Bertsche, Thilo; Niemann, Dorothee; Mayer, Yvonne; Ingram, Katrin; Hoppe-Tichy, Torsten; Haefeli, Walter E
Medication errors are frequent in a hospital setting and often caused by inappropriate drug handling. Systematic strategies for their prevention however are still lacking. We developed and applied a classification model to categorise medication handling errors and defined the urgency of correction on the basis of these findings. Nurses on medical wards (including intensive and intermediate care units) of a 1,680-bed teaching hospital. In a prospective observational study we evaluated the prevalence of 20 predefined medication handling errors on the ward. In a concurrent questionnaire survey, we assessed the knowledge of the nurses on medication handling. The severity of errors observed in individual areas was scored considering prevalence, potential risk of an error, and the involved drug. These scores and the prevalence of corresponding knowledge deficits were used to define the urgency of preventive strategies according to a four-field decision matrix. Prevalence and potential risk of medication handling errors, corresponding knowledge deficits in nurses committing the errors, and priority of quality improvement. In 1,376 observed processes 833 medication handling errors were detected. Errors concerning preparation (mean 0.88 errors per observed process [95% CI: 0.81-0.96], N = 645) were more frequent than administration errors (0.36 [0.32-0.41], N = 701, P drugs (1.10 [1.00-1.19], N = 492) were more often involved in errors than enteral drugs (0.32 [0.28-0.36], N = 794, P drugs, 81.6% by uncomplicated drugs, and 6.9% by nutritional supplements or diluents without active ingredient. According to the decision matrix that also considered knowledge deficits two error types concerning enteral drugs (flaws in light protection and prescribing information) were given maximum priority for quality improvement. For parenteral drugs five errors (incompatibilities, flaws in hygiene, duration of administration, check for visible abnormalities, and again prescribing
Luana de Rezende Spalla
Full Text Available ABSTRACT One of the current barriers proposed to avoid possible medication errors, and consequently harm to patients, is the medication reconciliation, a process in which drugs used by patients prior to hospitalization can be compared with those prescribed in the hospital. This study describes the results of a pharmacist based reconciliation conducted during six months in clinical units of a university hospital. Fourteen patients (23.33% had some kind of problem related to medicine. The majority (80% of medication errors were due to medication omission. Pharmaceutical interventions acceptance level was 90%. The results suggest that pharmacists based reconciliation can have a relevant role in preventing medication errors and adverse events. Moreover, the detailed interview, conducted by the pharmacist, is able to rescue important information regarding the use of drugs, allowing to avoid medications errors and patient injury.
Hastuti, Apriyani Puji; Nursalam, Nursalam; Triharini, Mira
Introductions: Medication error is one of many types of errors that could decrease the quality and safety of healthcare. Increasing number of adverse events (AE) reflects the number of medication errors. This study aimed to develop a model of medication error prevention based on knowledge management. This model is expected to improve knowledge and skill of nurses to prevent medication error which is characterized by the decrease of adverse events (AE). Methods: This study consisted of two sta...
Latimer, Sharon; Hewitt, Jayne; Stanbrough, Rebecca; McAndrew, Ron
Medication errors are a patient safety and quality of care issue. There is evidence to suggest many undergraduate nursing curricula do not adequately educate students about the factors that contribute to medication errors and possible strategies to prevent them. We designed and developed a suite of teaching strategies that raise students' awareness of medication error producing situations and their prevention. Copyright © 2017 Elsevier Ltd. All rights reserved.
Merry, Alan F; Anderson, Brian J
Medication errors in pediatric anesthesia represent an important risk to children. Concerted action to reduce harm from this cause is overdue. An understanding of the genesis of avoidable adverse drug events may facilitate the development of effective countermeasures to the events or their effects. Errors include those involving the automatic system of cognition and those involving the reflective system. Errors and violations are distinct, but violations often predispose to error. The system of medication administration is complex, and many aspects of it are conducive to error. Evidence-based practices to reduce the risk of medication error in general include those encompassed by the following recommendations: systematic countermeasures should be used to decrease the number of drug administration errors in anesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimized according to agreed standards; syringes should always be labeled; formal organization of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered. Dosage errors are particularly common in pediatric patients. Causes that should be addressed include a lack of pediatric formulations and/or presentations of medication that necessitates dilution before administration or the use of intravenous formulations for oral administration in children, a frequent failure to obtain accurate weights for patients and a paucity of pharmacokinetic and pharmacodynamic data. Technological innovations, including the use of bar codes and various cognitive aids, may facilitate compliance with these recommendations. Improved medication safety requires a system-wide strategy standardized at least to the level of the institution; it is the responsibility of institutional leadership to introduce such strategies
... for You Agency for Healthcare Research and Quality: Medical Errors and Patient Safety Centers for Disease Control and ... Quality Chasm Series National Coordinating Council for Medication Error Reporting and Prevention ... Devices Radiation-Emitting Products Vaccines, Blood & Biologics Animal & ...
