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When it comes to closed-loop medication administration, the final step is the most perilousIn this three-part series on medication administration, HCI looks at the information exchange points in the process where errors are most likely to be made.
Bedside administration is the last line of defense in preventing medication errors — and the place where most of them slip by. But before that final scan and click by the nurse, there are a lot of pieces involved — and a lot of processes. Joan Roscoe, CIO of six-hospital Valley Health in Winchester, Va., has seen big improvements since she started using bedside barcode scanning. Kathleen LePar, vice president of professional services at Beacon Partners, says new construction is a great place to start.
Dosing errors are the most common type of pediatric drug errors, with over-dose outnumbering under-dose errors. Results indicate that the over-all usability of the iDC was high (91.1) as compared to a benchmark of 68. The iDC proved to be safe and effective as a support for drug calculations when used in a simulated clinical environment. Technology in general, and computer-assisted computations in particular, can mitigate the disruptive impact of problematic work conditions, such as the interruptions and distractions that are a common occurrence in a busy clinical environment (Sharp, Preece, & Rogers, 2006).
The independent double check has been proposed as an intervention that can effectively detect and avert medication errors at the point-of-care. The simulation experiment involved 18 paediatric case scenarios which focused on postoperative care and pain management.
A within subjects crossover design was used with an experimental group (iDC) and a standard practice group (PPC), with three sets of conditions (errors, with interruptions, and control). Information about participant age, gender, and year of study in the nursing program was collected.
The SUS is a 10-item scale that assesses subjective perception of usability (Brooke, 1996). A subjective measure of perceived helpfulness of the visual aids, features and functions of the iDC was developed by the study authors.
Participants’ confidence in the accuracy of drug dose calculations and preparation was measured with a 6-item questionnaire.  Responses were on a 5-point Likert scale and ranged from strongly disagree to strongly agree. The experimenter activated a timer the moment the participant started reading the case scenario and stopped the timer when participants placed the morphine syringe on the medication administration tray indicating that it was ready to be administered to the patient. Six patient scenarios contained under or over-dose errors.  Participants were expected to detect these errors and choose not to administer the dosage to the patient until they consulted with the physician (similar to what they would do in a real clinical setting). The iDC was installed on two tablet computers to be used by the participant and the ‘double checker’. Participants were provided with a pencil, blank sheets of white paper and a calculator for the standard practice method of drug calculation.
Data collection for this study took place in the nursing simulation lab which provided an environment similar to a hospital room with beds, cribs, manikins, automated medication dispensing cabinet and other medical equipment. After approval of the study protocol by the University Research Ethics Board, students were recruited into the study. Participants prepared the morphine dose just as they would in a clinical situation and the master’s student simulated performing the independent double check. The overall SUS score is scored out of 100 and has two components: usability and learnability.
Visual aids such as the images of the patient’s height, the standard dose and therapeutic range, error warnings and the images of the vials and syringe were scored for helpfulness on a 1 to 5 scale and compared to a neutral score of 3. Participants were equally confident using the iDC or the PPC method to do the calculation components of the double check. A repeated measures ANOVA was used to compare the time it took to do the double check when using the iDC or the standard method. No significant differences were found when comparing the amount of errors detected when using the iDC versus PPC. Participants scored 0 if they needed to redo the calculation after the interruption and 1 if they did not need to start again.
A working prototype of the iDC, a graphic dose calculator, was designed to assist nurses with the calculation and verification components of preparing IV bolus morphine for pediatric patients. The primary design principle of the iDC was to present the required information in a visual, graphic format and not rely solely on alphanumeric data items as would be seen on a calculator.
Users responded favorably to the iDC over-all and to the specific graphical components of the interface. A primary aim of the simulation study was to demonstrate that the iDC was equally as safe and accurate as the standard PPC method of calculating a pediatric morphine dose.
Furthermore, the importance of providing adequate support to nurses performing drug calculations was illustrated by the initial difficulties students experienced performing the independent double check.
Even when provided with the formula to use for the calculations many students were hesitant to proceed with the calculation. The study involved 18 patient scenarios and the act of doing these calculations in succession over a 45-60 minute period was a useful exercise for the students.
In June, our first installment looked at the initial patient encounter and physician order. According to a 2008 HCI webinar, (see graph) 98 percent of medication errors that occur at the bedside reach the patient — as opposed to only 50 percent of errors made in the initial ordering. Once packaged and bar coded, the meds come to the floor in a Pyxis (from Cardin Health, Dublin, Ohio) cart interfaced with McKesson. In 2007, when we opened a new six-story patient tower on our north campus, we decided to put a computer in every patient room and open the hospital with nurses using bar-coded administration. Weight-based calculations are essential for proper dosing but complex in pediatric settings where patient weights may vary from 0.5 kg for a premature newborn to over 100 kg for an obese adolescent.

Participants detected errors equally with the PPC and the iDC but completed the calculation slightly faster with the iDC when the scenario contained an error. The results of this study enabled us to plan a follow up field study to test the iDC in a pediatric emergency department and post surgical care unit. The Institute for Safe Medication Practices (ISMP) defines the independent double check as a process whereby two nurses independently verify the patient, drug concentration, drug, dose, time and route. A counter-balanced design was used to ensure each participant received the same scenarios with dosing errors, interruptions, or neither (control) in a different order. The interface of the iDC uses blue, green and red to convey important dose information so participants were asked if they had problems distinguishing colours and if they were ever diagnosed with colour blindness.
The tool was based on a questionnaire addressing specific features and functions of the iDC on a scale from 1 (not helpful) to 5 (very helpful).
During error scenarios, the simulation ended when the participant detected the error and verbally stated that they needed to consult a physician about the prescribed dosage.
While participants were engaged in the drug calculation they were interrupted with a question specific to their patient or the clinical environment (e.g.
Information on the iDC interface is organized into three panels designed to be viewed from left to right. The formula for calculating the proper dose was posted on the wall directly in front of the medication preparation station. Participants were provided with all the equipment and supplies needed to prepare a dose of IV bolus morphine which took place at the medication dispensing cabinet. Upon arrival to the simulation lab, participants signed an informed consent and were administered the demographic questionnaire. When participants detected an error they would stop and provide instructions as to what should happen next (e.g. In addition, this SUS score is compared with a benchmark which indicates whether the score is above or below the average. Integrating the iDC into the independent double check process represents a practice change with the potential to introduce error. Results of this study indicate there were no significant differences in the number of errors detected when comparing the iDC to the PPC. During the pilot testing it became clear that participants were uncomfortable or unable to calculate the morphine dose.
Since the students spoke aloud during the simulations we were able to gain insight into how they were problem solving, recovering from interruptions, detecting errors and generally gaining confidence, speed and comfort with all components of the independent double check.
By conducting the study in a nursing simulation lab, we were able to manipulate the independent double check by introducing errors and interruptions without comprising patient safety. National collaborative: Top 5 drugs reported as causing harm through medication error in paediatrics. Hospitals are using a variety of systems to do this, whether they use a core vendor for most of the steps or not.
Roscoe now uses McKesson (Alpharetta, Ga.) as her core vendor for CPOE, charting, pharmacy and medadmin, which including nursing documentation.
Medication orders show up in the nurse's queue for administration, and the nurse bar codes both the patient's wristband and the nurse ID badge using a handheld device. We wanted to be paperless, as automated as possible and as clinically safe as we could be,” says Wolff. Participants preferred the iDC as compared to the PPC and were more confident performing the dose calculation without hesitation.
The iDC was developed in collaboration with professionals from nursing, pharmacy, information technology and human factors engineering. The dependent variables consisted of speed, error recognition, recovery after interruptions, system usability, perceived helpfulness, preference and confidence levels with the iDC versus the PPC method.
Further information was gathered about computer usage and degree of comfort with computer technology. Items are scored on a 5 point Likert scale with descriptors strongly disagree and strongly agree.
Participants were asked to respond to 5 questions about the helpfulness of visual aids such as the height of the patient, standard dose scale, written calculation, error warnings, and images of the vial(s) and syringe. However, if the error went undetected, the scenario ended when the participant placed the syringe on the medication tray. Patient weight and morphine dose are entered into two text boxes at the far left of the screen (refer to figure 1). Participants were then provided with a training scenario that served as a refresher on how to prepare IV bolus morphine and perform the double check. No participants reported being diagnosed with color blindness nor had difficulty distinguishing color.
By assessing 446 studies and over 5000 individual SUS responses in previous studies, a global benchmark of 68 was suggested by Sauro (2011).
Participants preferred the iDC as a general support for dose calculations, for the speed of dose calculations, as an accurate measure for dose calculations, as a support when detecting errors, and as a support during the double check (see Table 2). Consequently, phase one testing was completed in a simulated patient setting to ensure that the iDC is at least as safe and effective as the standard method of drug calculation which is typically a calculator, paper and pencil. 2002).This is particularly relevant in work contexts in which there are many distractions and interruptions, while the user is still required to perform the task accurately and efficiently. In addition, participants were more confident performing the calculation without hesitation using the iDC and the iDC proved to be more efficient as reflected in the shorter duration of scenarios with errors.
