The Effect Of Ilumination On Medication Preparation Errors In A Long Term Care Facility by Ranjani Varadarajan A disertation submited to the Graduate Faculty of Auburn University in partial fulfilment of the requirements for the Degree of Doctor of Philosophy Auburn, Alabama August 6, 2011 Keywords: medication preparation errors, ilumination, visual performance, nursing homes Copyright 2011 by Ranjani Varadarajan Approved by Kenneth N. Barker, Chair, Profesor Emeritus of Pharmacy Care Systems Elizabeth A. Flynn, Afiliate Asociate Research Profesor of Pharmacy Care Systems Salisa C. Westrick, Asociate Profesor of Pharmacy Care Systems Kristen L. Helms, Asociate Clinical Profesor of Pharmacy Practice Robert E. Thomas, Profesor Emeritus of Industrial & Systems Engineering Nathan T. Dorris, Afiliate Profesor of Industrial & Systems Engineering ii Abstract The main objectives of this study were to (1) measure the efect of increased ilumination levels on the medication preparation error rate in a long term care facility, and (2) measure the efect of increased ilumination levels on the medication preparation error types in the same facility. The data collection proces was divided into two phases: 1. Initial site visit to explore and operationaly define the variables of interest and collect demographic information about the subjects in the study. 2. Explanatory phase to study the efect of the intervention variable (increased ilumination level) on the dependant variable (medication preparation errors). The sampling unit was the preparation of an oral prescription medication dose by the nurse-subject in the particular section of the study site and observed by the principal investigator, before administration to the resident, during the study period. The data were collected by direct, undisguised observation method during the morning and evening medication pas shifts (8 am and 5 pm) at the study site, during a period of 45 days. The doses observed were randomly asigned for ilumination at one of three levels of ilumination (baseline, 100 and 145 foot-candles). Each nurse was observed for doses at al three ilumination levels, thus each subject served as their own control. The ilumination was controlled by a supplemental lighting apparatus (OttLite iii 508 Illumination TM rechargeable fluorescent task lamp), which was afixed to the study medication cart. Seven nurse-subjects prepared a total of 6,758 doses during the observation period, of which 467 doses were in error (error rate 6.7%). The most frequently observed medication preparation error was Omision (N = 190, 40%), followed by Wrong time (N = 146, 31%), Wrong form (N = 72, 15%), Wrong Dose (23, 5%) and Unauthorized Dose (4, 1%). A repeated - measures Analysis of Variance (ANOVA) was performed on the observation data for the study period. Significant treatment (ilumination) efect (F 2,5 =17.116, p < 0.05) was found on the medication preparation error rate, with Illumination level 3 (145 foot-candles; error rate 4.3%) significantly asociated with lower medication preparation error rate as compared to the baseline ilumination level (30 foot-candles; error rate 8.5%). Chi Square Analysis revealed Wrong dose form errors (X 2 =12.954, df =2, p < 0.05) and Omision errors (X 2 =180825, df =2, p < 0.05) to have significant relationship with the ilumination level. Linear regresion analysis revealed no significant linear relationship betwen medication preparation workload of the nurse-subjects and their medication preparation error rate for al three ilumination levels (Level 1: F 1,26 = 0.196, p > 0.05, Level 2: F 1,26 = 0, Level 2: p > 0.05, Level 3: F 1,26 = 0.122, p > 0.05). There were no significant diferences in the proportion of medication preparation errors for each nurse-subject for al three ilumination levels. It was concluded that adjustment of lighting from baseline level to 145 foot- candles achieved significant reduction in medication preparation errors. An important iv implication of this study is that the elevation of ilumination standards at long- term care facilities could reduce the rate of errors in the preparation of doses for administration on the order of 50%. The study directed atention to the need for seting higher ilumination standards at long-term care facilities, in order to facilitate optimum visual performance by the healthcare staf. v Acknowledgements First and foremost, I wish to thank Dr. Kenneth N. Barker, for being my advisor and mentor and guiding and motivating me through the entire proces of my disertation research. I would like to extend my heartfelt gratitude and appreciation to Dr. Elizabeth Flynn, Dr. Salisa Westrick, and Kristen Helms who agreed to be in my research commite and provided me with valuable fedback and insight, during the entire research proces. My heartfelt thanks to Dr. Robert Thomas and Dr. Nathan Dorris, for helping me understand and appreciate the engineering concepts applied in my research study. I am grateful to the faculty, staf and graduate students of the Department of Pharmacy Care Systems for their help, encouragement and kind words. Special thanks to al my dear friends for standing by me through the dificult phases, and providing me with encouragement and a sense of ?a home away from home?. A special heartfelt note of thanks to my family in India, for their unwavering support and trust in me. I couldn?t have pursued my dreams to reach where I am today, without their love, prayers, trust and support. vi Table of Contents Abstract................................................................................................................................ii Acknowledgments ...............................................................................................................v List of Tables.........?????????...?????????????????.xv List of Figures..........?????????????????????????...xvii I. Introduction..........?????????????.??????.??????? 1 General problem area???????????????????????. 1 Purpose of the Study???????????????????????.. 2 Significance ????????????????????????..?? 2 Summary of methods ??????????????????????? 3 II. Literature Review............................??????.????????..??..?. 4 Overview ???????????????????????...???? 4 Human vision?????????????????????????. ?4 Human error ?????????????????????????.. ...12 Visual fatigue ??????????????????????????13 Lighting and productivity????????????????????..... 14 Medication errors??????????????????????..?? 16 Observation method???????????????????????.. 18 Medication error problems in nursing homes?????????????... 20 Problems faced by the nursing facility ???????????...????.. 20 vii The problem of insufficient lighting in nursing facilities?????...???.. 24 Efect of ilumination on work performance??????????...???. 27 Efect of ilumination on medication errors...........................................................30 Rationale for study proposed ????????????????.?...??31 III. Statement Of The Problem................ ??????????????.??. ?..33 Main Research questions ????????????????????.?.33 Research hypotheses ????..????????????????.?..... 35 Hypothesis Testing ???????????????????.????.. 38 Concepts???????????????????????????.?40 Medication Preparation Error Categories??????????????..?43 Operational definitions ????????????????????.?.... 44 IV. Methodology.......... ???????????????????...????? 46 Population ???????????????????????????.46 Sample?????????????????????????.??.?..46 Study Subjects ????????????????????..????? 47 Independent Variable ?????????????????????.?.. 48 Supplemental Lighting Apparatus????????????????.??49 Research Design ?????????????????????????49 Design Structure ???????????????????.?????.. 50 Controls ???????????????????????????? 50 Data Collection ...............???????????????????..??52 Initial Visits for Orientation to Study Site ???????????????52 Site Selection??????????????????????????.52 vii Background Information about the facility???????????????54 Trip 1?????????????????????????????..53 Trip 2?????????????????????????????..55 Trip 3?????????????????????????????..56 Trip 4?????????????????????????????..58 Trip 5?????????????????????????????..58 Visit to Pharmacy??????????????????????...??62 Trip 6?????????????????????????????..67 Trip 7 ????????????????????????????.?70 Explanatory Study Phase????????????????????...?73 IRB Approval??????????????????????????.73 Informed Consent Leter??????????????????????73 Demographic Information?????????????????????..74 Visual Test???????????????????????????.74 Group Embedded Figures Test???????????????????..75 Observation Pilot Study??????????????????????.75 Explanatory level Study?????????????????????.....76 Statistical Analysis????????????????????????.78 Significance Level????????????????????????.79 V. Results...... ????????????????????????????..80 Study Subjects description?????????????????????.81 Pilot Study: General description and results ??????????????.83 Main Observation Study????????...???????????.........89 ix Medication Preparation Errors for the Study Sample????????..?..?91 Medication Preparation Errors, by study sections??????????..?...94 Section X??????????????????????????..?.95 Section Y??????????????????????????.?..98 Section Z??????????????????????????........99 Medication Preparation Errors, by nurse subjects???????????...101 Statistical Hypothesis and Analysis????????????????....106 Analysis of Medication Preparation Error Rate ???????????.....106 Analysis of Medication Preparation Error Rate (w/o wrong time errors) ?......110 Analysis of Medication Preparation Error Types??????????....?113 Analysis of Medication Preparation Workload????????????...119 Analysis of Observer Efect???????????????????.....122 Analysis of Medication Preparation Errors by Sections???..???....??126 Analysis of Medication Preparation Errors by Shifts?????...??...??128 Observation of Medication related incidents???????????..??.130 VI. Conclusion, Discussion, Limitations and Implications..................................??..132 Main Conclusions???????????????????.????...132 Discussion??????????????????????????...137 Exploratory finding regarding demographic variables????????..?..137 Age????????????????....??????........??...137 Employment Status???????????....??.???....?.??.138 Educational Level?????????????.....??.?????...138 Gender???????????????????....????..??139 x GEFT Scores????????????????.?....????.?..139 Visual Test Scores??????????????..??....????..140 Medication Preparation Workload???????????....??.......141 Explanatory Study Findings????????????????????.142 Efect Of Illumination On Medication Preparation Error Rate....................142 Efect Of Illumination On Medication Preparation Error Types.................144 Efect Of The Observer On The Observed..................................................146 Significance Of Nursing Sections................................................................147 Significance of Medication Shifts................................................................147 Limitations???????????????????...???????148 Recommendations????????????????...???????.151 Implications for Future Research??????????????...???..153 References........?????????????????????........??...??155 Appendices.......................................................................................................................165 Appendix A: Memorandum of the project ????????????......???....166 Appendix B: IRB Approval Forms..................................................................................168 Appendix C: Medication schedule???????????????.......??..?..171 Appendix D: Additional pictures from the nursing facility ???????..?.??.173 Appendix E: Copy of the Incident report form???????????.....???.. 180 Appendix F: Data Collection Forms................................................................................182 Appendix G: Informed Consent Leter............................................................................186 Appendix H: Renewal IRB Approval Forms...................................................................189 Appendix I: Medication Preparation Error Description...................................................192 xi List Of Tables Table 1. Factors afecting visual inspection acuracy ????????????.15 Table 2. Minimum average iluminance for diferent task areas???????..?27 Table 3. Demographic Information of the Study Subjects...........................................82 Table 4. Pilot Study.......................................................................................................84 Table 5. Frequency of error types during pilot study....................................................85 Table 6. Description of Each Error during the Pilot Study...........................................87 Table 7. Reasons for excluded doses............................................................................89 Table 8. Total observed doses for each nurse-subject for each Illumination level...........................................................................................90 Table 9. Medication Preparation Errors for the Study Site for three Illumination levels..........................................................................................92 Table 10. Total Medication Preparation Errors, by Error Types...................................93 Table 11. Medication Preparation Errors for Section X................................................94 Table 12. Medication Preparation Errors for Section X, by Error Types......................95 Table 13. Medication Preparation Errors for Section Y................................................96 Table 14. Medication Preparation Errors for Section Y, by Error Types......................97 Table 15. Medication Preparation Errors for Section Z.................................................99 Table 16. Medication Preparation Errors for Section Z, by Error Types....................100 Table 17. Medication Preparation Errors by Nurse-subjects ......................................102 xii Table 18. Medication Preparation Errors, by types for each nurse-subject..................104 Table 19. Descriptive Statistics ....................................................................................106 Table 20. Repeated Measures Univariate ANOVA .....................................................107 Table 21. Tests for Linear and Quadratic trends ..........................................................107 Table 22. Pairwise Comparisons of the Medication Preparation Error rate ................108 Table 23. Descriptive Statistics (excluding wrong time errors)...................................111 Table 24. Repeated Measures Univariate ANOVA .....................................................111 Table 25. Pairwise Comparisons (excluding wrong time errors).................................112 Table 26. Chi Square Analysis for Wrong Dose Preparation Errors............................114 Table 27. Wrong Dose Preparation error rate...............................................................114 Table 28. Chi Square Analysis for Wrong Form Preparation Errors............................115 Table 29. Wrong Form Preparation error rate..............................................................115 Table 30. Chi Square Analysis for Wrong Time Preparation Errors............................116 Table 31. Wrong Time Preparation error rate...............................................................116 Table 32. Chi Square Analysis for Omision Errors.....................................................117 Table 33. Omision error rate.......................................................................................117 Table 34. Chi Square Analysis for Unauthorized Dose Preparation Errors.................118 Table 35. Unauthorized Dose Preparation error rate....................................................118 Table 36. Analysis of Variance for Linear Regresion for Illumination level 1 ..........120 Table 37. Analysis of Variance for Linear Regresion for Illumination level 2...........120 Table 38. Analysis of Variance for Linear Regresion for Illumination level 3...........121 Table 39. Chi-Square Analysis for each nurse-subject by ilumination levels.............123 Table 40. Medication Preparation Errors by Sections.................................................127 xii Table 41. Medication Preparation Errors by medication shifts...................................129 Table 42. Analysis of Variance with respect to med-pas shifts ................................129 Table 43. Observation of Medication-Related Incidents.............................................130 Table 44. Nurse-subjects? comments re. the ilumination and the observer................131 Table 45. Results and Conclusions of Hypothesis testing ..........................................132 xiv List Of Figures Figure 1. Diagramatic horizontal section through the right eye ????????....5 Figure 2. Diagram of the visual system ?????????????????...?6 Figure 3. Relationship betwen candelas, foot-candles and lux ????????? 7 Figure 4. Decrease of visual acuity with age ????????????????10 Figure 5. Efect of light intensity on visual acuity ??????????????.12 Figure 6. Decrease in visual transmitance with age ?????????????..22 Figure 7. Visual performance and lighting levels for moderately dificult and dificult tasks?????????????????????....... 23 Figure 8. Layout of the nursing study site ????????????????? 57 Figure 9. Exit door ........................................................................................................58 Figure 10. Section X Medication cart upper surface ......................................................59 Figure 11. Section Y light measurements.......................................................................60 Figure 12. Dining /Activity room....................................................................................60 Figure 13. Section Y Medication cart upper surface.......................................................61 Figure 14. Window bars at the pharmacy site.................................................................63 Figure 15. Light fixtures used in the pharmacy...............................................................63 Figure 16. Blister packaging material for the medications..............................................64 Figure 17. Medications stacked in the cabinet.................................................................64 Figure 18. Hospice pharmacy cabinet..............................................................................65 Figure 19. Hospice pharmacy window.............................................................................65 xv Figure 20. Computer station 1........................................................................................66 Figure 21. Workstation overlooking an open window ...................................................66 Figure 22. Workstation overlooking a window with blinds...........................................67 Figure 23. Section X: Medication cart light measurement.............................................68 Figure 24. Section Y Medication cart ............................................................................69 Figure 25. Study site workflow diagram ........................................................................71 Figure 26. Blister packaging at the pharmacy................................................................72 Figure 27. Controlled substance form and label.............................................................72 Figure 28. Baseline measurement...................................................................................76 Figure 29. Experimental (Intervention) measurement....................................................77 Figure 30. Sample of Visual Stimuli...............................................................................77 Figure 31. Observation instruments used during the study.............................................78 Figure 32. Medication Preparation Errors for three ilumination levels.........................84 Figure 33. Frequency of error types for three ilumination levels..................................86 Figure 34. Doses prepared by each Nurse-subject (LPN) ..............................................91 Figure 35. Error rate for the study site for three ilumination levels..............................92 Figure 36. Frequency of Medication Preparation Error Types.......................................94 Figure 37. Medication Preparation Error rate for Section X..........................................95 Figure 38. Medication Preparation Errors, by Error Types for Section X......................96 Figure 39. Medication Preparation Error rate for Section Y..........................................97 Figure 40. Medication Preparation Errors, by Error Types for Section Y......................98 Figure 41. Medication Preparation Error rate for Section Z...........................................99 Figure 42. Medication Preparation Errors, by Error Types for Section Z....................100 xvi Figure 43. Medication Preparation Error rate for each nurse-subject..............................101 Figure 44. Medication Preparation Error types, by nurse-subjects..................................105 Figure 45. Box Plot of Medication Preparation Error rates ............................................108 Figure 46. Trend-line of Medication Preparation Errors for Illumination Level 1 .........124 Figure 47. Trend-line of Medication Preparation Errors for Illumination Level 2 .........124 Figure 48. Trend-line of Medication Preparation Errors for Ilumination Level 3 .........125 1 I. Introduction General Problem Area Patient safety is an important concern of current healthcare delivery systems. Medication errors are often used as an indicator of quality and patient safety in the healthcare environment. The Institute of Medicine published the Quality Chasm series (2007) wherein they estimated about 800,000 preventable medication errors to occur every year in long term care facilities, harming at least 1.5 milion people. One of the factors reported as contributing to the errors in the healthcare delivery system, is lack of proper lighting conditions (Santel, 2003; (MEDMARX Data Report, 2008) In the long-term care setings, the tasks performed during the medication delivery proces (transcription, verification, drug dispensing, preparation and administration) are highly visual in nature. The problem of performing these tasks gets compounded with factors such as ilegible prescriptions, look-alike/sound-alike drug names, high workload and visual fatigue. When such high visual demands must be met in unfavorable environmental conditions, the probability of making an error is higher. That the quantity and quality of light are of paramount importance for the medication distribution tasks that have a high visual component should not be surprising. Poor lighting environment can contribute to visual discomfort and eye strain (Boyce, 1981). Visual performance is the only performance outcome that changing the lighting conditions can afect directly (Alvarado, 2007). While proper lighting cannot 2 produce work itself, it can make details easier to discriminate and colors easier to judge, without producing discomfort or distraction (Sanders & McCormick, 1993) Although research in long term care setings for studying the efects of lighting conditions on medication errors has been minimal (non-existent), there has been evidence in other healthcare and human factors fields which has established that improved lighting conditions (such as increased ilumination and reduced glare) help in improving the visual performance of the subjects, and thus help in decreasing errors. Purpose Of The Study The purpose of this study was to investigate the efect of increased ilumination level on the medication preparation error rate in a nursing facility. Significance A survey of 53 nursing homes in four states found that the nursing home facilities were often dimly lit. The ilumination was rated as inadequate or barely adequate in 45 percent of halways, 17 percent of activity areas and 51 percent of the resident rooms (Sloane, Mitchel, Calkins, & Zimerman, 2000). There are no federal standards or regulations requiring the quality and quantity of light to met the visual needs of the older people in nursing homes. There is great variability among the nursing facilities in diferent states, regarding lighting regulations. Lack of lighting standards and specific minimum target iluminance values coupled with the aging nursing population catering to the nursing home residents likely aggravate the problem of medication errors in these facilities. 3 The consequences that medication errors can have in terms of mortality, morbidity and financial loss to both the patients and the nursing facility is wel documented in literature (Bootman et.al, 1997). If environmental factors such as ilumination can be shown to be related to the error rate, then greater emphasis can be placed upon the factors by governmental and profesional grouups in the form of high standards in lighting regulations requiring adherence by architects and facility designers. The significance of this study in particular is that the adjustment of lighting can be a relatively low cost measure requiring litle or no change in nursing procedures. Summary of Methods This was an explanatory level research study, where the data were collected by direct observation. The principal investigator was trained in the scientific observation techniques (Barker, 1980) and observed the nurse-subjects, in the study nursing home site. Data collection occupied 2 phases: 1) Exploratory phase ? where the variables of interest were explored and operationaly defined. 2) Explanatory phase ? where the efect of the intervention variable (increased ilumination level) was studied on the dependant variable (medication preparation error rate). 4 II. Literature Review Overview This review spans the literature from the general topic of human vision to the specific topic of studying the efect of ilumination levels on work performance; in this case medication errors in the long term care seting. The purpose of this literature review is: 1. To explain the need to conduct this study, 2. To explain the significance of this study with respect to the existing theory, 3. To explain the rationale for the study proposed. Human Vision The human eye, a very important receptor organ, senses the energy from the outside world in the form of light waves and converts these into a form of energy into nerve impulses. 5 Figure 1: Diagrammatic horizontal section through the right eye (K. Kroemer & E. Grandjean, 1997) The complete visual system controls about 90 percent of al our everyday activities (K. Kroemer & E. Grandjean, 1997) 6 Figure 2: Diagram of the visual system (K. Kroemer & E. Grandjean, 1997) 1 = cornea and lens; 2 = light received on the retina; 3= transmision of optical information along the optic nerve to the brain; 4 = synapses and fedback to the eye; 5 = visual perception of the external world in the conscious sphere of the brain. The human eye contains about 130 milion rods and 7 milion cones. Cones detect fine diferences in either color or shape but need high ilumination for this. Rods are more sensitive even in dim light, but conceive only shades of grey betwen black and white. They are the most important light-detecting organs in poor visibility and at night (K. Kroemer & E. Grandjean, 1997) Illumination is also caled as iluminance, and is the amount of light faling on to a surface (K. H. E. Kroemer & E. Grandjean, 1997; Niebel & Freivalds, 2003; Sanders & McCormick, 1993) It is measure in terms of luminous flux per unit area. The units of measurement are: Lux (an SI unit) = 1 lumen per square meter, the lumen being the unit of luminous flux 7 Foot-candle (USCS unit) = 1 lumen per square foot One foot-candle equals 10.76 lux, usualy rounded off to 10 lux for practical purposes.