Bencheikh, Rachida Soulaymani; Benabdallah, Ghita
Detecting medication errors needs collaboration between various organizations, such as patient safety institutions, pharmacovigilance centres, and poison control centres. In order to evaluate the input of pharmacovigilance centres and poison control centres in detecting and evaluating medication errors a pilot project was initiated by the World Alliance for Patient Safety in collaboration with the Uppsala Monitoring Centre; the Moroccan pharmacovigilance centre acted as project coordinator. As part of this project, a questionnaire on detecting medication errors was circulated to pharmacovigilance centres and poison control centres around the world, in order to assess their ability to detect and analyse medication errors. The results showed that through their databases pharmacovigilance centres can detect, identify, analyse, and classify medication errors and carry out root cause analysis, which is an important tool in preventing medication errors. The duties of pharmacovigilance centres in preventing medication errors include informing health-care professionals about the importance of reporting such errors and creating a culture of patient safety. Pharmacovigilance centres aim to prevent medication errors in collaboration with poison control centres. Such collaboration allows improved detection and improved preventive strategies. In addition, collaboration with regulatory authorities is important in finalizing decisions. Collaboration between pharmacovigilance centres and poison control centres should be strengthened and bridges need to be built linking pharmacovigilance centres, poison control centres, and organizations dedicated to patient safety, in order to avoid duplication of workload. PMID:19594539
Martin, Caren McHenry; Bryan, Gianna
Proper medication administration in the long-term care facility is vitally important, as many medications have specific administration parameters that are essential to their optimal efficacy. Pharmacists servicing long-term care facilities play an integral role in observing medication administration in the facility and educating facility staff on proper administration techniques. By being vigilant to potential problems, pharmacists can help ensure that facility residents receive their medications appropriately.
Goedecke, Thomas; Ord, Kathryn; Newbould, Victoria; Brosch, Sabine; Arlett, Peter
A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Reducing the risk of medication errors is a shared responsibility between patients, healthcare professionals, regulators and the pharmaceutical industry at all levels of healthcare delivery. In 2015, the EU regulatory network released a two-part good practice guide on medication errors to support both the pharmaceutical industry and regulators in the implementation of the changes introduced with the EU pharmacovigilance legislation. These changes included a modification of the 'adverse reaction' definition to include events associated with medication errors, and the requirement for national competent authorities responsible for pharmacovigilance in EU Member States to collaborate and exchange information on medication errors resulting in harm with national patient safety organisations. To facilitate reporting and learning from medication errors, a clear distinction has been made in the guidance between medication errors resulting in adverse reactions, medication errors without harm, intercepted medication errors and potential errors. This distinction is supported by an enhanced MedDRA(®) terminology that allows for coding all stages of the medication use process where the error occurred in addition to any clinical consequences. To better understand the causes and contributing factors, individual case safety reports involving an error should be followed-up with the primary reporter to gather information relevant for the conduct of root cause analysis where this may be appropriate. Such reports should also be summarised in periodic safety update reports and addressed in risk management plans. Any risk minimisation and prevention strategy for medication errors should consider all stages of a medicinal product's life-cycle, particularly the main sources and types of medication errors during product development. This article
Vinay BC; Nikhitha MK; Patel Sunil B
In this present review article, regarding medication errors its definition, medication error problem, types of medication errors, common causes of medication errors, monitoring medication errors, consequences of medication errors, prevention of medication error and managing medication errors have been explained neatly and legibly with proper tables which is easy to understand.
is only when mistakes are recognised that learning can occur...All our previous medical training has taught us to fear error, as error is associated with blame. This fear may lead to concealment and this is turn can lead to fraud'. How real this fear is! All of us, during our medical training, have had the maxim 'prevention is.
Neurosurgery represents a zero tolerance environment for medical errors, especially preventable ones like all types of wrong site surgery, complications due to the incorrect positioning of patients for neurosurgical interventions and complications due to failure of the devices required for the specific procedure. Following the excellent and encouraging results of the safety checklists in intensive care medicine and in other surgical areas, the checklist was naturally introduced in neurosurgery. To date, the reported world experience with neurosurgical checklists is limited to 15 series with fewer than 20,000 cases in various neurosurgical areas. The purpose of this review was to study the reported neurosurgical checklists according to the following parameters: year of publication; country of origin; area of neurosurgery; type of neurosurgical procedure-elective or emergency; person in charge of the checklist completion; participants involved in completion; whether they prevented incorrect site surgery; whether they prevented complications due to incorrect positioning of the patients for neurosurgical interventions; whether they prevented complications due to failure of the devices required for the specific procedure; their specific aims; educational preparation and training; the time needed for checklist completion; study duration and phases; number of cases included; barriers to implementation; efforts to implementation; team appreciation; and safety outcomes. Based on this analysis, it could be concluded that neurosurgical checklists represent an efficient, reliable, cost-effective and time-saving tool for increasing patient safety and elevating the neurosurgeons’ self-confidence. Every neurosurgical department must develop its own neurosurgical checklist or adopt and modify an existing one according to its specific features and needs in an attempt to establish or develop its safety culture. The world, continental, regional and national neurosurgical societies
Fortescue, Elizabeth B; Kaushal, Rainu; Landrigan, Christopher P; McKenna, Kathryn J; Clapp, Margaret D; Federico, Frank; Goldmann, Donald A; Bates, David W
Medication errors in pediatric inpatients occur at similar rates as in adults but have 3 times the potential to cause harm. Error prevention strategies in this setting remain largely untested. The objective of this study was to classify the major types of medication errors in pediatric inpatients and to determine which strategies might most effectively prevent them. A prospective cohort study was conducted of 1020 patients who were admitted to 2 academic medical centers during a 6-week period in April and May 1999. Medication errors were characterized by subtype. Physician raters evaluated error prevention strategies and identified those that might be most effective in preventing errors. Of 10 778 medication orders reviewed, 616 contained errors. Of these, 120 (19.5%) were classified as potentially harmful, including 115 potential adverse drug events (18.7%) and 5 preventable adverse drug events (0.8%). Most errors occurred at the ordering stage (74%) and involved errors in dosing (28%), route (18%), or frequency (9%). Three interventions might have prevented most potentially harmful errors: 1) computerized physician order entry with clinical decision support systems (76%); 2) ward-based clinical pharmacists (81%); and 3) improved communication among physicians, nurses, and pharmacists (86%). Interrater reliability of error prevention strategy assignment was good (agreement: 0.92; kappa: 0.82). Of the assessed interventions, computerized physician order entry with clinical decision support systems; ward-based clinical pharmacists; and improved communication among physicians, nurses, and pharmacists had the greatest potential to reduce medication errors in pediatric inpatients. Development, implementation, and assessment of such interventions in the pediatric inpatient setting are needed.
