HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary Medicalerrors:Glossary(variables,metricsandmeasurementmethods)

Environment feature Term Acuityadaptableroom Definition Metrics Roomsdesignedwithsufficientspaceandprovisionfor Yes/no,before/after equipment,medicalgases,andpowertoaccommodate (Hendrich,Fay,&Sorrells, 2004) anylevelofpatientacuity(Evans,Pati,&Harvey, 2008). Amedicationdispensingsystemthatusesbarcodesto Yes/no,before/after ensurethatthecorrectmedication,initscorrectdose (Poonetal.,2006). andformulation,isbeingdispensed(Poonetal.,2006). Apatientisidentifiedbyabarcode.Thebarcodeof everydrugisscannedandcheckedagainstthe informationinelectronicmedicationadministration recordsbeforeadministration.Whenawrongdrugor wrongpatientisscanned,acomputersignalpopsup andtheprocessisstoppeduntiltherightpatientor drugisidentified(Ros&deVreezeWesselink,2009). Measurementmethod Designmanipulation Thecoronarycriticalcareunitandmedicalstepdownunit wereredesignedandcombinedintooneacuityadaptableunit (Hendrich,Fay,&Sorrells,2004). Designmanipulation Adedicatedrepackingcenter(foraffixingabarcodeonto eachmedicationifthemanufacturerhadnotalreadydoneso) wasbuilttoimplementabarcodeassisteddispensingsystem in3configurations.In2configurations,alldoseswerescanned onceduringthedispensingprocess.Inthethirdconfiguration, only1ofseveraldosesofthesamemedicationbeing dispensedwasscanned(Poonetal.,2006).

Barcodeassisted dispensingsystem

Bedsideassortment picking(BAP)trolley

Anewtypeofdrugtrolleywithseparatecompartments Yes/no,before/after(Ros forwardspecificstockandpatientspecificmedicines. &deVreezeWesselink, Equippedwithawirelesslaptopthatconnectsto 2009). electronicmedicationadministrationrecordsand guidesthenursetothecorrectlocationofadrug(Ros d l k ) &deVreezeWesselink,2009).

Designmanipulation Anewtypeofdrugtrolleybedsideassortmentpicking trolleywasdevelopedandintroducedtoreplacea conventionaltrolley(Ros&deVreezeWesselink,2009).

Computerizedphysician orderentry(CPOE)

Yes/no,before/after(King Designmanipulation Computerbasedsystemsforautomatingthe etal.,2003) AcommerciallyavailableCPOEsystemdevelopedbyEclipsys medicationorderingprocess.AbasicCPOEensures standardized,legible,completeordersbyaccepting wasimplementedintwoinpatientwards.TheCPOEsystem onlythoseordersthataretypedandinastandardand wasoriginallyintroducedasCarevision,underwentperiodic completeformat(Kaushal&Bates,2001). productupgrades,andisnowcommerciallyavailableas SunriseClinicalManager(Kingetal.,2003). LightoriginatingfromthesunthatreachesEarths surfaceafterreflectingoffthesky'svault(Zunde& Bougdah,2006) Existingdata Averagehoursof daylight/darknessforeach Existingdatafrompublicweatherservice(Booker& month(Booker&Roseman, Roseman,1995) 1995)

Daylight

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HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary
Term Distraction Definition Anexternalstimuluscausingobservableresponses fromhealthcareworkerswithoutdisruptingthe ongoing,productiveactivity(Flynnetal.,1999). Metrics Distractioncondition versusnondistraction condition(Pluyteretal., 2010); Numberofdistractions perpharmacistperhalf hour(Flynnetal.,1999).; Measurementmethod Experimentalmanipulation Inoneexperimentalcondition,subjectslistenedtopopular songscombinedwithsocialconversationirrelevanttothe surgicaltaskandnonoptimallaparoscopenavigation(Pluyter etal.,2010). Videorecordingofactualworking Twovideocamerasrecordedprescriptionfillingoperations fromtwodifferentanglesthroughouteacheighthourstudy day.Thevideotapeswerereviewedsimultaneouslytorecord timeofinterruptionordistraction,prescriptionfillingtask affected,typeofinterruptionordistraction,reasonforthe interruptionordistraction,andstudyparticipantaffected (Flynnetal.,1999). Photometer Photometer(modelIL1350,serial2048,InternationalLight Inc.,Newburyport,MA)withanilluminancesensor(model SCD110,serial1366,Internationallight).Eightmeasurements weretaken,starting6inchesfromtheendoftheconveyor beltandevery12inchesthereafter.Theamountof illuminationrepresentsthemeanoftheeightmeasurements takendailyforsevendays(Buchananetal.,1991).

