( Critical Appraisal Tools Worksheet Template ) Evaluation Table Use this document to complete the evaluation table requirement of the Module 4 Assessment,Evidence-Based Project, Part 4A: Critical Appraisal of Research Full citation of selected article Article #1 Article #2 Article #3 Article #4 Ashcroft, D., Lewis, P., Tully, M., Farragher, T., Taylor, D., & Wass, V., Williams, S. D., & Dornan, T. (2015). Prevalence, Nature, Severity and Risk Factors for Prescribing Errors in Hospital Inpatients: Prospective Study in 20 UK Hospitals. Drug Safety, 38(9), 833-843. DOI: 10.1007/s40264-015-0320-x Carayon, P., Wetterneck, T., Cartmill, R., Blosky, M., Brown, R., & Kim, R., Kukreja, S., Johnson, M., Paris, B., Wood, K. E., & Walker, J. (2014). Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. BMJ Quality & Safety, 23(1), 56-65. DOI: 10.1136/bmjqs-2013-001828 Hines, S., Kynoch, K., & Khalil, H. (2018). Effectiveness of interventions to prevent medication errors. JBI Database Of Systematic Reviews And Implementation Reports, 16(2), 291-296. DOI: 10.11124/jbisrir-2017-003481 Khalil, H., Chambers, H., Sheikh, A., Bell, B., & Avery, A. (2017). Professional, structural and organisational interventions in primary care for reducing medication errors. Cochrane Database System Review, 10 (CD003942). DOI: 10.1002/14651858.CD003942.pub3. Conceptual Framework Describe the theoretical basis for the study The study deduced the reasoning that doctors during their first year of post-graduate training are prone to making disproportionate errors in their prescription. Safety during medication is a significant issue in healthcare more so in intensive care units (ICUs). Therefore, the complexity of the medication management process is reflected on the convolution of evaluating medication errors and adverse drug events in ICUs. This study seeks to assess the effectiveness of interventions developed to avert medication error during administration of medication, medication-related death, and medication-related harms among acute care patients. During primary care, there are adverse events associated with medication and they represent a significant cause of hospital admission and mortality and these events could be as a result of patient going through adverse drug reactions or medication errors and the latter is preventable. Design/Method Describe the design and how the study was carried out The study used pharmacists as their subjects across 20 health facilities over 7 selected days and the data was collected based on the number of checked medication orders, details of the prescribing errors, and the prescriber’s grade. As part of the study’s methodology, the research has assessed the effect of electronic medical record on the safety and quality across ICUs by having cross-sectional study which has reported on the medication safety before EHR was used in two ICU facilities ...

1. (
Critical Appraisal Tools Worksheet
Template
)
Evaluation Table
Use this document to complete the evaluation table requirement
of the Module 4 Assessment,Evidence-Based Project, Part 4A:
Critical Appraisal of Research
Full citation of selected article
Article #1
Article #2
Article #3
Article #4
Ashcroft, D., Lewis, P., Tully, M., Farragher, T., Taylor, D., &
Wass, V., Williams, S. D., & Dornan, T. (2015). Prevalence,
Nature, Severity and Risk Factors for Prescribing Errors in
Hospital Inpatients: Prospective Study in 20 UK Hospitals.
Drug Safety, 38(9), 833-843. DOI: 10.1007/s40264-015-0320-x
Carayon, P., Wetterneck, T., Cartmill, R., Blosky, M., Brown,
R., & Kim, R., Kukreja, S., Johnson, M., Paris, B., Wood, K. E.,
& Walker, J. (2014). Characterising the complexity of
medication safety using a human factors approach: an
observational study in two intensive care units. BMJ Quality &
Safety, 23(1), 56-65. DOI: 10.1136/bmjqs-2013-001828
Hines, S., Kynoch, K., & Khalil, H. (2018). Effectiveness of
interventions to prevent medication errors. JBI Database Of