(Sanders & McCormick, 1993) Figure 3: Relationship betwen candelas, foot-candles and lux (Sanders & McCormick, 1993) The amount of ilumination striking a surface drops off as the square of the distance ("White paper on Quality Pharmaceutical Care in Long Term Care,") in fet from the source of the surface (Niebel & Freivalds, 2003) : Illuminance = luminous intensity / d 2 8 Luminance - It is the amount of light reflected or emited from a surface (K. H. E. Kroemer & E. Grandjean, 1997). Its unit of measurement is: Candela per m 2 (SI unit) or mililambert and footlambert (USCS unit). One mililambert is the amount of light emited from a surface at the rate of 0.001 lm/cm 2 . A footlambert is the amount of brightnes of an idealy reflecting surface iluminated by one foot-candle (K. H. E. Kroemer & E. Grandjean, 1997). It is determined by the reflective properties of the surface, luminance = iluminance x reflectance (Niebel & Freivalds, 2003). Reflectance is measured and compared by the ratio betwen reflected and incident amounts of light. It is expresed as the percentage of reflected to incident light (K. H. E. Kroemer & E. Grandjean, 1997). Acommodation means the ability of the eye to bring into ?sharp focus? objects at varying distances from infinity down to the nearest point of vision, caled the ?near point? (K. Kroemer & E. Grandjean, 1997). The level of ilumination is a critical factor in acommodation. The beter the luminance contrast of visual targets against the background, the faster, easier and more precise the acommodation (K. Kroemer & E. Grandjean, 1997). It has been shown that speed and precision of acommodation decrease with age, there is a marked decrease from about the age of 40 (K. Kroemer & E. Grandjean, 1997). Glare is a gross overloading of the adaptation proceses of the eye, brought about by overexposure of the retina to light (K. Kroemer & E. Grandjean, 1997). 9 There are 3 types of glare: 1) Reflective glare, caused by excesive brightnes contrast betwen diferent parts of the visual field. 2) Absolute glare, when a source of light is so bright that the eye cannot possibly adapt to it (e.g. the sun) 3) Adaptive glare, a temporary efect during the period of light adaptation (e.g. coming out of a dark room into bright daylight). This phenomenon is also caled ?transient adaptation?. The most important visual capacities are: Visual acuity - It is the ability to detect smal details and to discriminate smal objects (K. Kroemer & E. Grandjean, 1997). Measurement of visual acuity commonly uses standardized black stimuli (e.g. Landolt rings or Snelen leters) on a white background. The influences on visual acuity are: (K. Kroemer & E. Grandjean, 1997) 1) Visual acuity increases with the level of ilumination, reaching a maximum at ilumination levels about 100 foot-candles (1000 lux). 2) It increases with the contrast betwen the test symbol and its imediate background, and with the sharpnes of signs or characters. 3) It is greater for dark symbols on a light background than for the reverse. 4) It decreases with age. 10 Figure 4: Decrease of visual acuity with age (K. Kroemer & E. Grandjean, 1997) Contrast sensitivity - It is the ability of the eye to perceive a smal diference in luminance.(K. Kroemer & E. Grandjean, 1997) It plays a very important role in jobs which involve visual inspection and product control. To measure contrast sensitivity, a procedure is used in which the luminance of a standardized target is compared with its surroundings. The influences on contrast sensitivity are: (K. Kroemer & E. Grandjean, 1997) 1) It is greater in large areas than for smal areas. 2) It is greater when boundaries are sharp and decreases when the change is gradual or indefinite. 11 3) It increases with the surrounding luminance and is greatest within the range of 70 cd/m 2 and 1000 cd/m 2 4) Within this luminance range, the background must be at least 2 per cent lighter or darker than the target. 5) It is greater when the outer parts of the visual field are darker than the center and weaker in the reverse contrast. Luckiesh and Moss (1937) conducted a series of experiments and concluded that raising the ilumination level from approximately 10 lux to 1000 lux (around 100 foot- candles) increases the visual acuity from 100 to 170 percent and contrast sensitivity up to 450 percent.(Luckiesh & Moss, 1937) They also recorded a decrease in muscular tension and rate of blinking the eyelids, which was interpreted as a reduction in nervous tension as a result of beter lighting. 12 Figure 5: Effect of light intensity on visual acuity(Luckiesh & Moss, 1937) Human Error Reason defined human error as the failure of a planned sequence of mental or physical activities to achieve its intended outcome, when these failures cannot be atributed to chance (Reason, 2003). Leape defined it as an unintended act (either of omision or commision) or one that does not achieve its intended outcome (Leape, 1994). 13 Errors have been clasified as skil, rule and knowledge based models (Reason, 2003). Skil-based errors are errors of action. Reason (2003) defined them as unintended acts, which occur when there is a break in the routine while the atention is diverted. Rule-based errors usualy occur during problem solving when a wrong decision is chosen- either because of a misperception of the situation and, thus, the application of a wrong rule or a misapplication of a right rule. Knowledge-based errors arise because of lack of knowledge or misinterpretation of the problem (Leape, 1994). Errors that occur during the prescribing, dispensing and administering stages are termed as Medication Errors (Bates, Boyle, Vliet, Schneider & Leape, 1995). Visual Fatigue Visual fatigue comprises al those symptoms that arise after excesive stres on any of the functions of the eye. One of the manifestations include reduced visual acuity, sensitivity to contrast and speed of perception (K. Kroemer & E. Grandjean, 1997). These symptoms are brought about in particular by strenuous fine work, poorly printed texts, inadequate lighting, and exposure to flickering light. Elderly people are more prone to visual fatigue (K. Kroemer & E. Grandjean, 1997). The efects of visual fatigue on a person?s occupation may include loss of productivity, lowering of quality, more mistakes and increased acident rate (K. Kroemer & E. Grandjean, 1997). 14 Grandjean (1988) referred to a report wherein experts concluded that bad lighting was the cause of 5 % of al industrial acidents and together with optical fatigue, it contributed to as much as 20 % (Grandjean, 1988). They concluded that work that requires high visual acuity and contrast sensitivity needs high levels of ilumination. Fine and delicate work need to be iluminated at 1000 (100 foot-candles) to 10,000 lux (1000 foot-candles) (Grandjean, 1988). Lighting and Productivity There are many studies that report increased productivity after the lighting was improved. These increases are partly a direct efect (through more rapid visual work asesment) and partly indirect (reduction in visual fatigue) (K. Kroemer & E. Grandjean, 1997). McCormick and Sanders (1987) provided a table summarizing the results of 15 industrial studies, al of which showed increases in output, ranging from 4 to 35 %, after increasing the ilumination level. But there were some reservations because of the existence of other uncontrollable factors that were present in such situations (Sanders & McCormick, 1993). 15 Table 1: Factors afecting visual inspection acuracy: diferent studies (Megaw, 1979) 16 Medication Errors Medication error was defined in 1962, as the ??administration of the wrong medication or dose of medication, drug, diagnostic agent, chemical, or treatment requiring the use of such agents, to the wrong patient or at the wrong time, or the failure to administer such agents at the specified time or in the manner prescribed or normaly considered as acepted practice??. (Kenneth N. Barker & McConnel, 1962). In hospitals, medication errors have been found to occur at the rate of about one per patient per day (Alan & Barker, 1990). This error rate includes the errors occurring in the dispensing and administration stages. The American Society of Health-System Pharmacy (1998) defined medication errors as any preventable event that may lead to inappropriate medication use or patient harm while the medication is in control of healthcare profesional, patient or consumer. Such events maybe related to profesional practice, healthcare products, procedures and systems, including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use?. The term ?opportunity for error? has been used as the basic unit of data for calculating the medication error rate. An opportunity for error includes any dose given plus any dose ordered but omited. The ?total opportunities for error? is the sum of al the doses ordered plus al the unordered doses given. The medication error rate is calculated as the number of doses in errors (incorrect in one or more ways) divided by the total opportunities for error (Kenneth N. Barker, Kimbrough, & Heler, 1966). 17 Medication error rate = Total number of actual errors Total opportunities for error A medication error may or may not be labeled as an ?Adverse event?, depending upon whether the error caused the patient harm or discomfort. An Adverse drug event is defined as an injury resulting from medical interventions related to a drug. Adverse event reports are the ?tip of the iceberg? of the problem of errors (sen as system failures), since most errors do not result in reported injuries (Bates et al, 1995). Medication errors have been categorized somewhat diferently depending upon the healthcare setings, inpatient or outpatient. Cohen (1999) defined the diferent types of medication errors as: Prescribing/Ordering errors - Mistakes made by the physician (prescriber) when ordering a medication. Transcription errors ? Deviations from the prescriber?s orders, made by the nursing staf or the pharmacist, when transcribing medication orders. Dispensing errors - Deviation from the prescriber?s order, made by pharmacy staf, when distributing medications to nursing units or to patient?s in an ambulatory seting. Administration errors ? The American society of hospital pharmacists & National League for Nursing liaison commite (1998) defined them as ?the administration of the wrong medication or dose of medication, drug, diagnostic agent, chemical, or treatment requiring the use of such agents, to the wrong patient or at the wrong time, or the failure 18 to administer such agents at the specified time or in the manner prescribed or normaly considered as aceptable practice.? Near Errors ? The Joint Commision on Acreditation and Healthcare Organizations (2001) defined near error as ?any proces variation which did not afect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome.? The Agency of Healthcare Research and Quality (2011) defined near errors as ?events in which the unwanted consequences were prevented because there was a recovery and correction of the failure.? Such errors show that the quality asurance system in the pharmacy is working, but they also maybe taken to reflect a weaknes exists in the dispensing system. Davis stated that near errors should be constantly analyzed in an efort to develop methods to systematicaly reduce their occurrence (N. M. Davis, 1990). Observation method The disguised observation study was developed by Barker and McConnel (Barker K. N & McConnel, 1962) for the detection of medication errors. The observation is disguised in the sense that the subject is unaware of the goal of the study. Some of the advantages of observation method are (Flynn, Barker, & Carnahan, 2003): ? Knowledge of error by the person involved is not required. ? Wilingnes to report the error is not a factor. ? Remembering to report or ability to communicate errors is not required ? Selective perception of the nurse or pharmacist is not involved. 19 ? Unsolicited comments collected through the observation proces can help identify or asociations betwen errors and possible causes (K. N Barker, 1980). The uses of observation data as suggested by Flynn et al (2002) are as follows: ? Indicate and signal major system breakdowns ? Evaluate expensive interventions ? Internaly and externaly benchmark for quality improvement ? Focus resource deployment for error correction and prevention ? Provide a source of examples for problem solving, continuing education programs ? Focus on root cause analysis. Observation tends to be tiresome, if conducted over a long period of time. Special training is required for the data collectors, and some personality types may be unsuited for the role of observer (Flynn, Barker, Pepper, Bates, & Mikeal, 2002). Direct observation might be more expensive per examined dose due to the normal delays involved in medication administration sesions. The efect of the observer on the observed is also a concern. Researchers have conducted various studies to detect any significant efect of the observer on the observed. The possible efect was studied by monitoring individual error rates for 5 consecutive days. The consistency of each subject?s medication error rate was interpreted to indicate that the observer did not afect the rate.(Kenneth N. Barker, et al., 1966). It has been long known that when observation is unobtrusive and non judgmental, 20 the subject(s) adapts quickly to an observer?s presence and act as they would usualy act (F.N Kerlinger & Le, 1999). Dean and Barber studied the efect of observer intervention on nurses. They found that tactful intervention by the observer does not have significant efect on the observed, and that an observation period of les than seven days by one observer had high observer reliability. They concluded that concerns about the validity and reliability of observational methods for identifying medication administration errors may be unfounded (Dean & Barber, 2001). Medication eror problem in nursing homes One of the earliest studies linking eyesight and medication errors in nursing students was conducted by Byrne (Byrne, 1953). Although the study did not specify environmental factors as causes of errors, it listed ?failure to acurately read the medicine card as one of the causes?. The observation study of medication administration errors in a 300-500 bed, non- governmental, health care facility by Barker et. al (Kenneth N. Barker, et al., 1966) found that some of the nurses involved in the medication administration errors had poor eyesight; and the lighting in the area where they prepared medications was poor. The authors suggested the need to improve the lighting conditions in the facility. A prospective cohort medication error study (Barker, Flynn et. al, 2002) of a stratified random sample of 36 healthcare institutions was conducted in Colorado and Georgia. Of the 36 institutions, 12 of them were skiled nursing facilities (6 facilities each 21 in Georgia and Colorado). The researchers found a medication error rate of 10.8% (Georgia) and 14.2 % (Colorado) at the skiled nursing facilities. A prospective observational study (Barber et. al, 2009) of residents at 55 UK nursing care homes found that 69.5% of the residents living there had encountered one or more errors; with each resident experiencing a mean of 1.9 medication errors. Main contributing factors for the errors were found to be staf?s high workload, interruptions during the drug rounds, insufficient nurse?s knowledge and inadequate information about the residents in the facility. Problems faced by the nursing facility The nursing population in the long term care facilities is aging (Joint Commision on Acreditation of Healthcare Organizations, August 2002). The average age of a working registered nurse today is 43.3 years, and that average age is increasing at a rate more than twice that of al other workforces in this country. Only 12 percent of registered nurses in the workforce are under the age of 30 years. By 2010, it is projected that the average age of the working registered nurse wil be 50.8 years.(Buerhaus, Staiger, & Auerbach, 2000; Joint Commision on Acreditation of Healthcare Organizations, August 2002) The performance of the human eye declines with age, with the efects beginning to be noticeable at 40 years of age. This leads to changes in the spectral light sensitivity that by 80 years of age causes loss of vision.(The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007) Research has established that aging eyes require more light as compared to younger eyes, for optimal visual performance.(M. O. Blackwel & Blackwel, 1980; Boyce, 1973; Crouch, 1965; Cullinan, 1986; R. G. Davis 22 & Garza, Winter 2002; Smith & Rea, 1978; The IESNA Commite for Healthcare Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007). Thus special atention must be given to the good visual performance, (and hence improved lighting conditions) for the aging care provider.(Alvarado, 2007) The following figures show that older eyes require increased lighting levels for beter visual performance. Figure 6: Figure depicting a decrease in the transmittance of the human eye, with age.(The IESNA Lighting for the Aged and Partially Sighted Committee, 2007) 23 Figure 7: Figures showing the relative visual performance (%) and lighting levels (lux) for moderately difficult and difficult tasks.(Bommel & Beld, 2004) Continuous line: young people, broken line: older people; EN ? European Norm 24 The problem of insufficient lighting in nursing facilities The problem of insufficient lighting in nursing homes was highlighted when a group of researchers (Lepeleire, Bouwen, Conninck, & Buntinx, 2007) measured lighting levels in diferent areas of a nursing home and found the lighting levels to be insufficient as per the lighting standards (The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007) for the nursing home residents. Although, this study was not conducted in a United States healthcare facility, it begs the question of whether this problem exists in American healthcare facilities. Visual display terminals in the healthcare seting (such as computers, automated dispensing machine- monitors) need diferent lighting conditions. It is a wel-known fact that too much lighting can cause reflected glare on the computer monitor (Henderson, Spring 1995; Sanders & McCormick, 1993; The IESNA Commite for Healthcare Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007). In addition to recommending minimum iluminance levels, the IESNA commite also highlighted other lighting isues in the healthcare areas, like reducing reflected glare on the computer monitor in the automated delivery system, facility design changes to improve beter light distribution, use of beter quality luminaries (light instalations) etc (The IESNA Commite for Healthcare Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007). The Centers for Medicare and Medicaid (CMS) has included adequate lighting requirements in their surveyor guidelines for inspections in long term care facilities (The Centers for Medicare & Medicaid Services, December 2006 edition). Although this 25 guideline is meant to be for resident comfort, it does highlight the fact that lighting conditions can be an indicator of good quality of care provided in the long term care facilities. One of the suggestions provided by Dr. Carolyn Clancy, the director for the Agency of Healthcare Research and Quality (AHRQ), to improve quality of care is to improve the lighting conditions in the American healthcare setings (Clancy, 2008). Special considerations should be given to the lighting conditions for health care staf that work during the night shifts. Lighting conditions have shown to have an efect on a person?s circadian rhythm (biological clock) and the level of alertnes, during work (Juslen, January 2005) A research study investigated the efects of light on alertnes and mood, under night shift conditions. The results concluded that although there is a decline in arousal over the night, the group with the increased ilumination level showed significantly increased arousal level, and thus beter alertnes and mood (Boulos Z, Campbel SS, Lewy JJ, & et.al., 1995). The Illuminating Engineering Society (IESNA) provides recommendations and guidelines for lighting conditions in healthcare facilities (The IESNA Commite for Healthcare Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007). IESNA formulates lighting standards using iluminance categories and weighting factors based upon the subjects? age, speed and acuracy required to complete the task, and reflectance of the task background (The IESNA Commite for Healthcare Facilities, 2006). The commite identified the areas requiring diferent iluminance categories, based on the complexity and demands on the healthcare visual performance. The 26 following table suggests minimum average iluminance for environments in a general hospital (Alvarado, 2007; Sanders & McCormick, 1993; The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007). Table 2: Minimum average iluminance recommended for diferent task areas (The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007) Environment Ambient light Lux/Footcandles Task Lighting Lux/Footcandles Patient rooms 300/30 750/75 Nursing station (day) 300/30 500/50 Nursing station (night) 100/10 500/50 Medication preparation 300/30 1000/100 27 Effect of ilumination on work performance The quantity and quality of light are of paramount importance for highly visual task components. Literature provides evidence demonstrating a positive relationship betwen ilumination and task performance. In fact, its been suggested that ilumination increases of up to 50 foot-candles results in the most dramatic increase in visual performance (Boyce, 1981). Speed and acuracy are the two objective measures of visual performance of a task. There are a number of features of the visual system that are likely to afect the relationship betwen ilumination and human performance:(Terry Le Buchanan, 1989) ? Nature of the visual task; simple detection, recognition or color discrimination ? Task characteristics; size, contrast and color details ? Event predictability ? Time for which the information wil be available ? Whether the stimuli is moving or stationary ? State of adaptation of the visual system Lyons estimates that at least 80% of the sensory data required by an average worker in the performance of his task is obtained through visual modality (Lyons, 1981). Two pioneers in the lighting field, H.C. Weston and H.R. Blackwel, developed visual performance models to beter describe the relationship betwen lighting and its efects on work performance. Weston?s model (Weston HC, 1945, 1949) concluded that performance increased with an increase in ilumination, but not linearly. Also significant, larger improvements in visual performance can be achieved by increasing the contrast 28 and print size than by increasing the iluminance alone. Finaly, one cannot reach the same level of performance for a visualy dificult task (smal print size and contrast) as compared to a visualy easy task, by simply increasing the ilumination level. Blackwel?s research on visibility threshold culminated in a model which characterized both threshold and suprathreshold visual performance.(H. R. Blackwel, 1961, 1964; R. H. Blackwel & Blackwel, 1968) He developed the Blackwel Visual Task Evaluator, which is a contrast-reducing meter. He used this meter to determine the visual task?s equivalent contrast. The visual task evaluator can be used to determine the ilumination levels required for a specific task. This system has been used for establishing recommendations of ilumination levels by the CIE (International Commision on Illumination) and the IESNA (Illuminating Engineering Society of North America). Faulkner (Faulkner & Murphy, 1973) suggested 2 basic approaches to improve task visibility: 1) Change the task; 2) Change the ilumination faling upon the task. The most obvious way of varying the ilumination level is by changing the intensity. In 1978 Smith and Rea studied proofreading under diferent levels of ilumination (Smith & Rea, 1978). They found that task performance improved as ilumination increased to the highest level with rapid improvements at low levels and more gradual improvement at the higher levels. They also found that the subject?s age and print quality of the visual task afected the results; with older subjects performed poorer as compared to younger subjects on the lower quality print tasks. 29 In 1982, Smith and Rea studied the performance of a reading test under diferent ilumination levels (Smith & Rea, October 1982). Two forms of tests (one with good print quality and another with poor print quality) were performed under four diferent levels of ilumination. The ilumination level had no significant efect on task performance, but print quality did show significant efect; with the poor quality resulting in poor performance. They conducted a similar study with a check number verification task under diferent ilumination levels, and found that handwriting quality and ilumination level had a significant efect on visual performance (Smith & Rea, Winter 1987). Rea studied the efects of lighting conditions on reading, which indicated that for the same contrast level, visual performance of the subjects increased at higher ilumination levels (Rea, Summer 1986). Some of the factors afecting the visual inspection proces include visual acuity, color-vision, age, lighting, noise, inspection time, complexity, paced versus unpaced, and number of inspectors (Megaw, 1979). A study conducted by Lion (Lion, Richardson, & Browne, 1967, 1969) looked at the performance of industrial inspectors under two diferent lighting types (tungsten and fluorescent). The tasks involved inspecting links for surface flaws and buttons for off- center holes on a moving conveyor belt. They found that there were fewer errors in the link inspection task under fluorescent lighting as compared to tungsten (this task required greater visual acuity), but there was no diference in performance for the button inspection task. 30 The Effect of Ilumination on Medication Errors The study by Buchanan (T.L Buchanan, Barker, & et, 1991) was first of its kind where the relationship betwen ilumination levels and the dispensing error rate in a high volume outpatient pharmacy was investigated. The study found a significantly lower error rate of 2.6% for an ilumination level of 146 foot-candles as compared to the error rate of 3.8% for the baseline ilumination level (45 foot-candles). Thus, this study provides a basis in fact for the belief that ilumination level is definitely asociated with the medication error rate in a healthcare facility. Poor lighting condition has been one of the important contributing factors to hospital medication errors, as reported by USP?s MEDMARX Program (MEDMARX Data Report, 2008). From the year 2002 -2006, hospitals have reported an average of 230 errors per year were contributed to poor lighting conditions. There is considerable research done studying the efect of ilumination on visual performance, in both laboratory and field setings. Illumination?s positive relationship to visual performance is strongly established both analyticaly and empiricaly.(Terry Le Buchanan, 1989) Illumination remains one of the most flexible and adjustable components of the visual performance model. Thus, there is considerable theoretical basis to expect a positive relationship betwen ilumination and a visualy demanding task such as medication preparation in a nursing home seting. 