Illuminationlevel (illuminance)

Theintensityofluminousflux(Stein,1997).

Lux(1lux=1lumen/m2) Footcandle(1ftc= 10.764lux)(Buchananet al.,1991)

Interruption p

Cessationofproductiveactivitybeforecompletinga Numberofinterruptions p y p g p prescriptionfillingtask,duetoanyexternallyimposed, perpharmacistperhalf observable,oraudiblereason.Interruptionscanbe hour(Flynnetal.,1999); causedbystafflookingatpeoplepassingthroughthe Numberofinterruptions ambulatorycarepharmacyandrelatedtoprescription duringonemedication processingquestions(Flynnetal.,1999). administration(Westbrook Situationinwhichanurseceasedamedication etal.,2010). preparationoradministrationtaskinordertoattendto anexternalstimulus(Westbrooketal.,2010).

Videorecording g See"distraction" Observation Observers(registerednursesandphysicians)useda structuredobservationaltoolonaPDAtorecordnumberof interruptionsthatanurseexperienced(Westbrooketal., 2010).

Lightfixture(luminaire)

Acompletelightingunitconsistingofalightsource (oneormorelamps),andthepartsdesignedto positionthelightsourceandconnectittothepower supply.Partsforprotectingthelightsourceorballast andfordistributingthelightmaybeincluded(National FireProtectionAssociation,2010)

Differentlighting conditionsdeterminedby supplementallighting fixturesandcolorfilters (Buchananetal.,1991).

Designmanipulation Theinstallationofsupplementallightfixturesandthe removalofcolorfilters(Buchananetal.,1991).

MedicalErrors:Glossary|2

HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary
Term Noise Definition Auditorystimulus,suchasachangeinloudness, bearingnoinformationalrelationshiptothepresence orcompletionofthetask.Sound:achangeinloudness bearingsomeinformationalrelationshipwiththetask athand(Flynnetal.,1996). Metrics Measurementmethod Numberof Videotaperecording unpredictable/controllable/ Twovideocamerasplacedininconspicuouslocations uncontrollablesoundsper recordedambientsounds.Thevideotapesweresynchronized minute; withthetimethateachpatientsprescriptionsetwasbeing Equivalentsoundlevel filledinordertodeterminewhichsoundsaffected (Leq)perhalfhour(Flynnet performance(Flynnetal.,1996). Noiseloggingdosimeter al.,1996). Soundlevelswerecontinuouslyrecordedindecibels(Ascale) byanoiseloggingdosimeter(QuestElectronicsNoiseLogging Dosimeter,modelM2812)locatedata70degreeangleabove themainprescriptionfillingarea;theLeqwascalculatedfor eachhalfhourusingthemethodsdescribedbyTaylor& Lipscomb(1978)foranalyzingdecibellevelsthatchangeover time(Flynnetal.,1996). Environmentalinspection Apharmacy'sdrugstockwasclassifiedintooneoftwo systems:stockedwithspacebetweenitemsortightlypacked ontoshelves(Flynnetal.,2002).

Physicalconfigurationof drugstockshelves

Separationandspace Spatialarrangementofdrugitemsincludingthe amountofspacebetweendrugitemsonshelves(Flynn betweenitemsversus tightlypackeditemson etal.,2002). shelves(Flynnetal.,2002).

Outcome

Adversedrugevent(ADE) Harmcausedbyadrugortheuseofadrug(Nebeker, Barach,&Samore,2004). Potentialdrugeventdefinedasdispensingerrorsthat can harm patients if not intercepted before medication canharmpatientsifnotinterceptedbeforemedication administration(Poonetal.,2006).

