Medication Errors in Vietnamese Hospitals

12 Pages·2015·0.23 MB·English

RESEARCHARTICLE
Medication Errors in Vietnamese Hospitals:
Prevalence, Potential Outcome and
Associated Factors
Huong-ThaoNguyen1,5,Tuan-DungNguyen1,EdwinR.vandenHeuvel2,3,FloraM.Haaijer-
Ruskamp4,KatjaTaxis5*
1 DepartmentofClinicalPharmacy,SchoolofPharmacy,UniversityofMedicineandPharmacyatHoChi
Minhcity,HoChiMinh,Vietnam,2 DepartmentofEpidemiology,UniversityMedicalCenterGroningen,
UniversityofGroningen,Groningen,theNetherlands,3 DepartmentofMathematicsandComputerScience,
EindhovenUniversityofTechnology,Eindhoven,theNetherlands,4 DepartmentofClinicalPharmacology,
UniversityMedicalCenterGroningen,UniversityofGroningen,Groningen,theNetherlands,5 Departmentof
Pharmacy,UnitofPharmacotherapyandPharmaceuticalCare,UniversityofGroningen,Groningen,the
Netherlands
*[email protected]
Abstract
OPENACCESS
Citation:NguyenH-T,NguyenT-D,vandenHeuvel
ER,Haaijer-RuskampFM,TaxisK(2015)Medication Background
ErrorsinVietnameseHospitals:Prevalence,Potential
Evidencefromdevelopedcountriesshowedthatmedicationerrorsarecommonand
OutcomeandAssociatedFactors.PLoSONE10(9):
e0138284.doi:10.1371/journal.pone.0138284 harmful.Littleisknownaboutmedicationerrorsinresource-restrictedsettings,including
Vietnam.
Editor:FrankEmmert-Streib,Queen'sUniversity
Belfast,UNITEDKINGDOM
Objectives
Received:November24,2014
Todeterminetheprevalenceandpotentialclinicaloutcomeofmedicationpreparationand
Accepted:August29,2015
administrationerrors,andtoidentifyfactorsassociatedwitherrors.
Published:September18,2015
Copyright:©2015Nguyenetal.Thisisanopen Methods
accessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense,whichpermits ThiswasaprospectivestudyconductedonsixwardsintwourbanpublichospitalsinViet-
unrestricteduse,distribution,andreproductioninany nam.Dataofpreparationandadministrationerrorsoforalandintravenousmedicationswas
medium,providedtheoriginalauthorandsourceare
collectedbydirectobservation,12hoursperdayon7consecutivedays,oneachward.Mul-
credited.
tivariablelogisticregressionwasappliedtoidentifyfactorscontributingtoerrors.
DataAvailabilityStatement:Dataareavailablefor
researcherswhoconfirmtheirstudywiththeMedical
Results
EthicsCommitteesofthestudyhospitals:Trung
VuongEmergencyhospitalandGiaDinhGeneral Intotal,2060outof5271doseshadatleastoneerror.Theerrorratewas39.1%(95%confi-
hospital,HoChiMinhcity,Vietnam.Pleasedirectall
denceinterval37.8%-40.4%).Expertsjudgedpotentialclinicaloutcomesasminor,moder-
requeststoKatjaTaxis,[email protected](Universityof
Groningen,UnitPharmacotherapyand ate,andseverein72(1.4%),1806(34.2%)and182(3.5%)doses.Factorsassociatedwith
PharmaceuticalCare,AntoniusDeusinglaan1, errorsweredrugcharacteristics(administrationroute,complexityofpreparation,drug
9713BVGroningen,TheNetherlands).Theauthors class;allpvalues<0.001),andadministrationtime(druground,p=0.023;dayoftheweek,
cannotmaketherawdatapubliclyavailableperthe
Ethicscommittee’srequest.Dataareavailableon p=0.024).Severalinteractionsbetweenthesefactorswerealsosignificant.Nurseexperi-
request,pendingethicalapproval. encewasnotsignificant.Highererrorrateswereobservedforintravenousmedications
PLOSONE|DOI:10.1371/journal.pone.0138284 September18,2015 1/12
MedicationErrorsinVietnameseHospitals
Funding:ThisstudywassupportedbyNUFFIC(the involvingcomplexpreparationproceduresandforanti-infectivedrugs.Slightlylowermedi-
NetherlandsOrganisationforInternational cationerrorrateswereobservedduringafternoonroundscomparedtootherrounds.
CooperationinHigherEducation).Thefundershad
noroleinstudydesign,datacollectionandanalysis,
Conclusions
decisiontopublish,orpreparationofthemanuscript.