2. Systematic Reviews And Implementation Reports, 16(2), 291-
296. DOI: 10.11124/jbisrir-2017-003481
Khalil, H., Chambers, H., Sheikh, A., Bell, B., & Avery, A.
(2017). Professional, structural and organisational interventions
in primary care for reducing medication errors. Cochrane
Database System Review, 10 (CD003942). DOI:
10.1002/14651858.CD003942.pub3.
Conceptual Framework
Describe the theoretical basis for the study
The study deduced the reasoning that doctors during their first
year of post-graduate training are prone to making
disproportionate errors in their prescription.
Safety during medication is a significant issue in healthcare
more so in intensive care units (ICUs). Therefore, the
complexity of the medication management process is reflected
on the convolution of evaluating medication errors and adverse
drug events in ICUs.
This study seeks to assess the effectiveness of interventions
developed to avert medication error during administration of
medication, medication-related death, and medication-related
harms among acute care patients.
During primary care, there are adverse events associated with
medication and they represent a significant cause of hospital
admission and mortality and these events could be as a result of
patient going through adverse drug reactions or medication
errors and the latter is preventable.
Design/Method Describe the design and how the study
was carried out
The study used pharmacists as their subjects across 20 health
facilities over 7 selected days and the data was collected based
on the number of checked medication orders, details of the
prescribing errors, and the prescriber’s grade.
As part of the study’s methodology, the research has assessed

3. the effect of electronic medical record on the safety and quality
across ICUs by having cross-sectional study which has reported
on the medication safety before EHR was used in two ICU
facilities in a tertiary care under community teaching hospital.
The study considered different systemic reviews which entailed
different health practitioners involved in prescription,
dispensation, and administration of medication to patients under
acute care. Therefore, information regarding this issue will be
retrieved from different databases such as the Cochrane Library,
Embase, Implementation Reports, MEDLINE, CINAHL, and the
JBI Database of Systematic Reviews Web of Science where the
researchers would look for theses, MedNar, and ProQuest
dissertations.
.
The researchers searched through CENTRAL, Embase,
MEDLINE, TWO REGISTRIES, and three other websites on 4
October 2016 as well as reference checking, contact with
authors to determine further researches, and citation searching.
Sample/Setting
The number and characteristics of patients, attrition rate, etc.
Over the 7-day duration of data collection, pharmacists
reviewed 26,019 patients and 124,260 medication orders.
Among these data collected, it was found that 10,986 had
prescription errors hence making the mean error rate to be at
8.8% for every 100 prescriptions.
The adult ICU entails a 24-bed capacity unit which concentrates
on trauma, critical care, and non-cardiac post-surgical care
hence making the average stay to be 7.1 days. On the other
hand, there is a cardiac ICU with capacity of 18 beds and it is
specialized in various cardiac-related care with an average stay
of 3.6 days. Therefore, this research evaluated data from 630
subsequent ICU patients admitted and 304 were from the adult
ICU between October 2006 and February 2007 whereas 326
were from the cardiac ICU between January and March 2007.
After the search for the relevant publications in the
aforementioned sites, the chosen citations will be gathered and

4. uploaded into Endnote and their duplicates removed as two
independent reviewers screen the abstracts and titles for
evaluation against the inclusion protocol for the assessment.
The research used 30 studies which had 169,969 subjects in
assessing the interventions to avert medication errors and 4
studies looked into professional intervention (8266 subjects)
whereas 26 subjects discussed the institutional interventions
(161,703 subjects). However, the research did not find any
study which discussed structural intervention.
Major Variables Studied
List and define dependent and independent variables
The dependent variables for this research include stage of
hospitalization when the medication was given to the patient,
type of prescription, and the type of prescriber.
The independent variable in this study is the severity of the
prescribing error.
The dependent variables for this research included potential
ADE events, preventable ADE events, as well as non-
preventable ADE events
The independent variable for this study was the medication
safety which entailed evaluation of ICU medication order.
The independent variables for this study include specific details
on the interventions, method of review, populations, as well as
the result of significance to the review question and particular
objectives.
The dependent variable is the medication error which the
researches seek to assess from different publications.
The independent variables are visit to the emergency
department, admission into the hospital, and mortality of the
patient.
The dependent variable was the natural units which entail the
number of subjects within an event per the cumulative number
of subjects at follow-up.
Measurement
Identify primary statistics used to answer clinical questions
The research used the logistic regression models which

