Title : "Bedside timeout": A novel method for medication preparation and administration error detection - A pilot study
Abstract:
Background: Medication preparation and administration errors are common in healthcare systems, particularly in pediatric intensive care units (PICUs). We sought to develop a simple method to detect such errors in order to better evaluate their frequency and develop prevention strategies.
Methods: This study was conducted in a 15-bed PICU at a tertiary care center. An observer approached nurses immediately prior to medication administration and reviewed the preparation and administration process in real time. Errors were recorded and categorized by severity as non-harmful, requiring monitoring, or harmful. Observed error rates were compared with rates of reported errors and near-misses submitted to the hospital’s risk management department.
Results: Among 100 observations, 19 errors (19%) were identified, including 13 preparation errors and 6 administration errors. The most frequent errors were incorrect dosing (8%) and wrong patient (4%). Eleven preparation errors were intercepted during routine double-check procedures, leaving 8 errors (8%; 2 preparation and 6 administration) that were close to reaching the patient but were prevented by the observer. Four of the 19 errors (21%) were classified as harmful. The observed error rate was significantly higher than the rate of reported errors and near-misses during the same period (19% vs. 0.15%, p<0.001). No significant differences were found in patient or nurse characteristics between observations with and without errors.
Conclusion: In this pilot study, we introduce “bedside timeout,” a straightforward direct-observation method for detecting medication preparation and administration errors. Further studies are needed to validate its effectiveness and applicability.
