title: The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study.
abstract: BACKGROUND
  Little is known about interventions to reduce intravenous medication administration errors in hospitals, especially in low- and middle-income countries.
  
  
  OBJECTIVE
  To assess the effect of a clinical pharmacist-led training programme on clinically relevant errors during intravenous medication preparation and administration in a Vietnamese hospital.
  
  
  METHODS
  A controlled before and after study with baseline and follow-up measurements was conducted in an intensive care unit (ICU) and a post-surgical unit (PSU). The intervention comprised lectures, practical ward-based teaching sessions and protocols/guidelines, and was conducted by a clinical pharmacist and a nurse. Data on intravenous medication preparation and administration errors were collected by direct observation 12 h/day for seven consecutive days. Generalised estimating equations (GEE) were used to assess the effect of the intervention on the prevalence of clinically relevant erroneous doses, corrected for confounding factors.
  
  
  RESULTS
  1204 intravenous doses were included, 516 during the baseline period (236 on ICU and 280 on PSU) and 688 during the follow-up period (407 on ICU and 281 on PSU). The prevalence of clinically relevant erroneous doses decreased significantly on the intervention ward (ICU) from 64.0% to 48.9% (p<0.001) but was unchanged on the control ward (PSU) (57.9% vs 64.1%; p=0.132). GEE analysis showed that doses on the intervention ward were 2.60 (1.27-5.31) times less likely to have clinically relevant errors (p=0.013).
  
  
  CONCLUSIONS
  The pharmacist-led training programme was effective, but the error rate remained relatively high. Further quality improvement strategies are needed, including changes to the working environment and promotion of a safety culture.
authors.affiliation: Department of Clinical Pharmacy, School of Pharmacy, University of Medicine and Pharmacy, , Ho Chi Minh City, Vietnam.
authors.forename: Huong-Thao
authors.initials: HT
authors.lastname: Nguyen
authors.forename: Hong-Tham
authors.initials: HT
authors.lastname: Pham
authors.forename: Dang-Khoa
authors.initials: DK
authors.lastname: Vo
authors.forename: Tuan-Dung
authors.initials: TD
authors.lastname: Nguyen
authors.forename: Edwin R
authors.initials: ER
authors.lastname: van den Heuvel
authors.forename: Flora M
authors.initials: FM
authors.lastname: Haaijer-Ruskamp
authors.forename: Katja
authors.initials: K
authors.lastname: Taxis
mesh_terms: D061605:Administration, Intravenous / Q000009:adverse effects; D065187:Controlled Before-After Studies; D064648:Critical Care Nursing / Q000193:education*; D004509:Education, Nursing, Continuing / Q000379:methods; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D010595:Pharmacists
keywords: Medication safety; Patient safety; Quality improvement