5. recognized different aspects of predicting the chances of
making erroneous prescription as well as its severity.
The data regarding medication safety events were collected
using four trained nurse data collectors through a prospective
cohort study process whereby the incident was detected by self-
report of the nurse data collectors. Therefore, this data
collection method entailed review of every ICU medication
order through the steps of medication-management process
hence seeing the errors and ADEs associated with the order.
Based on the paper chosen for this research, the data will be
retrieved by two independent reviewers through a standardized
data extraction tool from the JBI SUMARI.
The research used GRADE tool for assessment of certainty of
evidence.
Data Analysis
Statistical or
qualitative
findings
Univariable and multivariable logistic regression models were
applied in assessing the possible effect of different variables
such as the stage of hospitalization when the medication was
prescribed, type of prescription, and the type of prescriber.
Multinomial logistic regression model was also used to identify,
determine the severity of the prescribing error more so on the
aspects which were correlated with a critical or possibly grave
error instead of a minor error.
For data analysis, the researchers used the Cohen’s kappa score
which had the ability to measure the inter-rater agreement for
qualitative data by taking into account the chances of the
agreement occurring by chance. This statistical analysis found
that scores exceeding 0.97 for the error that occurred, grouped
medication error types, grouped the events into single,
sequential, or group error events, and it grouped errors at the
stage of medication-management process.
The findings which were extracted from these publications were
presented in tabular format where they were put in pairs

6. entailing the intervention and its subsequent outcomes.
Therefore, the strengths of evidence based on the effectiveness
of an intervention was based on three colors whereby green
designated an effective intervention, amber stood for no
difference or effect compared to a control intervention, and red
for a damaging intervention or one which is not effective as the
control.
The study included random trials whereby healthcare
practitioners offered community-based medical services and
they also added interventions within the outpatient facilities
connected with the hospital where patients are observed by
professionals but they are not admitted. Therefore, the research
used interventions which were focused on reducing medication
errors resulting in visits in the emergency department,
admission into the hospital, and death of the patient. The
subjects used in this research were ranging in different age but
they all have a history of being prescribed medication.
Findings and Recommendations
General findings and recommendations of the research
Hospitals are faced with issues such as prescription error and
this problem is not only evident among the young medical
practitioners hence the need to develop an intervention which
would improve the safety of patients under the care of all grades
of medical professions.
This study found out that medication errors and ADEs among
the sampled patients upon their admission was across 1,733
different occurrences whereby 549 of them did not have
potential for patient harm and 1,184 were potential and
avoidable ADEs. The percentage for significant, serious, and
life threatening harm was 38%, 44%, and 18%. Therefore, based
on these occurrences, there are various technologies which have
been proposed to improve the safety of these patients such as
CPOE technology which is considered as a convenient
intervention that can alleviate the ordering errors.
The findings table was summarized through GRADEPro GDT
software which graded the quality of evidence hence creating

7. the Summary of Findings Table that offered any suitable
information such as estimates of relative risk, absolute risk for
control and treatment, as well as quality ranking for evidence
based on the limitations of a given publication. Therefore, this
would create different outcomes such as medication error on a
given etiology, medication error-related death, and medication
error-related harm.
There is significant diversity based on the type of profession
involved and where the research was conducted but majority of
the intervention (61%) was one by pharmacists or an
amalgamation of them and doctors. Therefore, this review was
developed as a way of discussing and evaluating the best way of
alleviating medication errors among the primary healthcare
practitioners for adult patients.
Appraisal
Describe the general worth of this research to practice. What are
the strengths and limitations of study? What are the risks
associated with implementation of the suggested practices or
processes detailed in the research? What is the feasibility of use
in your practice?
This research is crucial in validating how medication orders can
have errors hence it shades light on this medical issue which has
not had much attention over the years and this study can be used
in substantiating where the problem lies and as a result, enable
the relevant bodies come up with necessary intervention to
alleviate the risk for errors and in turn improve the safety of
patients.
It is important to understand the intricate nature regarding the
vulnerabilities of the management process of medication which
is an important issue in developing solutions which will
enhance the safety of patients. Therefore, one of the steps
deemed necessary in improving safety during medication across
ICUs will involve the adoption of electronic health record
technology which is equipped with a computerized physician
order entry.
Medication safety is important during the process of

