Nurses and pharmacists collaborate to confront medication errors

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Nurses and pharmacists collaborate to confront
medication errors

• Eva Bolet
• Neonatal Nurse
• Prevention Medication Error Group
• Hospital de Barcelona

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Work multidisciplinary group_____________________
______

• Nurses 10
• Supervisors 2
• Pharmacists 1
• Physicians 1
• Technicians 1

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Method__________________________

• Monthly meetings
• Medication errors analysis
• Méthods Observation
• Communication
• Database registration
• To transmisse and to apply improvement measures

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Observation error rate___________________________
_

• n errors x 100
• ____________________
• n total opportunities

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Observation method

• Observation registration
• To check prescription and validation
• Database
• Improvement measures

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(No Transcript)
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Observation tracking form(anverso)
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Observation tracking form (reverso)Pharmacist
review
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Observer rules in the drug administration_______
____________________________

• To observe all drugs at specific time
• No more than five patients/observed nurse
• If it is detected any error, its necessary to
  correct it but to note down like an error

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Stages

• Pilot study 1994
• 200 observations
• 9 error rate founded
• 2. Statistics
• Sample for 500.000 drug administration
• in a year 800

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Error rate evolution Hospital de Barcelona ()
With time
Without time
1994 n855
1996 n739
1999 n937
1995 n839
1997 n776
1998 n736
2000 n764
2001 n728
2003 n707
2002 n725
2004 n829
2005 n844
2006 n820
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Efficacy comparison ()
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Observed influence by the observer?

• Punctual studies
• (Barker K, Barber N, Blasco P, etc)
• Disguised observer
• Observation objective is unknown
• independent and paid
• ME prevention group
• During limitated time
• some months, one year

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Hospital de Barcelona

• No disguised observer
• Other wards nurses
• Pharmacy students
• Every year continuous studies (14 years)

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Comparison with others

• Dean (1995) 6,9
• Borel (1995) 2,9
• Barker (1969) 1,9
• Few spanish observation studies (Alicante 8,6,
  1997)
• Hospital de Barcelona 2,9-6,5
• They are computerised unit dose ditribution
  systems (less Alicante) and time errors are not
  included

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Improvement measures (1)

• Normalized dilution of iv drugs and
  administration speed
• Administration in relation to foods
• Normalized timetable for drug administration
• Computerized control of allergies

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Improvement measures (2)

• Double control for pharmacy preparation
• Antibiotic and TE surgical prophylaxis
• Normalised procedures of post-surgical pain
  prevention, nausea and vomit
• No automatic validation prescriptions

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Improvement measures (3)

• To check MAR with prescription
• To extent CPOE (current 75)
• Spreading analysis and improvement measures for
  detected errors

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Quality of bedside information
Por cortesia de Swisslog
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Information transmission
Toapply improvementmeasures
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Conclusions (1)

• 1. The observation method is the most effective
  one to obtain medication errors rates.
• 2. Error rates, with observation and
  communication method, aproach with improvement of
  the prevention culture in the hospital.

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Conclusions (2)

• 3. You can obtain datum about drugs
  administration with the observation method and to
  apply improvement measures