CompetingInterests:Theauthorshavedeclared Potentiallyclinicallyrelevanterrorsoccurredinmorethanathirdofallmedicationsinthis
thatnocompetinginterestsexist. largestudyconductedinaresource-restrictedsetting.Educationalinterventions,focusing
onintravenousmedicationswithcomplexpreparationprocedure,particularlyantibiotics,
arelikelytoimprovepatientsafety.
Introduction
Medicationerrorsareaglobalissue,especiallyprescribingandadministrationerrors[1,2].
Drugadministrationisimportantbecausethepossibilitiestopreventorcorrecterrorsatthis
stagearelimited.Tworecentsystematicreviewsshowmedianerrorratesbetween8%and10%
(excludingtimeerrors)inmedicationpreparationandadministration[3,4].Mostofthese
studieshavebeencarriedoutindevelopedcountries.Insuchcountries,patientsafetyissues
havebeenrecognisedalongtimeagoandeffortstoincreasemedicationsafetysuchasimple-
mentationofelectronicprescribingsystems,barcoding,andinvolvingclinicalpharmacistsat
thewardlevelareon-going[5,6].
Littleisknownaboutpatientsafetyinresource-restrictedsettings,i.e.developingandtran-
sitionalcountries[7].Oneofthefewlargestudiesfoundthat2.5%to18.4%ofhospitaladmis-
sionswereassociatedwithanadverseeventandabout30%ofthoseresultedinthedeathof
thepatientwhichwasmuchhigherthanthoseindevelopedcountries[8].Poorhealthsystem
infrastructureandinadequatelytrainedhealthcarestaffprobablycontributedtothis[7,8].
Twosmallscalestudiesonmedicationerrors,eachincludingaboutonethousandprepara-
tionsandadministrations,havebeencarriedoutinaMalaysianteachinghospital[9,10].One
studywasconductedontwopaediatricwards[9]andtheotherwasdoneonahaematology
ward[10].Medicationsweresuppliedtowardseitherasabulkforthewholeward(forcom-
monlyusedmedications)orasunit-doses(formorespecificmedications).Therewerenoclin-
icalpharmacyservicesatwardlevel.Errorrateswerearound8%,whichiscomparabletothe
medianerrorratereportedbyKeersetal.[3].Moreevidenceisneededfromotherresource-
restrictedsettings.Especially,studieswithalargersamplesizewhichallowinvestigationof
factorscontributingtoerrorstoidentifyappropriateapproachestopreventerrors.Inthis
study,wedeterminedtheprevalenceandpotentialclinicaloutcomeofmedicationpreparation
andadministrationerrorsintwoVietnamesehospitalsandidentifiedassociatedfactorsina
multifactorialmodel.
Methods
Studydesignandsetting
Thisprospectivestudy,usinganobservation-basedapproach,tookplaceonsixwardsintwo
majorpublichospitalsinalargecityinVietnam.Bothwereprovincialgeneralhospitals,hospi-
talAhad700bedsandhospitalBhad1000beds.Ineachhospitalwestudiedanintensivecare
unit(ICU,20bedseachward)andapost-surgeryward(PS,12bedseachward),inhospitalA
wealsostudiedonegeneralinternalmedicineward(GIM,56beds)andinhospitalBone
traumaunit(TU,48beds).Thenumberofnursesvariedacrossthewards,butingeneral,in
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eachshift,eachnursewasassignedthreetosixpatients.MostnursesheldanAssociate’sDegree
inNursing.
Commonlyusedmedicationswerekeptattheward.Theremainderofthemedicationswas
dispensedfromthepharmacydepartmenteverymorningfortheweekdays,andonFriday
morningadditionallyfortheweekend.Ordersformedicationswerewrittenbydoctorsonto
thepatient’smedicalrecords.Nursestranscribedprescriptionseithermanuallyintoinpatient
drugcharts(paper,hospitalA)orenteredthemintothepatients’electronicdruguserecordsin
acomputerandprintedoutthedrugregimenforeachpatient(hospitalB).Allmedications
werepreparedandadministeredbynursesreferringtothesecharts.Medicationpreparations
wereundertakeneitherinaseparateroomoronadedicatedtrolley.Everydrugadministration
onthewardwasrecordedinthenursechartandonadisclosureformatthepatient’sbedside
whichwasattachedtothepatient’smedicalrecordondischarge.Clinicalpharmacistswerenot
availableatwardlevel.
Datacollection
DatawerecollectedbetweenMarchandJune2011byfourpharmacystudents(twoineach
hospital)usingdirectobservation[11,12].Thisstudywaspartofalargerprojectandresultson
errorsrelatedtoinsulinhavealreadybeenpublished[12].Moredetailsondatacollection
methodscanbefoundthere.Thestudentsweretrainedforaboutaweekinobservationtech-
niquebylecturesonmedicationerrorresearchaswellasward-basedobservationsbyasenior
researchertoensureallobserversusedthesamedefinitionofanerror.Aone-dayobservation
pilotwasconductedoneachstudywardpriortocommencementofthemainstudytohelpthe
observersgetfamiliarwithmedicationsandproceduresofthestudywards.Thisalsohelped
nursingstaffgetcomfortablewithsomeonebeingaroundandminimizedtheHawthorneeffect
[13].