Härkänen, Marja; Saano, Susanna; Vehviläinen-Julkunen, Katri
To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports. Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed. This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health
Vaida, Allen J
This article provides an overview on the Institute for Safe Medication Practices (ISMP), the only independent nonprofit organization in the USA devoted to the prevention of medication errors. ISMP developed the national Medication Errors Reporting Program (MERP) and investigates and analyzes errors in order to formulate recommendations to prevent further occurrences. ISMP works closely with the US Food and Drug Administration (FDA), drug manufacturers, professional organizations, and others to promote changes in package design, practice standards, and healthcare practitioner and consumer education. By collaborating with ISMP to share and disseminate information, Poison Control centers, emergency departments, and toxicologists can help decrease unintentional and accidental poisonings.
Morales-González, María Fernanda; Galiano Gálvez, María Alejandra
Our institution implemented the use of pre-designed labeling of intravenous drugs and fluids, administration routes and infusion pumps of to prevent medication errors. To evaluate the effectiveness of predesigned labeling in reducing medication errors in the preparation and administration stages of prescribed medication in patients hospitalized with invasive lines, and to characterize medication errors. This is a pre/post intervention study. Pre-intervention group: invasively administered dose from July 1st to December 31st, 2014, using traditional labeling (adhesive paper handwritten note). Post-intervention group: dose administered from January 1st to June 30th, 2015, using predesigned labeling (labeling with preset data-adhesive labels, color- grouped by drugs, labels with colors for invasive lines). Outcome: medication errors in hospitalized patients, as measured with notification form and record electronics. Tabulation/analysis Stata-10, with descriptive statistics, hypotheses testing, estimating risk with 95% confidence. In the pre-intervention group, 5,819 doses of drugs were administered invasively in 634 patients. Error rate of 1.4 x 1,000 administrations. The post-intervention group of 1088 doses comprised 8,585 patients with similar routes of administration. The error rate was 0.3 x 1,000 (p = 0.034). Patients receiving medication through an invasive route who did not use predesigned labeling had 4.6 times more risk of medication error than those who had used predesigned labels (95% CI: 1.25 to 25.4). The adult critically ill patient unit had the highest proportion of medication errors. The most frequent error was wrong dose administration. 41.2% produced harm to the patient. The use of predesigned labeling in invasive lines reduces errors in medication in the last two phases: preparation and administration.
Landau, Elliot; Hirschorn, David; Koutras, Iakovos; Malek, Alexander; Demissie, Seleshie
An error in laterality is the reporting of a finding that is present on the right side as on the left or vice versa. While different medical and surgical specialties have implemented protocols to help prevent such errors, very few studies have been published that describe these errors in radiology reports and ways to prevent them. We devised a system that allows the radiologist to view reports in a separate window, displayed in a simple font and with all terms of laterality highlighted in sep...
Cassatly, Michael G; Mitsch, Darelyn
The number and cost of preventable medical injuries and deaths continue to rise in the U.S. healthcare system despite many attempts to avert such occurrences. The Centers for Medicare & Medicaid Services has prudently decided to deny claims for the healthcare costs incurred in treating certain preventable injuries. With the passage of a the Patient Protection and Affordable Care Act, the list of denied healthcare procedures to correct preventable medical injuries will grow, resulting in a further squeezing of the profit margins of medical institutions and providers. In this article, we show that business coaching of the healthcare team is successful in reversing the alarming growth rate of medical errors, thus ensuring the financial success of healthcare institutions adopting business coaching practices.
