Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review

References

• Crossman M. Technical and environmental impact on medication error in paramedic practice: a review of causes, consequences and strategies for prevention. J Emerg Primary Health Care. 2009;7(3):1–10.
   Google Scholar
• Roughhead L, Semple S, Rosenfeld E. Literature review medication safety in Australia. Sydney (Australia): Australian Commission on Safety and Quality in Health Care; 2013. TRIM D14-3207.
   Google Scholar
• Aronson JK. Medication errors: what they are, how they happen, and how to avoid them. QJM. 2009;102(8):513–21. doi:10.1093/qjmed/hcp052.
   PubMed Web of Science ®Google Scholar
• Reason J. Human error: models and management. BMJ. 2000;320(7237):768–70. doi:10.1136/bmj.320.7237.768.
   PubMed Web of Science ®Google Scholar
• Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, Tizzard A. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000;320(7237):777–81. doi:10.1136/bmj.320.7237.777.
   PubMedGoogle Scholar
• Vincent C, Amalberti R. Safety in healthcare is a moving target. BMJ Qual Saf. 2015;24(9):539–40. doi:10.1136/bmjqs-2015-004403.
   PubMed Web of Science ®Google Scholar
• Keers RN, Williams SD, Cooke J, Ashcroft DM. Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Ann Pharmacother. 2013;47(2):237–56. doi:10.1345/aph.1R147.
   PubMed Web of Science ®Google Scholar
• Choi YJ, Kim H. Effect of pharmacy-led medication reconciliation in emergency departments: a systematic review and meta-analysis. J Clin Pharm Ther. 2019;44(6):932–45. doi:10.1111/jcpt.13019.
   PubMed Web of Science ®Google Scholar
• Hesselink G, Berben S, Beune T, Schoonhoven L. Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. 2016;6(1):e009837. doi:10.1136/bmjopen-2015-009837.
   PubMed Web of Science ®Google Scholar
• Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004;59(5):493–504. doi:10.1111/j.1365-2044.2004.03670.x.
   PubMed Web of Science ®Google Scholar
• Bigham BL, Buick JE, Brooks SC, Morrison M, Shojania KG, Morrison LJ. Patient safety in emergency medical services: a systematic review of the literature. Prehosp Emerg Care. 2012;16(1):20–35. doi:10.3109/10903127.2011.621045.
   PubMed Web of Science ®Google Scholar
• Atack L, Maher J. Emergency medical and health providers' perceptions of key issues in prehospital patient safety. Prehosp Emerg Care. 2010;14(1):95–102. doi:10.3109/10903120903349887.
   PubMed Web of Science ®Google Scholar
• Fairbanks RJ, Crittenden CN, O’Gara KG, Wilson MA, Pennington EC, Chin NP, Shah MN. Emergency medical services provider perceptions of the nature of adverse events and near‐misses in out‐of‐hospital care: an ethnographic view. Acad Emerg Med. 2008;15(7):633–40. doi:10.1111/j.1553-2712.2008.00147.x.
   PubMed Web of Science ®Google Scholar
• Wolf ZR, Hughes RG. Error reporting and disclosure. In: Hughes RG, editor. Patient safety and quality: an evidence-based handbook for nurses. Vol. 2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008. p. 333–379.
   Google Scholar
• Lifshitz AE, Goldstein LH, Sharist M, Strugo R, Asulin E, Bar Haim S, Feigenberg Z, Berkovitch M, Kozer E. Medication prescribing errors in the prehospital setting and in the ED. Am J Emerg Med. 2012;30(5):726–31. doi:10.1016/j.ajem.2011.04.023.
   PubMed Web of Science ®Google Scholar
• Hansen M, Eriksson C, Skarica B, Meckler G, Guise JM. Safety events in pediatric out-of-hospital cardiac arrest. Am J Emerg Med. 2018;36(3):380–3. doi:10.1016/j.ajem.2017.08.028.
   PubMed Web of Science ®Google Scholar
• Hobgood C, Bowen JB, Brice JH, Overby B, Tamayo-Sarver JH. Do EMS personnel identify, report, and disclose medical errors? Prehosp Emerg Care. 2006;10(1):21–7. doi:10.1080/10903120500366011.