Atthebeginningofeachdruground,theobserveraskedthenurseinchargeforpermission
toobserve.Nursesweretoldthattheobserverwasapharmacystudentwhowantedtolearn
moreaboutward-baseddrugpreparationandadministration.Theobserverfollowedthe
nursesduringallintravenousandoraldrugpreparationandadministration.Datawerecol-
lected12hoursperday(7am-7pm)onsevenconsecutivedays(Monday–Sunday)oneach
ward.Twoobserverswerepresentatthesametimetomaximisethenumberofobservations
perdrugroundincaseseveralnursesworkedinparallel.Detailsofdrugpreparationand
administrationwererecordedonthepre-specifieddatacollectionforms.Nurses’andpatients’
identitywasanonymisedandkeptconfidential.Forethicalreasons,theobserverintervenedin
caseofpotentiallyseriousmedicationerrorsabouttoreachthepatientinanon-judgmental
manner.Theseerrorswerealsoincludedintheanalysis.Aftereachroundofobservation,the
observerwentthroughalltheobservationnotesandcomparedtheinformationobservedwith
thedoctor’sorderstodetectanydiscrepancies.Allcollecteddatawasrevisedbyasenior
researchertoensurethevalidityandreliabilityofthedata.Disagreementswereresolved
throughdiscussion.
Ethicalconsideration
ThestudywasapprovedbyMedicalEthicsCommitteeandManagementBoardofthestudy
hospitals(TrungVuongEmergencyhospitalandGiaDinhGeneralhospital,HoChiMinh
city,Vietnam).Ashighlightedabove,nursesprovidedverbalconsenttoparticipateinthe
study.Thiswasdocumentedontheobservationsheets.Theresearchinvolvedminimalriskfor
thenurses(datawereanonymized)thereforewrittenconsentwasnotobtainedtominimise
administrativeload.ThisprocedurewasapprovedbybothMedicalEthicsCommittees.
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MedicationErrorsinVietnameseHospitals
Definitions
Medicationerrorsweredefinedasdeviationsinpreparationandadministrationoforalor
intravenousmedicationsfromthedoctors’prescriptions,thehospitalpoliciesandprocedures
orthemanufacturers’instructions[10,14].Medicationerrorswereclassifiedintothefollowing
categories,similartothatusedbyotherauthors[15,16]:wrongdrug,wrongdose,wrongdos-
age-form,deteriorateddrug,wrongpreparationtechnique,omission,unordereddrug,and
wrongadministrationtechnique.Dosesgivenearlierorlaterthantheprescribedtimewerenot
countedaserrors.Anerrorcouldbeclassifiedinonecategoryonly(Table1).
Potentialclinicaloutcomesoferrors
Fourhealthcareprofessionals(onedoctor,onenurse,andtwopharmacists)scoredthepoten-
tialclinicaloutcomeofeachmedicationwithoneormoreerrors(i.e.erroneousdose).A10
pointscalefromzero(labelledasnoharm)to10(death)wasused.Wecalculatedthemean
score.Avaluebelow3suggestedaminoroutcome,of3–7amoderateoutcome,andabove7a
severeoutcome.Thishasbeenshowntobeavalidandreliablemethod[20].
Dataanalysis
Calculationoferrorrate. Wecalculatedtheoverallerrorrate(with95%confidenceinter-
val)aspercentagebydividingthenumberofdoseswithoneormoreerrors(i.e.,erroneous
doses)bythesumofgivendosesplusomitteddoses,whichwerecalledtotalopportunitiesfor
errors(TOEs),thenmultiplyingitby100(Eq1).Likewise,therateofeacherrortypewascalcu-
latedbydividingthenumberoferrorsofthatparticulartypebythesumofgivendosesplus
Table1. Typesofmedicationerrors.