31 Rationale For Study Proposed The medication preparation proces is highly visual in nature. The nurse must be able to read the contents of the medication administration record (MAR), read the label of the drug prescribed, compare the label to the MAR record and read any distinguishing numbers or leters on the medication in order to identify it. Studies in human factors research have established that improving the quality and level of ilumination greatly improves the visual performance. Weston?s studies on the efect of light on visual tasks demonstrated that the visual performance increased with an increase in ilumination and contrast size (Weston HC, 1945). Blackwel developed the Blackwel Visual Task Evaluator (H. R. Blackwel, 1961), which is used by the Illuminating Engineering Society of North American (IESNA) to determine the levels of ilumination for a specific task, for eg. Medication preparation, in diferent healthcare facilities (The IESNA Commite for Healthcare Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007). In subsequent studies, it was shown that the quality of the visual performance is highly dependant on the quantity and quality of ilumination provided for the task (Belchambers & Philipson, 1962; R. H. Blackwel & Blackwel, 1968; R. G. Davis & Garza, Winter 2002; Dockhorn, Scholz, Vandahl, & Gal, 2005; Faulkner & Murphy, 1973; Megaw, 1979; Smith & Rea, 1978; Wei & Konz, 16-19 October 1978). The problem of insufficient lighting in nursing homes was highlighted when a group of researchers (Lepeleire, et al., 2007) measured lighting levels in diferent areas of a nursing home and found the lighting levels to be insufficient as per the IESNA (2007) guidelines for the nursing home residents and staf. 32 That increasing the ilumination can reduce the error rate was the finding of the study of dispensing errors by Buchanan (T.L Buchanan, et al., 1991). A significantly lower error rate was achieved by increasing the ilumination level from 45 to 146 foot- candles. This increase in ilumination produced a reduction in error rate from 3.8% down to 2.6%. This study thus found that ilumination level is definitely asociated with the medication error rate in a healthcare facility. A prospective cohort medication error study (Barker, Flynn et. al, 2002) of a random sample of 12 skiled nursing facilities in Colorado and Georgia found a medication error rate of 10.8% (Georgia) and 14.2 % (Colorado) respectively. It can be speculated that one of the contributing factors to the errors can be the improper preparation of medications during the preparation phase. USP?s MEDMARX Error Reporting Program also highlights Poor lighting conditions as one of the important factors contributing to hospital medication errors (MEDMARX Data Report, 2008). Acording to the MEDMARX reports, hospitals reported an average of 230 errors per year (for the years 2002-2006) which they atributed to poor lighting conditions. Al the above research studies support the need and value of focusing attention on the lighting system in the healthcare facilities. As the visual component in the healthcare medication distribution system becomes increasingly complex and possibly more prone to error, it is important that the positive impact that a good lighting system can have on the quality of care provided by long term care facilities receive further atention and study, thus ensuring patient as wel as healthcare staf safety. 33 III. Statement Of The Problem Problem Statement The main objective of the study was to measure the efect of increased ilumination levels on the medication preparation errors, by total error rate and error types, in a long-term care study site. Main Research Questions 1) Will increased ilumination level at the long-term care facility result in decrease of the medication-preparation error rate? 2) Will increased ilumination level at the long-term care facility have an efect on the medication-preparation errors, by error types? 3) Is there an asociation betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors detected for that nurse-subject in the long-term care facility? 34 4) Is there an asociation betwen the day of the ilumination period and the number of medication preparation errors made during that day, at the long-term care facility? 5) Is the proportion of medication preparation errors constant over al the sections at the study facility? 6) Is there an asociation betwen the medication shift (work shift) and the medication preparation errors for al three ilumination levels, at the study facility? 35 Research Hypotheses Null (H 0A ): An increased ilumination level at the long-term care facility will not have a significant efect on the medication-preparation error rate. Alternative (H 1A ): An increased ilumination level at the long-term care facility will result in decrease of the medication-preparation error rate. Null (H 0B1 ): An increased ilumination level at the long-term care facility will not have a significant efect on the medication-preparation errors, by wrong dose error type. Alternative (H 1B1 ): An increased ilumination level at the long-term care facility will have a significant efect on the medication-preparation errors, by wrong dose error type. Null (H 0B2 ): An increased ilumination level at the long-term care facility will not have a significant efect on the medication-preparation errors, by wrong form error type. Alternative (H 1B2 ): An increased ilumination level at the long-term care facility will have a significant efect on the medication-preparation errors, by wrong form error type. Null (H 0B3 ): An increased ilumination level at the long-term care facility will not have a significant efect on the medication-preparation errors, by wrong time error type. Alternative (H 1B3 ): An increased ilumination level at the long-term care facility will have a significant efect on the medication-preparation errors, by wrong time error type. 36 Null (H 0B4 ): An increased ilumination level at the long-term care facility will not have a significant efect on the medication-preparation errors, by omision error type. Alternative (H 1B4 ): An increased ilumination level at the long-term care facility will have a significant efect on the medication-preparation errors, by omision error type. Null (H 0B5 ): An increased ilumination level at the long-term care facility will not have a significant efect on the medication-preparation errors, by unauthorized dose error type. Alternative (H 1B5 ): An increased ilumination level at the long-term care facility will have a significant efect on the medication-preparation errors, by unauthorized dose error type. Null (H 0C ): There is no asociation betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors detected for that nurse-subject in the long-term care facility. Alternative (H 1C ): There is a significant asociation betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors detected for that nurse-subject in the long-term care facility. Null (H 0D ): There is no asociation betwen the day of the ilumination period and the number of medication preparation errors made during that day, at the long-term care facility. Alternative (H 1D ): There is a significant asociation betwen the day of the ilumination period and the number of medication preparation errors made during that day, at the long- term care facility. 37 Null (H 0E ): The medication preparation errors detected at the three sections of the study site are not significantly diferent. Alternative (H 1E ): The medication preparation errors detected at the three sections of the study site are significantly diferent.! Null (H 0F ): There is no asociation betwen the medication shift and the medication preparation errors for al three ilumination levels, at the study site. Alternative (H 1F ): There is significant asociation betwen the medication shift and the medication preparation errors for al three ilumination levels, at the study site. 38 Hypothesis Testing H 0A1 : u1 = u2 = u3 H 1A1 : one or more treatment means difer H 0A2 : u1 = u2 H 1A2 : u1 ? u2 H 0A3 : u1 = u3 H 1A3 : u1 ? u3 H 0A4 : u2 = u3 H 1A4 : u2 ? u3 H 0A5 : T linear = 0 H 1A5 : T linear ? 0 H 0A6 : T quadratic = 0 H 1A6 : T quadratic ? 0 H 0B1 : u1 = u2 = u3 H 1B1 : one or more treatment means difer H 0B2 : u1 = u2 = u3 H 1B2 : one or more treatment means difer H 0B3 : u1 = u2 = u3 H 1B3 : one or more treatment means difer H 0B4 : u1 = u2 = u3 H 1B4 : one or more treatment means difer H 0B5 : u1 = u2 = u3 H 1B5 : one or more treatment means difer 39 Illumination level 1 H 0C1 : M= 0 H 1C1 : M ? 0 Illumination level 2 H 0C2 : M= 0 H 1C2 : M ? 0 Illumination level 3 H 0C3 : M= 0 H 1C3 : M ? 0 For each individual nurse-subjects H 0D : u1= u2 =u3 H 1D : Error proportions difer for each nurse-subject for al 3 ilumination levels Illumination level 1 H 0E1 : U X = U Y = U Z H 1E1 : Error proportions difer for one or more study-sections Illumination level 2 H 0E2 : U X = U Y = U Z H 1E2 : Error proportions difer for one or more study-sections Illumination level 3 H 0E3 : U X = U Y = U Z H 1E3 : Error proportions difer for one or more study-sections For al 3 Illumination levels H 0F : U 9 AM = U 5 PM ; H 1F : U 9 AM ? U 5 PM 40 Concepts The concepts addresed in this study are as follows: Error - Failure of a planned sequence of mental or physical activities to achieve its intended outcome, when these failures cannot be atributed to chance . (Reason, 2003) It has also been defined as an unintended act (either of omision or commision) or the one that does not achieve its intended outcome (Reason, 2000, 2003). Medication error ? Errors occurring at any stage in the proces of ordering or delivering a medication. Medication errors can occur at any stage in the drug ordering, dispensing and administration proces (Leape, 1994). Prescription ? A medication order which designates a specific medication and dosage to be administered to a particular patient, at a specified time and isued by a physician or other properly licensed medical practitioner (Bates, Boyle, Vliet, Schneider, & Leape, 1995). Illumination level ? The ilumination level is defined as the rate of light energy emision faling on the unit area of the task surface as measured in foot-candles by a portable, calibrated photometer with an iluminance sensor (Buchanan & Barker, 1991). Nursing home ? A nursing home is a generic term used to describe non-hospital institutions which provide nursing and other health and social related supportive services to the chronicaly il and the elderly (Cheung & Vlases, 1985). 41 The Congresional Discursive Dictionary of Health care (Cheung & Vlases, 1985) defines nursing homes as ?generaly, a wide range of institutions other than hospitals, which provide various levels of maintenance, and personal or nursing care to people who are unable to care for themselves and who may have health problems which range from minimal to very serious. The term includes freestanding institutions, or identifiable components of other health facilities, which provide nursing care and other related services, personal care and residential care. Nursing homes include skiled nursing facilities, intermediate care facilities and extended care facilities, but not boarding houses.? Medication preparation - The preparation proces is divided into 6 steps: (Barker & Heler, 1963) ? Obtaining the ordered drug in the form available ? Separation of the quantity of drug required for one unit dose ? Physical or chemical alteration of the drug form as required ? Maintenance of proper environment for dose-unit ? Maintenance of proper identification and other required information with dose- unit ? Macroscopic inspection of dose-unit for signs of unsuitability of use. Ergonomics - Ergonomics the study of the relationship betwen the work system (the person, the job, and the work place) and human performance (Alexander, 1986). 42 Illumination - Also caled iluminance, is the amount of light faling on to a surface (Sanders & McCormick, 1993). It is measured in terms of luminous flux per unit area. The units of measurement are: Lux (an SI unit) = 1 lumen per square meter, the lumen being the unit of luminous flux. Foot-candle (USCS unit) = 1 lumen per square foot. One foot-candle equals 10.76 lux, usualy rounded off to 10 lux for practical purposes (Sanders & McCormick, 1993). Luminance - It is the amount of light reflected or emited from a surface (Kroemer & Grandjean, 1997). Its unit of measurement is: Candela per m 2 (SI unit) or mililambert and footlambert (USCS unit). Reflectance ? It is measured and compared by the ratio betwen reflected and incident amounts of light. It is expresed as the percentage of reflected to incident light. (Kroemer & Grandjean, 1997) Acommodation means the ability of the eye to bring into ?sharp focus? objects at varying distances from infinity down to the nearest point of vision, caled the ?near point? (Sanders & McCormick, 1993) Glare is a gross overloading of the adaptation proceses of the eye, brought about by overexposure of the retina to light (Sanders & McCormick, 1993) The most important visual capacities are (Sanders & McCormick, 1993): 43 Visual acuity - It is the ability to detect smal details and to discriminate smal objects. Contrast sensitivity - It is the ability of the eye to perceive a smal diference in luminance Medication Preparation Error Categories The medication preparation error categories addresed in this study are as follows (Cohen, 1999; Flynn, Barker, Pepper, Bates, & Mikeal, 2002): Unauthorized drug error ? Preparation of a dose of medication that was never ordered for that resident. Extra dose error - Any dose prepared in exces of the total number of times ordered by the physician, as documented in the MAR, such as a dose given on the basis of an expired order, after a drug had been discontinued, or after a drug's administration had been put on hold. Wrong dose error - Any dose of preformed dosage units (such as tablets) that contained the wrong strength or number. Omision error - Failure to prepare an ordered dose. Omisions wil be detected by comparing the medications prepared at the given observation period, with doses that should have been prepared at that time based on the physician's writen order and protocols. 44 Wrong form error ? The preparation of a dose in a diferent form than ordered by the physician when a form was specified. If enteric-coated aspirin is ordered, but plain aspirin is prepared, then a wrong form error wil be counted. Wrong time error - Preparation of a dose more than 60 minutes before or after the scheduled administration time. Routine administration times were obtained from study site, and times asigned on the MAR were used when no other policy was available. Operational Definitions The operational definitions addresed in this study are as follows: Increased ilumination level ? The ilumination level measured in foot-candles, by a portable, calibrated photometer with an iluminance sensor, when a supplemental task light fixture (of known and constant iluminance) is instaled in the study medication cart. This value/increased level (experimental/treatment measure) was kept constant for the entire study period. Medication preparation ?!It was defined as the proces where the nurse-subject reads the resident medication administration record, retrieves the oral medication from the task area medication cart and measures the medication (counts the number of pils in case of 45 solids, measures the volume in case of liquids) and places it on a medication tray, before administering it to the particular resident. Medication preparation error - A deviation from the resident?s physician record filed in the study nursing home pharmacy, as made by the nurse when preparing medications to be administered to the nursing home residents. Total opportunities for error - The total number of medication doses prepared (and omited) by the nurse, as observed, during the study period. Medication preparation error rate ? Number of medication preparation errors X 100 Total number of opportunities for error 46 IV. Methodology Population The target population for this study was al the oral prescription medication doses prepared by the nurses in the study facility. Sample This is a case study based on convenience sampling and based on the wilingnes of the nursing home staf to alow the study to be conducted. The study site must remain anonymous. Thus, any generalization to other nursing facilities must be made with caution. The study inpatient care section was selected based on the highest volume of prescriptions administered on a given shift. The morning and the evening shifts were selected for observation because they were identified as the busiest shifts at the study site. The work areas where medications were prepared had no windows, and thus no natural lighting. The medication pas rounds observed are: ? Morning med pas (8AM ? until end of the med-pas round, usualy 10 AM) ? Evening med pas (4 PM ? until end of the med-pas round, usualy 6 PM) 47 The sampling unit was an oral prescription medication dose prepared by the nurse-subject in the particular section of the study site and observed by the principal investigator, before administration to the resident, during the study period. The medications observed were retrieved from the nurse?s medication cart, located at the study section. Any medications that were not retrieved from the medication cart, were excluded, as the ilumination levels at the other storage/stock rooms were diferent than that of the study section area. But if the drug container (or blister card) was brought back to the medication cart for the appropriate dose to be prepared, then it was included in the study. Only oral prescription medications was included in the observation study for 3 reasons: ? Most of the doses prepared and administered at the study nursing home (around 85%) are oral medications. ? They are prepackaged by the pharmacy in blister cards or bottles (liquids) and have standardized medication labels. This helps in standardizing the visual information throughout the observation study. ? Most of the oral prescription medications are stored in the medication cart. Study Subjects The study subjects were the nurses working in the selected nursing home unit, during the morning (8am-10 am) and evening (4 pm ? 6 pm) medication pas shifts. Al nurses (LPNs) who were involved in the medication preparation proces and who had signed the informed consent leter were included in the study as subjects. 48 Independent Variable Illumination Level The baseline ilumination level (control measure) of the study study medication cart was measured using a calibrated photometer with an iluminance sensor. (Sper Scientific light meter 840021) The ilumination levels selected for the observation study were: Baseline ilumination level ? This was the current ilumination level at the study medication cart at the selected study section where the observations take place. Illumination level 2 ? The Illuminating Engineering Society (IESNA) provides recommendations and guidelines for lighting conditions in healthcare facilities (The IESNA Commite for Healthcare Facilities, 2006;The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007) The commite suggested an ilumination level of 100fc for areas where medications are prepared (Refer Table: 2). Illumination level 2 (experimental measure) was set at 100 fc, which was obtained by fixing a supplemental lighting fixture (with constant iluminance) over the medication cart at the selected study section. Illumination level 3 - This served as the experimental intervention measure. The increase in the ilumination level (experimental measure) was obtained by fixing a supplemental lighting fixture (with constant iluminance) over the medication cart at the selected study section. A previous study by Buchanan et al (Buchanan, 1991) found that an ilumination 49 level of 145 fc had a significant efect on the dispensing error rate of the study pharmacy. Therefore, ilumination level 3 was set at 145 fc. The three ilumination levels were randomly asigned during the study period (each medication pas round), so as to obtain equal days of observation for al the levels. During the observation phase, care was taken to ensure proper control of the ilumination level by periodic light measurements and controlling for any external sources of light near the study locations. Periodic light measurements were taken for the study area locations, during the observation phase, in order to ensure control of the ilumination level. Suplemental Lighting Aparatus In order to increase the baseline ilumination level to the higher levels of 100fc and 145fc, supplemental lighting fixture (OtLite 508 Illumination TM rechargeable fluorescent task lamp) was afixed to the study medication cart. Research Design This was an explanatory level research; with a repeated measures study design. Independent variable: Increased Illumination levels Dependent variable: Medication-preparation error rate The study was a (within subjects) repeated measures design. 50 Design Structure The study was (within subjects) repeated measures design. ~X Y A1 X Y A2 R a X - Experimental condition; ~X - Control condition Y A1 ? Measurement after the control stimulus; Y A2 ? Measurements after the experimental stimulus R a - Random asignment of the experimental stimulus. Controls This design uses the subjects (in the experimental group) as their own control, thus minimizing the efects of individual diferences. The nurse-subjects were checked for vision prior to the study. Nurses who had completed the visual acuity test (may have corrective glases/contact lenses) were included in the study. The nurse-subjects were administered a distractibility questionnaire, in order to measure their susceptibility to distractions that may occur during the observation period and thus help control the diferences betwen nurse-subjects? susceptibility to distractions from external variables during the study period. The observation method used had been studied and found to be unobtrusive and objective with minimal efect of the observer on the subjects. Standardization of the visual stimuli (medication labels) was achieved, as only oral prescription medications were included in the observation study. 51 The workload data of the nurses was examined prior and during the study. The random asignment of the ilumination levels ensured control over workload or any other individual diferences. Additional sources of light (such as sunlight) that might influence the study were observed and controlled. The study was designed to control for the threats to internal validity in the following ways: 1. Maturation - The study period was not long enough to cause maturation efects in the subject- nurses. The observer observed the nurse-subjects for the same shift- period (for eg. morning med pas rounds 8 am -10 am and evening med pas rounds 4 pm ? 6 pm), which controlled for factors such as fatigue. 2. Testing ? Testing in both the groups, involved observation during their regular med pas rounds. As the nurses are doing familiar activity, for both the groups, the efect of pre-testing were minimized. 3. Instrumentation ? The observer was trained in the scientific observation method (Barker, 1980) Research has established that, if the observer is non-judgmental, objective and unobtrusive, then the efect of the observer on the observed nurse-subject were minimal. The observed subject adapts to the presence of an observer, if the subject is doing familiar activity and the observation conducted is unobtrusive, nonjudgmental and objective (Buchanan, 1991) . 52 Data Collection Data collection occupied 2 phases: 1. Initial site visit ? where the variables of interest were explored and operationaly defined. 2. Explanatory phase ? where the efect of the intervention variable (increased ilumination level) upon the dependant variable (medication preparation errors) was studied. The explanatory phase consisted of: Observation pilot study, conducted from May 25, 2010 to May 28, 2010; Explanatory level study, conducted from June 1, 2010 to August 10, 2010. Phase I : Initial Visits For Orientation To Study Site Initial visits for orientation to the study site were conducted from August 2009 to December 2009 to gather data about the study facility characteristics and workflow. A review was conducted to understand the dynamics of the nursing administration schedules, as wel as help in operationaly defining the variables of interest. The principal investigator also reviewed the staf job profiles and responsibilities. Lighting measurements of the facility and pictorial representations from early visits were noted. Site Selection The principal investigator and her academic advisor visited the State Nursing Home Association headquarters to interview top officials. They were asked to help identify nursing facilities which might be suitable for the research study and found one conveniently located in Auburn, Alabama. The principal investigator and her advisor 53 received asurance from the Alabama nursing home asociation officials that the proposed study site was not atypical when compared to the other nursing facilities around the area. Background information about the facility The principal investigator obtained the following basic background information about the facility on the Internet. A lot of nursing home review websites had information about their facility, such as the number of beds, types of services offered and number of deficiencies cited in the previous years. Although the acuracy of al of the information is questionable, it helped the investigator to get a general idea of the facility. The nursing home study site is an average sized, non-profit facility with 85 beds. The facility has 73 residents indicating 97% of its beds are occupied, which is above average within this state. The provider participates in the Medicare & Medicaid programs and provides resident counseling services. A total of 49 Medicare patients were given 1,279 days of non-swing bed care and services in 2006 and this provider gave two Medicare patients outpatient care and services in 2006. (Anon, 2006) Further background information needed for the preparation of the proposal were obtained in a series of trips to the study home site, as follows: 54 Trip 1 The first trip was to met with the nursing home administrator. The principal investigator and her advisor met with him around 11 am. The purpose of the meting was to explain the significance of the light- study research and to ask for permision to use the nursing facility as a study site. The administrator agreed to let the principal investigator explore the lay out of the facility. In order to acquaint the staf, he suggested that the principal investigator prepare a one-page memo of the intent of the research, what she were doing at the site, the observation start date and an atached picture. He asked to submit the memo a wek before the observation start date. The principal investigator drafted a memorandum citing some brief information about the purpose of the exploratory visits, which was to be stuck on the notice board, next to the clock-in machine for the nursing staf to se. Please refer Appendix A for a copy of the memorandum. It was also learned that the study facility were surveyed every 9 months approximately; and the last time the state surveyors visited the site was in December 2008. Trip 2 The investigator met with the pharmacist at the facility. The conversation provided the following information about the pharmacy and the study facility. ? The on-site pharmacy was not yet functional; and was stil being set up. ? The nursing home orders al its medications on a monthly basis from a mail-order pharmacy, based in Alabama. 