NumberofADEsper1,000 Physicianreviewoferrorreports patientdays; Twophysiciansaccessedthemedicationerrordatabaseand Percentageof reviewedalloriginalincidentreports.Severitywasreclassified prescriptions involved in based on patient impact as an ADE potential ADE or other prescriptionsinvolvedin basedonpatientimpactasanADE,potentialADE,orother potentialADEsdividedby (Kingetal.,2003). thetotalnumberof Eachoftwoboardcertifiedinternistsindependently prescriptions(Kingetal., reviewedandratedtheseverityofeachdispensingerrorby 2003;Poonetal.,2006) usinganexplicitsetofcriteria.Eachphysicianreviewer determinedwhetherthepatientcouldhavehadaninjuryif thedispensingerrorhadreachedthepatient,definederrors thatcouldharmpatientsaspotentialADEs,andclassified potentialADEsassignificant,serious,andlifethreatening (Poonetal.,2006).

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HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary
Term Definition Metrics Measurementmethod Percentageofmedications Directobservation Medicationadministration Failuretocomplywithspecificmedication Observers(registerednursesandphysicians)useda proceduralfailure administrationprocedures,includingfailuretoreada withproceduralfailures structuredobservationaltoolonaPDAtorecordnursing (Westbrooketal.,2010). medicationlabel,failuretocheckpatients proceduresrelatedtomedicationadministration(Westbrook identification,temporarystorageofmedicationinan unsecuredenvironment,failuretorecordona etal.,2010). medicationchart,useofanonaseptictechnique,failure tocheckpulse/bloodpressure/bloodglucoselevel (whenapplicable),failureof2nursestocheck preparationofadangerousdrugorIVmedication (Moorthyetal.,2003). Medicationerror Numberofdispensing Errorthatoccurswhileordering,transcribing, Directobservation&expertevaluation dispensing,administering,ormonitoringmedications, errorsperpharmacistper Filledprescriptionsevaluatedbyresearchertodetect hour(Flynnetal.,1999); irrespectiveoftheoutcome(Kaushal&Bates,2001). deviationsfromphysician'sorders(Flynnetal.,1999;Flynnet Percentageof al.,2002) prescriptionsinvolvedin Aftertheroutinefinalcheckbyapharmacistbutbeforethe errorsdividedbythetotal drugwasdispensedtothepatient,everyprescriptionwas numberofprescriptions reviewedforcontentbytheobserver(Buchananetal.,1991) (Buchananetal.,1991;; Atrainedresearchpharmacistobserverinspectedthe Flynnetal.,1999; medicationsthathadalreadyundergonetheusual3step Westbrooketal.,2010). dispensingprocesstolookfordispensingerrorsandclassify Numberofnurse theerrortypes(Poonetal.,2006) medicationerrorsper Thedirectobservationmethodconsistsofanobserver month(Booker&Roseman, witnessingtheadministrationofmedicinestopatientsbythe 1995) nurse The observer checks the administration of each dose by 1995). nurse.Theobservercheckstheadministrationofeachdoseby Severityoferror:five thenursewiththehelpofanexactcopyofthemedication severityratinglevels(1 administrationrecord.Theobserverdoesnotinterfereifan littleornoeffecton errorisobserved.Iftheobserverestimatedthatthepatient's patient,2likelytoleadto safetyiscompromised,awarningisgiventothenursebefore increaseinlevelofcare,3 themedicineisactuallytakenbythepatient(Ros&deVreeze likelytoleadtopermanent Wesselink,2009). reductioninbodily Observers(registerednursesandphysicians)useda functioning,4likelyto structuredobservationaltoolonaPDAtorecorddetailsof leadtoamajorpermanent medicationadministratedandcomparethedatawithpatients' lossoffunction,5likelyto medicationchartstodeterminewhetherthemedication leadtodeath);two administrateddifferedfromwhatwasordered(Westbrooket categories(majorerrors al.,2010). levels45,minorerrors levels13)(Westbrooket al.,2010).