   PubMed Web of Science ®Google Scholar
• Vilke GM, Tornabene SV, Stepanski B, Shipp HE, Ray LU, Metz MA, Vroman D, Anderson M, Murrin PA, Davis DP, et al. Paramedic self-reported medication errors. Prehosp Emerg Care. 2007;11(1):80–4. doi:10.1080/10903120601021358.
   PubMed Web of Science ®Google Scholar
• Bigham BL, Bull E, Morrison M, Burgess R, Maher J, Brooks SC, Morrison LJ. Patient safety in emergency medical services: executive summary and recommendations from the Niagara Summit. CJEM. 2011;13(1):13–8. doi:10.2310/8000.2011.100232.
   PubMedGoogle Scholar
• Hoyle JD, Davis AT, Putman KK, Trytko JA, Fales WD. Medication dosing errors in pediatric patients treated by emergency medical services. Prehosp Emerg Care. 2012;16(1):59–66. doi:10.3109/10903127.2011.614043.
   PubMed Web of Science ®Google Scholar
• Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71.
   PubMed Web of Science ®Google Scholar
• Lizarondo L, Stern C, Carrier J, Godfrey C, Rieger K, Salmond S, Apostolo J, Kirkpatrick P, Loveday H. Chapter 8: mixed methods systematic reviews. In: Aromataris E, Munn Z, editors. JBI manual for evidence synthesis. JBI; 2020. doi:10.46658/JBIMES-20-09
   Google Scholar
• Walker D, Moloney C, SueSee B, Sharples R. Contributing factors that influence medication errors in the prehospital paramedic environment: a mixed-method systematic review protocol. BMJ Open. 2019;9(12):e034094. doi:10.1136/bmjopen-2019-034094.
   PubMed Web of Science ®Google Scholar
• Moola SM, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis P, Lisy K, Mu P-F. Chapter 7: systematic reviews of etiology and risk. In: Aromataris E, Munn Z, editors. JBI manual for evidence synthesis. JBI; 2020. doi: 10.46658/JBIMES-20-08
   Google Scholar
• Welsh E. Dealing with data: using NVivo in the qualitative data analysis process. Forum Qual Soc Res. 2002;3(2):Art 26. doi:10.17169/fqs-3.2.865
   Google Scholar
• Leech NL, Onwuegbuzie AJ. Beyond constant comparison qualitative data analysis: using NVivo. Sch Psychol Q. 2011;26(1):70–84. doi:10.1037/a0022711.
   Web of Science ®Google Scholar
• Wiltshier F. Researching with NVivo. Forum Qual Soc Res. 2011;12(1):Art 23. doi:10.17169/fqs-12.1.1628
   Google Scholar
• England E, Deakin CD, Nolan JP, Lall R, Quinn T, Gates S, Miller J, O'Shea L, Pocock H, Rees N, et al. Patient safety incidents and medication errors during a clinical trial: experience from a pre-hospital randomized controlled trial of emergency medication administration. Eur J Clin Pharmacol. 2020;76(10):1355–62. doi:10.1007/s00228-020-02887-z.
   PubMed Web of Science ®Google Scholar
• Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care. 2008;12(4):486–94. doi:10.1080/10903120802290752.
   PubMed Web of Science ®Google Scholar
• Campagne DD, Young M, Wheeler J, Stroh G. Pediatric tape: accuracy and medication delivery in the National Park Service. WestJEM. 2015;16(5):665–70. doi:10.5811/westjem.2015.6.25618.
   Google Scholar
• Rappaport LD, Brou L, Givens T, Mandt M, Balakas A, Roswell K, Kotas J, Adelgais KM. Comparison of errors using two length-based tape systems for prehospital care in children. Prehosp Emerg Care. 2016;20(4):508–17. doi:10.3109/10903127.2015.1128027.
   PubMed Web of Science ®Google Scholar
• Stevens AD, Hernandez C, Jones S, Moreira ME, Blumen JR, Hopkins E, Sande M, Bakes K, Haukoos JS. Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized crossover trial. Resuscitation. 2015;96:85–91. doi:10.1016/j.resuscitation.2015.07.035.
   PubMed Web of Science ®Google Scholar
• Hoyle JD, Jr., Ekblad G, Hover T, Woodwyk A, Brandt R, Fales B, Lammers RL. Dosing errors made by paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference. Prehosp Emerg Care. 2019;1–10. doi:10.1080/10903127.2019.161900.