55 ? The on-site pharmacy were fully functional by May 4 th 2009. ? The medications are packaged in blister packs and stored in the medication carts. ? The study facility had 75 residents at that time ? The facility had 3 sections (section X, Y and Z) and 2 nursing stations. One nursing station took care of Section X and the other took care of sections Y and Z. ? Section X had the maximum number of residents and additional rooms being added to it. ? For the storage of over-the-counter drugs, the study facility had a stock closet. ? The prescription and medication records were al paper based. ? The pharmacy catered to the medication needs for the study facility, the asisted living facility and hospice care. ? She also mentioned that the nursing home was recently bought by the local hospital system (name confidential). ? A consultant pharmacist visits the nursing home once every month for inspections. ? The staf in the pharmacy comprised of: ? A pharmacist ? A fil-in pharmacist ? A technician ? A biling person ? The technician wil manualy blister pack a month?s supply of medications for the nursing home residents. 56 ? A sheet containing the study facility medication schedule was handed over to the principal investigator. Please refer Appendix C. Trip 3 The main purpose of this meting was to met with the Director of Nursing. The principal investigator had an appointment with her in the afternoon; wherein they spoke about the nursing home in general and toured the facility. The information gathered: ? The study facility has 3 sections and 85 beds; al elderly patients. ? No specific services are provided in the sections; they are al general residents. ? The medication pas rounds occur at 6 am, 9 am, 1 pm, 5 pm and 9 pm ? The medication administration window is ? 60 minutes. ? There were around 650 medications administered at the study site during the busiest med pas rounds (9 am and 5 pm) ? There were 3 medication carts in total; and the main study station overlooked the medication needs of sections 2 and 3. ? Twelve new beds were being added to section 1 by the end of April; a new nursing station was also being built. ? The shifts are as follows ? 1 st shift - 7 am to 3 pm ( 3 nurses administer medications) ? 2 nd shift - 3 pm to 11 pm (3 nurses administer medications) ? 3 rd shift ? 11 pm to 7 am (2 nurses administer medications) ? There were 5 registered nurses in the facility during the day shift ? A new MDS coordinator was going to be appointed by May 4 th ? They had no designated Quality Asurance personnel. 57 Figure 8 : The general layout of the room was as follows: (not to scale) 58 Trip 4 The fourth trip was to measure and take some pictures of the lighting fixtures in the facility. Trip 5 The investigator took additional pictures and light measurements at diferent locations of the facility. She also visited the pharmacy, which was in the proces of stocking up on their medications. Section X Floor level (middle of the lobby) ? 41.8 fc Mid- air level - 109 fc Nursing station desk surface - 126 fc Near the exit doors Floor level - 114 fc Mid-air level - 147.8 fc Figure 9: Exit door 59 Figure 10: Section X Medication cart upper surface Fluorescent Light fixture 54 fc 24.4 fc 60 Section Y Floor level (middle of the lobby) ? 34.3 fc Mid- air level - 106 fc Nursing station desk surface - 124.3 fc Figure 11: Section Y light measurements. Figure 12: Dining /Activity room A table in Dining / Activity room - 125 fc 61 Figure 13: Section Y Medication cart upper surface Fluorescent Light fixture 13.18 fc 12.8 fc 62 Section Z Floor level (middle of the lobby) ? 33.4 fc Mid- air level - 125.6 fc Reception desk in front lobby - 91.8 fc Outside Gift shop in the front lobby - 37.5 fc (yelow light) The principal investigator was informed that the new section was filed with residents, and that there were 85 residents in the facility at the time of the study. Visit to the Pharmacy The pharmacy caters to the medication needs for long-term care, hospice and asisted living facilities. Although the medications for the hospice care were already set up, the long-term care section (nursing facility and asisted living facility) was stil under construction. 63 Here are some pictures and light measurements from the pharmacy site: Figure 14: Security measure at the pharmacy site; al windows had bars on them. Figure 15: Light fixtures used in the pharmacy 64 Figure 16: Blister packaging material for the medications Figure 17: Medications stacked in the cabinet; bar-coded label 65 Figure 18: Hospice pharmacy cabinet Hospice pharmacy medication cabinet floor - 10fc Figure 19: Hospice pharmacy window Hospice pharmacy pharmacist station (near window) ? 142.3 fc 66 Long term care section computer station Computer station 1 - 88 fc Figure 20: Computer station 1 Long term care section work stations Workstation overlooking an open window (light fixture on top) - 127. 3 fc Figure 21: Workstation overlooking an open window Workstation overlooking a window with blinds (light fixture on top) - 120 fc 67 Figure 22: Workstation overlooking a window with blinds Trip 6: The investigator went to the study site around 10.10 pm to measure the light levels. It was learned that some residents are administered their 11 pm medications, which are prepared at 10 PM. 68 Figure 23: Section X: Medication cart light measurement The nurse giving the medication pas was observed commenting on the light quality being dull. In her words she said, ??we need beter lights here??. Fluorescent Light fixture 15 fc 14.9 fc 14.5 fc 8.33 fc 8.0 fc 15.5 fc, 12.43 fc, 13.0 fc when open 14.6fc 8.5 fc 69 Figure 24: Section Y Medication cart The lights in the resident rooms are turned off at night, when they slep. So, in case the nurses have to administer medications, they turn on the light, after entering the resident room. Fluorescent Light fixture 45.6 fc 35.0 fc 22.4 fc 70 Trip 7: The principal investigator visited the new pharmacy, now fully functional. The pharmacy caters to the medication needs of the hospice, nursing and asisted living facility. Acording to the chief pharmacist there, they fil on an average about 172 prescriptions per day, out of which 88 are for the study facility. The estimated average number of prescriptions filed, per section per day are: Section 1 ~ 15/day Section2 ~ 13/day Section 3 ~ 10/day 71 ! Figure 25: The detailed workflow diagram is as follows: 26 Some pictures from the visit: Physician visits once a month; telephones/dictates orders Nurse stocks the medication in the medication cart for the specific nursing unit Nurse/nurse- secretary transcribes order Medication transcription is faxed to the on-site pharmacy Nurse administers medications to residents. Medication order gets updated on pharmacy database. Pharmacy prints out label and dispenses the drug in custom-made blister pack Pharmacy dispenses monthly suply to facility in the evenig everyday 72 Figure 26: Blister packaging at the pharmacy Figure 27: Controlled substance form and label beside it 73 Explanatory Study Phase This phase consisted of: Observation pilot study was conducted from May 25, 2010 to May 28, 2010; Explanatory level study was conducted from June 1, 2010 to August 10, 2010. IRB Aproval IRB approval (March 2010) was sought from Auburn University and the Study site, prior to data collection for the study. The IRB was renewed (February 2011) for the time-period of another year. (Refer Appendices B and H). Informed Consent Letter The principal investigator visited the study site on April 2, 2010 during the monthly nurse?s meting. At the meting, the investigator was formaly introduced to al the nurses by the study home administrator, and got a chance to brief them about the observation study. Each of the nurse-subject participating in the study was read an introduction memorandum explaining the research study and the role of the principal investigator. The nurses who were interested in participating in the study were then asked to sign the consent leter. (Please refer Appendix G). They were also briefed about taking the visual tests and distractibility questionnaire, as part of the study protocol. Out of 10 nurses (LPN), 9 of them signed the informed consent leter. One of the nurses semed a litle resistant to the visual tests and was observed teling the investigator ?You cannot force me to wear glases?, for which the investigator simply smiled. 74 Demographic Information Literature has suggested that demographic variables like person?s age (Cullinan, 1986; Blackwel, 1980), visual acuity have a significant impact on their visual performance and their reaction to diferent lighting levels. Prior to the start of the observation period, information about the demographic variables previously identified as possibly linked to medication errors like age, sex, nursing degree (education level), number of months employed in the study nursing home and employment status (RN, LPN, nurse intern) were collected from nurse-subjects who had signed the consent forms. The nursing home administrator provided the investigator with the demographic information for al the nurses. Workload information (number of residents and their medication regimen, number of doses prepared) for each nurse was also collected during the observation period by the principal investigator. Visual tests The nurses was administered a standardized visual acuity test by a licensed pharmacist ? faculty at Auburn University, helped by the principal investigator. Snelen chart (Wendy Strauss Wat, 2003) was used to measure the visual acuity of the nurses. The test was administered during the monthly nurse?s meting (for the month of July). One of the nurses, who did not show up for the meting was administered the test, the very next day. 75 Group Embeded Figures Test Distractibility was defined by the score achieved by subjects on the Group Embedded Figures Test(GEFT). The nurses were administered a distractibility questionnaire (Flynn E.A, 1994), in order to measure their susceptibility to distractions that may occur during the observation period. This writen test requires the subject to visualy distinguish a simple geometric figure from within a complex figure. One point is awarded for each correctly identified figure. Higher the score, the more field independent (les distractible) the subject. Each nurse was administered the test individualy, as per their convenience. The testing location was kept standard for al the nurses and the principal investigator briefed the nurses about the rules of the test. Each nurse was given sufficient time to ask questions, before they could begin their tests. The investigator timed each section, and the time limit for the test was kept constant for al the nurses. The investigator referred to the GEFT Manual (Witkins et.al) for instructions on administration and scoring of the distractibility questionnaire. Observation pilot study (May 25, 2010 - May 28, 2010) The main objectives of the pilot study were: 1) To estimate the sample size for the main study; 2) To identify and operationaly define the variables (error types) of the study; 3) To help design the med pas observation form for the main study; 4) To understand the med pas workload of nurses in al the three sections of the study site. 76 5) To help acquaint the observer/principal investigator with the pace of medication preparation by the nurses. Explanatory level study (June 1, 2010 to August 10, 2010) The main explanatory study began on June 1, 2010 and was concluded on August 10, 2010. The principal investigator observed each section for both the morning (9 am) and the evening (5 pm) med pas rounds. The observer randomized the Illumination level for that particular day by the using of the random number generator on the Excel software. The supplemental task light was placed on the study medication cart, irrespective of the ilumination level, in order to control for participant sensitization. The baseline level was achieved by measuring the light level on the medication cart, without switching on the supplemental task light apparatus. The experimental (intervention) levels were achieved by adjusting the arm of the apparatus, by moving it either up or down, until the desired level was met. 77 Figure 28: Baseline measurement Figure 29: Experimental (Intervention) measurement 78 Figure 30: Sample of Visual Stimuli (medication label fixed on the oral doses) Figure 31: Observation instruments used during the study 79 The observer recorded the medication preparation information as prepared by the nurse during the medication pas round and then noted the information from the original prescriber?s orders for that particular section, after the end of the observation period. Reconciliation of the observed data to the original orders were done after the end of the observation study for that particular section/nurse, in order to control for any observer bias. Statistical Analysis Repeated measures analysis of variance was used to compare the total medication preparation error rate, as detected by observation, for the three lighting conditions. Chi-square analysis was used to compare the medication preparation errors, by error types, as detected by observation, for the three lighting conditions. Linear regresion was used to examine the relationship betwen the daily medication pas workload and the medication preparation errors. Chi-square analysis was used to study the relationship betwen the day of the ilumination period and the number of medication preparation errors made on that day. This was to indicate the efect of the principal investigator/observer on the performance of the nurse-subjects. Significance Level The alpha level was preset at 0.05 for an estimated efect size of 0.2 and power of 0.8 (Cohen J, 1988). 80 V. Results In this chapter, the results are presented as follows: ? Demographic information of the study subjects ? General description and observed results of the pilot study sample (May 2010) ? General description of the main observation study sample (June - August 2010) ? Comparison of errors for al three ilumination levels ? Statistical tests and hypotheses 81 Study Subjects description This study looks at the efect of ilumination upon the performance of the nurses as they prepare the doses ordered by the physicians to be administered. The main focus of the study is the medication system, a ?non-machine system? in which the nurse-subject is the principal actor, though other environmental factors are present and may play a part in afecting the error rate. Of the 9 nurses, only 7 nurses who worked the day shifts were included in the observation study. The 2 nurses who worked the night shifts were excluded, as the dynamics of ilumination changes during the nighttime. The nurse-subjects, their eyesight, Group Embedded Figures Test (GEFT) scores and other demographics for which there is evidence of possible involvement in producing errors are shown in Table 3. Along with the nurse?s eyesight, the observer too recorded her eyesight and GEFT scores, which is provided in Table 3. None of the subjects in this study had significant visual impairment based on the results of the visual tests. The Group Embedded Figures Test (GEFT) scores ranged from 5 to 11 (out of possible zero to 18 range) with a mean of 8.14. Al the nurse-subjects were Licensed Practitioner Nurses (LPNs), and their duration of employment ranged from 9 months to 9 years. 82 Table 3: Demographic Information of the Study Subjects Nurse Age (yrs) Gen der Emplo ymt status Month s emplo yed at study site Shift timings Nurs ing unit Cor ective Meas ures Left Eye Vision Right Eye Vision Both Eyes Vision GEFT Score 1A 47 F LPN 17 6:45AM -3:15P Z Glas es 20/20 20/15 20/15 5 / 18 2B 24 F LPN 10 2:45PM- 11:15P M X Cont acts 20/13 20/30 20/15 12 / 18 3C 38 F LPN 16 2:45P- 11:15P M Y None 20/15 20/13 20/13 6 / 18 4D 23 F LPN 9 2:45P- 11:15P M vari es Glas es 20/40 20/30 20/40 10 / 18 5E 42 F LPN 112 (9yr4 mo.) 6:45AM -3:15P X Glas es 20/25 20/25 20/25 6 / 18 6F 25 F LPN 14 6:45AM -3:15P Y None 20/20 20/30 20/15 11 / 18 7G 37 F LPN 12 6.45 AM ? 3.15 PM vari es Cont acts 20/50 20/70 20/50 7 / 18 Obse rver F Cont acts 20/25 20/25 20/20 15 / 18 83 Pilot Study: General description and results The pilot observational study was conducted at the study site from May 25, 2010 to May 28, 2010, for the morning (9 am) and evening (5 pm) medication pas. The main objectives of the pilot study were: 1) To estimate the sample size for the main study; 2) To help design the med pas observation form for the main study; 3) To understand the med pas workload of nurses in al the three sections of the nursing site. 4) To help acquaint the observer/principal investigator with the pace of medication preparation by the nurses. A total of 653 medications were observed being prepared by the nurse subjects during the pilot study. A total of 34 medication preparation errors were confirmed; with an overal error rate of 5.2 %. The distribution of errors for each day of observation is shown in Table 4. An error-rate, excluding wrong time errors was also computed, which was 4.3%. The reason for computing this error rate was due to the fact that the observer noticed that sometimes the nurses prepared the doses wel in advance to the next medication pas rounds. For eg. Some of the nurses prepared the doses for the next medication pas round (9 pm) during their present med-pas (5 pm). Although, this may constitute a wrong time error, but the observer thought it would be useful to compute two error- rates, just to observe the efect of ilumination with and without the wrong time errors. 84 The total opportunity of errors (TOE) is the denominator of the measure of the workload demand upon the system, including the nurse-subjects (doses prepared and omited) during the observation period. Table 4: Pilot Study (May 25 ? May 28, 2010) Date Sec tio n Illumination Level (foot- candles) Obs Time Total Opp. for Errors Errors Error Rate Error Rate w/o wrong time errors May 25, 2010 Z Baseline * 9:00 AM 82 5 6.1% 6.1% Y Baseline * 4.00 PM 79 5 6.2% 5.1% May 26, 2010 X Baseline * 9.00 AM 95 6 6.3% 6.3% X 145 4.00 PM 91 4 4.4% 1.1% May 27, 2010 Z 100 9:00 AM 80 3 3.7% 3.7% Z 145 4.00 PM 75 4 5.3% 5.3% May 28, 2010 Y 145 9.00 AM 81 3 3.7% 2.5% Y 100 4:00 PM 72 4 5.5% 4.2% Total 655 34 5.2% 4.3% * Baseline level: Average ilumination level of 30 foot-candles. Figure 32: Medication Preparation Errors for three ilumination levels 6.2 5.8 4.6 4.6 4.5 2.9 0 1 2 3 4 5 6 7 Error rate (%) Error rate w/o wrong time (%) Pilot Study: Er ror rates Baseline 100 145 85 The nature and frequency of each error type detected during the pilot study is described in Tables 5 and 6, to judge the clinical significance of the error detected, al of which share equal status as an incidence of system failure. The distribution of error types for each ilumination level is shown in Figure 26. The ilumination levels 100 fc and 145 fc had fewer errors asociated with them as compared to the baseline measurement (an average ilumination level of 30 foot-candles) Table 5: Frequency of error types during pilot study Date Sectio n Ill. Level (foot- candles) Obs Time Errors Wrong dose errors Wrong form errors Omisio n erors Wrong time errors May 25, 2010 Z Baseline* 9:00 AM 5 2 3 Y Baseline* 5.00 PM 5 2 1 2 May 26, 2010 X Baseline* 9.00 AM 6 3 3 X 145 5.00 PM 4 1 3 May 27, 2010 Z 100 9:00 AM 3 2 1 Z 145 5.00 PM 4 2 2 May 28, 2010 Y 145 9.00 AM 3 1 1 1 Y 100 5:00 PM 4 2 1 1 Total 34 * Baseline level: Average ilumination level of 30 foot-candles. 86 Figure 33: Frequency of error types for three ilumination levels The errors observed during the pilot study helped the observer in the preparation of the medication observation form. The pilot study results revealed that Wrong time errors were frequently observed. It was observed that the nurse-subjects prepared some of the doses to be administered in the next med-pas round, during the previous round. But, this behavior was not observed uniformly across al nurse-subjects, so it was decided that the observation results be computed with and without wrong time errors. 1.3 2.7 2.6 1.2 0.8 0.7 1.6 2.7 1.6 0 0.5 1 1.5 2 2.5 3 Baseline 100 145 Er r or R ate (%) Illumination Levels Pilot Study: Error Types Omission Wrong Form Wrong Time Wrong Dose 87 Table 6: Description of Each Error during the Pilot Study Date Prescribed Drug Prepared Drug Error Type Notes May 25, 2010 9 AM Aspirin 81 mg Enteric Coated (EC) Aspirin 81 mg EC Crushed Wrong Form Nurse (LPN) said she was behind schedule and wanted to finish her med pas before 10 AM Colace Solution 5 ml Colace solution 10 ml Wrong Dose Oxybutynin ER 10 mg Oxybutynin ER 10 mg crushed Wrong form Nifedipine 30 mg ER Nifedipine 30 mg ER Crushed Wrong form Therapeutic Vitamin # 1 tab Therapeutic Vitamin # 2 tabs Wrong dose May 25, 2010 5 PM Senna S # 2 tabs Senna S # 1 tab Wrong dose Therapeutic Vitamin # 1 tab Therapeutic Vitamin # 2 tabs Wrong dose Simvastatin 40 mg; due at 9PM Simvastatin 40 mg; given at 4.30PM Wrong time Detrol LA 4 mg Detrol LA 4mg crushed Wrong Form Diazepam 5 mg; due at 9 PM Diazepam 5m; given at 5.35 PM Wrong time May 26, 2010 9 AM Aspirin 325 mg EC Aspirin 325 mg EC Crushed Wrong Form Bupropion HCL SR 100 mg Bupropion HCL SR 100 mg Crushed Wrong Form Aspirin 81 mg EC Aspirin 81 mg EC Crushed Wrong Form Loratadine 10 mg #1 tab po D Loratadine 10 mg #2 tabs Wrong dose Senna Plus # 2 tabs Senna Plus # 1 tab Wrong dose 88 Date Prescribed Drug Prepared Drug Error Type Notes Acetaminophen 325 mg #2 tabs Acetaminophen 325 mg #1 tab Wrong dose May 26, 2010 5 PM Seroquel 100 mg @ 9PM Seroquel 100 mg @ 4.35 PM Wrong time Aricept 10 mg @ 7 PM Aricept 10 mg @ 5.17 PM Wrong time Simvastatin 20 mg @ 9 PM Simvastatin 20 mg @ 5.30PM Wrong time Xanax 0.25 mg Xanax 0.25 mg Spils crushed pil; some leftover on table Wrong dose May 27, 2010 9 AM Fish Oil 3000 mg none Omision Aspirin 81 mg EC Aspirin 81 mg EC Crushed Wrong form Oxybutynin ER 10 mg Oxybutynin ER 10 mg Crushed Wrong form May 27, 2010 5 PM Klor Con M20 CR Klor Con M20 CR Crushed Wrong form Senna S #2 tabs Senna S # 1 tab Wrong dose Aspirin EC 81 mg ER Aspirin EC 81 mg ER Crushed Wrong form Golden age Liquid (Vitamin) 10 ml Golden Age Liquid 7 ml Wrong dose May 28, 2010 9 AM Calcium 600 + vitamin D; due at 7 am Calcium 600 + vitamin D; given at 9.17 am Wrong time Aspirin EC 81 mg Aspirin EC 81 mg crushed Wrong Form Colace solution 10 ml Colace solution 7 ml Wrong dose May 28, 2010 5 PM Calcium 600 + vitamin D; due at 7 am Calcium 600 + vitamin D; given at 10.07 am Wrong time 89 Date Prescribed Drug Prepared Drug Error Type Notes May 28, 2010 5 PM Klor Con M10 Klor Con M10 Crushed Wrong form Aspirin EC 81 mg Aspirin EC 81 mg Crushed Wrong Form Main Observation Study: Sample Description A total of 6,808 medication doses were observed being prepared by the nurse- subjects during the 45-day study period from June 1, 2010 to August 10, 2010. An average of 151 doses were observed per day, with an average of 76 doses per shift. The observation sample size of 6808 doses achieved a 95% confidence interval, with a relative acuracy of ? 5%, efect size of 0.2, power of 0.8 at an estimated medication error rate of 11%. (Flynn et.al, 2002) However, 50 medication doses were excluded due to the following reasons: Table 7: Reasons for excluded doses Reason for Exclusion # Doses Excluded Incomplete Information recorded 25 Illumination level not met 12 Physician handwriting ilegible 13 Total 50 90 So, a total of 6,758 prepared doses were included in the final study. The following table and figure summarize the characteristics of the observed sample with respect to the nurse-subjects who prepared them and the corresponding ilumination levels. Table 8: Total observed doses (after dose exclusion) for each nurse-subject for each Illumination level Nurse code Illumination Level 1 Baseline Illumination Level 2 100 fc Illumination Level 3 145 fc Total doses observed 1A 329 334 327 990 2B 389 399 406 1194 3C 218 230 223 671 4D 325 313 336 974 5E 325 332 341 998 6F 341 327 357 1025 7G 293 296 317 906 Total Doses Observed 6758 91 Figure 34: Doses prepared by each Nurse-subject (LPN) for three ilumination levels Medication Preparation Errors for the Study Sample (6,758 doses) The total number of medication preparation errors observed for al the three sections of the study site under three ilumination levels was 467, resulting in a total medication preparation error rate of 6.7%. The total opportunities for error (doses observed being prepared plus the doses omited by the nurses during the observation period) were 6,948 doses. Medication Preparation Error Rate = 467 / 6948 x 100 = 6.7% Excluding Wrong time errors, Medication Preparation Error Rate = 321 / 6948 x 100 = 4.6% 0 500 1000 1500 1A 2B 3C 4D 5E 6F 7G T otal d os e s ob s e r ve d LPN Code Total doses observed for each LP N Bas eline 100 fc 145 fc Total Meds observed 92 Table 9: Medication Preparation Errors for the Study Site for three ilumination levels Illumin ation level Average illuminatio n level (fc) Total meds observed Errors TOE Error rate (%) Error rate excluding wrong time erors (%) Baselin e 28.16 2220 196 2292 8.5 5.7 100 100.23 2231 173 2313 7.4 4.5 145 144.69 2307 98 2343 4.3 2.5 Total 6758 467 6948 6.7 4.6 Figure 35: Error rate for the study site for three ilumination levels The most frequently observed medication preparation error was Omision (N = 190, 40%), followed by Wrong time (N = 146, 31%), Wrong form (N = 72, 15%), Wrong Dose (23, 5%) and Unauthorized Drug (4, 1%). The observer observed that some of the nurse-subjects prepared few of the doses to be administered in the next med-pas round, during the previous round. But, this 8.5 5.7 7.4 4.5 4.3 2.5 0 1 2 3 4 5 6 7 8 9 Error Rate % Error Rate w/o wrong time Error Rate for Study Site Baseline 100 fc 145 fc 93 behavior was not observed uniformly across al nurse-subjects, so the results were computed with and without wrong time errors. Wrong Form errors frequently observed were those where the dose was crushed during preparation, despite a specific order to the contrary writen by the physician stating ?do not crush?. Such doses were sometimes for medications, which the manufacturer had enteric coated or otherwise intended for extended release. During the observation period, two nurses told the observer that the reason for crushing medications was to aid the resident in swalowing it. Although the observer understood the practical reason for crushing the doses, the operational definition of an error used in this study recognized the specific order by the physician as paramount for representing the best evidence of the outcome desired from the patient?s point of view. Therefore, such doses were considered Wrong Form errors. The description of errors by types is shown in Table 10, while Figure 36 describes the frequency of error types for each ilumination level. Table 10: Total Medication Preparation Errors, by Error Types Illuminati on level Total meds Errors TOE Error rate Una uth. Dose Wron g dose Omisio n Wron g Form Wron g Time Baseline 2220 196 2292 8.5 3 12 72 38 39 100 2231 173 2313 7.4 6 82 19 66 145 2307 98 2343 4.3 1 5 36 15 41 Total 6758 467 6948 6.7 4 23 190 72 146 94 ! * Error rates for Unauthorized Drugs were to low to report (Baseline : 0.004%; 145fc : 0.002%) Figure 36: Frequency of Medication Preparation Error Types, by Illumination levels Medication Preparation Errors, by Study Site Sections Section X: The study site has three sections, and the following tables show the distribution of errors and error types, across al the sections for al the three ilumination levels. The medication preparation error rate for Section X was 7.4%, with 235 detected errors for 3080 observed doses. 