Wang, Jerome K; Herzog, Nicole S; Kaushal, Rainu; Park, Christine; Mochizuki, Carol; Weingarten, Scott R
The purpose of this work was to characterize medication errors and adverse drug events intercepted by a system of pediatric clinical pharmacists and to determine whether the addition of a computerized physician order entry system would improve medication safety. The study included 16,938 medication orders for 678 admissions to the pediatric units of a large academic community hospital. Pediatric clinical pharmacists reviewed medication orders and monitored subsequent medication use. Medication errors and adverse drug events were identified by daily review of documentation, voluntary reporting, and solicitation. Each potentially harmful medication error was judged whether or not it was intercepted and, if not, whether it would have been captured by a computerized physician order entry system. Overall, 865 medication errors occurred, corresponding with a rate of 5.2 per 100 medication orders. A near-miss rate of 0.96% and a preventable adverse drug event rate of 0.09% were observed. Overall, 78% of potentially harmful prescribing errors were intercepted; however, none of the potentially harmful errors occurring at administration was intercepted and accounted for 50% of preventable adverse drug events. A computerized physician order entry system could capture additional potentially harmful prescribing and transcription errors (54%-73%) but not administration errors (0% vs 6%). A system of pediatric clinical pharmacists effectively intercepted inpatient prescribing errors but did not capture potentially harmful medication administration errors. The addition of a computerized physician order entry system to pharmacists is unlikely to prevent administration errors, which pose the highest risk of patient injury.
Huynh, Chi; Wong, Ian C K; Correa-West, Jo; Terry, David; McCarthy, Suzanne
Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.
White, Andrew A; Gallagher, Thomas H
Errors occur commonly in healthcare and can cause significant harm to patients. Most errors arise from a combination of individual, system, and communication failures. Neurologists may be involved in harmful errors in any practice setting and should familiarize themselves with tools to prevent, report, and examine errors. Although physicians, patients, and ethicists endorse candid disclosure of harmful medical errors to patients, many physicians express uncertainty about how to approach these conversations. A growing body of research indicates physicians often fail to meet patient expectations for timely and open disclosure. Patients desire information about the error, an apology, and a plan for preventing recurrence of the error. To meet these expectations, physicians should participate in event investigations and plan thoroughly for each disclosure conversation, preferably with a disclosure coach. Physicians should also anticipate and attend to the ongoing medical and emotional needs of the patient. A cultural change towards greater transparency following medical errors is in motion. Substantial progress is still required, but neurologists can further this movement by promoting policies and environments conducive to open reporting, respectful disclosure to patients, and support for the healthcare workers involved. © 2013 Elsevier B.V. All rights reserved.
Niemann, Dorothee; Bertsche, Astrid; Meyrath, David; Koepf, Ellen D; Traiser, Carolin; Seebald, Katja; Schmitt, Claus P; Hoffmann, Georg F; Haefeli, Walter E; Bertsche, Thilo
To prevent medication errors in drug handling in a paediatric ward. One in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce. A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling. After approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors. The number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct 'volume of solvent for IV drugs' from 49-25%. Paediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes. Worldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings. © 2014 John Wiley & Sons Ltd.
Snyder, Rita A; Abarca, Jacob; Meza, Jane L; Rothschild, Jeffrey M; Rizos, Albert; Bates, David W
Adapted National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index criteria were used in a study undertaken to evaluate commercial computerized provider order entry (CPOE) system impact on community hospital medication errors. This article describes: (1) adaptation of the Index, (2) classification criteria and processes used to assess the adapted Index, and (3) inter-rater reliability results. A random sample of 130 (17%) of 2251 medication safety events (MSEs) were classified based on event type, that is, adverse drug event (ADE) or potential ADE (PADE); preventability, that is, 'yes' or 'no,' and outcome severity. Event outcome severity was categorized using adapted Index categories E-I (ADEs) and B-D (PADEs). Decision rules were used for rule-based classification, while an MSE Case Review Panel used judgment-based classification when decision rules did not apply. Inter-rater reliability for both classification approaches was assessed with kappa coefficients, percentage agreement, and confidence intervals (CI). Level of agreement was substantial for both rule-based and judgment-based MSE classification for event type (6 = 0.70-0.90), preventability (6 = 0.67-0.82), and decision rule application (6 = 0.79). Rule-based agreement for ADE and PADE severity was almost perfect for discrete (6 = 0.83-0.84) and combined (6 = 0.87-0.90) Index categories. Judgment-based agreement was substantial for discrete (6 = 0.63-0.67) and combined (6 = 0.66-0.84) Index categories. The adapted Index yielded substantial agreement for event type, preventability, and severity. Adaptation of the Index to support classification of non-preventable ADEs was an important improvement. Copyright (c) 2007 John Wiley & Sons, Ltd.
Aline Melo Santos Silva
Full Text Available Objective: To identify and quantify the most frequent prescription errors in inpatients’ medical prescriptions. Methods: A survey of prescription errors was performed in the inpatients’ medical prescriptions, from July 2008 to May 2009 for eight hours a day. Rresults: At total of 3,931 prescriptions was analyzed and 362 (9.2% prescription errors were found, which involved the healthcare team as a whole. Among the 16 types of errors detected in prescription, the most frequent occurrences were lack of information, such as dose (66 cases, 18.2% and administration route (26 cases, 7.2%; 45 cases (12.4% of wrong transcriptions to the information system; 30 cases (8.3% of duplicate drugs; doses higher than recommended (24 events, 6.6% and 29 cases (8.0% of prescriptions with indication but not specifying allergy. Cconclusion: Medication errors are a reality at hospitals. All healthcare professionals are responsible for the identification and prevention of these errors, each one in his/her own area. The pharmacist is an essential professional in the drug therapy process. All hospital organizations need a pharmacist team responsible for medical prescription analyses before preparation, dispensation and administration of drugs to inpatients. This study showed that the pharmacist improves the inpatient’s safety and success of prescribed therapy.