   Web of Science ®Google Scholar
• Parush A, Haim N, Jaffe E, Wacht O. Design and test of a graphic medication dosage calculator in paramedic practice with children. Pediatr Emerg Care. 38(1):e343–e348. doi: 10.1097/pec.0000000000002280.
   Web of Science ®Google Scholar
• Kaufmann J, Roth B, Engelhardt T, Lechleuthner A, Laschat M, Hadamitzky C, Wappler F, Hellmich M. Development and prospective federal state-wide evaluation of a device for height-based dose recommendations in prehospital pediatric emergencies: a simple tool to prevent most severe drug errors. Prehosp Emerg Care. 2018;22(2):252–9. doi:10.1080/10903127.2016.1248257.
   PubMed Web of Science ®Google Scholar
• Hohenstein C, Fleischmann T, Rupp P, Hempel D, Wilk S, Winning J. German critical incident reporting system database of prehospital emergency medicine: analysis of reported communication and medication errors between 2005-2015. World J Emerg Med. 2016;7(2):90–6. doi:10.5847/wjem.j.1920-8642.2016.02.002.
   PubMed Web of Science ®Google Scholar
• Hobgood C, Weiner B, Tamayo-Sarver JH. Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ? Acad Emerg Med. 2006;13(4):443–51. doi:10.1197/j.aem.2005.11.005.
   PubMed Web of Science ®Google Scholar
• Hubble MW, Paschal KR, Sanders TA. Medication calculation skills of practicing paramedics. Prehosp Emerg Care. 2000;4(3):253–60. doi:10.1080/10903120090941290.
   PubMedGoogle Scholar
• Laws S, Wang C, Halter M. Knowledge, attitudes and practices of UK paramedics regarding pharmacology and the legal, management and administration aspects of medicines: a cross-sectional online quantitative survey. Br Paramed J. 2020;5(2):1–9. doi:10.29045/14784726.2020.09.5.2.1.
   PubMedGoogle Scholar
• Misasi P, Keebler J, Braithwaite S. Paramedics believe verbal verification with a team mate reduces medication errors more than mental verification alone. Ann Emerg Med. 2013;62(4):S47–S8. doi:10.1016/j.annemergmed.2013.07.412.
   PubMed Web of Science ®Google Scholar
• Misasi P, Keebler JR, Braithwaite S. Medication safety in EMS: paramedics who verify verbally with a team mate report fewer errors than those who verify mentally. 2015. https://www.researchgate.net/publication/281444273_Medication_safety_in_EMS_Paramedics_who_verify_verbally_with_a_team_mate_report_fewer_errors_than_those_who_verify_mentally
   Google Scholar
• Marung H, Teufel C, Kerner T, Harding U, Reifferscheid F. Medication safety and incident reporting in prehospital emergency care. Resuscitation. 2014;85:S58–S9. doi:10.1016/j.resuscitation.2014.03.148.
   Google Scholar
• Holgate R. The opinion of emergency medical service personnel regarding safety in pre-hospital emergency care practice. Johannesburg (South Africa): University of the Witwatersrand; 2015.
   Google Scholar
• Lammers R, Byrwa M, Fales W. Root causes of errors in a simulated prehospital pediatric emergency. Acad Emerg Med. 2012;19(1):37–47. doi:10.1111/j.1553-2712.2011.01252.x.
   PubMed Web of Science ®Google Scholar
• Lammers R, Willoughby-Byrwa M, Fales W. Medication errors in prehospital management of simulated pediatric anaphylaxis. Prehosp Emerg Care. 2014;18(2):295–304. doi:10.3109/10903127.2013.856501.
   PubMed Web of Science ®Google Scholar
• Lammers RL, Willoughby-Byrwa M, Fales WD. Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest. Simul Healthc. 2014;9(3):174–83. doi:10.1097/SIH.0000000000000013.
   PubMedGoogle Scholar
• Augustine JJ. The X vials. A medication near-miss spotlights drug safety. EMS World. 2014;43(8):14–7.
   Google Scholar
• Page D, Krost W. Culinary complications. A call becomes complicated by last night's dinner, a warm floor and a medication mishap. EMS World. 2016;45(2):12–3.
   Google Scholar
• Rajasekaran K, Fairbanks RJ, Shah MN. No more blame & shame [corrected] [published erratum appears in EMS MAG 2008 Oct;37(10):18]. EMS Mag. 2008;37(9):61–7.
