University of Alberta, College of Health Sciences, Edmonton, Alberta, Canada.
Sr Care Pharm. 2022 Sep 1;37(9):421-447. doi: 10.4140/TCP.n.2022.421.
To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Retrospective incident report review. A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. None. Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%, 43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8% (30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Administration and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.
描述尽管使用了电子用药管理记录和条码辅助用药管理（eMAR-BCMA），长期护理机构（LTCF）仍发生的报告用药事件的频率、类型和严重程度。该研究还使用已建立的 BCMA 规避分类法分析了员工规避措施对报告用药错误（MAE）的贡献，确定 eMAR-BCMA 技术是否促成了 MAE，并探讨影响事件严重程度的特征。回顾性事件报告审查。加拿大艾伯塔省的一家 239 张床位的长期护理机构，于 2013 年实施了 eMAR-BCMA。2015 年 6 月至 2017 年 10 月自愿提交的 270 份纸质用药事件报告。无。264 例居民特定用药事件中，216 例（83.0%，216/264）发生在管理或配药阶段，75 例（28.4%，264/264）导致暂时伤害。用药遗漏（43.7%，83/190）和时间错误（22.6%，43/190）是最常见的 MAE 类型。规避措施发生在 41.1%（78/190）的 MAE 中，最常见的是在用药前记录管理（44.9%，35/78）。非规避 MAE 中，52.7%（59/112）与 eMAR-BCMA 技术无关，26.8%（30/112）涉及系统设计缺陷，最明显的是在管理期间缺乏要求扫描每个用药袋。涉及规避措施的 MAE 不太可能影响居民（74.4%比 88.8%；相对风险=0.84，95%CI 0.72-0.97）。管理和配药错误是报告最多的用药事件。eMAR-BCMA 规避措施和设计缺陷在很大比例的报告 MAE 中涉及。需要注意优化 eMAR-BCMA 的使用和设计，以促进长期护理机构的用药安全。
