Medication Administration Errors in Nursing Homes Using an Automated Medication Dispensing System

• Published in: Journal of the American Medical Informatics Association : JAMIA 2009-07, Vol.16 (4), p.486-492
• Main Authors: van den Bemt, Patricia M.L.A., Idzinga, Jetske C., Robertz, Hans, Kormelink, Dennis Groot, Pels, Neske
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Decision Support Systems, Clinical; Female; Humans; Male; Medical Order Entry Systems; Medication Errors - statistics & numerical data; Medication Systems; Netherlands; Nursing Homes - organization & administration; Observation; Original Investigation: Research Paper; Prospective Studies; Risk Factors; Robotics
• ISSN: 1067-5027; 1527-974X
• DOI: 10.1197/jamia.M2959

To identify the frequency of medication administration errors as well as their potential risk factors in nursing homes using a distribution robot. The study was a prospective, observational study conducted within three nursing homes in the Netherlands caring for 180 individuals. Medication errors were measured using the disguised observation technique. Types of medication errors were described. The correlation between several potential risk factors and the occurrence of medication errors was studied to identify potential causes for the errors. In total 2,025 medication administrations to 127 clients were observed. In these administrations 428 errors were observed (21.2%). The most frequently occurring types of errors were use of wrong administration techniques (especially incorrect crushing of medication and not supervising the intake of medication) and wrong time errors (administering the medication at least 1 h early or late).The potential risk factors female gender (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.05–1.83), ATC medication class antibiotics (OR 11.11; 95% CI 2.66–46.50), medication crushed (OR 7.83; 95% CI 5.40–11.36), number of dosages/day/client (OR 1.03; 95% CI 1.01–1.05), nursing home 2 (OR 3.97; 95% CI 2.86–5.50), medication not supplied by distribution robot (OR 2.92; 95% CI 2.04–4.18), time classes “7–10 am” (OR 2.28; 95% CI 1.50–3.47) and “10 am-2 pm” (OR 1.96; 1.18–3.27) and day of the week “Wednesday” (OR 1.46; 95% CI 1.03–2.07) are associated with a higher risk of administration errors. Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload.