TABLE 3.
Systemic Defenses, Evidence Quality, Key Findings, and Statistical Significance of the Findings in the Included Studies (n = 46)
| Systemic Defense and Evidence Quality | Key Findings (Statistically Significant/Not Significant or Significance Not Reported) |
|---|---|
| Prescribing (n = 8) | |
| CPOE and CDSS (n = 2) | |
| Targeted alert for IV haloperidol (versus no alert) L70 | Decreased inappropriate prescribing (50% versus 14%; average of 4.1/mo to 1.5/mo)70 |
| Pediatric resuscitation orders (versus handwritten orders) L56 | Reduced time to order completion (14 min 42 s versus 2 min 14 s) and elimination of errors (3 versus 0)56 |
| Online dosing calculators and CDSS (n = 2) | |
| Complex dosing for obese patients (versus manual) L46 | Decreased frequency calculation errors (12.8% versus 4%) and prescribing errors (43% versus 20%)46 |
| Pediatric continuous infusions (versus manual) L52 | 83% fewer orders containing ≥1 errors (55% versus 6%) and elimination of high-risk errors (26% versus 0%)52 |
| Standard order form (n = 2) | |
| Pediatric resuscitation room (versus before) M44 | Increased order completeness (5% versus 33%) and decreased prescribing errors (15% versus 6%)44 |
| KCl infusions (versus before) M60 | Decreased postinfusion serum potassium elevations (7.7% versus 0%) and infusions administered to patients with high serum potassium (2.9% versus 0.0%)60 |
| Order verification by pharmacist present (n = 1; versus in hospital pharmacy) L47 | Patients received appropriate first antibiotic 93.4% of the time (versus 86.3%) and second 96.8% of the time (versus 83.3%). Time from order to verification for the first 2 doses was shorter (10.5 min versus 11.4 min).47 |
| Multidisciplinary intervention to improve IV PPI prescribing* (n = 1; versus before) L45 | In 2 patient groups, 26% and 41% reduction in patients without an appropriate indication45 |
| Dispensing (n = 1) | |
| CPOE infusion orders with standard concentrations (versus handwritten orders versus handwritten orders with errors; n = 1) L53 | Infusions processed from CPOE orders contained fewer errors (4% versus 26% versus 45%). Processing CPOE orders required less time.53 |
| Preparation (n = 6) | |
| Compounding workflow software (n = 2) | |
| Automated workflow management system (no comparison) L54 | Total error rate of 0.74%, of which the system detected 72.27% of errors (incorrect drug/diluent), and pharmacist’s inspection of 27.73% (wrong volume/damaged product) 54 |
| Gravimetric workflow software system (versus manual compounding) L55 | Higher error rate detected by the system (7% versus 0.096%). Barcode scanning detected 26% of the total errors; the gravimetric weighing, 71%; and vial reconstitution, 3%. 55 |
| Automated infusion production in pharmacy (n = 1; versus ward-based preparation) L48 | The mean concentration was closer to the target in machine-made solutions (101.1% versus 97.2%). Decrease in ≥5% (53% versus 16%) and >10% (22% versus 5%) deviations48 |
| Prefilled syringes for emergency situation (n = 1; versus preparing drug infusions at the bedside) L49 | Decreased time for the infusion to be started (276 s versus 156 s, a mean delay of 106 s). Errors were 17.0 times less likely with prefilled syringes. Infusions prepared by pharmacy and industry were more likely to contain the right concentration.49 |
| Standard concentrations, preparation protocols, and education (n = 1; versus before) L50 | Accuracy error rate decreased both in NICUs (54.7% versus 23%) and hospital pharmacy (38.3% versus 14.6%). Calculation errors decreased in NICUs (1.35% versus 0%). No calculation errors in hospital pharmacy samples50 |
| Automated quality check with tabletop-enhanced photoemission spectroscopy for IV admixtures (n = 1; no control) L71 | The device detected errors departing from the targeted concentration ≥20% with a sensitivity of ≥95%. Specificity in distinguishing among test medications at targeted concentrations was 100%. 71 |
| Administration (n = 24) | |
| Smart infusion pumps (n = 11) | |
| Systematic review of benefits and risks of smart pumps (n = 1) H24 | Smart pumps with only soft limits51,66,67 and both hard and soft limits42,58 are unlikely to reduce IV medication errors. In uncontrolled studies, 4.8%–14% of soft alerts led to averted errors.62,63,65 |
| Smart pumps with drug library (versus drug library off; n = 1) M67 | Decrease in wrong patient errors with smart barcode pump (88% versus 58% versus 46%) and wrong dose hard limit errors with smart pump and smart barcode pump (79% versus 75% versus 38%).66 |
| Smart pumps with drug library (versus conventional pumps; n = 3) L40,42,51 | Implementation of standard concentrations, smart pumps, and new labels resulted in a 73% reduction in error rate (0.8 versus 3.1/1000 doses, an absolute risk reduction of 2.3/1000 doses).40 |
| Smart pump with barcode (versus smart pump versus conventional infusion pump; n = 1) L66 | Decreased incidents related to changeover of vasoactive infusions (20% versus 11%).58 |
| Automated changeover of vasoactive drug infusion pumps (versus manual changeover; n = 1) L58 | According to a systematic review, the benefits of smart pumps are intercepting errors (e.g., wrong rate, dose, or pump settings), reduction of adverse drug events, practice improvements, and cost-effectiveness. Issues related to smart pumps were lower compliance rates, the overriding of soft alerts, nonintercepted errors, and the possibility of using the wrong drug library. 24 |
| Smart pumps with drug library (n = 3) L62–64 or electronic medical record smart system to notify of pump programming errors (n = 1) L65 (no comparison) | The compliance in drug library use reported in the studies has been variable and insufficient (62%–98%). 24,63,64,67 |
| Color-coded safety systems (n = 3) | |
| Color-coded prefilled syringes for pediatric resuscitations (versus before) L39 | Decreased time to medication administration (47 s versus 19 s) and decrease in critical dosing errors (17% versus 0%).39 |
| Pediatric emergency system* (versus before) L36 | Error reduction in dose conversion (25.6% versus 2.5%), dilution (35.6% versus 0.63%) and administration (54.7% versus 3.9%). Reduced median time to task completion (109 s versus 28 s).36 |
| Color-coded labels for emergency infusion fluids (versus before) L37 | Time improvement in all scenarios. Decreased wrong fluid errors (13 versus 0).37 |
| Anesthesia safety system (n = 2)† (versus before intervention) H,35 M43 | Decreased overall error rate (11.6 versus 9.1 errors/100 administrations). Lower error rate when barcode scanning before administration and keeping the voice prompt active were applied than when not applied (6.0 versus 9.7 errors/100 administrations).35 |
| Decreased errors (0.049% versus 0.032%; a relative reduction of 35%) and major adverse outcomes from errors (0.002% versus 0%).43 | |
| Standard operating procedure to prevent IV incompatibilities (n = 2; versus before) L68,69 | Reduction of incompatible drug pairs (5.8% versus 2.4%) and incompatible drug pairs that were governed by the new procedure (1.9% versus 0.5%).68 |
| Administration guidelines (n = 2) | Decrease in incompatible pantoprazole combinations (100.0% versus 56.2%).69 |
| Checklist to detect errors (versus old checklist) L33 | Increased overall error detection (38% versus 55%) and detection of identification errors (80% versus 15%). No significant difference in error detection related to pump programming, mismatch or clinical decisions.33 |
| Algorithms for pediatric chemotherapy (no control) L73 | The agreement in Delphi validation was 92.8%–99.0%. The algorithms are valid to prevent and manage antineoplastic agents’ extravasation. 73 |
| CPOE-generated infusion orders with standard concentrations (n = 1; versus handwritten orders) L57 | Nurses were able to check the accuracy of pump settings in less time (6 min 18 s ± 2 min 26 s versus 8 min 47 s ± 3 min 6 s), but CPOE did not improve the ability to detect pump programming errors.57 |
| Barcode drug verification (n = 1) (versus 2-person confirmation) L72 | Both methods were perceived to contribute to the prevention of errors, but barcode scanning is more feasible. There are limitations related to 2-person confirmation (e.g., continuous presence of the second person, no distraction, or time pressure). 72 |
| Calculator to convert orders to volumes and administration rates (n = 1; versus no intervention) L34 | Increased medication volumes calculated and drawn accurately (91% versus 61%) and correct recall of essential medication information (97% versus 45%), better recognition of unsafe doses (93% versus 19%). Reduced calculation times (1.5 min versus 1.9 min)34 |
| Interventions to prevent errors caused by interruptions‡ (n = 1; versus no interventions) L32 | Decreased error rate when interrupted during verification of syringe drug volumes (89% versus 58%), verification of drug volumes programmed in ambulatory pumps (94% versus 58%), IV push (89% versus 32%), and pump programming (39% versus 5%)32 |
| Treatment monitoring (n = 2) | |
| CPOE and CDSS (n = 2) | |
| IV insulin protocol (versus manual protocol) L74 CPOE set for IV haloperidol treatment monitoring (versus before) L75 | Reduced time from first glucose measurement to insulin initiation (2–3 d versus 12 h). Improved amount of all glucose readings in ideal range (29.3% versus 37.7%) and time spent in ideal range by patients on IV insulin for >24 h (116 min/d)74 |
| Patients were more likely to have 24-h cumulative dose <2 mg (47.8% versus 64.3%), baseline ECG (65.5% versus 80.6%), follow-up ECG within 24 h of administration (25.2% versus 58.5%), and Mg value assessed at time of administration (51.2% versus 74.6%).75 | |
| Standardization of high-risk medication use process (n = 5) | |
| Interdisciplinary intervention to increase dilution of IV acyclovir (versus before) L76 | The median volume in which the acyclovir dose was administered was significantly higher in the postintervention group (250 mL versus 100 mL).76 |
| Safety intervention in IV potassium use (versus before) L61 | The number of incidents was significantly reduced from 23 to 9, and the number of ampoules dispensed was reduced from 10, 100 to 0.61 |
| Computerized continuous IV insulin protocols for tight glycemic control (versus paper protocol) L38 | Fewer errors in the titration (13 versus 113) and transition phases (9 versus 23), fewer dosing errors in the initiation phase, and less time to complete the titration (6 versus 9.5 min)38 |
| PCA safety intervention (versus before) M41 | The odds ratio of a PCA error after intervention was 0.28 (95% CI, 0.14–0.53) and the odds ratio of a pump-programming error was 0.05 (95% CI, 0.001–0.30).41 |
| CDSS, CPOE, and PCA smart pumps (versus before) M59 | Decrease in PCA events detected by automated surveillance (22%; 4.2 versus 5.3/1000 PCA days) and voluntary report system (72%; 0.66 versus 2.4/1000 PCA days)59 |
Italics to indicate if the results were not statistically significant or significance was not reported.
Evidence quality: L, low; M, moderate; H, high.
*Color-coded weight zones, precalculated doses, and directions for administration, preparation, and monitoring.36
†Drug trays and trolley, prefilled syringes, color-coded labels, barcode drug verification and administration record, and safety alarms.35,43
‡Verification: verification booth, standard workflow, and speaking aloud; administration: visual timers for IV pushes, no interruption zones, speaking aloud, and reminder signage.32
CDSS, clinical decision support system; ECG, electrocardiogram; IV, intravenous; NICU, neonatal intensive care unit; PCA, patient-controlled analgesia; PPI, proton pump inhibitors.