution of drug-related problems; appraisal of therapeutic options; and communication with doctors and nurses. For 9 (15%) competencies, pharmacists were already performing at the maximum level (median score 4) at baseline and no change was recorded between observations. No competency demonstrated a decrease in performance between observations. When the mean scores with 95% confidence intervals for the clusters of competencies were compared over time all the mean scores except for discharge facilitation and medicines information/patient education/liaison showed a significant improvement. 52 pharmacists provided feedback on the baseline evaluation process and the majority found it a useful professional development tool. They considered the evaluation process fair and constructive but taxing. Conclusion: The GLF tool assisted with the identification of pharmacists' training needs, which are integral to their professional development.

Improvement in pharmacist's performance facilitated by an adapted competency-based general level framework

Background
Reporting of adverse clinical events is thought to be an effective method of improving the safety of healthcare. Underreporting of these adverse events is often said to occur with consequence of missing of opportunities to learn from these incidents. A clinical incident can be defined as any occurrence which is not consistent with the routine care of the patient or the routine operation of the institution.

Objectives
To assess the effects of interventions designed to increase clinical incident reporting in healthcare settings.

Search methods
We searched the the following databases: Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Social Science Citation Index and Science Citation Index (Web of Knowledge), Healthstar (OVID), INSPEC, DHSS-DATA, SIGLE, ISI Conference Proceedings, Web of Science Conference Proceedings Citation Index (Science), Database of Abstracts of Reviews of Effectiveness (DARE).

Selection criteria
Randomised controlled trials (RCT), controlled before-after studies (CBA) and interrupted time series (ITS) of interventions designed to increase clinical incident reporting in healthcare.

Data collection and analysis
At least two review authors assessed the eligibility of potentially relevant studies, extracted the data and assessed the quality of included studies.

Main results
Four studies (one CBA and three ITS studies) met our inclusion criteria and were included in the review. The CBA study showed a significant improvement in incident reporting rates after the introduction of the new reporting system. Just one of the ITS studies showed a statistically significant improved effectiveness of the new reporting system from nine months. The other two studies reported no statistically significant improvements.

Authors' conclusions
Because of the limitations of the studies it is not possible to draw conclusions for clinical practice. Anyone introducing a system into practice should give careful consideration to conducting an evaluation using a robust design.

Interventions to increase clinical incident reporting in health care

Aims and objectives
The Aims of this study were to explore the effects of nurses’ attitudes and intentions regarding medication administration error reporting on actual reporting behaviours.

Background
Underreporting of medication errors is still a common occurrence. Whether attitude and intention towards medication administration error reporting connect to actual reporting behaviours remain unclear.

Design
This study used a cross-sectional design with self-administered questionnaires, and the theory of planned behaviour was used as the framework for this study.

Methods
A total of 596 staff nurses who worked in general wards and intensive care units in a hospital were invited to participate in this study. The researchers used the instruments measuring nurses’ attitude, nurse managers’ and co-workers’ attitude, report control, and nurses’ intention to predict nurses’ actual reporting behaviours. Data were collected from September–November 2013. Path analyses were used to examine the hypothesized model.

Results
Of the 596 nurses invited to participate, 548 (92%) completed and returned a valid questionnaire. The findings indicated that nurse managers’ and co-workers’ attitudes are predictors for nurses’ attitudes towards medication administration error reporting. Nurses’ attitudes also influenced their intention to report medication administration errors; however, no connection was found between intention and actual reporting behaviour.

Conclusions
The findings reflected links among colleague perspectives, nurses’ attitudes, and intention to report medication administration errors. The researchers suggest that hospitals should increase nurses’ awareness and recognition of error occurrence.

Relevance to clinical practice
Regardless of nurse managers’ and co-workers’ attitudes towards medication administration error reporting, nurses are likely to report medication administration errors if they detect them. Management of medication administration errors should focus on increasing nurses’ awareness and recognition of error occurrence.

Nurses' attitude and intention of medication administration error reporting

Nurses’ experiences in voluntary error reporting: An integrative literature review

Purpose The temperature profiles of antibiotic-containing elastomeric infusion devices used by ambulatory care patients under various environmental conditions were evaluated. Methods A prospective, descriptive survey of temperature exposure was conducted in 4 publically funded hospitals. Over a 12-month period, electronic temperature-recording devices were attached to the antibiotic infusion devices (infusers) of prospectively randomized hospital-in-the-home (HITH) participants. Temperatures were recorded immediately after infuser connection and every 5 minutes thereafter for 24 hours. A structured data collection form was used to collect information on basic clinical and demographic characteristics and aspects of daily living (i.e., how and where the infuser was carried during the day, times the participant went to and arose from bed, location of the infuser while sleeping, and dates and times the infuser was connected and disconnected). Results A total of 115 patients successfully completed the study (17–91 years old, 55% males). A total of 31,298 temperature readings were collected. The storage location of the infuser did not influence daytime readings. However, the overnight storage location did have a significant impact on the temperatures recorded overnight. The mean temperatures of infusers stored on the bed or on the body overnight were significantly higher than those for infusers stored away from the bed. Diurnal and seasonal influences were also detected. Significantly warmer temperatures were recorded in afternoons and evenings and during the summer months. Conclusion Antibiotics administered to HITH patients via continuous infusion were frequently exposed to temperatures in excess of 25 °C. Specific patient behaviors and seasonal and chronological factors influenced temperatures. The findings challenge the validity of current fixed-temperature models for testing stability, which do not reflect conditions found in clinical practice.

Temperature profiles of antibiotic-containing elastomeric infusion devices used by ambulatory care patients.

Aim

To investigate factors influencing recruitment and retention of the pharmacy workforce within an Area Health Service.



Method

An online survey was used to collect data from pharmacy staff and responses were analysed with a focus on recruitment, retention and factors influencing job satisfaction.



Results

The response rate was 50%. The Area Health Service pharmacy service is comprised of full-time (70%), permanent (93%) employees aged 25 to 34 years (38%) or over 45 years (39%). Location was found to be the primary motivator when applying for positions, followed by work hours, type of position and professional development opportunities. Most staff achieved their employment expectations (67%) and received regular supervision/support (72%). However, 31% indicated an intention to leave within 2 years. The main drivers of job satisfaction were relationship with peers, job security and staff support. In those intending to leave, there were significant differences for flexibility of work hours, support, communication, access to professional development and ability to influence decisions/success (p < 0.05).



Conclusion

An insight was gained into motivators for employment and influencers of work place satisfaction. Further research is needed to explore how these variables are influenced by recruitment and retention strategies and how they compare with other public sector settings.

Pharmacy Workforce Recruitment and Retention: An Australian Area Health Service Perspective

Background

Unintentional discrepancies in medication lists at the time of discharge are common and a significant cause of avoidable harm. Electronic discharge referral (eDR) systems represent an opportunity to reduce the risk of harm. However, there are few Australian studies describing this approach.



Aim

To investigate the impact of an eDR system on the quality of medication prescribing.



Method

A prospective, observational study of discharge medication orders was undertaken in a 520-bed principal referral hospital. A structured audit tool was used to assess the quality (volume, type and severity) of prescribing errors on patients' discharge summaries for 2 weeks immediately before the implementation of the eDR system (pre-eDR) and re-audited 6 weeks after implementation (post-eDR).



Results

Discharge summaries from 776 patients were evaluated (n = 377 pre-eDR (handwritten process); n = 399 post-eDR (electronic process)). The number of discharges with one or more prescribing errors decreased significantly after implementation of the eDR system (relative difference −39.6%; P < 0.001), including errors relating to: supply quantities (P < 0.001), legibility (P < 0.0001), drug selection (P = 0.009), prescription format selection (P = 0.026), patient details (P = 0.039) and signing of orders (P = 0.007). However, no significant difference was observed in the overall mean severity score for errors between the electronic and handwritten discharge processes (3.5 vs 3.4; P = 0.28).



Conclusion

Implementation of an eDR system resulted in an improved quality and potential safety of patients' discharge medication orders. However, despite a reduced frequency of errors, the emergence of new error types was observed, and the profile and overall severity of prescribing errors remained unchanged.

Does an Electronic Discharge Referral System Improve the Quality of Medication Prescribing

Background

Pharmacist interventions improve patient outcomes and highlight the profession's contribution to the healthcare team. Under-reporting of interventions is common and result from a variety of interrelated workplace barriers and individual beliefs and attitudes.



Aim

To investigate the barriers to pharmacists' recording clinical interventions via the Incident Information Management System within an area health service.



Method

All pharmacists within the area health service were surveyed to explore their opinions about intervention reporting and to identify potential barriers and incentives to reporting. Responses were also analysed for aspects relating to the type/severity and frequency of clinical interventions reported.



Results

Pharmacists are most likely to report actual interventions and those of a greater clinical severity than near-misses or those of lesser significance. Approximately, only 20% of serious interventions were reported into the Incident Information Management System. Significant barriers to reporting interventions were time constraints, lack of feedback, difficulties with the reporting software and poor computer access. Respondents had a strong belief that interventions were an important part of a pharmacist's role (98%) and that they improve patient outcomes (92%). However, the pharmacists had a lesser belief in the value of reporting these activities (p < 0.005).



Conclusion

Despite pharmacists attributing importance to clinical interventions, this activity was not well reported. The most important barriers were time constraints and technological limitations. An awareness of these barriers can assist in the development of work practices and technological solutions to improve clinical intervention reporting.

Beliefs and Attitudes that Influence Reporting of Clinical Interventions by Pharmacists

Background

Medication-related harm is a major cause of morbidity in hospitalised patients. Incident reporting is a core initiative in improving this safety risk.



Aim

To describe the impact of a purpose-built incident reporting application; and to investigate the influence of clinical duties/pharmacists' characteristics on incident reporting at an area health service.



Method

Following implementation of the incident reporting application at the area health service, data (volume and severity on incidents by therapeutic group, error type, medication) were extracted for a 12-month period. Pharmacists concurrently completed a data collection form to record ‘time in clinical areas’ and profile their clinical activities.



Results

Post-implementation, 2887 incident reports were recorded by 29 pharmacists; a 20-fold increase from baseline. The 2887 incident reports included 4106 error types for 43 therapeutic groups comprising 388 different medications. ‘Prescribing errors on admission’ (n = 562), incidents relating to ‘anticoagulants, antithrombotics’ (n = 457) and 23 medications were most commonly reported (p , 0.05). No significant differences emerged for the severity of incident by error type, therapeutic group or medication. There was no difference between ‘high’ and ‘low’ reporting pharmacists for most characteristics, such as time in clinical areas, profile of clinical activities, grade and years of experience.



Conclusion

Streamlining incident reporting and actively engaging pharmacists can reduce safety risk as well as highlight the professional role of pharmacists in improving patient safety. Workplace safety culture and individual beliefs in the reporting process need to be explored further.

Engaging Pharmacists in Adverse Medication Incident Reporting: Pilot of a Streamlined Reporting Application

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