Typeoferrors Definition
Preparation
Wrongdrug Preparationofadrugwhichdiffersfromthatprescribed
Wrongdose Preparationofadosethatishigherthan,orlessthan,theamountprescribed
(±10%)
Wrongdosage-form Formulationofdrugdeviatesfromthatprescribed
Deteriorateddrug Preparationofadrugthathasexpiredorforwhichthephysicalorchemical
dosage-formintegrityhasbeencompromised
Wrongpreparation Inappropriateprocedureorimpropertechniqueinthepreparationofadrug
technique (comparedtothemanufacturer’sinstructionsorhospitalpolicy,including
wrongdiluent,wrongsolvent,wrongvolume,possibleincompatibility)
Administration
Omission Failuretoadministeranordereddosetoapatient
Unordereddrug Administrationtothepatientofnon-prescribedmedication
Wrongadministration Inappropriateprocedureorimpropertechniqueintheadministrationofadrug
technique (rate,incompatibility,route,dose(±10%)ifpreparedwithcorrectdose).A
rateerrorwasidentifiedifadministrationtooklessthan3ormorethan5min
(forabolusdose)or15%shorter/longerthantherequiredinfusiontime(foran
infusiondose).Anincompatibilityerrorwasdeterminediftherewas
incompatibilityinformationavailableinatleastoneoffourdocuments
includingtheHandbookonInjectableDrugs,15thedition[17],AHFSDrug
Information2009[18],VietnamNationalDrugFormulary,2ndedition[19]and
themanufacturers’instructions.
doi:10.1371/journal.pone.0138284.t001
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omitteddoses,thenmultiplyingitby100.
Thenumberof doseswithoneormoreerrors
Overallerrorrate¼ x100 ð1Þ
GivendosesþomitteddosesðTOEsÞ
Eq1.Overallerrorratecalculation(TOEs=totalopportunitiesforerrors)
Multivariablelogisticregression. Multivariablelogisticregressionwasperformedto
explorefactorsassociatedwitherrors.Independentvariableswerecharacteristicsofdrug(ATC
—AnatomicalTherapeuticChemical—class,complexityofpreparation,andadministration
route),administrationtime(dayoftheweek,druground)andexperienceofnurseincharge,
correctedforhospital,ward,andobserver.DatawereanalyzedusingSPSSstatisticalpackage
(SPSS20.0,SPSSInc.,IBMCorporation,Somers,NY,USA).
Definitionofvariables. Thefollowingdefinitionswereused:medicationsweregrouped
usingtheATC/WHOclassification(http://www.whocc.no/atc_ddd_index),lesscommonly
usedmedications,i.e.frequencyaround5%orlower,weregroupedasothers.Amedication
preparationwasdefinedasfollows:simplepreparationsdidnotinvolveanymanipulations,e.g.
thisincludeddrawingupaninjectablesolutionwithasyringe.Complexoralpreparations
includedmanipulationssuchascrushingtabletsoropeningcapsulesanddissolvingthem.
Complexintravenouspreparationsincludedmanipulationsofoneormorestepssuchasrecon-
stitutingamedication.Administrationroutewereeitherintravenous(includingshortIVinjec-
tions,bolus,andinfusions)ororal.Accordingtostudywards/hospitals,therewerefivedrug
roundsaday:morning(7am-11am),lunch(11am-2pm),afternoon(2pm-5pm),evening
(5pm-9pm),andnight(after9pmtill7amnextday).So,ourobservationtime(7amto7pm)
includedfourdrugrounds.Nurseexperiencewasclassifiedintofourgroups:(cid:2)1,>1–2,>2–6,
and>6workingyears.Wealsoincludedinteractionsterms(i.e.theeffectofaspecificfactor
wasmodifiedbytheothers)intothemodel.Backwardeliminationusingthelikelihoodratio
testwasappliedtotestfortheeffectsofinteractionsandvariables.Thelevelofsignificancewas
setat0.05.
Results
Atotalof6232medicationswereprescribedduringthestudyperiod.Amongthose,5271
(84.6%)drugpreparationsandadministrationsinvolving327patientswereincluded:2996in
hospitalAand2275inhospitalB.
Prevalenceandpotentialclinicaloutcomesoferrors
Intotal,2060outof5271doseshadatleastoneerror,affecting92.4%(302outof327)patients.
Theerrorratewas39.1%(95%confidenceinterval(CI)37.8%-40.4%).Amongthose,336
doseshad2errorsand8had3errors.Overall,2412errorswereidentified.Expertsjudged
potentialclinicaloutcomesasminor,moderate,andseverein72(1.4%),1806(34.2%)and182
(3.5%)doses.
Mostfrequenterrorswerewrongadministrationtechnique(23.5%),followedbywrong
preparationtechnique,omission,andwrongdose(15.7%,2.3%,and1.8%,respectively).There
werenowrongdosage-formerrors(Table2).
Theobserversintervenedtwicetopreventerrorsfromoccurring:oneinvolvedamixtureof
10IUfast-actinginsulinand10mLKCl10%inglucose5%tothewrongpatient,theotherwas
thewrongdoseofmidazolam(50mginsteadof25mg)whichwasabouttobeaddedtoan
infusionbag.
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Table2. Frequenciesoferrortypes(n=2412errorsoutof2060erroneousdoses).