3.1 3.5 1.5 1.7 0.8 0.6 1.7 2.9 1.7 0.5 0.3 0.2 0 0.5 1 1.5 2 2.5 3 3.5 4 Bas eline 100 145 Er r or R ate (%) Illumination Le vels Error Types for the Study S ite Omission Wrong F orm Wrong Time Wrong D ose Unauthorized Drug* 95 Table 11: Medication Preparation Errors for Section X Illum n. level Average il level (fc) Total meds observed Errors TOE Error rate (%) Error rate exclud wrong time erors (%) Baseline 29.38 964 98 988 9.8 5.0 100 100.14 957 84 1003 8.2 5.9 145 144.75 1159 53 1179 4.5 2.4 Total 3080 235 3170 7.4 4.2 Figure 37: Medication Preparation Error rate for Section X, by Illumination levels The most frequently observed medication preparation error for Section X was Wrong time (N = 101, 43%) followed by Omision (N = 90, 38%), Wrong form (N = 25, 1%), Wrong Dose (N = 15, 6%) and Unauthorized Drug (N = 4, 2%). The description of errors by types is shown in Table 12, while Figure 38 describes the frequency of error types for each ilumination level, for Section X. The description of each preparation error observed for Section X is provided in Appendix I. 96 Table 12: Medication Preparation Errors for Section X, by Error Types Ill level Total meds Error s TOE Error rate Unaut hDose Wron g dose Omisio n Wron g Form Wron g Time Baselin e 964 98 988 9.8 3 8 24 13 50 100 957 84 1003 8.2 0 5 46 8 25 145 1159 53 1179 4.5 1 2 20 4 26 Total 3080 235 3170 7.413 4 15 90 25 101 Figure 38: Medication Preparation Errors, by Error Types for Section X 2.4 4.6 1.7 1.3 0.8 0.3 5 2.5 2.2 0.3 0.08 0.8 0.5 0.1 0 1 2 3 4 5 6 Baseline 100 145 Er r or R ate (%) Illumination Levels Error Types for Section X Omission Wrong Form Wrong Time Unauthorized Drug Wrong Dose 97 Section Y: The medication preparation error rate for Section Y was 6.7%, with 149 detected errors for 2,166 observed doses. Table 13: Medication Preparation Errors for Section Y Il level Average il level (fc) Total meds observed Errors TOE Error rate (%) Error rate exclud wrong time erors (%) Baseline 27.74 788 68 818 8.4 6.3 100 100.175 635 45 659 6.8 4.3 145 144.7 743 36 756 4.8 3.4 Total 2166 149 2233 6.7 4.6 Figure 39: Medication Preparation Error rate for Section Y, by Illumination levels 8.4 6.3 6.8 4.3 4.8 3.4 0 1 2 3 4 5 6 7 8 9 Error rate (%) Error rate w/o wrong time (%) Error Rate for Section Y Baseline 100 145 98 The most frequently observed medication preparation error for Section Y was Omision (N = 67, 45%) followed by Wrong time (N = 47, 32%), Wrong form (N = 27, 18%) and Wrong Dose (N = 8, 5%). The description of errors by types is shown in Table 14, while Figure 33 describes the frequency of error types for each ilumination level, for Section Y. The description of each preparation error observed for Section Y is provided in Appendix I. Table 14: Medication Preparation Errors for Section Y, by Error Types Ill level Total meds Error s TOE Error rate Unaut hDose Wrong dose Omisi on Wron g Form Wron g Time Baselin e 788 68 818 8.4 0 4 30 13 21 100 635 45 659 6.8 0 1 24 4 16 145 743 36 756 4.8 0 3 12 10 10 Total 2166 149 2233 6.7 0 8 67 27 47 Figure 40: Medication Preparation Errors, by Error Types for Section Y 3.6 3.6 1.6 1.6 0.6 1.3 2.5 2.4 1.3 0.5 0.1 0.4 0 0.5 1 1.5 2 2.5 3 3.5 4 Baseline 100 145 Er r or R ate (%) Illumination Levels Error Types for Section Y Omission Wrong Form Wrong Time Wrong Dose 99 Section Z: The medication preparation error rate for Section Z was 5.37%, with 83 detected errors for 1,512 observed doses. Table 15: Medication Preparation Errors for Section Z Ill level Average il level (fc) Total meds observed Errors TOE Error rate (%) Error rate exclud wrong time erors (%) Baseli ne 27.88 468 30 486 6.25 6.25 100 100.41 639 44 651 6.77 2.88 145 144.6 405 9 408 2.22 0.94 Total 1512 83 1545 5.4 3.4 Figure 41: Medication Preparation Error rate for Section Z, by Illumination levels 6.25 6.25 6.77 2.88 2.22 0.94 0 1 2 3 4 5 6 7 8 Error Rate % Error Rate w/o wrong time Error Rate for Section Z Baseline 100 fc 145 fc 100 The most frequently observed medication preparation error for Section Z was Omision (N = 33, 40%) followed by Wrong time (N = 30, 36%) and Wrong form (N = 20, 24%). The description of errors by types is shown in Table 16, while Figure 35 describes the frequency of error types for each ilumination level, for Section Z. The description of each preparation error observed for Section Z is provided in Appendix I. Table 16: Medication Preparation Errors for Section Z, by Error Types Ill level Total meds Erro rs TOE Erro r rate Unaut hDose Wrong dose Omisio n Wrong Form Wrong Time Baselin e 468 30 486 6.25 0 0 18 12 0 100 639 44 651 6.77 0 0 12 7 25 145 405 9 408 2.22 0 0 3 1 5 Total 1512 83 1545 5.37 0 0 33 20 30 Figure 42: Medication Preparation Errors, by Error Types for Section Z 3.7 1.8 0.7 2.5 1.1 0.2 3.8 1.2 0 0.5 1 1.5 2 2.5 3 3.5 4 Baseline 100 145 Er r or R ate (%) Illumination Levels Error Types for Section Z Omission Wrong Form Wrong Time 101 Medication Preparation Errors, by Nurse-Subjects Seven nurse-subjects prepared the medication doses for the mornings and evening medication pas rounds (9 am and 5 pm respectively) at the study site, during the observation period. The distribution of preparation errors by nurse-subjects and ilumination levels is shown in Table 38. Pictorial representation is shown in Figure 43. Nurse-subject 7G was asociated with the highest medication preparation error rate of 10.4%, whereas Nurse-subject 1A was asociated with an error rate of 2.8%. Figure 43: Medication Preparation Error rate for each nurse-subject, by ilumination types 4.2 10.7 9.9 7.6 11.3 4.9 11.3 2.9 6.8 7.5 12.3 5.4 4.8 11.8 1.2 4.3 6.2 4.8 2.9 3.2 7.2 0 2 4 6 8 10 12 14 1A 2B 3C 4D 5E 6F 7G Er r or R ate LPN Code Med Error Rate for each LPN Baseline 100 fc 145 fc 102 Table 17: Medication Preparation Errors by Nurse-subjects for 3 Illumination levels Nurse subject Illumination level Average illumination level Total meds Errors TOE Error rate (%) Error rate exclud wrong time erors 1A B 35.25 329 14 333 4.2 4.2 100 100.48 334 10 338 2.9 2.9 145 144.68 327 4 330 1.2 1.2 Total 990 28 1001 2.8 2.8 2B B 19 389 43 394 10.7 2.78 100 99.9 399 28 407 6.8 1.88 145 144.37 406 18 410 4.3 0.94 Total 1194 89 1211 7.3 1.9 3C B 19.4 218 22 223 9.9 4.53 100 100.53 230 18 238 7.5 4.58 145 144.33 223 14 226 6.2 3.09 Total 671 54 687 7.9 4.1 4D B 29.87 325 25 334 7.6 5.0 100 100.16 313 40 321 12.3 2.425 145 145.1 336 16 338 4.8 0.5625 Total 974 81 993 8.2 2.7 5E B 26.02 325 38 338 11.3 8.58 100 100.17 332 18 336 5.4 4.48 145 144.92 341 10 346 2.9 2.88 Total 998 66 1020 6.5 5.3 103 Nurse subject Illumination level Average illumination level Total meds Errors TOE Error rate (%) Error rate exclud wrong time erors 6F B 17.87 341 17 348 4.9 4.60 100 100.07 327 17 340 4.8 4.17 145 144.82 357 12 362 3.3 2.73 Total 1025 46 1050 4.4 3.9 7G B 15.36 293 37 322 11.3 10.3 100 100.32 296 42 333 11.8 11.2 145 144.65 317 24 331 7.2 6.0 Total 906 103 986 10.4 9.2 The following table describes the medication error types asociated with each nurse-subject. Of the 467 errors, it was observed that Nurse-subject 7G was asociated with the highest frequency of Omision errors (N = 80, 17%), whereas Nurse-subject 2B was asociated with the highest frequency of Wrong time errors (N = 66, 14%). 104 Table 18: Medication Preparation Errors, by types for each nurse-subject Nurse subject Ilumination level Errors Unauth. Dose Wrong dose Omision Wrong Form Wrong Time 1A B 329 4 10 100 334 4 6 145 327 3 1 Total 11 17 2B B 43 6 5 20 100 28 8 14 145 18 4 32 Total 6 17 66 3C B 22 3 5 2 12 100 18 8 3 7 145 14 1 3 3 7 Total 4 16 8 26 4D B 25 1 9 1 14 100 40 8 32 145 16 2 0 14 Total 1 19 1 60 5E B 38 3 1 13 12 9 100 18 4 4 7 3 145 10 1 5 4 Total 4 5 22 23 12 6F B 17 7 9 1 100 17 1 13 1 2 145 12 5 5 2 Total 1 25 15 5 7G B 293 1 29 4 3 100 296 1 37 2 2 145 317 4 14 2 4 Total 6 80 8 9 105 Figure 44: Medication Preparation Error types, by nurse-subjects 6 7 7 1 8 2 6 39 19 30 23 33 54 78 61 15 1 35 33 8 74 48 74 18 11 9 0 20 40 60 80 100 120 1A 2B 3C 4D 5E 6F 7G Er r or s (%) LPN Code Error Types for each LPN Wrong Time Wrong Form Omission Wrong dose Unauth dose 106 Statistical Hypotheses and Analysis Research Question Wil increased ilumination level at the nursing home study site result in decrease of the medication-preparation error rate? Research Hypotheses Null (H 0A1 ): An increased ilumination level at the nursing home study site wil not have a significant efect on the medication-preparation error rate. Alternative (H 1A1 ): An increased ilumination level at the nursing home study site wil result in decrease of the medication-preparation error rate. Analysis Repeated measures analysis of variance (ANOVA) was used to compare the total medication preparation error rate, as detected by observation, for the three lighting conditions. The Statistical package used for the analysis was SPS for Windows 18.0 version. Table 19: Descriptive Statistics of the Total Medication Preparation Error rate, for each nurse-subject, by Illumination level Illuminatn Mean Std. Deviation N Baseline 8.557 3.0199 7 100 fc 7.357 3.5293 7 145 fc 4.271 2.0345 7 * Baseline level: Average ilumination level of 28 fot-candles. 107 Table 20: Repeated Measures Univariate ANOVA on the total medication preparation error rate, for nurse-subject by ilumination level. Effect Value F Hypothe sis df Error df Sig. Noncent. Parameter Observed Power b Pilai's Trace .873 17.12 a 2.000 5.000 .006 34.233 .906 Wilks' Lambda .127 17.12 a 2.000 5.000 .006 34.233 .906 Hoteling's Trace 6.847 17.12 a 2.000 5.000 .006 34.233 .906 Roy's Largest Root 6.847 17.12 a 2.000 5.000 .006 34.233 .906 a. Exact statistic, b. Computed using alpha = .05 The data was also analyzed for linear and quadratic trends using the Repeated Measures Univariate Analysis of Variance as shown in Table 21. ! Table 21: Tests for Linear and Quadratic trends using Repeated Measures Univariate ANOVA on the total medication preparation error rate for each nurse-subject, by Illumination level Source Type II Sum of Squares df Mean Square F Sig. Linear 64.286 1 64.286 17.12 .003 Illumination Error (Illumination) Quadratic 4.149 1 4.149 .90 .191 Linear 16.424 6 2.737 Error(ilumination) Quadratic 27.801 6 4.634 108 Table 22: Pairwise Comparisons of the Medication Preparation Error rate for each nurse- subject, by Illumination levels. Paired Diferences 95% Confidence Interval of the Diference Illumination Mean Std. Deviation Std. Error Mean Lower Upper t df Sig. (1- tailed) level1 - level2 1.2000 3.4093 1.2886 -1.9531 4.353 1 .94 6 .194 level1 - level3 4.2857 2.3398 .884 2.1217 6.449 7 4.85 6 .001 level2 - level3 3.0857 2.2394 .8464 1.0146 5.156 8 3.65 6 .005 *Level 1 : Baseline, Level 2 : 100 fc, Level 3 : 145 fc Figure 45: Box Plot of Medication Preparation Error rates for each nurse-subject across three Illumination Levels Medication Preparation Error Rate Ilumination Levels 109 Repeated measures Analysis of Variance was conducted with the factor being the three Illumination levels and the dependant variable being the Medication Preparation Error Rate. The mean and standard deviations for the Error Rates are presented in Table 40. The results for the ANOVA indicated a significant ilumination efect, Wilks?s ? = 0.127, F 2,5 =17.12, p < 0.05, multivariate ? 2 = 0.54. The results of the paired samples t-test (Table 22) indicated that the mean medication preparation error rates for Illumination level 3 (M = 4.27, SD = 2.01) are significantly diferent from that of Illumination level 1 (M = 8.6, SD = 3.01) and Illumination level 2 (M = 7.4, SD = 3.5). But, there was no significant diference found betwen the mean medication preparation error rates of Illumination levels 1 and 2. Follow-up polynomial contrasts indicated a significant linear efect with mean error rates decreasing with increasing ilumination levels, F 1,6 = 17.12, p < 0.05. Higher order polynomial contrast (quadratic) was non-significant. 110 Research Question Wil increased ilumination level at the nursing home study site have an efect on the medication-preparation error rate (after exclusion of wrong time errors)? Research Hypotheses Null (H 0A1 ): An increased ilumination level at the nursing home study site wil not have a significant efect on the medication-preparation error rate (after exclusion of wrong time errors). Alternative (H 1A1 ): An increased ilumination level at the nursing home study site wil have a significant efect on the medication-preparation error rate (after exclusion of wrong time errors). Analysis Repeated measures analysis of variance (ANOVA) was used to compare the total medication preparation error rate (excluding wrong time errors), as detected by observation, for the three lighting conditions. The Statistical package used for the analysis was SPS for Windows 18.0 version. 111 Table 23: Descriptive Statistics of the Total Medication Preparation Error rate (excluding wrong time errors), for each observation day by Illumination level Illumination Mean Std. Deviation N Baseline 5.750 3.5297 27 100 fc 4.522 4.3421 27 145 fc 2.467 2.0707 27 * Baseline level: Average ilumination level of 28 foot-candles; N: Observations for each level. Table 24: Repeated Measures Univariate ANOVA on the total medication preparation error rate (excluding wrong time errors), for each observation day by ilumination level. Effect Valu e F Hypothesis df Error df Sig. Partial Eta Squared Noncent. Parameter Pilai's Trace .632 21.433 a 2.000 25.000 .00 .632 42.866 Wilks' Lambda .368 21.433 a 2.000 25.000 .00 .632 42.866 Hoteling's Trace 1.715 21.433 a 2.000 25.000 .00 .632 42.866 Roy's Largest Root 1.715 21.433 a 2.000 25.000 .00 .632 42.866 a. Exact statistic, b. Computed using alpha = .05 112 Table 25: Pairwise Comparisons of the Medication Preparation Error rate (excluding wrong time errors) for each observation day, by Ilumination levels. Paired Diferences 95% Confidence Interval of the Diference Mean Std. Deviati on Std. Error Mean Lower Upper t df Sig. (2- tailed) Pair 1 level1 - level2 1.228 1 4.8372 .9309 -.6854 3.1417 1.319 26 .19 Pair 2 level1 - level3 3.283 3 3.3417 .6431 1.9614 4.6053 5.105 26 .00 Pair 3 level2 - level3 2.055 2 3.0425 .585 .8516 3.2587 3.510 26 .002 *Level 1 : Baseline, Level 2 : 100 fc, Level 3 : 145 fc A repeated measures univariate Analysis of Variance was conducted with the factor being the three Illumination levels and the dependant variable being the Medication Preparation Error Rate (without wrong time errors). The mean and standard deviations for the Error Rates are presented in Table 23. The results for the ANOVA indicated a significant ilumination efect, Wilks?s ? = 0.37, F 2,25 =21.4, p < 0.05, multivariate ? 2 = 0.63. The results of the paired samples t-test (Table 25) indicated that the mean medication preparation error rates for Illumination level 3 (M =2.5, SD =2.1) are significantly diferent from that of Illumination level 1 (M = 5.7, SD = 3.5) and Illumination level 2 (M =4.5, SD =4.3). But, there was no significant diference found betwen the mean medication preparation error rates of Illumination levels 1 and 2. 113 Medication Preparation Error Types Research Question Wil increased ilumination level at the nursing home study site have an efect on the medication-preparation errors, by error types? Research Hypotheses Null (H 0B1 ): An increased ilumination level at the nursing home study site wil not have a significant efect on the medication-preparation errors, by error types. Alternative (H 1B1 ): An increased ilumination level at the nursing home study site wil have a significant efect on the medication-preparation errors, by error types. Analysis Chi-square (Independent samples Chi square test)!analysis was used to compare the medication preparation errors by error types for the three lighting conditions. The analysis was conducted using electronic software tool for Chi Square Analysis (Preacher, 2003) 114 Research Hypotheses Null (H 0B1 ): An increased ilumination level at the nursing home study site wil not have a significant efect on the medication-preparation errors, by wrong dose error type. Alternative (H 1B1 ): An increased ilumination level at the nursing home study site wil have a significant efect on the medication-preparation errors, by wrong dose error type. The analysis output table is as follows: Table 26: Chi Square Analysis for Wrong Dose Preparation Errors Analysis Value Degres of Fredom Significance Pearson?s Chi Square 3.888 2 0.143 Yates? Chi Square 2.833 2 0.242 Table 27: Wrong Dose Preparation error rate Baseline 100 fc 145 fc Error rate 12/2292 x100 = 0.5 % 6/2313 x100 = 0.3 % 5/2343 x 100 = 0.2 % The Chi Square analysis for Wrong Dose Preparation Errors, for al three ilumination levels did not demonstrate significant diference (X 2 =3.88, df =2, p>0.05). Thus, the error rates detected for Wrong Dose Preparation Errors across al three ilumination levels were not significantly diferent. So, the null hypothesis was not rejected. However it is important to note that the overal error rate for wrong dose errors for al three ilumination levels was found to be low, which may efect the power to test for significance. 115 Research Hypotheses Null (H 0B2 ): An increased ilumination level at the nursing home study site wil not have a significant efect on the medication-preparation errors, by wrong form error type. Alternative (H 1B2 ): An increased ilumination level at the nursing home study site wil have a significant efect on the medication-preparation errors, by wrong form error type. The analysis output table is as follows: Table 28: Chi Square Analysis for Wrong Form Preparation Errors Analysis Value Degres of Fredom Significance Pearson?s Chi Square 12.954 2 0.0015 Yates? Chi Square 11.798 2 0.0027 Table 29: Wrong Form Preparation error rate Baseline 100 fc 145 fc Error rate 38/2292 x 100 = 1.7 % 19/2313 x 100 = 0.8 % 15/2343 x 100 = 0.6 % The Chi Square analysis for Wrong Form Preparation Errors, for all three ilumination levels demonstrated significant diference. (X 2 =12.954, df =2, p < 0.05). Thus, the error rates detected for Wrong Form Preparation Errors across al three ilumination levels were significantly diferent. So, the null hypothesis was rejected. 116 Research Hypotheses Null (H 0B3 ): An increased ilumination level at the nursing home study site wil not have a significant efect on the medication-preparation errors, by wrong time error type. Alternative (H 1B3 ): An increased ilumination level at the nursing home study site wil have a significant efect on the medication-preparation errors, by wrong time error type. The analysis output table is as follows: Table 30: Chi Square Analysis for Wrong Time Preparation Errors Analysis Value Degres of Fredom Significance Pearson?s Chi Square 9.121 2 0.05 Yates? Chi Square 8.423 2 0.05 Table 31: Wrong Time Preparation error rate Baseline 100 fc 145 fc Error rate 39/2292 X 100 = 1.7 % 66/2313 X 100 = 2.8 % 41/2343 X 100 = 1.7 % The Chi Square analysis for Wrong Time Preparation Errors, for all three ilumination levels did not demonstrate significant diference (X 2 =9.121, df =2 , p = 0.05). Thus, the error rates detected for Wrong Time Preparation Errors across al three ilumination levels were not significantly diferent. So, the null hypothesis was not rejected. It must be noted that during the study period, it observed that some of the nurse- subjects prepared few of the doses to be administered in the next med-pas round, during the previous round. But, this behavior was not observed uniformly across al nurse- subjects. 117 Research Hypotheses Null (H 0B4 ): An increased ilumination level at the nursing home study site wil not have a significant efect on the medication-preparation errors, by omision error type. Alternative (H 1B4 ): An increased ilumination level at the nursing home study site wil have a significant efect on the medication-preparation errors, by omision error type. The analysis output table is as follows: Table 32: Chi Square Analysis for Omision Errors Analysis Value Degres of Fredom Significance Pearson?s Chi Square 18.825 2 0 Yates? Chi Square 17.951 2 0 Table 33: Omision error rate Baseline 100 fc 145 fc Error rate 72/2292 X 100 = 3.1 % 82/2313 X 100 = 3.5 % 36/2343 X 100 = 1.5 % The Chi Square analysis for Omision Errors, for al three ilumination levels demonstrated significant diference (X 2 =18.825, df =2, p < 0.05). Thus, the error rates detected for Omision Errors across al three ilumination levels were significantly diferent. So, the null hypothesis was rejected. 118 Research Hypotheses Null (H 0B5 ): An increased ilumination level at the nursing home study site wil not have a significant efect on the medication-preparation errors, by Unauthorized Drug error type. Alternative (H 1B5 ): An increased ilumination level at the nursing home study site wil have a significant efect on the medication-preparation errors, by Unauthorized Drug error type. The analysis output table is as follows: Table 34: Chi Square Analysis for Unauthorized Drug Preparation Errors Analysis Value Degres of Fredom Significance Pearson?s Chi Square 3.559 2 0.168 Yates? Chi Square 1.59 2 0.451 Table 35: Unauthorized Drug Preparation error rate Baseline 100 fc 145 fc Error rate 3/2292 X 100 = 0.13 % 0/2313 X 100 = 0 1/ 2343 X 100 =0.04 % The Chi Square analysis for Unauthorized Drug Preparation Errors, for al three ilumination levels did not demonstrate any significant diference (X 2 =3.559, df =2, p > 0.05). Thus, the error rates detected for Unauthorized Drug Preparation Errors for al three ilumination levels were not significantly diferent. So, the null hypothesis was not rejected. However it is important to note that the overal error rate for Unauthorized Drug errors for al three ilumination levels was found to be very low, which may efect the power to test for significance. 119 Medication Preparation Workload Research Question Is there an asociation betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors commited by that nurse- subject at the study site? Research Hypotheses Null (H 0C ): There is no asociation betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors commited by that nurse-subject at the study site. Alternative (H 1C ): There is a significant asociation betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors commited by that nurse-subject at the study site. Analysis Simple linear regresion was used to investigate the relationship betwen daily medication pas workload and medication preparation errors for each individual nurse subject, across al three ilumination levels. An Analysis of Variance (ANOVA) procedure was used to test for Regresion. 120 Table 36: Analysis of Variance for Linear Regresion of Medication Preparation Errors with respect to the daily Medication doses prepared for Illumination level 1 (Baseline) Model Sum of Squares df Mean Square F Sig. Regresion 3.447 1 3.447 .196 .662 a Residual 439.738 25 17.590 1 Total 443.185 26 a. Computed using alpha = .05 The Regresion analysis for the daily medication pas workload and medication preparation errors for each individual nurse subject, for ilumination level 1 was not found to be significant. (F 1,26 = 0.196, p > 0.05). No asociation was found betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors commited by that nurse-subject in the nursing home study site. The null hypothesis was not rejected. Table 37: Analysis of Variance for Linear Regresion of Medication Preparation Errors with respect to the daily Medication doses prepared for Illumination level 2 (100 fc) Model Sum of Squares df Mean Square F Sig. Regresion .004 1 .004 .00 .989 a Residual 518.515 25 20.741 1 Total 518.519 26 a. Computed using alpha = .05 121 The Regresion analysis for the daily medication pas workload and medication preparation errors for each individual nurse subject, for ilumination level 2 was not found to be significant. (F 1,26 = 0, p > 0.05). Thus, there is no asociation betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors commited by that nurse-subject in the nursing home study site. The null hypothesis was not rejected. Table 38: Analysis of Variance for Linear Regresion of Medication Preparation Errors with respect to the daily Medication doses prepared for Illumination level 3 (145fc) Model Sum of Squares df Mean Square F Sig. Regresion .527 1 .527 .12 .730 a Residual 107.769 25 4.311 1 Total 108.296 26 a. Computed using alpha = .05 The Regresion analysis for the daily medication pas workload and medication preparation errors for each individual nurse subject, for ilumination level 3 was not found to be significant. (F 1,26 = 0.122, p > 0.05). Thus, there is no asociation betwen the total number of medications prepared by an individual nurse-subject each day and the medication preparation errors commited by that nurse-subject at the study site. The null hypothesis was not rejected. 122 Observer Efect Research Question Is there an asociation betwen the day of the ilumination period and the number of medication preparation errors made during that day, at the nursing home study site? Research Hypotheses Null (H 0 ): There is no asociation betwen the day of the ilumination period and the number of medication preparation errors made during that day, at the nursing home study site. Alternative (H 1 ): There is a significant asociation betwen the day of the ilumination period and the number of medication preparation errors made during that day, at the nursing home study site. Analysis A Chi-Square Analysis was performed on the medication preparation error data for each nurse-subject to determine the relationship betwen the day of the ilumination period and the number of preparation errors made by the nurse-subjects during that day. 123 Table 39: Chi-Square Analysis of the Medication Preparation errors for each nurse-subject by ilumination levels Nurse - subjects Baseline 100 fc 145 fc 1A X 2 =0.74 df=3 p > 0.01 X 2 =1.907 df=3 p > 0.01 X 2 =1.896 df=3 p > 0.01 2B X 2 =6.048 df=3 p > 0.01 X 2 =2.387 df=3 p > 0.01 X 2 =2.883 df=3 p > 0.01 3C X 2 =0.738 df=2 p > 0.01 X 2 =0.123 df=2 p > 0.01 X 2 =0.128 df=2 p > 0.01 4D X 2 =1.75 df=3 p > 0.01 X 2 =1.979 df=3 p > 0.01 X 2 =0.733 df=3 p > 0.01 5E X 2 =11.31 df=3 p ? 0.01 X 2 =8.388 df=3 p > 0.01 X 2 =1.833 df=3 p > 0.01 6F X 2 =0.052 df=3 p > 0.01 X 2 =8.319 df=3 p > 0.01 X 2 =1.619 df=3 p > 0.01 7G X 2 =1.448 df=3 p > 0.01 X 2 =8.223 df=3 p > 0.01 X 2 =1.649 df=3 p > 0.01 The results of the analysis for the three ilumination levels indicated that the proportion of medication preparation errors remained constant. 124 Figure 46: Trend-line of Medication Preparation Errors for Illumination Level 1 (Baseline) Figure 47: Trend-line of Medication Preparation Errors for Illumination Level 2 (100 fc) R?!=!0.035! 0! 20! 40! 60! 80! 100! 120! 1.6! 8.6!15.6!22.6!29.6!6.7!13.7!20.7!27.7!3.8! Errors for Illum Level 1 Errors for Illum Level 1 Trendline R?!=!0.094! 0! 2! 4! 6! 8! 10! 12! 14! 16! 18! 20! 2.6! 9.6! 16.6! 23.6! 30.6! 7.7! 14.7! 21.7! 28.7! Errors for Illum Level 2 Errors for Illum Level 2 Trendline 125 Figure 48: Trend-line of Medication Preparation Errors for Illumination Level 3 (145 fc) The Regresion Analyses for the observer efect on medication preparation error rates for ilumination level 1 (F 1,26 = 3.665, p > 0.05); ilumination level 2 (F 1,26 =2.60 , p > 0.05) and ilumination level 3 (F 1,26 =2.163 , p > 0.05) demonstrated no significant diference. R?!=!0.08! 0! 1! 2! 3! 4! 5! 6! 7! 8! 9! 10! 2.6! 9.6! 16.6!23.6!30.6! 7.7! 14.7!21.7!28.7! 4.8! Errors for Illum Level 3 Errors for Illum Level 3 Trendline 126 Medication Preparation Errors for Sections Research Question Is the proportion of medication preparation errors constant over al the three sections at the study site? Research Hypotheses Null (H 0E ): The medication preparation errors detected at the three sections of the study site are not significantly diferent. Alternative (H 1E ): The medication preparation errors detected at the three sections of the study site are significantly diferent.! Analysis A Chi-Square Analysis was performed on the medication preparation error data of each section for al three ilumination levels. 127 Table 40: Medication Preparation Errors for al three ilumination levels, by Sections Section Illumination level Total meds Errors TOE X 1 964 98 988 2 957 84 1003 3 1159 53 1179 Y 1 788 68 818 2 635 45 659 3 743 36 756 Z 1 468 30 486 2 639 44 651 3 405 9 328 The Chi-Square Analysis results were as follows: For Illumination level 1: X 2 =4.719, df =2, p > 0.01 For Illumination level 2: X 2 =2.11, df =2, p > 0.01 For Illumination level 3: X 2 =4.698, df =2, p > 0.01 The results of the analysis for the three ilumination levels indicated that the proportion of medication preparation errors remained constant for al the sections at the study site. So, the null hypothesis was not rejected. 