8. prescribing, dispensing, and administration of medication.
Therefore, it is important to note that the process is complicated
based on the number of people involved hence being potential
for the occurrence of a given error. The research has
recommended more effective and recognized interventions
which can be applied in practice hence averting medical error
and enhances safety during medication.
The research asserted on the interventions within primary care
which would alleviate medication errors hence making a
difference to the number of patients hospitalized, died, or
visited the emergency room. However, it is important to note
that during assessment of different studies, there were reports of
bias with only 18 studies showing sufficient hiding of allocation
whereas 12 of them reported on sufficient protection from
contamination and all of them affected the general influence
approximated and the pooled estimate.
General Notes/Comments
Despite the study focusing on the new medical practitioners, it
has comprehensively evaluated the cases of medication error
and how this problem can be sorted out across health facilities.
This research has evaluated the extensive effect of medication
errors and how adopting computer and electronic technology
will be important in alleviating this issue.
This study has reiterated on the essence of having good
medication practices as art of upholding patient safety.
This research has deduced that it is important to ensure there is
no medication error more so for the primary healthcare facilities
because this issue can affect every medical profession.
Levels of Evidence Table
Use this document to complete the levels of evidence table
requirement of the Module 4 Assessment,Evidence-Based

9. Project, Part 4A: Critical Appraisal of Research
Author and year of selected article
Article #1
Article #2
Article #3
Article #4
Ashcroft, D., Lewis, P., Tully, M., Farragher, T., Taylor, D., &
Wass, V., Williams, S. D., & Dornan, T. (2015).
Carayon, P., Wetterneck, T., Cartmill, R., Blosky, M., Brown,
R., & Kim, R., Kukreja, S., Johnson, M., Paris, B., Wood, K. E.,
& Walker, J. (2014).
Hines, S., Kynoch, K., & Khalil, H. (2018).
Khalil, H., Chambers, H., Sheikh, A., Bell, B., & Avery, A.
(2017).
Study Design
Theoretical basis for the study
The study discusses that medical practitioners who are less
experienced have higher chances of making disproportionate
errors in their prescription.
The complexity of the medication management process is
reflected on the convolution of evaluating medication errors and
adverse drug events in ICUs.
This study evaluates the effectiveness of interventions
developed to avert medication error during administration of
medication, medication-related death, and medication-related
harms among acute care patients.
During primary care, there are adverse events associated with
medication and they represent a significant cause of hospital
admission and mortality and these events could be as a result of

10. patients going through adverse drug reactions or medication
errors and the latter is preventable.
Sample/Setting
The number and
characteristics of
patients
The pharmacists evaluated 26,019 patients and 124,260
medication orders and from the data collected, it was found that
10,986 had prescription errors hence making the mean error rate
to be at 8.8% for every 100 prescriptions.
The adult ICU entails a 24-bed capacity unit which concentrates
on trauma, critical care, and non-cardiac post-surgical care
hence making the average stay to be 7.1 days. Additionally, the
research also evaluated the cardiac ICU with capacity of 18
beds and it is specialized in various cardiac-related cares with
an average stay of 3.6 days.
The information on medication error was retrieved from
different databases such as the Cochrane Library, Embase,
Implementation Reports, MEDLINE, CINAHL, and the JBI
Database of Systematic Reviews Web of Science where the
researchers would look for theses, MedNar, and ProQuest
dissertations.
The study searched through CENTRAL, Embase, MEDLINE,
TWO REGISTRIES, and three other websites on 4 October 2016
as well as reference checking, contact with authors to determine
further researches, and citation searching. Therefore, used 30
studies which had 169,969 subjects in assessing the
interventions to avert medication errors.
Evidence Level *
(I, II, or III)
Level III
Level V
Level IV
Level II