HospitalA HospitalB Total Rate(%)
Errortype ICU PS GIM ICU PS TU
Wrongdrug 2 0 55 3 2 2 64 1.2
Wrongdose 8 7 10 26 24 18 93 1.8
Wrongdosage-form 0 0 0 0 0 0 0 0.0
Deteriorateddrug 5 0 0 0 4 0 9 0.2
Wrongpreparationtechnique 316 40 88 104 201 81 830 15.7
Omission 2 1 60 21 0 39 123 2.3
Unordereddrug 1 8 12 7 13 15 56 1.1
Wrongadministrationtechnique 257 212 191 136 265 176 1237 23.5
Total 591 268 416 297 509 331 2412
ICU:intensivecareunit,PS:post-surgery,GIM:generalinternalmedicine,TU:traumaunit.
doi:10.1371/journal.pone.0138284.t002
Factorsassociatedwitherrors
Usingbackwardeliminationofinteractionsandvariablesinthelogisticregressionanalysis,
correctedforhospital,ward,andobserver,weobservedthaterrorswereassociatedwithcharac-
teristicsofthedrug(administrationroute,complexityofpreparation,ATCclass,allp
values<0.001),andadministrationtime(druground,p=0.023;dayoftheweek,p=0.024).
Alltwo-wayinteractionsbetweenadministrationroute,complexityofpreparation,andATC
classweresignificant(allpvalues<0.001).Therewasalsoasignificantinteractionbetween
ATCclassanddruground(p=0.007).Nurse’sexperiencewasnotsignificant.
Togivemoreinsightintothedata,Tables3–5describeerrorratesstratifiedbysignificant
factorsandinteractions.
Muchhighererrorrateswereobservedforintravenousmedicationsthanfororalones
(73.2%vs.11.8%),andforcomplexpreparationproceduresthanforsimpleones(58.0%vs.
25.9%).Highererrorrateswereobservedforintravenousmedicationsinvolvingcomplexprep-
arationproceduresthanforsimpleintravenousones(90.2%vs.53.9%).Thiswasconsistentfor
mostdrugclasses.
Table3. Numberofincludeddoses(n)anderrorrates(%)stratifiedbydrugclass,administrationrouteandpreparationprocedure.
Administrationroute Oral Intravenous Total
Preparationprocedure Simple Complex Simple Complex
n % n % n % n % n %
ATCclass
A 731 9.4 370 21.1 72 91.7 187 92.5 1360 28.4
B 106 17.0 97 7.2 531 33.0 101 77.2 835 33.3
C 418 10.0 188 18.1 66 84.8 71 98.6 743 27.2
J 59 10.2 2 0.0 170 63.5 724 89.2 955 79.6
N 437 5.5 84 11.9 180 63.9 70 95.7 771 28.0
Others 255 20.4 182 3.3 79 91.1 91 96.7 607 35.9
Total 2006 10.5 923 14.6 1098 53.9 1244 90.2 5271 39.1
ATC:AnatomicalTherapeuticChemical
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Table4. Numberofincludeddoses(n)anderrorrates(%)stratifiedbydayoftheweek,administrationrouteandpreparationprocedure.
Administrationroute Oral Intravenous Total
Preparationprocedure Simple Complex Simple Complex
n % n % n % n % n %
Dayoftheweek
Sunday 271 7.0 124 15.3 147 53.1 201 91.5 743 40.4
Monday 317 13.2 54 24.1 128 56.3 133 93.2 632 39.7
Tuesday 276 10.1 134 11.9 147 48.3 162 88.9 719 36.0
Wednesday 252 11.1 176 15.9 182 56.6 195 91.8 805 42.0
Thursday 314 10.2 165 10.9 181 51.9 190 86.8 850 36.4
Friday 298 10.7 139 13.7 167 54.5 169 87.6 773 37.5
Saturday 278 10.8 131 16.8 146 56.8 194 91.8 749 41.8
Total 2006 10.5 923 14.6 1098 53.9 1244 90.2 5271 39.1
doi:10.1371/journal.pone.0138284.t004
Intermsofdrugclass,thehighesterrorrates(79.6%)wereobservedforanti-infectivedrugs
(ATCclassJ).Lowerrorrateswereobservedforcardiovasculardrugs(ATCclassC),butagain,
higherrorrateswereobservedforcomplexpreparationproceduresandintravenousadminis-
trationsofcardiovascularmedications(Table3).
Medicationerrorsseemedtobesimilarforalldaysoftheweekwitherrorratesranging
from36.0%to42.0%.Whenstratifyingthedatabyadministrationrouteandpreparationpro-
cedure,almostallerrorrateswerehigheronMondayscomparedtootherdays(Table4).
Slightlyfewererrorsoccurredduringafternoonroundsthanatothertimesoftheday.This
wasnotconsistentacrossalldrugclasses.Forexample,errorratesofanti-infectivemedications
(ATCclassJ)weresimilaracrossdrugrounds(Table5).