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HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary
Term Definition Metrics Measurementmethod Adverseeventreportingsystem Apassivereportingsystem.Thenurseandphysicianinvolved inamedicationerrorcompleteanincidentreportand documenttheincident.Theseverityofpatientharmisrated asnone,mild,moderate,orsevere.Medicationerrorsare thensenttothepharmacydepartmentandenteredintoa spreadsheetdatabase(Kingetal.,2003). Theannualmedicationerrorindexwasmeasuredbythe hospitalsstandardsystemforreportingadverseevents (Hendrich,Fay,&Sorrells,2004). Errorsweredocumentedonastandarderrorreportingform completedbythenursecommittingtheerrorand/orstaff discoveringtheerror(Booker&Roseman,1995).

Surgicalerrors

Errorsintheperformanceofsurgicalprocedures.Ina laparoscopictask,skillbasederrorsinvolveddropped objectsandobjectsplacedinaccuratelyinthedisc eitherontheirsideorincompletelywithinthezone; knowledgebasederrorsoccurredwhenobjectswere placedinthewrongzone(Moorthyetal.,2003).

Numberoferrorsina surgicaltask(taskerror score)(Moorthyetal., 2003;Pluyteretal.,2010)

Surgerysimulationsystem XitactLC3.0virtualrealitysimulator(XitactSA,Morges, Switzerland).Theclipandcutassessed(CCA)taskintheClip andCut(C&C)modulewasused.Taskerrorswererecordedby thesimulator(Pluyteretal.,2010).

Transport,patientintra hospitaltransport

Medicalandoperationaldata Transportofpatientswithinthehospital(Ulrich&Zhu, Numberofpatient 2007) transportsbetweennursing DatacollectedfromTransitionSystem,Inc.(TSI)by VanderbiltUniversityMedicalCenter,Nashville,TN(Hendrich, units/month(Hendrich, Fay,&Sorrells,2004). Fay,&Sorrells,2004).

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HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary Medicalerrors:Articleanalysis
Environmentalfeature Variable Booker,J.M.,&Roseman,C.(1995).Aseasonal Lengthofdaylight patternofhospitalmedicationerrorsinAlaska. PsychiatryResearch,57 (3),251257. Reference Metric Averagehoursofdarknessforeach month(hr,datafrompublicweather service) Outcome Variable Medicationerrors(omission, wrongtime,wrongpatient,wrong dose,wrongmedication,errorin transcriptionofphysician'sorder, allergicmedication,repeated medication,wrongrouteof administration,medication discontinuedwithoutphysician authorization) Studydesign Results Setting Metric #oferrorspermonth(errorreporting Observationalstudy, Thenumberoferrorspermonthwaspositively A140bed associatedwiththeaveragelengthofdarkness acutecare correlational formcompletedbythenurse analysis committingtheerrorand/orstaff hospitalin twomonthsearlier. discoveringtheerror) Alaska Sample 262medicationerrorsby nursesina5yearperiod

Buchanan,T.L.,Barker,K.N.,Gibson,J.T., Illuminationlevel Jiang,B.C.,&Pearson,R.E.(1991). Illuminationanderrorsindispensing.American JournalofHospitalPharmacy,48(10),2137 2145.