   PubMedGoogle Scholar
• Sinclair JE, Austin MA, Bourque C, Kortko J, Maloney J, Dionne R, Reed A, Price P, Calder LA. Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study. Prehosp Emerg Care. 2018;22(6):762–72. doi:10.1080/10903127.2018.1469703.
   PubMed Web of Science ®Google Scholar
• Hoyle JD, Sleight D, Henry R, Chassee T, Fales B, Mavis B. Pediatric prehospital medication dosing errors: a mixed-methods study. Prehosp Emerg Care. 2016;20(1):117–24. doi:10.3109/10903127.2015.1061625.
   PubMed Web of Science ®Google Scholar
• Guise J-M, Meckler G, O'Brien K, Curry M, Engle P, Dickinson C, Dickinson K, Hansen M, Lambert W. Patient safety perceptions in pediatric out-of-hospital emergency care: children's safety initiative. J Pediatr. 2015;167(5):1143–8. doi:10.1016/j.jpeds.2015.07.023.
   PubMed Web of Science ®Google Scholar
• Byrne E, Bury G. Barriers to the medication error reporting process within the Irish National Ambulance Service, a focus group study. Ir J Med Sci. 2018;187(4):867–71. doi:10.1007/s11845-018-1745-x.
   PubMed Web of Science ®Google Scholar
• Hoyle JD, Crowe RP, Bentley MA, Beltran G, Fales W. Pediatric prehospital medication dosing errors: a national survey of paramedics. Prehosp Emerg Care. 2017;21(2):185–91. doi:10.1080/10903127.2016.1227001.
   PubMed Web of Science ®Google Scholar
• Cushman JT, Fairbanks RJ, O'Gara KG, Crittenden CN, Pennington EC, Wilson MA, Chin NP, Shah MN. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care. 2010;14(4):477–84. doi:10.3109/10903127.2010.497901.
   PubMed Web of Science ®Google Scholar
• Howard I, Castle N, Al Shaikh L, Jesaimani A, Owen R. Understanding system-focused barriers to the identification and reporting of medication errors and adverse drug events in emergency medical services. Drugs Ther Perspect. 2019;35(6):285–95. doi:10.1007/s40267-019-00628-6.
   Google Scholar
• Kaji AH, Gausche-Hill M, Conrad H, Young KD, Koenig WJ, Dorsey E, Lewis RJ. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493–500. doi:10.1542/peds.2006-0854.
   PubMed Web of Science ®Google Scholar
• Kupas DF, Shayhorn MA, Green P, Payton TF. Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors. Prehosp Emerg Care. 2012;16(1):67–75. doi:10.3109/10903127.2011.621046.
   PubMed Web of Science ®Google Scholar
• Friedman BT, Chen BC, Latimer AJ, Valento MJ. Iatrogenic pediatric hydroxocobalamin overdose. Am J Emerg Med. 2019;37(7):1394.e1–e2.
   PubMed Web of Science ®Google Scholar
• Davis CO, Wax PM. Prehospital epinephrine overdose in a child resulting in ventricular dysrhythmias and myocardial ischemia. Pediatr Emerg Care. 1999;15(2):116–8.
   PubMed Web of Science ®Google Scholar
• Buckle P, Clarkson P, Coleman R, Bound J, Ward J, Brown J. Systems mapping workshops and their role in understanding medication errors in healthcare. Appl Ergon. 2010;41(5):645–56. doi:10.1016/j.apergo.2009.12.013.
   PubMed Web of Science ®Google Scholar
• Horowitz BZ, Jadallah S, Derlet RW, Horowitz BZ, Jadallah S, Derlet RW. Fatal intracranial bleeding associated with prehospital use of epinephrine. Ann Emerg Med. 1996;28(6):725–7. doi:10.1016/s0196-0644(96)70100-2.
   PubMed Web of Science ®Google Scholar
• Callum J, Rivlin M, Carroll P. Epinephrine overdose: various toxicities secondary to medication error: case report. Reactions Weekly. 2020;1792(1):96.
   Google Scholar
• Murphy SL, Blair L, Phillippi R, Meredith ML, Arnold DH. Characteristics associated with problematic pediatric transports to a regional children's hospital. Am J Emerg Med. 2019;37(1):163–4. doi:10.1016/j.ajem.2018.05.043.