Discussions
OurstudyonsixwardsintwoVietnamesehospitalsshowedthatinmorethanathirdofall
medicationpreparationsandadministrationspotentiallyclinicallyrelevanterrorsoccurred.
Errorswereassociatedwithdrugcharacteristics(intravenousmedications,complexprepara-
tionprocedures,anti-infectives),andadministrationtime(drugroundanddayoftheweek),
butnotassociatedwithnursingexperience.
Table5. Numberofincludeddoses(n)anderrorrates(%)stratifiedbydrugclassanddruground.
Druground Morning Lunch Afternoon Evening Total
n % n % n % n % n %
ATCclass
A 618 32.2 253 31.6 404 18.6 85 37.6 1360 28.4
B 354 34.5 207 40.1 212 25.9 62 29.0 835 33.3
C 308 26.6 144 29.2 232 26.3 59 28.8 743 27.2
J 482 80.1 203 80.8 199 80.9 71 69.0 955 79.6
N 269 22.7 168 36.3 231 29.0 103 26.2 771 28.0
Others 248 39.1 111 28.8 190 31.6 58 50.0 607 35.9
Total 2279 41.6 1086 42.5 1468 32.6 438 39.3 5271 39.1
ATC:AnatomicalTherapeuticChemical
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Theerrorrateof39.1%(37.8%-40.4%)identifiedinourstudyisrelativelyhigh.Previous
studiesusingsimilarmethodologyincludingoralandinjectablemedicationsfounderrorrates
(withouttimeerrors)between7.5%and33%[10,16,21,22].Ourhighererrorratemaybepartly
duetoobservingahighproportionofintravenousmedications.Thiswas44%inourstudy
whereasbetween9%[21]and26%[10]intravenous/injectableswereobservedinotherstudies.
Inaddition,theotherstudiesdidnotincludealldaysoftheweek[10,16,21,22].Furthermore,
theremayhavebeensubtledifferencesinthedefinitionofamedicationerror.Wewerestrict
aboutcriteriaofpreparationtechniqueerrors,wheremixing/shakingerrorswereincluded(for
exampleadoseofceftriaxone1gwasincompletelydissolvedin10mLsterilewaterbecauseof
insufficientshaking)whileotherauthorsdidnotclearlyspecifythis.Incontrasttotheprevious
studies,themajorityoferroneousdosesinourstudywerejudgedtobepotentiallyclinicallysig-
nificantandonlyfewwereconsideredminor.Howeverduetodifferentmethodsusedtoassess
clinicaloutcomethesedataaredifficulttocompare.
Inlinewithareviewonintravenousmedicationerrors[23]weobservedfrequentlyadmin-
istrationtechnique,preparationtechnique,omissionanddoseerrors.Abouthalfoferrorswere
wrongadministrationtechniqueandmostofthesewererateerrorsinvolvingbolusmedica-
tions,whichshouldhavebeengivenwithin3–5minutesaccordingtotheVietnamNational
DrugFormulary[19].Thesecondmostcommonerrorinvolvedpreparationtechniquewhere
nursesdidnotshakeormixproperlywhilereconstitutingintravenousmedicationsorusedthe
wrongvolumeofsolvent/diluent.Fororalmedications,themostfrequentpreparationtech-
niqueerrorswerecrushingtabletsorcapsulesthatshouldnothavebeencrushed,forexample,
sustainedorextendedreleasedosage-formsorcoatedtablets.Mostomissionanddoseerrors
involvedoralmedicationswhichwereunavailableorwherenursesmisinterpreted/mistran-
scribedtheprescriptions.Inaround40%ofdoseerrors,halfthedoseortwicethedosewas
given.Forexample,twotabletsofalphachymotrypsinweregiveninthemorninginsteadof
administeringthisintwodoses(morningandevening)asthedoctorintended.Thiswasproba-
blyduetoambiguousprescriptions:alphachymotrypsin1tabletx2.Wedidnotfindthistype
oferrorbeingreportedinotherstudies.
Intravenousadministrationroutehadabiggereffectonerroroccurrencecomparedtooral
one.Thepotentialforerrorsincreasedwhenthe(intravenous)medicationinvolvedacomplex
preparationprocess.Thiswasinlinewithapreviousstudyonintravenousmedicationsshow-
ingthatmultiplesteppreparationsinvolvedmoreerrorsthansimpleones[24].Areviewesti-
matedthatremovingthereconstitutionstep(complexpreparations)byprovidingprepared
injections(simplepreparations)wouldreducetheoverallerrorratefrom73%to17%[23].