Threelightinglevelsbymanipulating Prescriptiondispensingerrorrate Numberofprescriptionsdeviatingin oneormorewaysfromprescriber's supplementallightingfixtures(no supplementalfixtures45ftc,two writtenordersdividedbythetotal standard4footfluorescentlighting numberofprescriptionscheckedby fixtureswithcolorfilter102ftc,and eachpharmacistandreviewedbythe withoutcolorfilter146ftc);lighting observer levelmeasuredusingphotometer #ofinterruptionsanddistractionsper Prescriptiondispensingerrorrate #ofdispensingerrorsperpharmacist Flynn,E.A.,Barker,K.N.,Gibson,J.T.,Pearson, Interruption(thecessationof R.E.,Berger,B.A.,&Smith,L.A.(1999). perhalfhour; productiveactivitybeforecurrent pharmacistperhalfhour(videotape Impactofinterruptionsanddistractionson #ofprescriptionsinvolvederrors prescriptionfillingtaskwas review) dispensingerrorsinanambulatorycare dividedbythetotal#ofprescriptions completedforanyexternally pharmacy.AmericanJournalofHealthSystems imposed,observable,oraudible (%,filledprescriptionsevaluatedby Pharmacy,56 (13),13191325. researchertodetectdeviationsfrom reason); physician'sorders) Distraction(anexternalstimulus followedbythepharmacist continuingproductiveactivity whilerespondingtothestimulus inamannerthatwasobservable) Flynn,E.A.,Barker,K.N.,Gibson,J.T.,Pearson, Frequencyofunpredictable, R.E.,Smith,L.A.,&Berger,B.A.(1996). controllable/uncontrollable Relationshipsbetweenambientsoundsandthe sounds; accuracyofpharmacists'prescriptionfilling Soundlevel performance.HumanFactors,38 (4),614622. Prescriptiondispensingerror #ofunpredictable/controllable/ uncontrollablesoundsperminute (videotapereview); Equivalentsoundlevel(Leq)pereach halfhour(noiseloggingdosimeter) Whetherornotoneormore dispensingerrorsexistinselected prescriptionset

Experiment,within Pharmacistsmadesignificantfewererrorsin dispensingprescriptionswhenilluminationlevel subjectrepeated washigh(146ftc,2.6%)thanwhenthe measurements illuminationlevelwasrelativelylow(3.8%).

Anoutpatient Fivepharmacists pharmacyina acutecare Armyhospital

Observationalstudy, Thenumberofinterruptionsanddistractions perhalfhourwaspositivelyrelatedtothe correlational analysis numberofdispensingerrorsperhalfhour. Sourcesofinterruptionsanddistractions includedunrelatedtraffics,prescription processingquestions,etc.Itwasrecommended toeliminatetrafficfromotherareasby relocatingtheambulatorycarepharmacy, providingvisualbarriersaroundthepharmacy, orreroutingtraffictoanentrancethatdoesnot requirepassagethroughtheambulatorycare pharmacy. Observationalstudy, Unpredictableandcontrollablesoundsmight haveaarousaleffectandreduceddispensing repeated errors.Theerrorrateincreasedtoapointthen measurements decreasedwhenequivalentsoundlevels withinsubjects increased.

Anambulatory 14pharmacistsand10 pharmacyata technicians generalacute carehospital

Apharmacyat 31matchedpairsof ageneralacute prescriptionsetsby12 carehospital pharmacists

Flynn,E.A.,Dorris,N.T,Holman,G.T., Garnahan,B.J.,&Barker,K.N.(2002). Medicationdispensingerrorsincommunity pharmacies:Anationwidestudy.Proceedings oftheHumanFactorsandErgonomicsSociety 46thAnnualMeeting ,14481451.

Illuminationlevel; Soundlevel; Physicalconfigurationofdrug stockstorageshelves

Illuminationlevelabovevs.below94 ftc,measuredbyaSperScientificlight meter; SoundlevelrecordedbyaSper Scientificsoundmeter; Physicalconfigurationofdrugstock storageshelvesseparationandspace inbetweenitemsvs.tightlypacked itemsonshelves

Prescriptiondispensingerrorand #ofdispensingerrorsandnearerrors Observationalstudy Thephysicalconfigurationofdrugstockstorage 50pharmacies 5784prescriptions,91 nearerror(dispensingerrorrefers %ofdispensingerrorsandnearerrors errors,74nearerrors shelveswithseparationandspaceinbetween insixstates toanydeviationfromthe (undisguisedobservationtodetect drugitemswasassociatedwithfewercontent (chain, interpretableprescription deviationsfromphysician'sorders) errorsthantheconfigurationwithminimal independent, spacebetweenitems.Moreerrorsweremadein andhealth includingcontenterrors[incorrect pharmacieswithlowerlightinglevels.Higher system drug,form,quantity,andstrength] lightinglevelandlowersoundlevelwasalso pharmacies) andlabelingerrors[incorrect associatedwithhigherrateofdetectionof instructionsandinformation]; nearerrorreferstoanerror errorsbypharmacystaff. discoveredandcorrectedbythe pharmacystaff) #oftransports/month(medical records); #oferrors/patientdays(hospital's adverseeventreportingsystem) Comparisonofdata collected before/afterthe renovationof nursingunit Aftermovingtoacuityadaptablerooms,the numberofpatienttransportsbetweenunits decreasedby90%;theannualindexof medicationerrorsdecreasedby70%. Coronarycare 2yearsofdatabefore unit(critical renovationand3yearsof dataafter and progressive care)