11. Outcomes
This study is important in validating how medication orders can
have errors more so among the new health practitioners hence it
can be used to substantiate where the problem lies and as a
result, enable the professionals to develop the necessary
intervention to eliminate the risk for errors which will improve
the safety of patients.
The evidence provided in this study entailed review of every
ICU medication order through the steps of medication-
management process hence seeing the errors and ADEs
associated with the order. Moreover, it is clear that electronic
medical records improved the overall safety of the patients
under acute care by alleviating cases of wrong medication.
The strengths of this evidence is based on the effectiveness of
an intervention which is based an effective intervention, no
difference or effect compared to a control intervention, and a
damaging intervention or one which is not effective as the
control.
There is significant diversity based on the type of profession
involved and where the research was conducted hence pointing
out the issues existing within different professions when it
comes to medication error.
General Notes/Comments
This study is important in shading light regarding medication
errors but it is equally important to conduct more research
regarding the reduction of these high-risks errors which can
affect the safety of patients.
Medication safety is a complex aspect based on the findings of

12. this study but it is worth noting that they are preventable.
Moreover, it is important to note that medication errors are
prevalent during order and administration stages hence the need
to adopt EHR technology combined with CPOE as a way of
improving safety during medication.
The study has highlighted that medication error is one of the
main errors which can affect the safety of a patient hence the
need to develop approaches which can improve this safety.
Additionally, medication errors are mainly caused by human
factors thus the need to adopt technology to conduct the process
because it will offer more accuracy.
Based on the reviews conducted and analyzed, it is important to
have the necessary interventions in primary care so that medical
errors can be reduced hence reducing its detrimental effects.
Moreover, it would be important to address various
organizational and professional interventions prior to the
development of evidence-based recommendation.
* Evidence Levels:
· Level I
Experimental, randomized controlled trial (RCT), systematic
review RTCs with or without meta-analysis
· Level II
Quasi-experimental studies, systematic review of a combination
of RCTs and quasi-experimental studies, or quasi-experimental
studies only, with or without meta-analysis
· Level III
Nonexperimental, systematic review of RCTs, quasi-
experimental with/without meta-analysis, qualitative,
qualitative systematic review with/without meta-synthesis
· Level IV
Respected authorities’ opinions, nationally recognized expert
committee/consensus panel reports based on scientific evidence

13. · Level V
Literature reviews, quality improvement, program evaluation,
financial evaluation, case reports, nationally recognized
expert(s) opinion based on experiential evidence
Outcomes Synthesis Table
Use this document to complete the outcomes synthesis table
requirement of the Module 4 Assessment,Evidence-Based
Project, Part 4A: Critical Appraisal of Research
Author and year of selected article
Article #1
Article #2
Article #3
Article #4
Ashcroft, D., Lewis, P., Tully, M., Farragher, T., Taylor, D., &
Wass, V., Williams, S. D., & Dornan, T. (2015).
Carayon, P., Wetterneck, T., Cartmill, R., Blosky, M., Brown,
R., & Kim, R., Kukreja, S., Johnson, M., Paris, B., Wood, K. E.,
& Walker, J. (2014).
Hines, S., Kynoch, K., & Khalil, H. (2018).
Khalil, H., Chambers, H., Sheikh, A., Bell, B., & Avery, A.
(2017).
Sample/Setting
The number and
characteristics of
patients
The pharmacists evaluated 26,019 patients and 124,260
medication orders and from the data collected, it was found that
10,986 had prescription errors hence making the mean error rate

14. to be at 8.8% for every 100 prescriptions.
The adult ICU entails a 24-bed capacity unit which concentrates
on trauma, critical care, and non-cardiac post-surgical care
hence making the average stay to be 7.1 days. Additionally, the
research also evaluated the cardiac ICU with capacity of 18
beds and it is specialized in various cardiac-related cares with
an average stay of 3.6 days.
The information on medication error was retrieved from
different databases such as the Cochrane Library, Embase,
Implementation Reports, MEDLINE, CINAHL, and the JBI
Database of Systematic Reviews Web of Science where the
researchers would look for theses, MedNar, and ProQuest
dissertations.
The study searched through CENTRAL, Embase, MEDLINE,
TWO REGISTRIES, and three other websites on 4 October 2016
as well as reference checking, contact with authors to determine
further researches, and citation searching. Therefore, used 30
studies which had 169,969 subjects in assessing the
interventions to avert medication errors.
Outcomes
This study is important in validating how medication orders can
have errors more so among the new health practitioners hence it
can be used to substantiate where the problem lies and as a
result, enable the professionals to develop the necessary
intervention to eliminate the risk for errors which will improve
the safety of patients.
The evidence provided in this study entailed review of every
ICU medication order through the steps of medication-
management process hence seeing the errors and ADEs
associated with the order. Moreover, it is clear that electronic
medical records improved the overall safety of the patients
under acute care by alleviating cases of wrong medication.
The strengths of this evidence is based on the effectiveness of
an intervention which is based an effective intervention, no

