Estimating the impact of label design on reducing the risk of medication errors by applying HEART in drug administration

Carlos Aceves-Gonzalez, Angela Caro-Rojas, John A. Rey-Galindo, Luz Aristizabal-Ruiz, Karen Hernández-Cruz
2023 · doi:10.21203/rs.3.rs-3250873/v1
preprint OA: closed CC-BY-4.0
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Abstract

Abstract Medication errors are one of the biggest problems in healthcare. The medicines ' poor labelling design (i.e., Look-Alike labels) is a well-recognised risk for potential confusion, wrong administration, and patient damage. Human Factors and Ergonomics (HFE) encourages the human-centred design of system elements, which might reduce medication errors and improve people's well-being and system performance. Objective: The aim of the present study is twofold: (i) to use a human reliability analysis technique to evaluate a medication administration task within a simulated scenario of a Neonatal Intensive Care Unit (NICU); (ii) to estimate the impact of a Human-Centred Design (HCD) label in medication administration compared to a Look-Alike (LA) label. Method: This paper used a modified Human Error Assessment and Reduction Technique (HEART) version to analyse a medication administration task in a simulated NICU scenario. The modified technique involved expert nurses quantifying the likelihood of unreliability of a task and rating the conditions, including medicine labels, which most affect the successful completion of the task. Results: Findings suggest that Error Producing Conditions (EPCs), such as a shortage of time available for error detection and correction, no independent checking of output, and distractions, might increase Human Error Probability (HEP) in administering medications. Results also showed that the assessed HEP and the relative percentage of contribution to unreliability reduced by more than 40% when the HCD label was assessed compared to the LA label. Conclusion: Including labelling design based on HFE might help increase human reliability when administering medications under critical conditions.

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License: CC-BY-4.0