Outcomes of an interventional program for reducing intravenous medication errors at a General Hospital in Ho Chi Minh City
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Abstract
A pre-post intervention study was conducted on 45 nurses at a general hospital in Ho Chi Minh City in 2024 to evaluate the outcomes of the PRIME–JCI program in reducing intravenous (IV) medication errors. The results showed that the overall medication error rate significantly decreased from 83.3% to 46.7% (p < 0.001). Logistic regression analysis confirmed that the intervention helped reduce the risk of errors by approximately 5.6 times (OR = 0.18; p < 0.001). The complexity of errors improved markedly: before the intervention, 76% of unsafe acts contained 2 to 3 simultaneous errors, whereas after the intervention, 90.5% of unsafe acts involved only a single error. Nevertheless, preparation technique errors remained elevatedat 51.1%. The study concludes that the PRIME–JCI program is highly effective in reducing the frequency and complexity of medication errors in intravenous therapy, while emphasizing the need for additional systemic solutions to further mitigate medication errors.
Article Details
Keywords
Medication errors, intravenous therapy, PRIME program, patient safety, nursing
References
2. National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors [Internet]. [cited 2024 Dec]. Available from: https://www.nccmerp.org/about-medication-errors.
3. Gebremariam SN, Sema FD, Jara AG, et al. Medication error and associated factors among adults admitted to emergency ward at the university of Gondar comprehensive specialized hospital, North-West Ethiopia: a cross-sectional study, 2022. J Pharm Policy Pract. 2023;16(1):148. doi:10.1186/s40545-023-00616-2
4. Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ. 2003;326(7391):684. doi:10.1136/bmj.326.7391.684
5. Đỗ Văn Trang, Đỗ Hà Ngọc Trâm, Nguyễn Ngọc Duyên, và cs. Thực trạng sai sót trong sử dụng thuốc ở bệnh nhân được điều trị nội trú tại Trung tâm Y tế thị xã Bến Cát năm 2023. Tạp chí Y học Việt Nam. 2024;534(1). doi:10.51298/vmj.v534i1.8047.
6. Nguyen HT, Nguyen TD, van den Heuvel ER, et al. Medication Errors in Vietnamese Hospitals: Prevalence, Potential Outcome and Associated Factors. PloS One. 2015;10(9):e0138284. doi:10.1371/journal.pone.0138284
7. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. doi:10.1136/bmj.320.7237.768
8. Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(11):1045-1067. doi:10.1007/s40264-013-0090-2
9. Fell GL, O’Loughlin AA, Nandivada P, et al. Methods to Reduce Medication Errors in a Clinical Trial of an Investigational Parenteral Medication. Contemp Clin Trials Commun. 2016;4:64-67. doi:10.1016/j.conctc.2016.06.005
10. Giri J, Poojary A, Coto BS, et al. Preventing Risks of Infections and Medication Errors in IV therapy (PRIME): a patient safety initiative. Br J Nurs. 2023;32(14):S4-S12. doi:10.12968/bjon.2023.32.14.S4
11. Westbrook JI, Sunderland NS, Woods A, et al. Changes in medication administration error rates associated with the introduction of electronic medication systems in hospitals: a multisite controlled before and after study. BMJ Health Care Inform. 2020;27(3). doi:10.1136/bmjhci-2020-100170
12. Barker KN, Flynn EA, Pepper GA. Observation method of detecting medication errors. Am J Health-Syst Pharm AJHP Off J Am Soc Health-Syst Pharm. 2002;59(23):2314-2316. doi:10.1093/ajhp/59.23.2314
13. Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients. BMJ Qual Saf. 2021;30(4):320-330. doi:10.1136/bmjqs-2020-011473
14. Lý Khoa Đăng, Nguyễn Hương Thảo. Khảo sát tình hình chuẩn bị và thực hiện thuốc tiêm/tiêm truyền tại khoa Chăm sóc tích cực thuộc một trung tâm y tế tỉnh Bạc Liêu. Tạp Chí Học Thành Phố Hồ Chí Minh. 2020;24
15. Dubrofsky L, Kerzner RS, Delaunay C, et al. Interdisciplinary Systems-Based Intervention to Improve IV Hydration during Parenteral Administration of Acyclovir. Can J Hosp Pharm. 2016;69(1):7-13. doi:10.4212/cjhp.v69i1.1517
16. Koyama AK, Maddox CSS, Li L, et al. Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Qual Saf. 2020;29(7):595-603. doi:10.1136/bmjqs-2019-009552
17. Tsegaye D, Alem G, Tessema Z, et al. Medication Administration Errors and Associated Factors Among Nurses. Int J Gen Med. 2020;13:1621-1632. doi:10.2147/IJGM.S289452
18. Brabcová I, Hajduchová H, Tóthová V, et al. Reasons for medication administration errors, barriers to reporting them and the number of reported medication administration errors from the perspective of nurses: A cross-sectional survey. Nurse Educ Pract. 2023;70:103642. doi:10.1016/j.nepr.2023.103642
19. Westbrook JI, Li L, Hooper TD, Raban MZ, et al. Effectiveness of a “Do not interrupt” bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study. BMJ Qual Saf. 2017;26(9):734-742. doi:10.1136/bmjqs-2016-006123
20. Feleke SA, Mulatu MA, Yesmaw YS. Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC Nurs. 2015;14:53. doi:10.1186/s12912-015-0099-1
21. Bacon O, Hoffman L. System-Level Patient Safety Practices That Aim to Reduce Medication Errors Associated With Infusion Pumps: An Evidence Review. J Patient Saf. 2020;16(3S Suppl 1):S42-S47. doi:10.1097/PTS.0000000000000722