Sarfati, Laura; Ranchon, Florence; Vantard, Nicolas; Schwiertz, Vérane; Larbre, Virginie; Parat, Stéphanie; Faudel, Amélie; Rioufol, Catherine
In the past 2 decades, there has been an increasing interest in simulation-based learning programs to prevent medication error (ME). To improve knowledge, skills, and attitudes in prescribers, nurses, and pharmaceutical staff, these methods enable training without directly involving patients. However, best practices for simulation for healthcare providers are as yet undefined. By analysing the current state of experience in the field, the present review aims to assess whether human simulation in healthcare helps to reduce ME. A systematic review was conducted on Medline from 2000 to June 2015, associating the terms "Patient Simulation," "Medication Errors," and "Simulation Healthcare." Reports of technology-based simulation were excluded, to focus exclusively on human simulation in nontechnical skills learning. Twenty-one studies assessing simulation-based learning programs were selected, focusing on pharmacy, medicine or nursing students, or concerning programs aimed at reducing administration or preparation errors, managing crises, or learning communication skills for healthcare professionals. The studies varied in design, methodology, and assessment criteria. Few demonstrated that simulation was more effective than didactic learning in reducing ME. This review highlights a lack of long-term assessment and real-life extrapolation, with limited scenarios and participant samples. These various experiences, however, help in identifying the key elements required for an effective human simulation-based learning program for ME prevention: ie, scenario design, debriefing, and perception assessment. The performance of these programs depends on their ability to reflect reality and on professional guidance. Properly regulated simulation is a good way to train staff in events that happen only exceptionally, as well as in standard daily activities. By integrating human factors, simulation seems to be effective in preventing iatrogenic risk related to ME, if the program is
Background. Patients can make contributions to the safety of chemotherapy administration but little is known about their motivations to participate in safety-enhancing strategies. The theory of planned behavior was applied to analyze attitudes, norms, behavioral control, and chemotherapy patients' intentions to participate in medical error prevention. Methods. A quantitative, cross-sectional survey study among chemotherapy patients treated at the oncology/hematology department of a large regional hospital was conducted. Confirmatory factor analysis and structural equation modeling were used to investigate the relationship between patients' responses to measures of attitudes, norms, and behavioral control and their intentions. Results. Four hundred seventy-nine patients completed the survey (52% response rate). Attitudes, perceived behavioral control, and subjective norms explained 62% of the variance in intentions to engage in error monitoring and reporting. Perceived behavioral control (β = 0.476), norms relating to patients' relatives (β = 0.343), and instrumental attitudes (β = 0.281) were the strongest (direct) predictors of patients' intentions. Experiential attitudes had the smallest effect on intentions (β = 0.178). Subjective norms relating to expectations attributed to oncology staff had strong direct and indirect effects on patients' intentions (total effect, 0.382). Conclusions. Patients acknowledge the benefit of error monitoring and reporting and anticipate positive outcomes of involvement, but their valuations of the process of engaging in error prevention are less positive. Behavioral control and perceptions of staff approval are central for patients. Involvement of cancer patients in safety requires oncologists to address their patients' normative and control beliefs through education and proactive approval of patient engagement. PMID:20682607
Otero, Paula; Leyton, Andrea; Mariani, Gonzalo; Ceriani Cernadas, José María
The objective of this study was to assess the prevalence and characteristics of medication errors in pediatric and neonatal inpatients and to measure the impact of interventions to reduce medication errors. A preintervention and postintervention cross-sectional study was conducted of a sample of prescriptions that were ordered by physicians and medications that were administered by nurses to patients at the NICU, PICU, and general pediatric settings at the Hospital Italiano de Buenos Aires Department of Pediatrics in 2002 and 2004. Number and type of errors, time shift on which they occurred, and whether they had any kind of adverse event on the patient were recorded. Medication errors were stratified according to physicians' and nurses' status. Several interventions, including incorporating a positive safety culture without a punitive management of errors and specific prescribing and drug-administration recommendations were implemented between the 2 phases of the study. A total of 590 prescriptions and 1174 drug administrations for 95 patients in the first phase of the study and 1144 prescriptions with 1588 drug administrations for 92 patients in the second phase were evaluated. The prevalence of medication error rate in the second phase was 7.3% (199 of 2732) and 11.4% (201 of 1764) in the first phase. The risk difference was -4.1%. The development of a program mainly centered on the promotion of a cultural change in the approach to medical errors can effectively diminish medication errors in neonates and children.
