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dc.contributor.authorJones, MD
dc.contributor.authorClarke, J
dc.contributor.authorFeather, C
dc.contributor.authorFranklin, BD
dc.contributor.authorSinha, R
dc.contributor.authorMaconochie, I
dc.contributor.authorDarzi, A
dc.contributor.authorAppelbaum, N
dc.date.accessioned2021-05-25T14:01:44Z
dc.date.available2021-05-25T14:01:44Z
dc.identifier.citationThe Annals of pharmacotherapy, 2021, pp. 1060028021999647 - ?
dc.identifier.issn1060-0280
dc.identifier.urihttps://repository.icr.ac.uk/handle/internal/4587
dc.identifier.eissn1542-6270
dc.identifier.eissn1542-6270en_US
dc.identifier.doi10.1177/1060028021999647
dc.identifier.doi10.1177/1060028021999647en_US
dc.description.abstractBackground In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs).Objective The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice (<i>discrepancies</i>) that contributed to large-magnitude and/or clinically significant MAEs.Methods Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study.Results In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs.Conclusion and relevance Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.
dc.formatPrint-Electronic
dc.format.extent1060028021999647 - ?
dc.languageeng
dc.language.isoeng
dc.rights.urihttp://creativecommons.org/licenses/by/4.0/
dc.titleUse of Pediatric Injectable Medicines Guidelines and Associated Medication Administration Errors: A Human Reliability Analysis.
dc.typeJournal Article
dcterms.dateAccepted2021-03-01
rioxxterms.versionVoR
rioxxterms.versionofrecord10.1177/1060028021999647
rioxxterms.typeJournal Article/Review
dc.relation.isPartOfThe Annals of pharmacotherapy
pubs.notesNot known
pubs.organisational-group/ICR
pubs.organisational-group/ICR
pubs.publication-statusPublished
pubs.embargo.termsNot known
dc.contributor.icrauthorDarzi, Araen


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