A post-study debriefing was carried out to highlight errors and clarify the calculation steps.
Testing the usability and the attributes of the iDC in an environment similar to a healthcare setting provided insight into the usability and applicability of the tool in high stress environments where nurses work.

Medication errors in children: a descriptive summary of medication error reports submitted to the United States Pharmacopeia. In our final installment below, we turn to the last step in medication delivery — the bedside transmission of drugs from nurse to patient. The McKesson software matches both to the order and drops a bill into the McKesson billing system upon administration. High alert drugs are those that bear a heightened risk of errors causing significant harm (ISMP, 2008).  Pediatric drug calculations are typically weight-based and nurses administering medications ascertain the accuracy and appropriateness of the dose using the patient’s weight (Conroy, Sweis, Planner, et al. Six of the 18 scenarios had errors that were either an under-dose or an overdose, and 6 of the scenarios included interruptions to the process of dose calculation. Participants were asked about their degree of confidence in drug calculations, degree of anxiety with drug calculations, and perceived difficulty with drug calculations. The scores for each question are multiplied by 2.5 and final SUS score can range from 0 to 100, where higher scores indicate better usability. Two questions about ease of error recovery and the iDC as an accurate method to prepare IV bolus morphine were also scored on a 1 to 5 scale. If the scenario had an interruption, the observer introduced the interruption in the form of a question while the participant was performing the dose calculations. In addition there was no difference between third and fourth year students with respect to their ability to recover from interruptions.
In addition, the study results provided us with information about the applicability of the iDC for use with nursing students. This visual graphic approach has been implemented in many other High Reliability Organizations such as aviation and the nuclear power industry. The iDC is highly usable (‘user friendly’) and was preferred by participants over the standard PPC method of calculation. Students were unprepared to do the drug calculations, despite lab training and experience in a clinical setting with drug calculations and the independent double check. Limitations include the potential for limited generalizability as the participants were students and had very limited experience with medication administration and preparation of high alert drugs.
A graphic object display     improves an anesthesiologist’s performance in a simulated diagnostic  task.
Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. A cognitive systems perspective on human performance in the pharmacy: implications for accuracy, effectiveness and job satisfaction. Medication errors in a pediatric teaching hospital in the UK: five years of operational experience. An integrated graphic display improves detection and identification of critical events during anesthesia. These include cost of implementation of the system, resistance to the system by ICU physicians and nurses, and integration of data systems and clinical information into the remote electronic ICU model. Phase 1 testing of the iDC took place in a nursing simulation center with third and fourth year baccalaureate nursing students.
The center panel provides information about the appropriateness of the dose as compared to the standard and about the size of the child based on the weight entered and compared to a background image of 180 cm. The participant moved away from the medication preparation station and consulted a booklet for the answer to the question then resumed drug preparation. Aircraft cockpit displays and nuclear power control rooms incorporate multimodal display information to facilitate better monitoring, control, and decision making (Wickens, Lee, Liu, & Gordon-Becker, 2004). Participant’s positive response to the iDC visuals were reflected both in their comments and in their scores on the helpfulness questionnaire. Taken together, these results indicate that the iDC is at least as safe and accurate as the standard method and is ready to be field tested in a clinical setting. The usability of the iDC and the helpfulness of the particular components of the interface might be different when used by experienced nurses in a clinical environment. Visual display  format affects the ability of anesthesiologists to detect acute physiologic  changes.
In this chapter, we will provide background information on error reduction theory and the role of the remote ICU model, review current data supporting use of the remote ICU system, address the current obstacles to effective implementation, and look to the future of the field for solutions to these challenges. Phase 2 testing will take place in a pediatric hospital on a post surgical unit and the emergency department.
Weight-based calculations are essential for proper dosing but complex in pediatric settings where patient weights may vary from 0.5 kg for a premature newborn to over 100 kg for an obese adolescent (American Academy of Pediatrics, 2003). A score of 0 was noted if they returned to the calculation without obvious difficulty and 1 if they restarted their calculations after the interruption. The third panel provides a visual image of the number of vials of morphine to use and a visual image of the correct amount of drug in the appropriate syringe. A one-sample t-test was used to compare the overall usability score with the benchmark value of 68.
Prepared for the Division of Risk Analysis and Applications, Office of Nuclear Regulatory Research, U.S.
The debriefing involved an overview of participants’ performance and feedback about any performance errors that may have occurred during the simulation in order to clarify misunderstandings and to take advantage of a ‘teachable moment’.

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