Hendrich,A.L.,Fay,J.,&Sorrells,A.K.(2004). Acuityadaptableroom Effectsofacuityadaptableroomsonflowof patientsanddeliveryofcare.AmericanJournal ofCriticalCare,13 (1),3545.

Renovationofnursingunitby Patienttransportsbetweenunits; combiningtwoseparateunits(critical Annualindexofmedicationerrors careunitandstepdownunit)intoone acuityadaptableunit

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HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary
Reference Environmentalfeature Variable King,W.J.,Paice,N.,Rangrej,J.,Forestell,G.J., Computerizedphysicianorder &Swartz,R.(2003).Theeffectofcomputerized entry(CPOE) physicianorderentryonmedicationerrorsand adversedrugeventsinpediatricinpatients. Pediatrics,112 (3Pt1),506509. Outcome Studydesign Variable Metric Quasiexperiment; Rateofmedicationerror(reported #ofmedicationerrorsper1000 patientdays(adverseeventreporting Retrospective adverseeventinvolving database); medicationprescription, #ofADEsper1000patientdays dispensing,administration,or monitoring); (physicianreview) Rateofadversedrugevent(ADE,a medicationerrorresultinginan injurytothepatient) Errorscore(summationofallthe errorsforthetask) Simulated experiment,within subjectrepeated measurements Results Setting Sample 36103dischargesand 179183patientdays

Metric CPOEimplementedin2nursingunits, comparedwithotherunitsusinghand writtenorders

TheCPOEresultedintosignificantdecreasein Atertiary reportedmedicationerrorrates(4.48to3.13 pediatric errorsper1000patientdays)intheintervention hospital units.AftertheimplementationofCPOE,the medicationratewas40%lowerinthe interventionunitsthaninthecontrolunits.Only 18ADEswereidentified.NoeffectsofCPOEon ADErateweredemonstrated. Significantlymoreerrorsweremadeundernoisy Operating conditionthanquietcondition.Highnoiselevels rooms inoperatingroomsmayinducestressand increasesurgicalerrors.

Moorthy,K.,Munz,Y.,Dosis,A.,Bann,S.,& Darzi,A.(2003).Theeffectofstressinducing conditionsontheperformanceofa laparoscopictask.SurgicalEndoscopy,17 (9), 14811484. Pluyter,J.R.,Buzink,S.N.,Rutkowski,A.F.,& Jakimowicz,J.J.(2010).Doabsorptionand realisticdistractioninfluenceperformanceof componenttasksurgicalprocedure?Surgical Endoscopy,24 (4),902907.

Noise

Operatingroombackgroundnoise(80 Surgicalerror(skillbased, to85dB)vs.quietcondition knowledgebased)

13surgeonswithvarious levelofexperience

Distractions(popularsongs Distractingconditionvs.non combinedwithsocialconversation distractioncondition irrelevanttothesurgicaltaskand nonoptimallaparoscope navigation)

Surgicalperformanceofaclipand Taskscore,taskcompletion,task cutassessed(CCA)task errors,totaltime(measuredbythe simulator)

Surgicaltaskperformancedeclinedanderrors Operating Simulated experiment,within increasedsignificantlywhenasurgicaltaskwas rooms subjectrepeated performedunderdistractingcondition. measurements

12medicaltrainees

Poon,E.G.,Cina,J.L.,Churchill,W.,Patel,N., Abarcodeassisteddispensing Featherstone,E.,Rothschild,J.M.,...Gandhi, system;adedicatedmedication T.K.(2006).Medicationdispensingerrorsand repackagingcenterinpharmacy potentialadversedrugeventsbeforeandafter implementingbarcodetechnologyinthe pharmacy.AnnalsofInternalMedicine,145(6), 426434.