15. difference or effect compared to a control intervention, and a
damaging intervention or one which is not effective as the
control.
There is significant diversity based on the type of profession
involved and where the research was conducted hence pointing
out the issues existing within different professions when it
comes to medication error.
Key Findings
Hospitals are faced with issues such as prescription error and
this problem is not only evident among the young medical
practitioners hence the need to develop an intervention which
would improve the safety of patients under the care of all grades
of medical professions.
This study found out that medication errors and ADEs among
the sampled patients upon their admission was across 1,733
different occurrences whereby 549 of them did not have
potential for patient harm and 1,184 were potential and
avoidable ADEs. The percentage for significant, serious, and
life threatening harm was 38%, 44%, and 18%. Therefore, based
on these occurrences, there are various technologies which have
been proposed to improve the safety of these patients such as
CPOE technology which is considered as a convenient
intervention that can alleviate the ordering errors.
The findings table was summarized through GRADEPro GDT
software which graded the quality of evidence hence creating
the Summary of Findings Table that offered any suitable
information such as estimates of relative risk, absolute risk for
control and treatment, as well as quality ranking for evidence
based on the limitations of a given publication. Therefore, this
would create different outcomes such as medication error on a
given etiology, medication error-related death, and medication
error-related harm.
There is significant diversity based on the type of profession
involved and where the research was conducted but majority of
the intervention (61%) was one by pharmacists or an

16. amalgamation of them and doctors. Therefore, this review was
developed as a way of discussing and evaluating the best way of
alleviating medication errors among the primary healthcare
practitioners for adult patients.
Appraisal and Study Quality
This research is crucial in validating how medication orders can
have errors hence it shades light on this medical issue which has
not had much attention over the years and this study can be used
in substantiating where the problem lies and as a result, enable
the relevant bodies come up with necessary intervention to
alleviate the risk for errors and in turn improve the safety of
patients. However, one limitation of this study which turns out
to be the bias of the research is that it has focused its case on
new doctors but most literature have asserted that medication
error is prone to any medical practitioner regardless of their
experience.
It is important to understand the intricate nature regarding the
vulnerabilities of the management process of medication which
is an important issue in developing solutions which will
enhance the safety of patients. Therefore, one of the steps
deemed necessary in improving safety during medication across
ICUs will involve the adoption of electronic health record
technology which is equipped with a computerized physician
order entry. However, it is important to note that this research
invested in significant amount of resources and time towards the
nurse data collectors as a prerequisite to ensuring they collected
data on medication errors.
Medication safety is important during the process of
prescribing, dispensing, and administration of medication.
Therefore, it is important to note that the process is complicated
based on the number of people involved hence being potential
for the occurrence of a given error. The research has
recommended more effective and recognized interventions
which can be applied in practice hence averting medical error
and enhances safety during medication.

17. The research asserted on the interventions within primary care
which would alleviate medication errors hence making a
difference to the number of patients hospitalized, died, or
visited the emergency room. However, it is important to note
that during assessment of different studies, there were reports of
bias with only 18 studies showing sufficient hiding of allocation
whereas 12 of them reported on sufficient protection from
contamination and all of them affected the general influence
approximated and the pooled estimate.
General Notes/Comments
This research has compared the prevalence of prescription error
which is common among the first year post-graduate medical
practitioners compared to other senior doctors thus deducing the
grave nature of this issue.
Technology is important in solving problems such as medication
errors which is common in healthcare facilities.
Based on the systematic review, there are various outcomes
which can be used to compute medication error.
There are various factors such as the organizational,
professional, and structural interventions which are used to find
comparison between standard cares hence being crucial in
alleviating preventable problems such as medication error.
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