Yousef, Nadin; Yousef, Farah
Whereas one of the predominant causes of medication errors is a drug administration error, a previous study related to our investigations and reviews estimated that the incidences of medication errors constituted 6.7 out of 100 administrated medication doses. Therefore, we aimed by using six sigma approach to propose a way that reduces these errors to become less than 1 out of 100 administrated medication doses by improving healthcare professional education and clearer handwritten prescriptions. The study was held in a General Government Hospital. First, we systematically studied the current medication use process. Second, we used six sigma approach by utilizing the five-step DMAIC process (Define, Measure, Analyze, Implement, Control) to find out the real reasons behind such errors. This was to figure out a useful solution to avoid medication error incidences in daily healthcare professional practice. Data sheet was used in Data tool and Pareto diagrams were used in Analyzing tool. In our investigation, we reached out the real cause behind administrated medication errors. As Pareto diagrams used in our study showed that the fault percentage in administrated phase was 24.8%, while the percentage of errors related to prescribing phase was 42.8%, 1.7 folds. This means that the mistakes in prescribing phase, especially because of the poor handwritten prescriptions whose percentage in this phase was 17.6%, are responsible for the consequent) mistakes in this treatment process later on. Therefore, we proposed in this study an effective low cost strategy based on the behavior of healthcare workers as Guideline Recommendations to be followed by the physicians. This method can be a prior caution to decrease errors in prescribing phase which may lead to decrease the administrated medication error incidences to less than 1%. This improvement way of behavior can be efficient to improve hand written prescriptions and decrease the consequent errors related to administrated
Mutter, Michael L
The Valley Hospital of Ridgewood, New Jersey, is proposing to extend a limited but highly successful specimen management and medication administration medical errors reduction initiative on a hospital-wide basis...
Miyo, Kengo; Nittami, Yuki S; Kitagawa, Yoichiro; Ohe, Kazuhiko
The purpose of this study was to develop a new alerting and recommender system for preventing medication errors. In recent years, alerting systems have been widely implemented, but because these systems apply a same static threshold for all patients in all cases, they produce excessive alerts and subject physicians to "alert fatigue". We believe that the most commonly-written prescription for a patient's status is the safest one. From this standpoint, we developed a real-time case-based medication alerting and recommender system linked to a database of past prescriptions. When a physician issues his or her prescription, our system dynamically compares it with past ones for similar patients in the database. An analysis of the 10 most frequently-used drugs in the University of Tokyo Hospital revealed that our system reduced the number of false alerts compared to the traditional static alert method. Our system contributes to the creation of alerts that are appropriate for patients' clinical conditions and based on physicians' empirical discretion.
Rorat, Marta; Jurek, Tomasz
Health, safety and medical errors are currently the subject of worldwide discussion. The authors analysed medico-legal opinions trying to determine types of medical errors and their impact on the course of sepsis. The authors carried out a retrospective analysis of 66 medico-legal opinions issued by the Wroclaw Department of Forensic Medicine between 2004 and 2013 (at the request of the prosecutor or court) in cases examined for medical errors. Medical errors were confirmed in 55 of the 66 medico-legal opinions. The age of victims varied from 2 weeks to 68 years; 49 patients died. The analysis revealed medical errors committed by 113 health-care workers: 98 physicians, 8 nurses and 8 emergency medical dispatchers. In 33 cases, an error was made before hospitalisation. Hospital errors occurred in 35 victims. Diagnostic errors were discovered in 50 patients, including 46 cases of sepsis being incorrectly recognised and insufficient diagnoses in 37 cases. Therapeutic errors occurred in 37 victims, organisational errors in 9 and technical errors in 2. In addition to sepsis, 8 patients also had a severe concomitant disease and 8 had a chronic disease. In 45 cases, the authors observed glaring errors, which could incur criminal liability. There is an urgent need to introduce a system for reporting and analysing medical errors in Poland. The development and popularisation of standards for identifying and treating sepsis across basic medical professions is essential to improve patient safety and survival rates. Procedures should be introduced to prevent health-care workers from administering incorrect treatment in cases. © The Author(s) 2015.
Matlow, Anne; Stevens, Polly; Harrison, Christine; Laxer, Ronald M
The 1999 release of the Institute of Medicine's document To Err is Human was akin to removing the lid of Pandora's box. Not only were the magnitude and impact of medical errors now apparent to those working in the health care industry, but consumers or health care were alerted to the occurrence of medical events causing harm. One specific solution advocated was the disclosure to patients and their families of adverse events resulting from medical error. Knowledge of the historical perspective, ethical underpinnings, and medico-legal implications gives us a better appreciation of current recommendations for disclosing adverse events resulting from medical error to those affected.