128 Medication Preparation Errors for Medication Pas Shifts Research Question Is there an asociation betwen the medication shift and the medication preparation errors for al three ilumination levels, at the study site? Research Hypotheses Null (H 0F ): There is no asociation betwen the medication shift and the medication preparation errors for al three ilumination levels, at the study site. Alternative (H 1F ): There is significant asociation betwen the medication shift and the medication preparation errors for al three ilumination levels, at the study site. Analysis An Analysis of Variance test was performed on the medication preparation error data to test for asociation betwen the preparation errors and the medication shifts for al three ilumination levels at the study site. 129 Table 41: Medication Preparation Errors for al three ilumination levels, by medication shifts Med Pass Shifts Illumination level Errors TOE 9 AM 1 99 1264 2 78 1206 3 31 1117 5 PM 1 97 1028 2 95 1107 3 67 1226 Table 42: Analysis of Variance of Medication Preparation Errors with respect to med- pas shifts for al three ilumination levels Sum of Squares df Mean Square F Sig. Betwen Groups 57.664 1 57.664 3.775 .060 Within Groups 1206.879 79 15.277 Total 1264.543 80 The results indicate that there was no significant diference (F 1,80 = 3.775, p >0.05) betwen the medication preparation error rates, for both the medication pas shifts (9 am and 5 pm) for al three ilumination levels. 130 Observation of Medication related incidents, which were not an error. The observation of some of the medication-related incidents, as witnesed by the observers are presented in the following table. The observer recorded the prescribed dose the dose prepared by the nurse-subject and nurse-subject comments and actions. Table 43: Observation of Medication-Related Incidents Prescribed Drug Prepared Drug (Near) Eror type Notes Digoxin 125 mcg None Omision Resident refused meds Lisinopril 2.5 mg None Omision Resident refused meds Klor Con M10 None Omision Resident refused meds Glyburide Metformin 2.5mg/ 5mg None Omision Resident refused meds Furosemide 40 mg None Omision Resident refused meds Paroxetine 20 mg None Omision Resident refused meds Megestrol Acetate 10 ml None Omision Resident refused meds Lorazepam 0.5 mg None Omision Resident refused meds Sena S # 2 pils Sena S # 1 pil Wrong Dose Near Error Nurse re-checks the MAR twice; and then puts in one more Sena-S pil Coumadin 5 mg Coumadin 2.5 mg Wrong Dose Near Error Nurse puts the pill in trash and gets the right strength. Wrong resident Near Eror Nurse does not recognize the resident, had to get help from the Certified Nursing Assistant to get to the right resident. 131 The observer also noted down the comments/fedback that nurse-subjects made during or after the observation period, regarding the ilumination (supplemental lighting apparatus and/or the increased ilumination levels) and the observer presence. The comments are listed in Table 44. Table 44: Nurse-subjects? comments regarding the ilumination and the observer LPN/urse Comments Observer Actions 1 ?I like the light, can se much beter? 2 ?I love this light, I like being able to se.? 3 ?Are you going to tel them to give us the light? I realy like the light. We move a lot so I like this extra light!? 4 ?Its Bright!? 5 ?I love this light.? 6 ? I forgot you were here? 7 Nurse-subject to observer ?What are you writing in your note-pad?? The observer promptly shows the Nurse-subject the data collection form and observation notes. 132 VI. Conclusion, Discussion, Limitations and Implications The purpose of this chapter is to present and discuss the conclusions and general findings, their implications, the limitations of the study and to suggest topics for future research. Main Conclusions The main conclusions from the Statistical Analyses are as follows: Table 45: Results and Conclusions of Hypothesis testing Hypothesis Values Conclusion based on Results H 0A1 : u1 = u2 = u3 H 1A1 : one or more treatment means difer F =17.12 p < 0.05 Reject the null. Increase in ilumination levels resulted in reduction of medication preparation error rate. H 0A2 : u1 = u2 H 1A2 : u1 ? u2 t = 0.94 p > 0.05 Do not reject null. Increase in ilumination level from Baseline to 100 fc did not result in reduction of medication preparation error rate. 133 Hypothesis Values Conclusion based on Results H 0A3 : u1 = u3 H 1A3 : u1 ? u3 t = 4.85 p < 0.05 Reject the null. Increase in Illumination level from Baseline to 145 fc resulted in reduction of medication preparation error rate. H 0A4 : u2 = u3 H 1A4 : u2 ? u3 t = 3.65 p < 0.05 Reject the null. Increase in Illumination level from 100 fc to 145 fc resulted in reduction of medication preparation error rate. H 0A5 : T linear = 0 H 1A5 : T linear ? 0 F = 17.12 p < 0.05 Reject the null. There was a linear decrease in medication preparation error rates for increasing Illumination levels. H 0A6 : T quadratic = 0 H 1A6 : T quadratic ? 0 F = 0.895 p > 0.05 Do not reject null. The mean medication preparation error rates did not decrease at a quadratic trend for increasing ilumination levels. H 0B1 : u1 = u2 = u3 H 1B1 : one or more treatment means difer X 2 = 3.89 p > 0.05 Do not reject null. Increase in ilumination levels did not result in reduction of Wrong dose preparation errors. 134 Hypothesis Values Conclusion based on Results H 0B2 : u1 = u2 = u3 H 1B2 : one or more treatment means difer X 2 =12.95 p < 0.05 Reject the null. Increased ilumination levels resulted in reduction of Wrong form preparation errors. H 0B3 : u1 = u2 = u3 H 1B3 : one or more treatment means difer X 2 = 9.12 p = 0.05 Do not reject null. Increase in ilumination levels did not result in reduction of Wrong time preparation errors H 0B4 : u1 = u2 = u3 H 1B4 : one or more treatment means difer X 2 = 18.8 p < 0.05 Reject the null. Increased ilumination levels resulted in reduction of Omision errors. H 0B5 : u1 = u2 = u3 H 1B5 : one or more treatment means difer X 2 = 3.56 p > 0.05 Do not reject null. Increase in ilumination levels did not result in reduction of Unauthorized drug preparation errors Illumination level 1 H 0C1 : M= 0 H 1C1 : M ? 0 F = 0.196 p > 0.05 Do not reject null. Total number of medications prepared, did not afect the mean medication preparation error rate. Illumination level 2 H 0C2 : M= 0 H 1C2 : M ? 0 F = 0 p > 0.05 Do not reject null. Total number of medications prepared, did not afect the mean medication preparation error rate. 135 Hypothesis Values Conclusion based on Results Illumination level 3 H 0C3 : M= 0 H 1C3 : M ? 0 F = 0.122 p > 0.05 Do not reject null. Total number of medications prepared, did not afect the mean medication preparation error rate. For each individual nurse- subjects H 0D : u1= u2 =u3 H 1D : Error proportions difer for al 3 ilumination levels Chi square Analysis results on Table 60 p > 0.01 Do not reject null. The presence of an observer did not afect the proportions of errors, detected for each nurse-subject. Illumination level 1 H 0E1 : U X = U Y = U Z H 1E1 : Error proportions difer for one or more study-sections X 2 =4.719 p > 0.01 Do not reject null. The proportions of medication preparation errors remained constant for al the three sections Illumination level 2 H 0E2 : U X = U Y = U Z H 1E2 : Error proportions difer for one or more study-sections X 2 =2.11 p > 0.01 Do not reject null. The proportions of medication preparation errors remained constant for al the three sections 136 Hypothesis Values Conclusion based on Results Illumination level 3 H 0E3 : U X = U Y = U Z H 1E3 : Error proportions difer for one or more study-sections. X 2 =4.698 p > 0.01 Do not reject null. The proportions of medication preparation errors remained constant for al the three sections. For al 3 Illumination levels H 0F : U 9 AM = U 5 PM H 1F : U 9 AM ? U 5 PM F = 3.78 p > 0.05 Do not reject null. The time of the medication shift (morning or evening) does not afect the medication preparation errors. 137 Discusion Exploratory Findings Related To Demographic Variables Of Nurse-Subjects Age The performance of the human eye declines with age, with the efects beginning to be noticeable at 40 years of age. This leads to changes in the spectral light sensitivity that by 80 years of age causes loss of vision. Research has established that aging eyes require more light as compared to younger eyes, for optimal visual performance.(M. O. Blackwel & Blackwel, 1980; Boyce, 1973; Crouch, 1965; Cullinan, 1986; R. G. Davis & Garza, Winter 2002; Smith & Rea, 1978; The IESNA Commite for Healthcare Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 2007). Figures 6 and 7 provide additional proof older eyes require increased lighting levels for beter visual performance. The average age of the nurse-subjects in the study was 34 years; with the oldest subject being 47 years and the youngest being 23 years old. The average age for this study is far les as compared to the national average of 51 years, as stated by the Joint Commision. (Joint Commision on Acreditation of Healthcare Organizations, August 2002). The study results revealed no patern linking the age of the nurse-subject and the medication preparation errors asociated with them. 138 Employment Status Al the nurse-subjects were employed by the study facility for at least a period of 9 months, with the employment period ranging from 9 months to 112 months. It was the investigator?s speculation that the longer the subject was employed by the facility, the beter the subject?s familiarity with the residents and the facility surroundings. This experience might provide the subject some improvement in his/her medication preparation and administration performance. But, there has been no research in the healthcare field investigating this asociation. Exploratory observation of the study data suggested no direct relationship betwen employment status and the medication preparation error rate of the nurse- subjects. Future studies need to be conducted to further explore the asociation betwen medication errors and employment status (including overal nursing experience). Educational Level The results from literature investigating the asociation betwen level of healthcare staf credentials and the frequency of medication errors has been mixed. While some studies reported significant diferences in error rates for diferent levels of staf credentials (Registered Nurses (RN) and Licensed Practitioner Nurses (LPN)) and medication error frequency (Barker KN, Flynn EA et. al., 2002; Pape et. al., 2005; Peletier, 2001), the study by Scott-Cawiezel, Pepper GA et.al, 2007 found no significant diferences among the error rates for RNs, LPNs and CMTs (Certified Medication Technicians). 139 Al the nurse-subjects in this study were Licensed Practitioner Nurses (LPNs), as only LPNs were asigned to prepare and administer medications in the study facility. Gender The task of medication preparation and administration often involves dosage calculations, which requires significant mathematical skils. Studies have shown that as many as 33% of the medication errors are the result of administering the wrong dosage (Bates et. al, 1995); which cals into question the dosage calculation skils of the nursing staf involved. The vast majority of nursing personnel are women; therefore, examining gender-asociated factors in mathematics (dose calculations) achievement sems relevant. Research investigating the role of gender, personal atributes and self- eficacy in nursing students found no significant relationship betwen the gender of the nursing students and medication errors (Hodge M.B., 1999). All the nurse-subjects who participated in this study were females, and thus the asociation of gender with medication preparation error rates was excluded from examination in this study. Distractibility (GEFT) Scores Research has shown that distractions negatively efect medication errors, wherein the higher the frequency of distractions, the higher the error rate of the particular subject. (Flynn E.A,1994). GEFT scores were used as an indicator of distractibility, where higher GEFT scores were asociated with lower susceptibility to distractions, hence fewer error 140 rates; and lower GEFT scores were asociated with higher susceptibility to distractions, hence higher error rates by the study subject. (Flynn E.A, 1994). The GEFT scores of the nurse-subjects in the study ranged from 5 (low score) to 11 (medium score). But, comparison of the GEFT scores with the frequency of medication preparation errors for individual nurse-subjects did not reveal in any trend/patern. The nurse-subject asociated with the lowest GEFT score (high susceptibility to distractions) happened to have the lowest medication preparation error rate in the study (2.8%). Visual test scores for nurse-subjects Visual performance of the nurse-subjects was tested using Snelen charts (Wendy Strauss Wat, 2003). As a study measuring visual performance of nurses under varying ilumination levels, measurement control for visual acuity of the nurses prior to the study was of paramount importance. None of the subjects in this study had significant visual impairment based on the results of the Snelen tests. Most of the subjects wore corrective visual aids, such as glases or contacts to help with their visual performance. One of the nurses with the lowest overal visual acuity score (20/50) was asociated with the highest medication preparation error rate (10.4%) in the study. But, as the study design was repeated measures within-subjects design, it offered control for such personal characteristics of the study-subjects. 141 Medication Preparation Workload The efect of medication preparation workload of each nurse-subject on the number of incorrect medications prepared by that nurse was investigated by simple linear regresion analysis. The analysis results did not show any significant linear relationship betwen medication preparation workload of the nurse-subjects and their medication preparation error rate for al three ilumination levels. These findings are contrary to the results reported by other studies (Guernsey et al., 1983; Buchanan, 1989) wherein the authors found significant linear relationship betwen dispensing errors and prescription workload. One reason for this deviation might be that the nurse-subjects in this study prepared an average of 85 doses (with a range betwen 65 to 108 doses) per medication pas round, which was much les compared to the prescription workload of some of the pharmacists in the Buchanan study. None of the nurse-subjects in the study were new to the facility and they prepared many of the same medications (the physician reviews the medication order every month) for a particular medication pas round, so they were familiar with the daily medications to be prepared and administered to the residents. Also, the workload for the medication pas rounds was relatively constant, which might help speculate the deviation of the study findings from previous literature. 142 Explanatory (Observation) Study Findings Efect Of Illumination On Medication Preparation Error Rate The first main finding of the study was that there was a significant treatment (ilumination) efect (F 2,5 =17.116, p < 0.05) on the medication preparation error rate. There was sufficient theoretical basis in the Human Factors and Ergonomics literature to expect a strong linear relationship betwen increased ilumination levels and error rate (Blackwel, 1964-1968; Buchanan TL, 1989), and the present study results support the theory. The study found that Illumination level 2 (100 foot-candles) had no significant efect on medication preparation error rate, whereas ilumination level 3 (145 foot- candles) had a significant efect. This result was suggested by the results of previous studies of dispensing errors, (Buchanan TL, 1989; Buchanan & Barker, 1991), where the authors detected similar results. The overal medication preparation error rate for the baseline ilumination level (30 foot-candles) was 8.5%, and it decreased to 4.3% for ilumination level 3 (145 foot- candles). The study?s results support the theoretical basis that since the task of medication preparation has a high visual component, the visual performance is positively afected by increasing the ilumination level. The observation data were also analyzed for polynomial contrasts, to se if there was a strong linear/quadratic trend to the data. The analysis revealed that the data had a strong linear trend, but no significant quadratic trend. That is, the relationship betwen ilumination level and medication preparation rate is linear (F 1,6 = 23.48, p < 0.05), but not quadratic (curvilinear). By inspecting the mean error rates in Table 19, it is evident that the linear efect is due to decrease in medication preparation error rates with 143 increasing ilumination levels; therefore the significant linear trend was due to the increase in ilumination levels. The strong linear trend supports the theoretical basis in ilumination sciences literature (Blackwel HR, 1961; Blackwel HR, 1964) that suggest that the positive efect of increasing ilumination levels on visual performance has a strong linear relationship initialy, followed by a quadratic trend at higher ilumination levels, as the efect levels off or even declines. This finding was slightly diferent from the previous study (Buchanan 1989, Buchanan & Barker, 1991) investigating the efect of ilumination levels on dispensing error rate, wherein the dispensing error rate showed significant linear and quadratic trend. The quadratic trend was due to the slight increase in dispensing error rate for ilumination level of 102 foot-candles, as compared to the baseline measurement (46 foot-candles). The observation error data were also analyzed after excluding the Wrong time errors, in order to check for any significant diferences betwen the error rate and the ilumination levels. The observer calculated the error rate with and without Wrong time errors, when it was observed that the nurse-subjects prepared some of the doses to be administered in the next med-pas round, during the previous round. But, this behavior was not observed uniformly across al nurse-subjects, so the results were computed with and without wrong time errors. The analysis found a significant relationship betwen the medication preparation error rate, excluding Wrong time errors and ilumination levels (F 2,25 =21.4, p < 0.05). The analysis also found that Illumination level 2 (100 foot-candles) had no significant efect on medication preparation error rate, whereas ilumination level 3 (145 144 foot-candles) had a significant efect.!!The results were consistent with the previous findings. Efect Of Illumination On Medication Preparation Error Types The second finding of the study was that there were mixed results of significant asociations betwen increased ilumination levels and the medication preparation error types. Of the five types of error analyzed (wrong dose errors, wrong time errors, omision errors, wrong form errors and Unauthorized Drug errors), only wrong form errors (X 2 =12.954, df =2, p < 0.05) and omision errors (X 2 =18.825, df =2, p < 0.05) had a significant relationship with the ilumination levels. Only wrong form error was found to have a linear relationship with increasing linear relationship, with the mean error rate decreasing from 1.7% at baseline ilumination level to 0.8 % at 100 foot-candles and finaly to 0.6% at 145 foot-candles. (Refer Table 29). A reduction in the error rates of Wrong Dose (n=23) and Unauthorized Drug (n=4) errors occurred also, from baseline to 145 foot-candles, though the power was too low for statistical significance. It must also be noted that during the observation period, two of the nurses mentioned that the reason behind them crushing the medications was to aid the resident in swalowing the medications. Although the observer understood the practical reason for crushing the medications, but for the purposes of the study, for the medications on the ?do not crush? list or when it was contra-indicated in the prescriber?s orders, such instances were counted as an error of wrong form. 145 The observer noted the practice of preparing few of the doses to be administered in the next med-pas round, during the previous round, by some of the nurses. This behavior was not observed uniformly across al nurse-subjects, so medication preparation error rates were computed with and without the wrong time errors. Wrong time errors did not demonstrate a significant asociation with increased ilumination levels (Table 30). Although there may be reason to speculate that some of the wrong form errors and wrong time errors may not have been afected by ilumination, it should be done with caution, as no follow up study (or interview) was conducted to explore the subject behavior or intention. The primary focus of this study was to explore the asociation betwen increased ilumination levels and medication preparation errors. It is important to note that no causal conclusion can be made about the efect of ilumination on medication preparation error types. This asociation must be further explored in future studies, with specific focus on the efect of ilumination on vision-related medication errors. Reason (2003) defined human error as the failure of a planned sequence of mental or physical activities to achieve its intended outcome, when these failures cannot be atributed to chance. Whereas he defined mistakes as deficiencies/failures in the judgmental and/or inferential proceses involved in the selection of an objective or in the specification of the means to achieve it, irrespective of whether or not the actions directed by this decision-scheme run acording to plan. (Reason, 2003). So, interventions such as ilumination can directly afect errors, whereas actions that are clasified as mistake might need additional intervention tools like educational training or change in policies to addres them. It may be speculated that certain behavior like preparing medications for the next 146 med-pas round during the present med-pas round, as wel as crushing of medications that are contra-indicated for crushing might be examples of a mistake (or intended action), as per Reason?s definitions. But such speculations must be carried out with extreme caution, as this study did not explore the intentions of the subjects for their behavior. The observer recognizes the fact that changing/increasing the ilumination levels is a part of the strategy (along with providing training tools, altering other environmental variables that impact errors) to reduce medication preparation errors. Efect Of The Observer On The Observed The efect of the presence of an observer on the nurse-subject being observed was analyzed using Chi-Square Analysis (Table 39) and found to be minimal. Specificaly, the proportion of errors for each nurse-subject, for the entire observation period was examined for al three ilumination levels. The analysis revealed that the proportions remained constant over each ilumination period for each nurse-subject. This finding supports the literature (Barker, 1980) which suggests that the observed adapt quickly to the observer after an initial aclimation period. If the observer is trained to be non judgmental and unobtrusive, and his/her behavior convinces the study subjects that he/she is no longer a threat, then the efect of the observer on the observed can be minimized. (Barker,1980). Qualitative fedback/comments from the nurse-subjects (Table 44) also helped reinforce the analysis findings that the nurses were not threatened by the presence of the observer. A graph of Medication preparation error rates was plotted for al 147 observation days, by ilumination level (Figures 46 - 48). The error trend-line remained fairly constant for al three ilumination levels, emphasizing that the proportion of errors by nurse-subjects were not asociated with the presence of an observer, during the study period. Significance Of Nursing Sections Statistical control measures were implemented by analyzing the proportion of medication preparation errors for al the three sections of the long-term care study site, by ilumination levels. The results of the analysis for the three ilumination levels indicated that the proportion of medication preparation errors remained constant for al the sections at the study site (for baseline ilumination level: X 2 =4.719, p > 0.01; for 100 foot-candles Illumination level: X 2 =2.11, p > 0.01; for 145 foot-candles Illumination level: X 2 =4.698, p > 0.01). Significance of Medication Shifts Analysis of Variance was used to test for any asociation betwen the medications prepared during the medication pas shift (morning med-pas at 9 am and evening med- pas at 5 pm) and the medication preparation error rates. The results indicate that there was no significant diference (F 1,80 = 3.775, p >0.05) betwen the medication preparation error rates, for both the medication pas shifts (9 am and 5 pm) for al three ilumination levels. 148 Limitations Sampling Inadequacies Sampling inadequacies may pose a limitation to the generalization of this study. A. Only oral prescription medications (with pharmacy packaged medication labels) were included in the observation study, which limits the generalizability of the study. However, the study facility administered about 85% of its medications in oral form. B. The study seting was in a long-term care facility with some unique characteristics (for eg. Onsite pharmacy, medication pas timings, baseline ilumination levels etc.) that would be expected to difer from other facilities. Therefore, any generalization must be carried out with extreme caution. Efect of the Observer on the observed The observation method has advantages for certain kinds of studies, but there are some limitations that should be considered. Foremost is the danger of the efect of the observer on the observed. It is wel known that the observer can afect the subjects of the observation simply by mere presence. However this efect varies greatly with the subject mater. Measures to counter this efect include the observer being trained to be non judgmental and unobtrusive and hence been shown to be efective, in short, subjects sem to get used to an observer if his behavior convinces the group members that he is no threat. 7 149 Observer (Investigator) Acuracy Also of concern is the possibility of errors by the observer, who was subject to some of the same environmental factors as the nurse-subjects during the observation period. Scientific training by the observer in the observation method as wel as experience in observing medication pas rounds was important as a source of control. In addition, prior to the observation period, the observer had her vision checked (vision results: 20/20) and took the GEFT distractibility questionnaire with a medium score of 15/18. In case of omision errors, the observer was not permited to look at the MAR at the medication cart to confirm the reason for omision of certain doses. The basis of deciding on an omision error was by reconciling the observed information with that of the original physician?s orders. Blinding of the Observer Since the observer was not blinded to the particular ilumination level for a given medication shift, there might be potential bias introduced during the medication observation phase. In order to control for this bias, the observer masked the ilumination level from the observation notes, during the medication review phase. Subject Participation The study subjects were selected by voluntary participation. The nurse-subjects were briefed about the main objectives of the observation study and the data collection proces. The nurses who signed the Informed Consent Form (Appendix G) and met the 150 study criteria were included as subjects to be observed in the study. Al the nurses, excluding one male nurse, signed the consent form. Potential Extraneous variables The investigator collected information on demographics such as age, level of experience, GEFT (distractibility) scores, educational levels and vision, as a measure of control for these potential extraneous variables. Medication preparation workload was analyzed for its efect on the preparation error rate, and was found to be non-significant. The investigator exercised caution during data collection, by keeping the ilumination level constant, taking multiple measurement of the ilumination levels during the observation period and not observing near any window or other external light sources. 