Implementationofthebarcode assisteddispensingsystemin3 configurations,buildingofthe dedicatedmedicationrepackaging centerduringtheconversionprocess

Targetdispensingerrors(errors thatthebarcodetechnologywas specificallydesignedtoaddress, includingwrongmedication, wrongstrengthordose,wrong formulation,expiredmedication); Targetpotentialadversedrug event(errorsthatcanharm patients) Dispensingerror(unordereddrug, extradose,wrongdose,omission, wrongtime,wrongrouteof administration,wrongform, wrongadministrationtechnique)

Targetdispensingerrorrate(%,direct Beforeafterstudy observationbyatrainedresearch pharmacist); Targetadversedrugeventrate(%, errorsreviewedby2boardcertified internists)

Aftertheimplementationofthebarcode system,ratesofdispensingerrorandpotential adversedrugeventdecreasedsignificantly. Systemconfigurationsthatrequiredscanningof everydosehadabiggerreductioninerrorsthan configurationthatdidnotrequirescanningof everydose.

About370,000medications Hospital pharmacyata 735bed hospital

Ros,H.&deVreezeWesselink,E.(2009). Computerizedphysicianorder ImplementationoftheCPOEsystem Reducingthenumberofdispensingerrorsby entry(CPOE);Abarcodeassisted andthebedsideassortmentpicking implementingacombinationofaCPOEsystem dispensingsystemusingabedside (BAP)trolley andabarcodeassisteddispensingsystem:The assortmentpicking(BAP)trolley BAPconcept.EJHPScience,15 (4),8692.

Dispensingerrorrate(#oferrors Beforeafterstudy dividedbythesumofalldoses (baseline, orderedandthenumberofunordered implementationof CPOE,andthen dosesgiven,expressedin%,direct implementationof observation) BAPtrolley) Observational Percentageofadministrationswith proceduralfailures(%,direct observationusingastructuredtoolon aPDA); Percentageofadministrationswith medicationerrors(%,comparisonof observationaldatawithmedical charts); Errorseveritymajorvs.minorerrors (researcherdeterminationbasedon5 pointseverityassessmentscale)

Thedispensingerrorratereducedby47%after theimplementationoftheCPOEsystem(from 3.1%to1.7%).BAPtrolleyresultedinan additionalreductionindispensingerrorsof49% (from1.7%to0.84%).ForBAPtrolley,awell protectedcordlessnetworkisneeded.

A36bed neurology wardinThe Netherlands.

Over12,500doses

Westbrook,J.I.,Woods,A.,Rob,Marilyn,I., Interruptions Dunsmuir,W.T.M.,&Day,R.O.(2010). Associationofinterruptionswithanincreased riskandseverityofmedicationadministration errors.ArchivesofInternalMedicine,170 (8), 683690.

#ofinterruptionsduringone medicationadministration

Medicationadministration proceduralfailurerate(%of medicationswithprocedural failures); Medicationadministrationerror rate(%ofmedicationswith errors); Severityoferror(fiveseverity ratinglevelandtwocategories majorandminorerrors)

Overall,proceduralfailuresoccurredin74.4%of TwoAustralian 4271drugadministrations medicationadministrations,anderrorsoccurred hospitals for720patients in25%ofadministrations.Theratesof proceduralfailuresandmedicationerrorsas wellaserrorseveritywerepositivelyrelatedto thenumbersofinterruptionspermedication administration.

MedicalErrors:ArticleAnalysis|2

HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary Medicalerrors:Matrixofrelationships
Variable Outcome Medication errors Adversedrug Medication administration event procedural Surgicalerrors Intrahospital patienttransfer

Environment feature

Distraction/Interruption Noise Lightfixture Illuminationlevel Daylight Acuityadaptableroom Barcodeassisteddispensing system Bedsideassortmentpicking(BAP) trolley Physicalconfigurationofdrug stockshelves Computerizedphysicianorder entry(CPOE)

Note:Cellsshadedingrayindicatetheexistenceofevidencesupportingrelationshipsbetweenenvironmentalfeaturesandoutcomes

MedicalErrors:MatrixofRelatioships|1