Anti-infectivedrugsforsystemicusewereshownasthemosterror-pronemedicationsasmost
antibioticsobservedinvolvedcomplexpreparationprocedures(724outof955,Table3).We
alsofoundanassociationbetweenadministrationtimeanderrors.Theriskforerrorswas
higheratalltimesduringthedayexcepttheafternoonround.Areasonforthismaybethatthe
afternoonwastheleastbusytimeofthedayforthenurses.Forinstances,inthemorning
nursesalsohadtotakebloodsamples,transcribeprescriptionsandduringlunchandevening
rounds,theyhadtogiveoutmeals.Underlyingthiscouldbefrequentinterruptionsofstaff
duringbusytimesonthewards[25,26]orthenumberofpatientsanursehastotakecareof
[16,21].Dayoftheweekwasasignificanttermwhichremainedinthefinallogisticregression
model,butitwasnoteasytoidentifythemostriskydayforerrors.Thisisprobablydueto
unequaldistributionofmedicationsobservedintermsofdrugcharacteristics(i.e.administra-
tionroute,preparationprocedure,andATCclass)acrossdaysoftheweek.Forexample,a
higherproportionofsimpleoralmedicationswaspreparedandadministeredonMonday
(50.2%)comparedtootherdays.Whenadministrationrouteandpreparationprocedurewere
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keptconstant,Mondayturnedouttobeanerror-proneday.Thishasbeenreportedinanother
study[22].
Nursingexperiencewasnotsignificant,irrespectiveofadministrationrouteaswellastype
ofpreparation.Incontrast,anAustralianstudyonintravenousmedicationsfoundthateach
yearofexperience,upto6years,reducedtheriskoferrorby11%[27].MaybeinAustralia,
nursesarecontinuouslytrainedaftergraduation,whileinVietnamcontinuingeducationfor
healthcareprofessionals,includingnurses,isaconceptintroducedrecently[28].Nursesmay
havelearntfromthesenioronesandtheyhavelittleopportunitiestoupdateknowledgeand
practice.Alternatively,seniornursesmaybebetterthanjuniorones,butbecauseofmore
responsibilitiestheymayhavetocarryoutseveraltaskssimultaneouslyandmaybeinterrupted
moreoftenwhichisassociatedwitherrors[25,26].
Arangeofdifferentmeasuresarerecommendedforerrorreductionincludingimproving
thecompetenceofhealthcareprofessionals,controllingworkingenvironment,andenhancing
thesafetyculture[6,29].Preparationtechniqueerrorscouldbereducedbyprovidingmedica-
tions,particularlyintravenousones,withsimplepreparationssuchasreadytousemedica-
tionswhicheitherpreparedbypharmaceuticalcompanyorpharmacydepartment[23].
Administrationtechniqueerrors,especiallyrateerrors,couldbeeliminatedbyusing(smart)
infusionpumps[30].However,inthecontextofresourcelimitedsettings,theimplementa-
tionsofsuchinterventionsmaybetoocostlyandunfeasible.Nurseexperiencehadnoimpact
ontheerrorrate.Guidelinesseemedtobeabsentornotuptodateonthestudywards.This
wouldsuggeststartingimprovementsbyintroducinganeducationaltrainingprogrammefor
nursestargetingthemosterror-pronemedications(intravenousmedicationinvolvingcom-
plexpreparationprocedures)aswellasprovidingguidelines.Recentstudiesconfirmedthat
education,protocolsandguidelinesareasuccessfulapproachtoreducemedicationerror
rates,alsoinresource-restrictedsettings[31–33].Thiswouldbeinlinewithpatientsafety
researchfromresourcerestrictedsettingsidentifyinginadequatetrainingofclinicalstaffand
lackofprotocol/policyasimportantfactors[7,8].Errorswerelikelytooccurduringbusydrug
rounds(alldrugroundsexceptafternoon).Thiswouldsuggestthatworkingpatternsand/or
systemofmedicationmanagementshouldbeadaptedtoassigncomparableworkloadfor
everydruground[31],andtominimizeinterruptions[26,34–36],ortohavededicatednurses
whoareresponsibleformedicationadministrations,butresearchonthelatterisinconclusive
sofar[37].Asafirststeptofosteracultureofsafety,clinical/hospitalpharmacistscoulddis-
cusstheerrorsandpreventionstrategieswithwardstaff.Thiswouldstimulateinterestsand
concernsinpatientsafety,andcreateacomfortableenvironmenttolearnfromerrors.Inlater
stages,implementationofan(non-punitive)errorreportingsystemwouldberecommended.
Inspiteofunderestimation,thissystemhasbeenindicatedasavaluabletoolforpreventing
futureerrors[38].
Strengthsandlimitations
Incontrasttomostpreviousstudiesonadministrationerrors,westudiedalargenumberof
variablesandinteractionsbetweenthesevariablesaspotentialfactorscontributingtoerrors.
