аЯрЁБс>ўџ 57ўџџџ4џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС №ПБbjbjрр-*‚j‚jќџџџџџџl```````tюююю њ tвддд8 ˆ” ˆ$ ?ц@`@``СЌ``ввФЦ``Ц №ТH;$УtzюО:ЦЦ з0Ц%ј %Цtt````йDevelopment of a framework to investigate intravenous medication errors Katja Taxis Centre for Pharmacy Practice, School of Pharmacy, University of London. Introduction Providing intravenous (IV) therapy to patients requires a complex health care technology and includes risks such as adverse drug reactions, thrombophlebitis, infections, and medication errors. The aim of this part of the PhD project is to develop a framework to explore causes of IV medication errors. Increasingly, medical accidents are investigated using human error theory. For example Vincent et al. 1 developed a framework using such an approach to explore risk and safety in clinical medicine. The framework distinguishes between latent and active failures: Latent failures originate at the organisational level and influence the conditions of work such as workload, supervision and communication and active failures include slips, cognitive failures and violations 1. Methods Vincent=№s model was adopted and tested for the analysis of IV medication errors. Case reports about IV medication errors were identified from records of hearings before the Professional Conduct Committee of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) and from files of the Medical Defence Union (MDU). MDU files contained statements of doctors about adverse incidents when they were seeking legal help from the MDU. Furthermore, qualitative interviews were carried out with a convenience sample of nurses, doctors and pharmacists about their experiences when prescribing, preparing and administering IV medication. The case reports and the interview data were used to describe, adopt and extend the categories of Vincent=№s framework. Results and Discussion Twenty-six case reports were analysed from the MDU and 7 case reports were analysed from the UKCC. Interviews were carried out with 14 nurses, doctors and pharmacists in 4 different hospitals. Latent failures at the organisational level of the hospital included lack of resources, clear guidelines and training. For example interviewees mentioned the lack of suitable clean areas for drug preparation or the lack of infusion devices for drug administration. A case report from the UKCC showed that ambiguous guidelines for the administration of syntocinon contributed to nurses administering the drug for too long to a pregnant patient causing distress to the foetus who subsequently died. Also the nurses had not been trained in using the new guidelines. The conditions of work caused problems, interviewees reported about the lack of qualified staff resulting in delay of IV drug administrations. Another factor was identified in MDU cases: Lack of supervision of inexperienced staff. A newly qualified junior doctor, with no experience in IV drug administration, flushed a patient=№s cannula with potassium chloride resulting in the immediate death of the patient. Other factors were lack of communication and problems with handling technology such as the failure to maintain equipment or insufficient knowledge about IV medication or administration equipment. Active failures were identified in MDU case reports where health care professionals selected the wrong syringe or line. Violations of accepted standards or guidelines such as the deliberate misuse of equipment was found in the MDU files as well. A doctor did not follow the manufacturer=№s guidelines when administering a bolus dose of propofol via infusion pump. He released the roller clamp and subsequently free flow of the drug occurred and the patient had to be resuscitated. Another important category was patients=№ or relatives=№ characteristics and behaviour. Like in a case where relatives pushed in a patient=№s syringe driver containing narcotics. Conclusion Interviews and case reports were successfully used to adopt a framework 1 to investigate likely causes of IV medication errors in hospitals. The data has shown that IV medication errors can be caused by multiple factors originating at several levels. The framework will be used in the next part of the study to analyse data obtained from observing IV drug preparation and administration in a hospital. Reference: 1 Vincent C, TaylorAdams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. British Medical Journal 1998;316:11541157. HIUžЊ8>?@пю'9n}ЏАВК   J Ю ь 0'вдю№”–фќŽ„›ЁЄАБ§іёщтктвтктктктвтщтЧтЧтщтктктЧтктЧтЧтЧтЧтщтвтёФРФМФЕ CJmH sH 5CJ6CJCJCJOJQJmH sH CJH*mH sH 6CJmH sH  CJmH sH 5CJmH sH mH sH  CJmH sH CJ5HIUžЋВГЛ  L фцўАБ§ћљєяяяяяяяяяяяяяяя$a$$a$Б§+0PА. АХA!А "А #S$ %АА А  i<@ёџ< Normal1$CJ_HhmH sH tHFA@ђџЁF Standardskrifttype i afsnit2&@ђџё2 Fodnotehenvisning2>@2 Titel$a$5mH sH u@J@@ Undertitel$a$5>*mH sH uќ*џџџџHIUЋВГЛТУкНОЪ\]ў˜€€˜€€˜€€˜€€š€€˜€€˜€€˜€€š€€˜€€˜€€š€€˜€€˜€€š€€˜€€š€€БББIN7GЛФ ­Жћ     ? 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