Langer, Thorsten; Martinez, William; Browning, David M; Varrin, Pamela; Sarnoff Lee, Barbara; Bell, Sigall K
Despite growing interest in engaging patients and families (P/F) in patient safety education, little is known about how P/F can best contribute. We assessed the feasibility and acceptability of a patient-teacher medical error disclosure and prevention training model. We developed an educational intervention bringing together interprofessional clinicians with P/F from hospital advisory councils to discuss error disclosure and prevention. Patient focus groups and orientation sessions informed curriculum and assessment design. A pre-post survey with qualitative and quantitative questions was used to assess P/F and clinician experiences and attitudes about collaborative safety education including participant hopes, fears, perceived value of learning experience and challenges. Responses to open-ended questions were coded according to principles of content analysis. P/F and clinicians hoped to learn about each other's perspectives, communication skills and patient empowerment strategies. Before the intervention, both groups worried about power dynamics dampening effective interaction. Clinicians worried that P/F would learn about their fallibility, while P/F were concerned about clinicians' jargon and defensive posturing. Following workshops, clinicians valued patients' direct feedback, communication strategies for error disclosure and a 'real' learning experience. P/F appreciated clinicians' accountability, and insights into how medical errors affect clinicians. Half of participants found nothing challenging, the remainder clinicians cited emotions and enormity of 'culture change', while P/F commented on medical jargon and desire for more time. Patients and clinicians found the experience valuable. Recommendations about how to develop a patient-teacher programme in patient safety are provided. An educational paradigm that includes patients as teachers and collaborative learners with clinicians in patient safety is feasible, valued by clinicians and P/F and promising for
Gouyon, J-B; Cransac, A; Sgro, C
Neonatal units have the highest incidence of medication errors (approximately 5%) compared to adult and pediatric wards. Medication errors include prescribing errors, transcription errors, dispensing errors, medication administration errors, and monitoring. Dosing error is the most common prescribing error. Prevention of medication error must be global. The implementation of a computerized physician order entry significantly reduces prescribing errors but other preventive measures remain necessary. Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Chen, Chia-Chi; Hsiao, Fei-Yuan; Shen, Li-Jiuan; Wu, Chien-Chih
Medication errors may lead to adverse drug events (ADEs), which endangers patient safety and increases healthcare-related costs. The on-ward deployment of clinical pharmacists has been shown to reduce preventable ADEs, and save costs. The purpose of this study was to evaluate the ADEs prevention and cost-saving effects by clinical pharmacist deployment in a nephrology ward.This was a retrospective study, which compared the number of pharmacist interventions 1 year before and after a clinical pharmacist was deployed in a nephrology ward. The clinical pharmacist attended ward rounds, reviewed and revised all medication orders, and gave active recommendations of medication use. For intervention analysis, the numbers and types of the pharmacist's interventions in medication orders and the active recommendations were compared. For cost analysis, both estimated cost saving and avoidance were calculated and compared.The total numbers of pharmacist interventions in medication orders were 824 in 2012 (preintervention), and 1977 in 2013 (postintervention). The numbers of active recommendation were 40 in 2012, and 253 in 2013. The estimated cost savings in 2012 and 2013 were NT$52,072 and NT$144,138, respectively. The estimated cost avoidances of preventable ADEs in 2012 and 2013 were NT$3,383,700 and NT$7,342,200, respectively. The benefit/cost ratio increased from 4.29 to 9.36, and average admission days decreased by 2 days after the on-ward deployment of a clinical pharmacist.The number of pharmacist's interventions increased dramatically after her on-ward deployment. This service could reduce medication errors, preventable ADEs, and costs of both medications and potential ADEs.
Rishoej, Rikke Mie; Almarsdóttir, Anna Birna; Christesen, Henrik Thybo
The aim was to describe medication errors (MEs) in hospitalized children reported to the national mandatory reporting and learning system, the Danish Patient Safety Database (DPSD). MEs were extracted from DPSD from the 5-year period of 2010–2014. We included reports from public hospitals...... on patients aged 0–17 years and categorized by reporters as medication-related. Reports from psychiatric wards and outpatient clinics were excluded. A ME was defined as any medication-related error occurring in the medication process whether harmful or not. MEs were categorized as harmful if they resulted...... in actual harm or interventions to prevent harm. MEs were further categorized according to occurrence in the medication process, type of error, and the medicines involved. A total of 2071 MEs including 487 harmful MEs were identified. Most MEs occurred during prescribing (40.8%), followed by dispensing (38...
Roh, HyeRin; Lee, Kuhn Uk; Lee, Yoon Seong; Kim, Ock Joo; Kim, Sun Whe; Choi, Jae Woon
The aims of this study were to define the necessity and effectiveness of patient safety education during surgical clerkship to develop competency for managing and preventing medical errors. Fifty 3rd-year students participated in the patient safety education program during a 4-week surgical clerkship. The students were divided into 4 groups: control group, pretest-only group, education-only group, and pretest and education group. Students were assessed using short essays and an oral exam for reasoning skills, clinical performance exams for patient education and communication skills, and multisource feedback and direct observation of error reporting for real-world problem-solving skills. The results were analyzed with SPSS 14.0K. The reliability (Cronbach alpha) of the entire assessment was 0.893. There was no difference in scores between early and late clerkship groups. Reasoning skills were improved by the pretest. Reasoning, patient education, and error reporting skills were much more developed by patient safety education. Real-world error identification, reporting, and communication did not change after the 4-week course. Patient safety education during surgical clerkship is necessary and effective. Error prevention and competency management in the real world should developed.
This paper addresses the concept of moral luck. Moral luck is discussed in the context of medical error, especially an error of omission that occurs frequently, but only rarely has adverse consequences. As an example, a failure to compare the label on a syringe with the drug chart results in the wrong medication being administered and the patient dies. However, this error may have previously occurred many times with no tragic consequences. Discussions on moral luck can highlight conflicting intuitions. Should perpetrators receive a harsher punishment because of an adverse outcome, or should they be dealt with in the same way as colleagues who have acted similarly, but with no adverse effects? An additional element to the discussion, specifically with medical errors, is that according to the evidence currently available, punishing individual practitioners does not seem to be effective in preventing future errors. The following discussion, using relevant philosophical and empirical evidence, posits a possible solution for the moral luck conundrum in the context of medical error: namely, making a distinction between the duty to make amends and assigning blame. Blame should be assigned on the basis of actual behavior, while the duty to make amends is dependent on the outcome.
Full Text Available Abstract Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to ‘treat' drug errors is to prevent them. Wrong medication (due to syringe swap, overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error, incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and ‘just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.