Forinstance,Chuaetal.usedχ2testtofindtheeffectofadministrationrouteanddruground
[10].Butanimbalance,e.g.moreintravenousmedicationsgivenduringaparticularround,
willnotbetakenintoaccountinunivariableanalysis.Forexampleourdescriptivedata
showednodifferencesinerrorratesbetweendaysoftheweek.Onlyafterstratification,we
foundhighererrorratesonMondays.Surprisingly,wefoundanumberofsignificantinterac-
tions.Thissuggestedthatthecomplexityofclinicalpracticeshouldbetakenintoaccountand
confirmedthenecessityofcontrollingforotherfactors,knownorsuspectedtohaveanimpact
PLOSONE|DOI:10.1371/journal.pone.0138284 September18,2015 9/12
MedicationErrorsinVietnameseHospitals
onerrors,whileevaluatingpotentialfactors.Thesefindingshavenotbeenreportedinthe
literature.
Weuseddirectobservationtodetecterrorswhichisrecognizedasthe“goldstandard”
[11,39].Theobservationratewashigh(84.6%)andobservationswereonlymissedinsome
cases,forexample,iftherewasmorethanonenursepreparing/administeringdrugsatthe
sametimeorincaseswhereobservationwasinappropriateforseriouslyillpatients.Itshould
benotedthatpartoftheeveningroundsandnightshiftswerenotincluded.Therefore,the
errorrateduringthenightremainsunknown.Almostallpatients(92.4%)experiencedatleast
onemedicationerrorduringtheirhospitalstay.Aswithallobservationbasedstudies,wedid
notcollectdataontherealconsequencesoferrors,butifonlyafractionofthe3.5%potentially
severecasesresultinactualharm,therewouldbemanypatientsaffected,giventhefactthat
aboutonethousandmedicationswereadministeredperweekoneachward.
Conclusions
Inthislargestudyofmedicationpreparationandadministrationerrorsinaresource-restricted
setting,wefoundthatpotentiallyclinicallyrelevanterrorsoccurredinmorethanathirdofall
medications.Administrationtechnique,preparationtechnique,omission,anddoseerrorswere
mostcommonlyencountered.Interventions,probablystartingwitheducation,focusingon
intravenousmedicationswithcomplexpreparationprocedure,particularlyantibiotics,are
neededtoimprovepatientsafety.
Acknowledgments
Theauthorswouldliketothankallthestudentswhoparticipatedinthedatacollection.We
alsothankthefourhealthprofessionalswhoassessedtheclinicalrelevanceofthedata.
AuthorContributions
Conceivedanddesignedtheexperiments:HTNTDNERHFMHRKT.Performedtheexperi-
ments:HTNTDNKT.Analyzedthedata:HTNERHKT.Wrotethepaper:HTNTDNERH
FMHRKT.
References
1. Krahenbuhl-MelcherA,SchliengerR,LampertM,HaschkeM,DreweJ,KrahenbuhlS(2007)Drug-
relatedproblemsinhospitals:Areviewoftherecentliterature.DrugSaf 30:379–407.PMID:17472418
2. RossLM,WallaceJ,PatonJY(2000)MedicationerrorsinapaediatricteachinghospitalintheUK:Five
yearsoperationalexperience.ArchDisChild 83:492–497.PMID:11087283
3. KeersRN,WilliamsSD,CookeJ,AshcroftDM(2013)Prevalenceandnatureofmedicationadministra-
tionerrorsinhealthcaresettings:Asystematicreviewofdirectobservationalevidence.AnnPharmac-
other 47:237–256.doi:10.1345/aph.1R147PMID:23386063
4. BerdotS,GillaizeauF,CarubaT,PrognonP,DurieuxP,SabatierB(2013)Drugadministrationerrors
inhospitalinpatients:Asystematicreview.PLoSOne 8:e68856.doi:10.1371/journal.pone.0068856
PMID:23818992
5. DuckersM,FaberM,CruijsbergJ,GrolR,SchoonhovenL,WensingM(2009)Safetyandriskmanage-
mentinterventionsinhospitals:Asystematicreviewoftheliterature.MedCareResRev 66:90S–
119S.doi:10.1177/1077558709345870PMID:19759391
6. KeersRN,WilliamsSD,CookeJ,WalshT,AshcroftDM(2014)Impactofinterventionsdesignedto
reducemedicationadministrationerrorsinhospitals:Asystematicreview.DrugSaf 37:317–332.doi:
10.1007/s40264-014-0152-0PMID:24760475
7. JhaAK,Prasopa-PlaizierN,LarizgoitiaI,BatesDW,ResearchPrioritySettingWorkingGroupofthe
WHOWorldAllianceforPatientSafety(2010)Patientsafetyresearch:Anoverviewoftheglobalevi-
dence.QualSafHealthCare 19:42–47.doi:10.1136/qshc.2008.029165PMID:20172882
PLOSONE|DOI:10.1371/journal.pone.0138284 September18,2015 10/12