   PubMed Web of Science ®Google Scholar
• Lim CAE, Kaufman BJ, O’Connor J, Cunningham SJ. Accuracy of weight estimates in pediatric patients by prehospital emergency medical services personnel. Am J Emerg Med. 2013;31(7):1108–12. doi:10.1016/j.ajem.2013.04.018.
   PubMed Web of Science ®Google Scholar
• Wallace M, Meredith M. Potentially fatal mistakes. Why pediatric dosing errors happen & how to avoid them. JEMS. 2013;38(8):28–31.
   PubMedGoogle Scholar
• Coppler PJ, Padmanabhan R, Martin-Gill C, Callaway CW, Yealy DM, Seymour CW. Accuracy of prehospital intravenous fluid volume measurement by emergency medical services. Prehosp Emerg Care. 2016;20(1):125–31. doi:10.3109/10903127.2015.1051681.
   PubMed Web of Science ®Google Scholar
• Donnelly EA, Bradford P, Davis M, Hedges C, Socha D, Morassutti P, Pichika SC. What influences safety in paramedicine? Understanding the impact of stress and fatigue on safety outcomes. J Am Coll Emerg Phys Open. 2020;1(4):460–73. doi:10.1002/emp2.12123.
   PubMedGoogle Scholar
• Misasi P, Keeble JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther Adv Drug Saf. 2019;10:1–14.
   Web of Science ®Google Scholar
• Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: a pilot study. World J Emerg Med. 2018;9(1):41–5. doi:10.5847/wjem.j.1920-8642.2018.01.006.
   PubMed Web of Science ®Google Scholar
• Woods B, Lang B, Blayney C, O'Mahony L, Vander Tuig A, Rea T, Carlbom D, Sayre M, King M. Medic One Pediatric (MOPed) cards: standardising paramedic paediatric resuscitation. BMJ Open Qual. 2019;8(3):e000534. doi:10.1136/bmjoq-2018-000534.
   PubMedGoogle Scholar
• Bruns BM, Dieckmann R, Shagoury C, Dingerson A, Swartzell C. Safety of pre-hospital therapy with morphine sulfate. Am J Emerg Med. 1992;10(1):53–7. doi:10.1016/0735-6757(92)90127-J.
   PubMed Web of Science ®Google Scholar
• Haynes BE. Two deaths after prehospital use of adenosine. J Emerg Med. 2001;21(2):151–4. doi:10.1016/S0736-4679(01)00358-4.
   PubMed Web of Science ®Google Scholar
• Watson A, Michaels L. Images in cardiology. Incorrect administration of buccal glyceryl trinitrate. Heart. 2002;87(3):209. doi:10.1136/heart.87.3.209.
   PubMed Web of Science ®Google Scholar
• Meckler G, Hansen M, Lambert W, O'Brien K, Dickinson C, Dickinson K, Van Otterloo J, Guise J-M. Out-of-hospital pediatric patient safety events: results of the CSI chart review. Prehosp Emerg Care. 2018;22(3):290–9. doi:10.1080/10903127.2017.1371261.
   PubMed Web of Science ®Google Scholar
• Edwards S, Axe S. The 10 ‘‘Rs’’ of safe multidisciplinary drug administration. Nurse Prescribing. 2015;13(8):398–60. doi:10.12968/npre.2015.13.8.398.
   Google Scholar
• Smeulers M, Verweij L, Maaskant JM, de Boer M, Krediet CTP, Nieveen van Dijkum EJM, Vermeulen H. Quality indicators for safe medication preparation and administration: a systematic review. PLoS One. 2015;10(4):e0122695. doi:10.1371/journal.pone.0122695.
   PubMed Web of Science ®Google Scholar
• Siebert JN, Bloudeau L, Combescure C, Haddad K, Hugon F, Suppan L, Rodieux F, Lovis C, Gervaix A, Ehrler F, et al. Effect of a mobile app on prehospital medication errors during simulated pediatric resuscitation: a randomized clinical trial. JAMA Netw Open. 2021;4(8):e2123007. doi:10.1001/jamanetworkopen.2021.23007.
   PubMed Web of Science ®Google Scholar
• Australian Commission on Safety and Quality in Health Care. Risk management approach. Canberra (Australia): Australian Commission on Safety and Quality in Health Care; 2014. TRIM: 72919
   Google Scholar