151 Recommendations Based on the study findings, the following recommendations are proposed: 1. It is recommended that the study be repeated in other long-term care facilities. Also, the study should investigate ilumination level above 145 foot candles. This range of ilumination wil perhaps help us understand the presumed linear relationship betwen ilumination and medication errors; and if there is a level where the efect reaches a plateau or even results in a decrement. 2. It is recommended that in addition to medication preparation errors, medication administration errors also be studied. This wil help in beter understanding the ilumination level required in patient rooms, for the visual performance of healthcare staf to function optimaly. 3. It is recommended that the explanatory study be repeated for the night shift (11 PM). Many long-term care facilities switch off some of the lights for the night shift, in order to facilitate rest for the residents. This decrease in the ilumination level throughout the facility in addition to the resident rooms, might act as a barrier for the healthcare staf who are administering medications during the night shift. . Also there wil be a higher level of contrast betwen the task and ambient lighting. It wil also be interesting to look at the efect of increased ilumination levels and the visual performance of the healthcare staf during the night shift. 4. It is recommended that this experimental study be expanded by simulation in a laboratory seting, in order to study the efects of lower ilumination levels (lower than 100 foot-candles) on visual performances of the nurses. A more complicated 152 study would be to study the efects of ilumination and varying workload levels on the visual performances of the nurses. 5. It is recommended that the efect of variables such as label contrast and font size on the medication preparation and administration error rate be investigated. Research studies in Illumination Sciences have suggested that variables such as font size and contrast impact visual performance; hence afect the medication preparation and administration error rate. 6. It is recommended that in addition to controlling for the subject?s demographic variables and medication workload, an explanatory study be designed to control for environmental variables such as noise, interruptions and distractions. Medication error research studies have demonstrated that increase in the incidences of interruptions, distractions and high noise levels led to an increase in medication errors, hence the need to control these variables. 7. Based on the study findings, an ilumination level of 145 foot candles led to the lowest medication preparation error rate of 4.3%, which is lower than the 5% medication error standard set by the Centers for Medicare and Medicaid (CMS) for long-term care facilities (Centers for Medicare and Medicaid Services, 2006). The federal government needs to place greater emphasis in the form of high standards in lighting regulations requiring adherence by architects and facility designers. In the light of the error rate improvement, CMS should consider seting standards for ilumination levels at the long-term care facilities, in order to facilitate optimum visual performance by the healthcare staf. 153 8. It is important to note that this study found no significant improvement in the medication preparation error rate when the ilumination was increased from baseline (average of 30 foot-candles) to 100 foot-candles. The Illumination Engineering Society of North America (IESNA), which serves as an expert for ilumination standards and guidelines across facilities, should reconsider its general ilumination recommendation for the medication preparation area. (Ambient lighting recommendation is 30 foot-candles; Task lighting recommendation is 100 foot- candles). Implications for Future Research There is great variability among the nursing facilities in diferent states regarding lighting regulations. Lack of lighting standards and specific minimum target iluminance values coupled with the aging nursing population catering to the increase in long term- care residents may aggravate the problem of medication errors in these facilities. The consequences, that medication errors can have in terms of mortality, morbidity and financial loss to both the patients and the nursing facility is wel documented in literature (Bootman et.al, 1997). This study demonstrated that it was possible to achieve a medication preparation error rate of no more than 4.3% by increasing the ilumination level from 30 foot-candles to 145 foot-candles. The significance of this study in particular is to show that the adjustment of lighting from baseline level to 145 foot-candles, a relatively low cost measure requiring litle or no change in nursing procedures, can achieve a reduction in 154 the medication preparation error rate of more than 50%, and thus surpas the CMS maximum medications error rate standard of 5% for long-term care facilities.(Centers for Medicare and Medicaid Services, 2006). The findings of this study have implications for research in the area of the efect of varying ilumination levels on medication errors in diferent healthcare setings. Future studies investigating the efect of ilumination levels (maybe greater than 145 foot-candles) on the medication preparation error rate in diferent healthcare setings might help in understanding vision related medication preparation errors and likely reduce them to near zero. The findings of this research study suggest the need to investigate the efect of ilumination on target errors. A target error is defined as an error for which there is evidence or theoretical basis for hypothesizing that a particular intervention, in this case ilumination, wil change their occurrence or frequency. Future research can also addres the relation betwen label contrast and font size and its efect on the visual performance of the healthcare staf, under varying levels of ilumination. It wil be interesting to study the efects of workload, interruptions, distractions and environmental variables such as noise, temperature and humidity on the medication preparation error rate under diferent ilumination conditions. Research has demonstrated that the nursing homes with more deficiencies and those with more serious deficiencies are at higher odds of being sued as compared to the ones with fewer deficiencies cited by the CMS (Studdert, Spital et. al., 2011). This simple intervention (increasing light levels) has the ability to significantly decrease preparation errors and perhaps liability exposure. 155 References AHRQ (2011) The Agency of Healthcare Research and Quality. Retrieved from http:/ww.ahrq.gov/. AJHP (1998). American Journal of Health-System Pharmacy (55), 165-166. Alan, E. L. (1994). Relationships among facility design variables and medication erors in a pharmacy. Auburn University, Auburn. Alan, E. L., & Barker, K. N. (1990). Fundamentals of medication error research. American Journal of Health-System Pharmacy, 47, 555-571. Alvarado, C. (2007). The physical environment in health care. In P. Carayon (Ed.), Handbook of Human Factors and Ergonomics in healthcare (pp. 287-307). Mahwah, New Jersey. Alexander, D. C. (1986). The practice and management of industrial ergonomics (Vol. 2). Englewood Clifs, NJ: Prentice-Hall. Anon (2006). Study site nursing home: Detailed report on the nursing home located in Auburn, Alabama Retrieved May 6, 2009, from http:/citehealth.com/nursing- homes/alabama/cities/auburn Barber ND, Aldred DP, Raynor DK, Dickinson R, Garfield S, Jeson B, et al. (2009). The Care Homes Use of Medicines Study: prevalence, causes and potential harm of medication errors in care homes for older people. Quality and Safety in Healthcare, 18(5), 341-346. 156 Barker K. N, & McConnel, W. E. (1962). The problem of detecting medication errors in hospitals. American Journal of Health-System Pharmacy, 19, 360-369. Barker, K. N., & Heler, W. M. (1963). The development of a centralized unit-dose dispensing system at U.A.M.C Unit dose drug distribution systems (Vol. 20, pp. 612-623): American journal of Hospital Pharmacy. Barker, K. N. (1980). Data Collection Techniques: Observation. American Journal of Health-System Pharmacy, 37, 1235-1243. Barker, K. N., Kimbrough, W. W., & Heler, W. M. (1966). A study of medication erors in a hospital. Fayetevile: University of Arkansas. Barker, K. N., & McConnel, W. E. (1962). The problem of detecting medication errors in hospitals. American Journal of Health-System Pharmacy, 19, 360-369. Barker, K. N., Flynn, E. A., Bates, D. W., & Mikeal, R. L. (2002). Medication Errors Observed in 36 Health Care Facilities. Archives of Internal Medicine, 162, 1897- 1903. Bates, D. W., Boyle, D. L., Vliet, M. V., Schneider, J., & Leape, L. L. (1995). Relationship betwen Medication Errors and Adverse Drug Events. Journal of General Internal Medicine, 10, 199-205. Belchambers, H. E., & Philipson, S. M. (1962). Lighting for inspection. Transactions of the Illuminating Engineering Society, 27, 71-87. Blackwel, H. R. (1961). Development of visual task evaluators for use in specifying recommended ilumination levels. Illuminating Engineering, 56, 543-544. 157 Blackwel, H. R. (1964). Further validation studies of visual task evaluation. Illuminating Engineering, 59(9), 627-641. Blackwel, R. H., & Blackwel, M. D. (1968). The efect of Illumination quantity upon the performance of diferent visual tasks. Illuminating Engineering, 63, 143-152. Blackwel, M. O., & Blackwel, R. H. (1980). Individual responses to lighting parameters for a population of 235 observers of varying ages. Journal of the Illuminating Engineering Society, 4, 205-232. Blackwel, R. H., & Blackwel, M. D. (1968). The efect of Illumination quantity upon the performance of diferent visual tasks. Illuminating Engineering, 63, 143-152. Bommel, W. v., & Beld, G. v. d. (2004). Lighting for work: a review of visual and biological efects. Lighting Research & Technology, 36(4), 255-269. Bootman, J. L., Harrison, D. L., & Cox, E. (1997). The healthcare cost of drug-related morbidity and mortality in nursing facilities. Archives of internal medicine, 157, 2089- 2096. Boulos Z, Campbel S, Lewy J, & et.al. (1995). Light treatment for slep disorders. Biological Rhythms, 10, 167-176. Boyce, P. R. (1973). Age, iluminance, visual performance and preference. Lighting Research & Technology, 5(3), 125-144. Boyce, P. R. (1981). Human Factors in Lighting. New York, NY: Macmilan. Buchanan, T. L. (1989). On the efect of varying levels of ilumination on the prescription dispensing eror rate in an army high-volume outpatient pharmacy service. Auburn Univeristy, Auburn. 158 Buchanan, T. L., Barker, K. N., & et, a. (1991). Illumination and errors in dispensing. American Journal of Hospital Pharmacy, 48, 2137-2145. Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2000). Implications of an Aging Registered Nurse Workforce. Journal of American Medical Asociation, 283, 2948-2954. Byrne, A. K. (1953). Errors in Giving Medication. The American Journal of Nursing, 53(7), 829-831. The Centers for Medicare & Medicaid Services. Interpretive guidelines for surveyors [? 483.70)(g)(1)] and [(? 483.15)(h)(5)]. The Long term Care Survey. Washington DC: American Health Care Asociation; December 2006 edition. Cheung, A., & Vlases, P. H. (1985). Chapter 96: Long term care facilities. In A. R. Gennaro (Ed.), Remington's Pharmaceutical Sciences (17 ed., pp. 4-14). Easton, Pennsylvania: Mack Publishing Company. Clancy, C. M. (2008). Designing for Safety: Evidence-based design and hospitals. American Journal of Medical Quality, 23(1), 66-69. Cohen, M. R. (1999). Medication erors. Washington D.C.: American Pharmaceutical Asociation. Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences. 2nd ed. 1988: Lawrence Erlbaum Asociates. Commite on Identifying and Preventing Medication Errors. Preventing Medication Erors: The Quality Chasm Series: The National Academies Pres; 2007. Crouch, C. L. (1965). Lighting needs for older eyes. The Sight-saving review, 35(4), 213- 215. 159 Cullinan, T. (1986). Visual disability in the elderly. Sydney, Australia: Croom Helm Ltd. Davis, N. M. (1990). Detection and Prevention of Ambulatory Care Pharmacy Dispensing Errors. Hospital Pharmacy, 25, 18-22. Davis, R. G., & Garza, A. (Winter 2002). Task Lighting for the elderly. Journal of the iluminating Engineering Society, 31(1), 20-32. Dean, B., & Barber, N. (2001). Validity and reliability of observational methods for studying medication administration errors. American Journal of Health-System Pharmacy, 58, 54-59. Dockhorn, V., Scholz, M., Vandahl, C., & Gal, D. (2005). Proper Illumination from Surgical Light Reduces Fatigue and Improves Concentration: Hospital engineering and facilities management : busines briefing. Faulkner, T. W., & Murphy, T. J. (1973). Lighting for dificult visual tasks. Human Factors, 15(2), 149-162. Flynn EA. Relationships Among Facility Design Variables and Medication Erors in a Pharmacy. Auburn: Pharmacy Care Systems, Auburn University; 1994. Flynn, E. A., Barker, K. N., & Carnahan, B. J. (2003). National observational study of prescription dispensing acuracy and safety in 50 pharmacies. Journal of the American Pharmaceutical Asociation., 43(2), 191-200. Flynn, E. A., Barker, K. N., Pepper, G. A., Bates, D. W., & Mikeal, R. L. (2002). Comparison of methods for detecting medication errors in 36 hospitals and skiled -nursing facilities. American Journal of Health-System Pharmacy, 59, 436-446. 160 Flynn, E.A., et al. (2002). Comparison of methods for detecting medication erors in 36 hospitals and skiled -nursing facilities. American Journal of Health-System Pharmacy, 59: p. 436-446. Grandjean, E. (1988). Fiting the task to the man. New York: Taylor and Francis. Henderson, Z. P. (Spring 1995). Computers require low light. Human Ecology, 23(2). Hodge, M. B. (1999). Do Anxiety, Math Self-Eficacy, and Gender afect nursing students' drug dosage calculations? Nurse Educator, 24(4), 36-41. Joint Commision on Acreditation of Healthcare Organizations (August 2002). Healthcare at the crossroads: strategies for addresing the evolving nursing crisis Retrieved May 2008 from http:/ww.jointcommision.org/NR/rdonlyres/5C138711-ED76-4D6F-909F- B06E0309F36D/0/health_care_at_the_crossroads.pdf Juslen, H. (January 2005). Improving health and healthcare with light: International Federation of Hospital Engineering. Kerlinger F.N, & Le, H. B. (1999). Foundations of Behavioral Research (4th ed.). United States: Earl McPek. Faulkner, T. W., & Murphy, T. J. (1973). Lighting for dificult visual tasks. Human Factors, 15(2), 149-162. Kroemer, K., & Grandjean, E. (1997). Fitting the task to the human: A textbook of occupational ergonomics (5th ed.): Taylor and Francis. Kroemer, K. H. E., & Grandjean, E. (1997). Ergonomic principles of lighting Fiting the task to the human : A textbook of occupational ergonomics (5th ed., pp. 295-318): Taylor and Francis. 161 Leape, L. L. (1994). Error in Medicine. Journal of American Medical Asociation, 272(23), 1851-1857. Lepeleire, J. D., Bouwen, A., Conninck, L. D., & Buntinx, F. (2007). Insufficient lighting in nursing homes. Journal of American Medical Directors Asociation, 8(5), 314- 317. Lion, J. S., Richardson, E., & Browne, R. C. (1967, 1969). A study of the performance of industrial inspectors under two kinds of lighting. Paper presented at the Procedings of the symposium on 'Ergonomics in machine design', Prague 2-7 Oct. 1967, Geneva, 1969. Luckiesh, M., & Moss, F. K. (1937). The Science of Seeing: Van Nostrand Co. Lyons, S. L. (1981). Handbook of Industrial Lighting (Vol. 1). London: Butterworths. MEDMARX Data Report (2008). A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine?s Cal for Action. Findings 2003-2006 and Trends 2002-2006. Rockvile, MD: Center for the Advancement of Patient Safety, US Pharmacopeia. Megaw, E. D. (1979). Factors afecting visual inspection acuracy. Applied Ergonomics, 10(1), 27-32. Niebel, B., & Freivalds, A. (2003). Work Environment Design Methods, Standards and Work design (11th ed., pp. 233-242): McGraw Hil. Pape, T. M., Guerra, D. M., Bryant, M., & Ingram, J. B. (2005). Innovative approaches to reducing nurses' distractions during medication administration. Journal of Continuing Education in Nursing, 36, 108 - 116. Peletier, P. L. (2001). Medication errors: A leson from long-term care. Nursing 162 Management, 32(11), 49 - 50. Rea, M. S. (Summer 1986). Toward a model of visual performance: foundations and data. Journal of the Illuminating Engineering Society, 15, 41-57. Reason, J. (2000). Human error : models and management. British Medical Journal, 320, 768-770. Reason, J. (2003). Human Eror. United Kingdom: Cambridge University Pres. Sanders, M. S., & McCormick, E. J. (1993). Human Factors In Engineering and Design (7th ed.). New York: McGraw-Hill. Scott-Cawiezel, J., Pepper, G. A., Madsen, R. W., Petroski, G., Vogelsmeier, A., & Zelmer, D. (2007). Nursing home error and level of staf credentials. Clinical Nursing Research, 16, 72-78. Sloane, P., Mitchel, C., Calkins, M., & Zimerman, S. (2000). Light and noise levels in Alzheimer's Disease Special Care Units. Research and Practice in Alzheimer's Disease, 4, 241-249 Smith, S. W., & Rea, M. S. (1978). Proofreading under diferent levels of ilumination. Journal of the Illuminating Engineering Society, 8, 47-52. Smith, S. W., & Rea, M. S. (October 1982). Performance of a reading test under diferent levels of ilumination. Journal of the Illuminating Engineering Society, 29-33. Smith, S. W., & Rea, M. S. (Winter 1987). Check value verification under diferent levels of ilumination. Journal of the Illuminating Engineering Society, 143-149. Studdert, D. M., Spital, M. J., Melo, M. M., O'Maley, J., & Stevenson, D. G. (2011). Relationship betwen Quality of Care and Negligence Litigation in Nursing Homes. New England Journal of Medicine, 364, 1243-1250. 163 The Centers for Medicare & Medicaid Services (December 2006 edition). Interpretive guidelines for surveyors [? 483.70)(g)(1)] and [(? 483.15)(h)(5)] The Long term Care Survey. Washington DC: American Health Care Asociation. The IESNA Commite for Healthcare Facilities (2006). An IESNA Recommended Practice : Lighting for hospitals and health care facilities. New York: Illuminating Engineering Society of North America and American National Standard Institute RP-29-06. The IESNA Lighting for the Aged and Partialy Sighted Commite (2007). Recommended Practice for Lighting and the Visual Environment for Senior Living. New York: Illuminating Engineering Society of North America and American National Standard Institute, RP-28-07. United States Pharmacopeia. General Chapter 1066 : Physical Environments that promote safe medication use. Pharmacopeial Forum. Nov - Dec 2008;34(6):1549- 1558. Varadarajan, R., Barker, K. N., Flynn, E. A., & Thomas, R. E. (2005). An Exploratory Study And Comparison Of Two Eror Detection Methods In A Mail Order Pharmacy Serving Correctional Facilities. Auburn University, Auburn, Alabama. Wei, W. K., & Konz, S. (16-19 October 1978). The efect of lighting and low power magnification on inspection performance. Paper presented at the 22nd Annual Meting of the Human Factors Society, `People on the Move', Detroit, Michigan. Wendy Strauss Wat, O. D. (October 2003). How visual acuity is measured. Retrieved from http:/ww.mdsupport.org/library/acuity.html Weston HC (1945). The relation between ilumination and visual eficiency - The efect of brightnes contrast. London: His Majesty's Stationery Ofice. 164 Weston HC (1949). Sight, light and eficiency. London: H.K Lewis and Company. Witkin, H. A., Oltman, P. K., Raskin, E., & Karp, S. A. Group Embedded Figures Test Manual (pp. 1-32). Palo Alto, California: Consulting Psychologists Pres. 165 APENDICES 166 APENDIX A MEMORANDUM OF THE PROJECT 167 APENDIX A I. Copy of the memorandum To: Al nursing staff From: Investigator (Harrison School of Pharmacy, Auburn University) Re: Student-researcher observing nursing staff regarding their work. Date: March 31, 2009 ??????????????????????.????????????? The investigator is a student - researcher from Auburn University. She is interested in studying the lighting levels at a nursing facility and its impact on work there. As part of this research, she wil be observing the nurses during their medication pas rounds and asking them questions, if necesary. The researcher wil not interrupt the daily work schedule of the staf, and wil shadow them without disturbing them. The researcher wil measure lighting levels at diferent places in the nursing facility, and that includes the medication carts and the nursing stations. She may also take pictures of certain areas to show the fixtures and equipment, while measuring the light levels. The data collected during the observation period wil be used for research purposes, and wil be kept strictly confidential. The researcher wil start her observation from April 7, 2009 and wil continue until she collects enough data for her research. If you have any questions, please contact: (Name with-held for confidentiality reasons). Aproved by: _____________________________ 168 APENDIX B IRB APROVAL FORMS ! ! 170! ! ! ! ! ! ! 170! ! 171 APENDIX C MEDICATION SCHEDULE 172 APENDIX C I. Medication schedule ! ! 173 APENDIX D ADITIONAL PICTURES FROM THE NURSING FACILITY 174 APENDIX D Pictures of the nursing facility Typical medication cart in all sections 175 Blister card from Pharmacy Memo stuck on the notice board 176 Resident Medication administration records stacked according to room numbers at the nursing stations MAR folder for controlled substances 177 A typical resident room Resident activity room 178 Light fixtures used in the facility 179 180 APENDIX E COPY OF INCIDENT REPORT FORM 181 APENDIX E Incident report form ! 182 APENDIX F DATA COLECTION FORMS ! ! 183! Form1 : Drug pass workshet (Observation phase) Page # ______ ; Date and Day: ___________ ; Obs time : _______; Illumination Level: ___; Nursing unit: __________ ! ! 184! Form 2: Drug Orders (Reconciliation phase) Date: _________; Resident initial/room number: _______; Nursing unit:______ ! ! 185! Form 3: Medication eror summary shet Nursing unit: _____________________ ; Illumination level: ______________ Day/Date: ____________________; Time/shift : _______________________ Total Errors = _________________ ; Total Opportunities for errors = _______ (# of doses given ____ + doses omited _____) Error rate = ____________ % ; [(Total errors / T.O.E.) X 100] Excluding wrong time errors; Error rate = ________ % ; [{(Total errors - wrong time errors) / T.O.E.} X 100] 186 APENDIX G INFORMED CONSENT LETER ! ! 187! ! ! ! ! ! ! ! 188! ! 189 APENDIX H RENEWED IRB APROVAL FORMS ! ! 190! ! ! ! ! ! 191! ! ! 192 APENDIX I MEDICATION PREPARATION ERROR DESCRIPTION ! ! 193! Appendix I: Table 1I: Medication Preparation Error Types and Frequencies for Section X Date Nurse code Ill. Level Errors Unauth. Dose Wrong dose Omisio n Wrong Form Wrong Time 6/1/10 5E B 19 1 8 1 9 6/2/10 5E 100 10 2 4 1 3 6/3/10 5E 145 3 3 6/9/10 5E 145 4 2 2 6/10/10 5E 100 3 1 2 6/11/10 5E B 6 2 4 6/15/10 5E 100 3 1 2 6/16/10 5E B 5 1 1 3 6/17/10 5E 145 2 1 1 6/23/10 5E B 8 2 2 4 6/24/10 5E 145 1 1 6/25/10 5E 100 2 2 6/3/10 4D B 5 2 3 6/4/10 4D B 5 2 3 6/8/10 4D 145 4 1 3 7/30/10 4D 145 4 1 3 8/2/10 4D 145 3 3 6/2/10 2B 145 8 1 7 6/7/10 2B B 18 1 3 14 6/10/10 2B 100 11 4 7 6/11/10 2B 100 6 1 5 6/24/10 2B 145 3 2 1 6/25/10 2B B 6 6 6/28/10 2B B 12 5 2 5 7/1/10 2B 100 4 4 ! ! 194! Date Nurse code Ill. Level Errors Unauth. Dose Wrong dose Omisio n Wrong Form Wrong Time 7/16/10 2B 145 4 1 3 7/9/10 2B B 7 7 7/15/10 2B 145 3 3 7/16/10 2B 100 7 3 4 6/4/10 7G 100 19 18 1 6/8/10 7G 100 14 1 13 6/22/10 7G B 7 1 2 1 3 6/30/10 7G 145 9 1 6 2 7/7/10 7G 145 5 1 3 1 7/19/10 7G 100 5 3 1 1 TOTAL 235 4 15 90 25 101 Note: It might be possible that some doses categorized as omision erors were prepared and administered while the observer was not present at the study site. For the purposes of this study, if the observer did not observe the prescribed dose being prepared during the medication pass round (with a window of ? 60 minutes), it was termed an omision eror. ! ! 195! Table 2I : Description of Medication Preparation Errors for Section X Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes 6/1/10 Baseline Metronidazole 250 mg None Omision 9 AM Aspirin EC 81 mg Aspirin EC 81 mg crushed Wrong form Senna Plus None Omision Cetirizine 10 mg None Omision Namenda 10 mg None Omision Acetaminophen 325 mg None Omision Calcium 600 + Vit D None Omision Aspirin 325 mg None Omission Glimepiride 2 mg None Omision Furosemide 6/2/10 100 fc Bupropion HCL SR 100 mg Bupropion HCL SR 100 mg; crushed Wrong form LPN comme nts ?Its bright? 9 AM Meclizine 25 mg None Omision Glimepiride 2 mg None Omision Loratadine 10 mg # 1 Loratadine 10 mg#2 Wrong dose Furosemide 20 mg # ? tab Furosemide 20 mg # 1 Wrong dose Ibuprofen 400 mg none Omision 6/2/10 145 fc Famotidine 20 mg None Omision 5 PM Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.28 PM Wrong time ! ! 196! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes 6/2/10 145 fc Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 5.20 PM Wrong time 5 PM Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.35 PM Wrong time Carbi-Levo 25/100; due at 6 PM after food Carbi-Levo 25/100; given at 4.40 PM Wrong time Seroquel 100 mg; due at 9 PM Seroquel 100 mg; given at 5 PM Wrong time Metformin 25 mg; due at 7 PM Metformin 25 mg; given at 5.10 PM Wrong time Vytorin 10-20 mg; due at 7 PM Vytorin 10-20 mg; given at 5.35 PM Wrong time 6/3/10 145 fc Glimepiride 2 mg None Omision 9 AM Ibuprofen 400 mg None Omision Therapeutic Vitamin None Omision 6/3/10 B Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.35 PM Wrong time 5 PM Xanax 0.25 mg; due at 9 PM Xanax 0.25 mg; given at 4.40 PM Wrong time Metoprolol 50 mg None Omision Ferrous Sulphate 325 mg; due at 9 PM Ferrous Sulphate; given at 4.50 PM Wrong time Colace 100 mg None Omision 6/4/10 100 fc Omeprazole 25 mg None Omision 9 AM Atenolol 25 mg None Omision ! ! 197! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Famotidine 40 mg None Omision Senna Plus None Omision Cetirizine 10 mg None Omision Citalopram 20 mg None Omision Aspirin 81 mg None Omision 6/4/10 100 fc Namenda 10 mg None Omision LPN says ? Light is good; can se much beter?. 9 AM Calcium + Vit D None Omision Tylenol 325 mg None Omision Metoprolol 25 mg; due at 7 AM Metoprolol 25 mg; given at 9.30 AM Wrong time Therapeutic Vitamin None Omision Metronidazole 250 mg None Omision KCL 10 MEQ None Omision Claritin 5 mg None Omision Azithromycin 250 mg None Omision Colace 100 mg None Omision Therapeutic Vitamin None Omision Sodium citrate- citric acid solution 10 ml None Omision ! ! 198! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes 6/4/10 B Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.15 PM Wrong time 5 PM Xanax 0.25 mg; due at 9 PM Xanax 0.25 mg; given at 4.25 PM Wrong time Metoprolol 50 mg None Omision Ferrous Sulphate 325 mg; due at 9 PM Ferrous Sulphate; given at 5.10 PM Wrong time Colace 100 mg None Omision 6/7/10 B Singulair 10 mg None Omision 5 PM Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.30 PM Wrong time Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 4.45 PM Wrong time 6/7/10 B Megestrol Acetate 40mg/ml (10ml); due at 9 PM Megestrol Acetate 40mg/ml (10ml); given at 4.45 PM Wrong time 5 PM Seroquel 100 mg; due at 9 PM Seroquel 100 mg; given at 4.55 PM Wrong time Benzonatate 100 mg; due at 9 PM Benzonatate 100 mg; given at 5.10 PM Wrong time Doxepin 10 mg; due at 9 PM Doxepin 10 mg; given at 5.20 PM Wrong time Ibuprofen 400 mg None Omision Vytorin 10-40 mg; due at 9 PM Vytorin 10-40 mg; given at 5.35 PM Wrong time Aricept 10 mg; due at 9 pm Aricept 10 mg; given at 5.25 PM Wrong time ! ! 199! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.53 PM Wrong time Metronidazole 250 mg None Omision Metoprolol 25 mg; due at 7 PM Metoprolol 25 mg; given at 5.18 PM Wrong time Vytorin 10-20 mg; due at 7 PM Vytorin 10-20 mg; given at 5.33 PM Wrong time Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 5.20 PM Wrong time Aricept 5 mg Aricept 10 mg Wrong dose Mirtazapine 25 mg; due at 9 PM Mirtazaping 25 mg; given at 5.11 PM Wrong time Alprazolam 0.25mg; due at 9 PM Alprazolam 0.25 mg; given at 5.31 PM Wrong time 6/8/10 100 fc Cal-carb 600+ Vit D None Omision 9 AM Therapeutic tablet None Omision Cefuroxine 250 mg None Omision Aspiring 325 mg None Omision Cal-carb 600+ Vit D None Omision Namenda 10 mg None Omision 6/8/10 100 fc Ibuprofen 400 mg None Omision 9 AM Colace 100 mg None Omision Alprazolam 0.25 mg None Omision Doxycycline 100 mg None Omision ! ! 200! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Warfarin Sodium 1 mg None Omision Atenolol 25 mg Atenolol 20 mg Wrong dose Omeprazole 20 mg None Omision Metronidazole 250 mg None Omision 6/8/10 145 fc Metoprolol 50 mg None Omision 5 PM Ferrous Sulphate 325 mg; due at 9 PM Ferrous Sulphate 325 mg; given at 5 PM Wrong time Xanax 0.25 mg; due at 9 PM Xanax 0.25 mg; given at 5.10 PM Wrong time Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 5.35 PM Wrong time 6/9/10 145 fc Glimepiride 2 mg None Omision 9 AM Thiamine HCL 100 mg None Omision Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong Form Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong Form 6/10/10 100 fc Bupropion SR 100 mg Bupropion SR 100 mg; crushed Wrong form 9 AM Aspirin EC 81 mg; # 1 Aspirin EC 81 mg; #2 Wrong dose Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form 6/10/10 100 fc Ibuprofen 400 mg None Omision 5 PM Citalopram 40 mg None Omision Colace 100 mg None Omision ! ! 201! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Metformin HCl 500 mg None Omision Xanax 0.25 mg; due at 9 PM Xanax 0.25 mg; given at 5.20 PM Wrong time 6/10/10 100 fc Vytorin 10-20 mg; due at 7 PM Vytorin 10-20 mg; given at 4.20 PM Wrong time 5 PM Metoprolol 25 mg; due at 7 PM Metoprolol 25 mg; given at 4.38 PM Wrong time Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.45 PM Wrong time Vytorin 10-40 mg; due at 9 PM Vytorin 10-40 mg; given at 5 PM Wrong time Senna Plus; due at 9 PM Senna Plus; given at 5.15 PM Wrong time Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 5.20 PM Wrong time 6/11/10 B Haldol 1 mg Haldol 1 mg; crushed Wrong form 9 AM Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form Bupropion SR 100 mg Bupropion SR 100 mg; crushed Wrong form Senna Plus None Omision Tylenol 325 mg None Omision 6/11/10 100 fc Atenolol 0.25 mg; due at 9 PM Atenolol 0.25 mg; given at 4.18 PM Wrong time 5 PM Seroquel 100 mg; due at 9 PM Seroquel 100 mg; given at 4.35 PM Wrong time ! ! 202! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 4.47 PM Wrong time Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 5.10 PM Wrong time Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 5.13 PM Wrong time Klor Con None Omision 6/15/10 100 fc Aspirin EC 81 mg Aspirin EC 81 mg; crushed and removed outer coating Wrong form 9 AM Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form Hydroxyzine 25 mg Hydroxyzine 20 mg Wrong dose 6/16/10 B Bupropion SR 100 mg Bupropion SR 100 mg; crushed Wrong form 9 AM Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form Aspirin EC 325 mg Aspirin EC 325 mg; crushed Wrong form Pyridium 200 mg Unauthorize d drug Senna S None Omision 6/17/10 145 fc Pyridium 200 mg Unauthorize d drug Big lunch today, so med pas early 9 AM Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form 6/22/10 B Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.17 PM Wrong time 5 PM Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.11 PM Wrong time ! ! 203! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Ceftin 250 mg; due at 9 PM Ceftin 250 mg; given at 4.21 PM Wrong time Omeprazole 20 mg None Omision Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form KCL 10 MEQ Wrong dose Spils the crushed contents Ibuprofen 400 mg None Omision 6/23/10 B Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form 9 AM Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form 6/23/10 B Senna S Unauthorize d drug 9 AM Senna S Unauthorize d drug Doxycycline 100 mg None Omision Lansoprazole SR 30 mg Lansoprazole SR 30 mg; crushed Wrong form Metoprolol ER 50 mg Metoprolol ER 50 mg; crushed Wrong form 6/23/10 B Ibuprofen 400 mg None Omision 9 AM 6/24/10 145 fc Metoprolol ER 50 mg Metoprolol ER 50 mg; crushed Wrong form 9 AM 6/24/10 145 fc Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.15 PM Wrong time 5 PM Metronidazole 250 mg None Omision ! ! 204! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Klor Con M10 None Omision 6/25/10 100 fc Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form 9 AM Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form 6/25/10 B Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.45 PM Wrong time 5 PM Seroquel 100 mg; due at 9 PM Seroquel 100 mg; given at 4.55 PM Wrong time Senna S; due at 9 PM Senna S; given at 4.59 PM Wrong time Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 5.11 PM Wrong time Senna S; due at 9 PM Senna S; given at 5.17 PM Wrong time Meclizine 12.5 mg; due at 7PM Meclizine 12.5 mg; given at 5.20 PM Wrong time 6/28/10 B Seroquel 100 mg; due at 9 PM Seroquel 100 mg; given at 4.01 PM Wrong time 5PM Doxepin 10 mg None Omision Hydroxyzine 25 mg None Omision Senna S; due at 9 PM Senna S; given at 4.57 PM Wrong time Senna S; due at 9 PM Senna S; given at 5.17 PM Wrong time Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 5.21 PM Wrong time 6/28/10 B Mirtazapine 15 mg Wrong dose LPN crushes the pills and drops the med-cup. More than half of the contents spil on the cart ! ! 205! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes 5PM Senna S Wrong dose Xanax 2.5 mg Wrong dose Aricept 5 mg Wrong dose Carbi-Levo 25/100 Wrong dose Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 5.50 PM Wrong time 6/30/10 145 fc Senna Plus None Omision 5 PM Tylenol 325 mg None Omision Resident asks for it; LPN ignores. Colace 100 mg None Omision Mirtazapine 30 mg None Omision Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.15 PM Wrong time Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 5.30 PM Wrong time 7/1/10 100 fc Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.27 PM Wrong time 5 PM Seroquel 100 mg; due at 9 PM Seroquel 100 mg; given at 4.31 PM Wrong time Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 4.45 PM Wrong time Xanax 0.5 mg; due at 9 PM Xanax 0.5 mg; at 4.51 PM Wrong time ! ! 206! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes 7/6/10 145 fc Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 4.17 PM Wrong time 5 PM Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.31 PM Wrong time Starlix 120 mg None Omision Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.47 PM Wrong time LPN comment s ? I forgot you were here? 7/7/10 145 fc Sensipar 30 mg None Omision 5 PM Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.27 PM Wrong time Sod- citrate + Citric acid solution 30 ml Sod- citrate + Citric acid solution 25 ml Wrong dose Colace 100 mg None Omision Carbi-Levo 25/100 None Omision 7/9/10 B Meclizine 12.5 mg; due at 7 PM Meclizine 12.5 mg; given at 4.11 PM Wrong time 5 PM Seroquel 100 mg; due at 9 PM Seroquel 100 mg; given at 4.25 PM Wrong time Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.47 PM Wrong time Xanax 0.5 mg; due at 9 PM Xanax 0.5 mg; given at 4.50 PM Wrong time Senna S; due at 9 PM Senna S; given at 4.55 PM Wrong time Senna S; due at 9 PM Senna S; given at 5.10 PM Wrong time ! ! 207! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Vytorin 10-40 mg; due at 9 PM Vytorin 10-40 mg; given at 5.15 PM Wrong time 7/15/10 145 fc Seroquel 100 mg; due at 9 PM Seroquel 100 mg; given at 4.10 PM Wrong time LPN moves med cart to new spots, as CNAs kept distractin g. 5 PM Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.27 PM Wrong time Xanax 0.5 mg; due at 9 PM Xanax 0.5 mg; given at 4.30 PM Wrong time 7/16/10 100 fc Aricept 10 mg; due at 9 PM Aricept 10 mg; given at 4.17 PM Wrong time 5 PM Xanax 0.5 mg; due at 9 PM Xanax 0.5 mg; given at 4.24 PM Wrong time Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 4.27 PM Wrong time Senna S; due at 9 PM Senna S; given at 4.54 PM Wrong time Ibuprofen 400 mg None Omision Metformin HCl 500 mg None Omision Colace 100 mg None Omision 7/19/10 100 fc Xanax 0.25 mg; due at 9 PM Xanax 0.25 mg; given at 4.45 PM Wrong time 5 PM Famotidine 40 mg None Omision Senna Plus None Omision ! ! 208! Date Ilumination level Prescribed Drug Prepared Drug Error Type Notes Senna Plus None Omision Aspirin EC 81 mg Aspirin EC 81 mg; crushed Wrong form 7/30/10 145 fc Ferrous Sulphate 325 mg; due at 9 PM Ferrous Sulphate 325 mg; given at 5.10 PM Wrong time 5 PM Metoprolol 50 mg None Omision Xanax 0.25 mg; due at 9 PM Xanax 0.25 mg; given at 5.15 PM Wrong time Aricept 10 mg;due at 9 PM Aricept 10 mg; given at 5.20 PM Wrong time 8/2/10 145 fc Xanax 0.25 mg; due at 9 PM Xanax 0.25 mg; given at 4.17 PM Wrong time 5 PM Aricept 10 mg;due at 9 PM Aricept 10 mg; given at 4.23 PM Wrong time Ferrous Sulphate 325 mg; due at 9 PM Ferrous Sulphate 325 mg; given at 5.10 PM Wrong time ! ! 209! Table 3I: Medication Preparation Error Types and Frequencies for Section Y Date Nurse code Il. Level Med pass time Total meds Errors TOE Error rate Error rate exclud wrong time erors 7/22/10 4D 100 5:00 PM 78 10 81 12.3 3.7 7/23/10 4D B 5:00 PM 75 7 75 9.33 8 7/26/10 4D B 5:00 PM 75 8 80 10 7.5 6/28/10 7G 145 9:00 AM 76 5 79 6.33 6.33 7/9/10 7G B 9:00 AM 79 14 92 15.2 15.2 8/9/10 7G 145 5:00 PM 87 5 89 5.61 4.49 6/29/10 6F B 9:00 AM 81 4 83 4.81 4.81 6/30/10 6F 100 9:00 AM 84 10 94 10.64 10.64 7/6/10 6F 100 9:00 AM 87 3 89 3.37 3.37 7/7/10 6F 145 9:00 AM 92 5 95 5.26 4.21 7/13/10 6F 145 9:00 AM 90 2 92 2.17 2.17 7/20/10 6F B 9:00 AM 85 4 87 4.59 4.59 7/21/10 6F 100 9:00 AM 74 3 75 4 2.66 7/23/10 6F 100 9:00 AM 82 1 82 1.22 0 7/27/10 6F B 9:00 AM 82 4 84 4.76 4.76 7/28/10 6F 145 9:00 AM 90 3 90 3.33 2.22 7/29/10 6F B 9:00 AM 93 5 94 5.32 4.25 7/30/10 6F 145 9:00 AM 85 2 85 2.35 2.35 6/9/10 3C B 5:00 PM 69 7 70 10 4.29 6/14/10 3C 100 5:00 PM 73 5 75 6.66 4 ! ! 210! Date Nurse code Il. Level Med pass time Total meds Errors TOE Error rate Error rate exclud wrong time erors 6/15/10 3C 100 5:00 PM 81 7 85 8.23 5.88 6/16/10 3C 100 5:00 PM 76 6 78 7.69 3.85 6/17/10 3C 145 5:00 PM 75 5 75 6.66 1.33 6/23/10 3C 145 5:00 PM 75 5 76 6.58 3.95 6/29/10 3C B 5:00 PM 70 9 74 12.16 6.76 7/5/10 3C B 5:00 PM 79 6 79 7.59 2.53 7/8/10 3C 145 5:00 PM 73 4 75 5.33 4 TOTAL 2166 149 2233 6.672 4.57 ! ! 211! Table 4I : Description of Medication Preparation Errors for Section Y Date Illumination level Prescribed Drug Prepared Drug Error Type Notes 6/9/10 Baseline Sertraline 50 mg; due at 9 PM Sertraline 50 mg; given at 4.15 PM Wrong time 5 PM Renagel 80 mg; # 4 pils Renagel 800 mg; #2 pils Wrong dose Furosemide 40 mg None Omision Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 4.45 PM Wrong time Calcium 60 mg + Vit D; due at 7 PM Calcium 60 mg + Vit D; given at 4.47 PM Wrong time Simvastatin 10 mg; due at 9 PM Simvastatin 10 mg; given at 5.02 PM Wrong time Detrol LA 4 mg Detrol LA 4 mg; crushed Wrong form 6/14/10 100 fc Hydralazine 25 mg None Omision 5 PM Xanax 0.25 mg None Omision Detrol LA 4 mg Detrol LA 4mg crushed Wrong form Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 5.30 PM Wrong time Ferous Gluconate 324 mg; due at 9 PM Ferous Gluconate 324 mg; given at 5.47 PM Wrong time 6/15/10 100 fc Sena Plus None Omision 5 PM Sena Plus None Omision Megestrol Acetate 40 mg/ml None Omision Ferous Gluconate 324 mg; due at 7PM Ferous Gluconate 324 mg; given at 4.50 PM Wrong time Klor Con M10 None Omision ! ! 212! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes 6/15/1 0 100 fc Calcium 60 mg + Vit D; due at 7 PM Calcium 60 mg + Vit D; given at 5.40 PM Wrong time 5 PM 6/16/1 0 100 fc Sena Plus None Omision 5 PM Detrol LA 4 mg Detrol LA 4mg curshes Wrong form Aspirin 325 mg None Omision Ferous Gluconate 324 mg; due at 7PM Ferous Gluconate 324 mg; given at 4.30 PM Wrong time Calcium 60 mg + Vit D; due at 7 PM Calcium 60 mg + Vit D; given at 5.10 PM Wrong time Simvastatin 20 mg; due at 9PM Simvastatin 20 mg; gien at 5.35 PM Wrong time 6/17/1 0 145 fc Ferous Gluconate 324 mg; due at 7PM Ferous Gluconate 324 mg; given at 4.10 PM Wrong time 5 PM Simvastatin 20 mg; due at 9PM Simvastatin 20 mg; gien at 4.25 PM Wrong time Calcium 60 mg + Vit D; due at 7 PM Calcium 60 mg + Vit D; given at 5.17 PM Wrong time Detrol LA 4 mg Detrol LA 4mg curshes Wrong form Simvastatin 10 mg; due at 9PM Simvastatin 10 mg; gien at 5.48 PM Wrong time 6/23/1 0 145 fc Miralax Powder None Omision 5 PM Colace solution 10 ML Colace solution 5 ML Wrong dose Simvastatin 20 mg; due at 9PM Simvastatin 20 mg; at 5.1 Wrong time ! ! 213! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes Calcium 60 mg + Vit D; due at 7 PM Calcium 60 mg + Vit D; given at 5.21 PM Wrong time Detrol LA 4 mg Detrol LA 4mg curshes Wrong form 6/28/1 0 145 fc Aspirin 81 mg, EC Aspirin 81 mg EC, crushes Wrong form 9 AM Sena solution 15 ML Sena solution around 5 ML Wrong dose LPN does not accurately measure the solution. Carvedilol 6.25 MG None Omision LPN takes pil; but puts it in trash Calcitrol 25 MG None Omision Miralax Powder None Omision 6/29/1 0 B Omeprazole DR 20 mg Omeprazole DR 20 mg; crushes Wrong form 9AM Metoprolol Sucinate ER 50 mg Metoprolol Sucinate ER 50 mg; crushes Wrong form Megestrol Acetate solution 10 ml None Omision LPN says not on cart; wil give it later. Did not given until observer present at site. Lorazepam 0.5 mg None Omision 6/29/1 0 B Klor Con M10 None Omision 2 residents hospitalized; 1 resident pased away; LPN expressed concern. 5PM Sertraline 50 mg; due at 9PM Sertraline 50 mg; given at 4.37 PM Wrong time ! ! 214! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes Renagel 80 mg; # 4 Renagel 80 mg; # 3 given Wrong dose LPN comented ?I could use a light here!? Furosemide 40 mg None Omision Amoxycilin 50 mg None Omision Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 5.15 PM Wrong time 6/29/1 0 B Calcium 60 mg+ Vit D; due at 7 PM Calcium 60 mg+ Vit D; given at 5.27 PM Wrong time 5 PM Megestrol Acetate 10 ml None Omision Simvastatin 10 mg; due at 9 PM Simvastatin 10 mg; given at 5.30 PM Wrong time Stoped med- pas at 5.30 PM to fed residents. Asked observer to leave. 6/30/1 0 100 fc Carvedilol 6.25 mg None Omision Interuptions by family members of a resident. LPN comented ?I like that light?. One LPN to another ?Do you like to keep that light?? Study LPN ?I don?t know; but I like that light.? Fire alarm dril from 9.03 am to 9.06 am; LPN works throughalarm. ! ! 215! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes 9 AM Sena S None Omision Resident refused the folowing 9 medications; so LPN trashes all the meds. Digoxin 125 mcg None Omision Lisinopril 2.5 mg None Omission Klor Con M10 None Omision 6/30/1 0 Glyburide Metformin 2.5mg/ 5mg None Omision 9 AM Furosemide 40 mg None Omision Paroxetine 20 mg None Omision Megestrol Acetate 10 ml None Omision Lorazepam 0.5 mg None Omision 7/5/10 B Detrol LA 4mg Detrol LA 4mg; crushes Wrong form 5 PM Ferous Gluconate 324 mg; due at 7 PM Ferous Gluconate 324 mg; given at 4.15 PM Wrong time Calcium 60 mg + Vit D; due at 7 PM Calcium 60 mg + Vit D; given at 4.23 PM Wrong time Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 4.47 PM Wrong time Sertraline 50 mg; due at 9 PM Sertraline 50 mg; given at 5.25 PM Wrong time Sena solution 10 ml Sena solution; measured around 5 ml Wrong dose ! ! 216! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes 7/6/10 100 fc Aspirin 325 mg None Omision 9 AM Miralax Powder None Omision Colace solution 10 ml Colace solution; around 5 ml Wrong dose 7/7/10 145 fc Carvedilol 6.25 mg None Omision LPN comented that she did not slep the whole night. 9AM Torsemide 20 mg None Omision Colace 10 mg None Omision Aspirin EC 81 mg Aspirin EC 81 mg crushes Wrong form Calcium 60 mg + Vit D; due at 7 AM Calcium 60 mg + Vit D; given at 9.25 AM Wrong time 7/8/10 145 fc Namenda 10 mg None Omision 5 PM Detrol LA 4 mg Detrol LA 4mg; crushes Wrong form Ferous Gluconate 324 mg; due at 7 PM Ferous Gluconate 324 mg; given at 5.10 PM Wrong time Klor Con M10 None Omision LPN got distracted watching TV 7/9/10 B Metformin 100 mg None Omision 9 AM Sena solution 15 ml None Omision LPN on seeing observer enter site ? oh, she is again on my face!? But did not stop observer from observation. ! ! 217! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes Colace solution 10 ml None Omision KCL 10 MEQ None Omision Colace 10 mg None Omision Zyrtec 10 mg None Omision Protonix 40 mg; due at 7 AM Protonix 40 mg; given at 9.45 AM Omision Torsemide 20 mg None Omision Ranitidine 150 mg None Omision Sena S none Omision Sena S None Omision Carvedilol 6.25 mg None Omision Calcitrol 0.25 mg None Omision 7/13/1 0 145 fc Torsemide 20 mg None Omision 9AM Amitiza 24 mcg None Omision 7/20/1 0 B Omeprazole DR 20 mg Omeprazole DR 20 mg; crushes Wrong form 9AM Metoprolol Sucinate ER 50 mg Metoprolol Sucinate ER 50 mg; crushes Wrong form Aspirin 325 mg None Omision Torsemide 20 mg None Omision 7/21/1 0 100 fc Aspirin EC 81 mg Aspirin EC 81 mg; crushes Wrong form 9AM Calcium 60 mg + Vit D; due at 7 AM Calcium 60 mg + Vit D; given at 9.23 Wrong time ! ! 218! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes Namenda 10 mg None Omision 7/22/1 0 100 fc Colace 10 mg None Omission 5PM Warfarin sodium 2 mg None Omision Ferous Gluconate 324 mg; due at 7 PM Ferous Gluconate 324 mg; given at 5.07 PM Wrong time Klor Con M10 None Omision Diazepam 5 mg; due at 7 PM Diazepam 5mg; given at 5.19 PM Wrong time Simvastatin 40 mg; due at 9 PM Simvastatin 40 mg; given at 5.23 PM Wrong time Haldol 2 mg; due at 9PM Haldol 2 mg; given at 5.26 PM Wrong time Simvastatin 20 mg; due at 9 PM Simvastatin 20 mg; given at 5.31 PM Wrong time Calcium 60 mg+Vit D; due at 7 PM Calcium 60 mg +Vit D; given at 5.33PM Wrong time Clonazepam 0.5 mg; due at 9 PM Clonazepam 0.5 mg; given at 5.35 PM Wrong time 7/23/1 0 9AM 100 fc Calcium 60 mg+ Vit D; due at 7 AM Calcium 60 mg+ Vit D; given at 10.25 Am Wrong time LPN stopped med-pas at 9.30 am, as one of the resident?s blood sugar level elevated. Resumed med-pas , but remained concerned and distracted for rest of med-pas ! ! 219! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes 7/23/1 0 B Renagel 80 mg # 4 Renagel 80 mg #2 Wrong dose 5 PM Simvastatin 10 mg; due at 9 PM Simvastatin 10 mg; given at 4.30 PM Wrong time Simvastatin 40 mg; due at 9 PM Simvastatin 40 mg; given at 4.47 PM Wrong time Ferous Gluconate 324 mg; due at 7 PM Ferous Gluconate 324 mg; given at 5.11 PM Wrong time Haldol 2 mg; due at 9PM Haldol 2mg; given at 5.17 PM Wrong time Diazepam 5 mg; due at 9PM Diazepam 5 mg; given at 5.27 PM Wrong time 7/26/1 0 B Simvastatin 40 mg; due at 9 PM Simvastatin 40 mg; given at 4.30 PM Wrong time 5 PM Colace 10 mg None Omision Sena Plus None Omision Sena Plus None Omision Diazepam 5 mg; due at 9 PM Diazepam 5 mg; given at 4.47 PM Wrong time Carvedilol 6.25 mg None Omision Warfarin Sodium 2.5mg None Omission Detrol LA 4 mg Detrol LA 4mg; crushes Wrong form 7/27/1 0 B Omeprazole DR 20 mg Omeprazole DR 20 mg; crushes Wrong form 9 AM Detrol LA 4 mg Detrol LA 4 mg; crushes Wrong form Amitiza 24 mcg None Omision ! ! 220! Date Illumination level Prescribed Drug Prepared Drug Error Type Notes Calcium 60 mg + Vit D None Omision 7/28/1 0 145 fc Calcium 60 mg +Vit D; due at 7 AM Calcium 60 mg+ Vit D; given at 9.10 AM Wrong time 9 AM Detrol LA 4 mg Detrol LA 4 mg; crushes Wrong form Aspirin EC 81 mg Aspirin EC 81 mg crushes Wrong form 7/29/1 0 B Calcium 60 mg+Vit D; due at 7 AM Calcium 60 mg +Vit D; given at 9.17 AM Wrong time 9 AM Lortab 7.5/50 mg None Omision LPN drops pil, but does not replace it. Detrol LA 4 mg Detrol LA 4 mg crushes Wrong form KCL 10 MEQ KCL 10 MEQ crushes Wrong form LPN observed dropping pils at 3 diferent instances. KCL 10 MEQ KCL 10 MEQ crushes Wrong form 7/30/1 0 145 fc Detrol LA 4 mg Detrol LA 4 mg crushes Wrong form 9 AM Klor Con M10 Klor Con M10 crushes Wrong form Rx stated ?do not crush? 8/9/10 145 fc Detrol LA 4mg Detrol LA 4mg crushes Wrong form 5 PM Colace solution 10 ml Colace solution; around 5 ml Wrong dose Miralax powder None Omision Verapamil 80 mg None Omision Trazodone 50 mg; due at 9 PM Trazodone 50 mg; given at 5.10 PM Wrong time ! ! 221! Table 5I : Medication Preparation Error Types and Frequencies for Section Z Date Nurse code Ill. Level Errors Unauth. Dose Wrong dose Omision Wrong Form Wrong Time 7/13/10 4D 100 9 1 8 7/14/10 4D 100 14 4 10 7/20/10 4D 145 5 5 7/21/10 4D 100 7 7 7/2/10 7G 100 4 3 1 7/26/10 7G B 8 8 8/6/10 7G B 8 6 2 7/1/10 1A B 4 1 3 7/2/10 1A 100 2 2 7/5/10 1A 100 3 3 7/8/10 1A 100 4 3 1 7/14/10 1A 145 1 1 7/15/10 1A 145 2 2 7/16/10 1A 145 1 1 7/19/10 1A 145 0 7/22/10 1A B 2 2 8/2/10 1A B 4 2 2 8/3/10 1A 100 1 1 8/9/10 1A B 4 1 3 TOTAL 83 0 0 33 20 30 ! ! 222! Table 6I: Description of Medication Preparation Errors for Section Z Date Illuminati on level Prescribed Drug Prepared Drug Error Type Notes 7/1/201 0 B Colace 10 mg None Omision LPN said she was behind schedule; so was rushing her med- pas. Wanted to finish before 10 AM 9 AM Aspirin EC 81 mg Aspirin EC 81 mg crushes Wrong form LPN said for some reason I keep losing the Aspirin tablet. Oxybutynin ER 10mg Oxybutynin ER 10mg crushed Wrong form KCL 10 MEQ KCL 10 MEQ; crushed Wrong form Order states? do not crush? 7/2/10 100 fc Aspirin EC 81 mg Aspirin EC 81 mg crushed Wrong form 9 AM Oxybutynin ER 10mg Oxybutynin ER 10mg crushed Wrong form Order states? do not crush? 7/2/10 100 fc Erythromycin ER 250 mg None Omision 5PM Colace 10 mg None Omision Sena Plus None Omision KCL 10 MEQ KCL 10 MEQ; crushed Wrong form Order states? do not crush? 7/5/10 100 fc KCL 10 MEQ KCL 10 MEQ; crushed Wrong form Order states? do not crush? 9 AM Aspirin EC 81 mg Aspirin EC 81 mg crushed Wrong form Oxybutynin ER 10mg Oxybutynin ER 10mg crushed Wrong form do not crush? ! ! 223! Date Illuminati on level Prescribed Drug Prepared Drug Error Type Notes 7/8/10 100 fc KCL 10 MEQ KCL 10 MEQ; crushed Wrong form Order states? do not crush? 9 AM Colace 10 mg None Omision Vitamin D None Omision Therapeutic Tablet None Omision 7/13/10 100 fc Sena tablet; due at 9 PM Sena tablet; given at 4.08 PM Wrong time LPN: Are you going to tell them to give us this light? I realy like the light. We move a lot, so I like this extra light. 5 PM Sena tablet; due at 9 PM Sena tablet; given at 4.09 PM Wrong time Hydralazine 50 mg; due at 9 PM Hydralazine 50 mg; given at 4.20 PM Wrong time Mirtazapine 30 mg; due at 9 PM Mirtazapine 30 mg; given at 5.11 PM Wrong time Seroquel 25 mg; due at 9 PM Seroquel 25 mg; given at 5.15 PM Wrong time Niacin SR 250 mg; due at 9 PM Niacin SR 250 mg; given at 5.30 PM Wrong time Vytorin 10/20; due at 9 PM Vytorin 10/20; given at 5.47 PM Wrong time Erythromycin film coated 250 mg None Omision Simvastatin 40 mg; due at 7 PM Simvastatin 40 mg; given at 5.53 PM Wrong time 7/14/10 145 fc Erythromycin film coated 250 mg None Omision 9 AM ! ! 224! Date Illuminati on level Prescribed Drug Prepared Drug Error Type Notes 7/14/10 100 fc Hydralazine 50 mg; due at 9 PM Hydralazine 50 mg; given at 4.25 PM Wrong time 5 PM Sena tablet; due at 9 PM Sena tablet; given at 4.39 PM Wrong time Colace; due at 9 PM Colace; given at 5.09 PM Wrong time Simvastatin 40 mg; due at 7 PM Simvastatin 40 mg; given at 5.20 PM Wrong time Diltiazem 240 mg None Omision Lisinopril 20 mg None Omision Lisinopril 20 mg None Omision Therapeutic tablet None Omision Simvastatin 40 mg; due at 9 PM Simvastatin 40 mg; given at 5.27 PM Wrong time Vytorin 10/20; due at 9 PM Vytorin 10/20; given at 5.31 PM Wrong time Niacin SR 250 mg; due at 9 PM Niacin SR 250 mg; given at 5.37 PM Wrong time Aspirin EC 81 mg due 30 mins before Niacin (8.30 PM) Aspirin EC 81 mg ; given at 5.40 PM Wrong time KCL 10 MEQ; due at 9 P KCL 10 MEQ; given at 5.41 PM Wrong time Mirtazapine 30 mg; due at 9 PM Mirtazapine 30 mg; given at 5.45 PM Wrong time 7/15/10 145 fc Erythromycin film coated 250 mg None Omision 9AM KCL 10 MEQ KCL 10 MEQ; crushed Wrong form Order states? do not crush? 7/16/10 145 fc Aspirin EC 81 mg Aspirin EC 81 mg crushed Wrong form 9 AM 7/20/10 145 fc Aspirin EC 81 mg due 30 mins before Niacin (8.30 PM) Aspirin EC 81 mg ; given at 4.10 PM Wrong time ! ! 225! Date Illuminati on level Prescribed Drug Prepared Drug Error Type Notes 5 PM Colace; due at 9 PM Colace; given at 4.19 PM Wrong time Lipitor 80 mg; due at 9 PM Lipitor 80 mg; given at 4.21 PM Seroquel 25 mg; due at 9 PM Seroquel 25 mg; given at 4.35 PM Wrong time Mirtazapine 30 mg; due at 9 PM Mirtazapine 30 mg; given at 4.45 PM Wrong time 7/21/10 100 fc Colace; due at 9 PM Colace; given at 4.09 PM Wrong time 5 PM Aspirin EC 81 mg due 30 mins before Niacin (8.30 PM) Aspirin EC 81 mg ; given at 4.13 PM Wrong time Niacin SR 250 mg; due at 9 PM Niacin SR 250 mg; given at 4.27 PM Wrong time LPN: This light is realy good. You should patent it. I wil ask the administr ator to get a light like this for me. I cant see otherwis e. Seroquel 25 mg; due at 9 PM Seroquel 25 mg; given at 4.35 PM Wrong time Hydralazine 50 mg; due at 9 PM Hydralazine 50 mg; given at 4.39 PM Wrong time Simvastatin 40 mg; due at 9 PM Simvastatin 40 mg; given at 5.07 PM Wrong time KCL 10 MEQ; due at 9 P KCL 10 MEQ; given at 5.1 PM Wrong time 7/22/10 B Aspirin EC 81 mg Aspirin EC 81 mg crushed Wrong form 9 AM Oxybutynin ER 10mg Oxybutynin ER 10mg crushed Wrong form Order states? do not crush? 7/26/10 B Vitamins None Omision ! ! 226! Date Illuminati on level Prescribed Drug Prepared Drug Error Type Notes 9 AM Dulcolax 5 mg None Omision Miralax Powder; 1 capful None Omision Loratadine 10 mg None Omision Nexium 40 mg None Omision Zyrtec 10 mg None Omision Colace 10 mg None Omision Saltropine 0.4 mg None Omision 8/2/10 B Aspirin EC 81 mg Aspirin EC 81 mg crushed Wrong form 9 AM Oxybutynin ER 10mg Oxybutynin ER 10mg crushed Wrong form Order states? do not crush? Dulcolax 5 mg None Omision Erythromycin film coated 250 mg None Omision 8/3/10 100 fc Erythromycin film coated 250 mg None Omision 9 AM 8/6/10 B KCL 10 MEQ KCL 10 MEQ; crushed Wrong form Order states? do not crush? 9 AM Erythromycin film coated 250 mg None Omision Nifedipine ER 30 mg None Omision Ferous Sulphate 325 mg None Omision Paroxetine HCL 10 mg None Omision Metorpolol Sucinate ER 50 mg None Omision ! ! 227! Date Illuminati on level Prescribed Drug Prepared Drug Error Type Notes Aspirin EC 81 mg None Omision Oxybutynin ER 10mg Oxybutynin ER 10mg crushed Wrong form Order states? do not crush? 8/9/10 B KCL 10 MEQ KCL 10 MEQ; crushed Wrong form Order states? do not crush? 9 AM Erythromycin film coated 250 mg None Omision Aspirin EC 81 mg Aspirin EC 81 mg crushed Wrong form Oxybutynin ER 10mg Oxybutynin ER 10mg crushed Wrong form Order states? do not crush?