María Fernanda Morales-González; María Alejandra Galiano Gálvez
Resumen INTRODUCCIÓN La seguridad en la administración de medicamentos requiere sistemas de prevención de errores. Para prevenirlos, se implementó como estrategia el uso de un etiquetado prediseñado de medicamentos y fluidos intravenosos de las vías de administración y bombas de infusión. OBJETIVO Evaluar la efectividad del etiquetado prediseñado en la disminución de errores de medicación en las fases de preparación y administración, en pacientes hospitalizados con vías invasivas...
This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3-16% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems. Copyright © 2013 S. Karger AG, Basel.
Velo, Giampaolo P; Minuz, Pietro
1. Medication errors are common in general practice and in hospitals. Both errors in the act of writing (prescription errors) and prescribing faults due to erroneous medical decisions can result in harm to patients. 2. Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common. 3. Inadequate knowledge or competence and incomplete information about clinical characteristics and previous treatment of individual patients can result in prescribing faults, including the use of potentially inappropriate medications. 4. An unsafe working environment, complex or undefined procedures, and inadequate communication among health-care personnel, particularly between doctors and nurses, have been identified as important underlying factors that contribute to prescription errors and prescribing faults. 5. Active interventions aimed at reducing prescription errors and prescribing faults are strongly recommended. These should be focused on the education and training of prescribers and the use of on-line aids. The complexity of the prescribing procedure should be reduced by introducing automated systems or uniform prescribing charts, in order to avoid transcription and omission errors. Feedback control systems and immediate review of prescriptions, which can be performed with the assistance of a hospital pharmacist, are also helpful. Audits should be performed periodically.
Medication errors may occur during parental administration of prescription and over-the-counter medications in the outpatient pediatric setting. Misinterpretation of medication labels and dosing errors are two types of errors in medication administration. Health literacy may play an important role in parents' ability to safely manage their child's medication regimen. There are several proposed strategies for decreasing these medication administration errors, including using standardized dosing instruments, using strictly metric units for medication dosing, and providing parents and caregivers with picture-based dosing instructions. Pediatric healthcare providers should be aware of these strategies and seek to implement many of them into their practices.
McPhillips, Heather A; Stille, Christopher J; Smith, David; Hecht, Julia; Pearson, John; Stull, John; Debellis, Kristin; Andrade, Susan; Miller, Marlene; Kaushal, Rainu; Gurwitz, Jerry; Davis, Robert L
To determine the prevalence of potential dosing errors of medication dispensed to children for 22 common medications. Using automated pharmacy data from 3 health maintenance organizations (HMOs), we randomly selected up to 120 children with a new dispensing prescription for each drug of interest, giving 1933 study subjects. Errors were defined as potential overdoses or potential underdoses. Error rate in 2 HMOs that use paper prescriptions was compared with 1 HMO that uses an electronic prescription writer. Approximately 15% of children were dispensed a medication with a potential dosing error: 8% were potential overdoses and 7% were potential underdoses. Among children weighing error rates were not lower at the site with an electronic prescription writer. Potential medication dosing errors occur frequently in outpatient pediatrics. Studies on the clinical impact of these potential errors and effective error prevention strategies are needed.
Lisby, Marianne; Pape-Larsen, Louise; Sørensen, Ann Lykkegaard
Abstract Authors: Lisby M, Larsen LP, Soerensen AL, Nielsen LP, Mainz J Title: Prioritising interventions against medication errors – the importance of a definition Objective: To develop and test a restricted definition of medication errors across health care settings in Denmark Methods: Medication...... errors constitute a major quality and safety problem in modern healthcare. However, far from all are clinically important. The prevalence of medication errors ranges from 2-75% indicating a global problem in defining and measuring these . New cut-of levels focusing the clinical impact of medication...... errors are therefore needed. Development of definition: A definition of medication errors including an index of error types for each stage in the medication process was developed from existing terminology and through a modified Delphi-process in 2008. The Delphi panel consisted of 25 interdisciplinary...
Ali Banaozar Mohammadi
Full Text Available Background: Medication errors due to different reasons may alter the outcome of all patients, especially patients with drug poisoning. We introduce one of the most common type of medication error in the present article. Case:A 48 year old woman with suspected organophosphate poisoning was died due to lethal medication error. Unfortunately these types of errors are not rare and had some preventable reasons included lack of suitable and enough training and practicing of medical students and some failures in medical students’ educational curriculum. Conclusion:Hereby some important reasons are discussed because sometimes they are tre-mendous. We found that most of them are easily preventable. If someone be aware about the method of use, complications, dosage and contraindication of drugs, we can minimize most of these fatal errors.
Alexander, Diana C; Bundy, David G; Shore, Andrew D; Morlock, Laura; Hicks, Rodney W; Miller, Marlene R
We sought to describe pediatric cardiovascular medication errors and to determine patients and medications with more-frequently reported and/or more-harmful errors. We analyzed cardiovascular medication error reports from 2003-2004 for patients error, no harm; E-I, harmful error). Proportions of harmful reports were determined according to drug class and age group. "High-risk" drugs were defined as antiarrhythmics, antihypertensives, digoxin, and calcium channel blockers. A total of 147 facilities submitted 821 reports with community hospitals predominating (70%). Mean patient age was 4 years (median: 0.9 years). The most common error locations were NICUs, general care units, PICUs, pediatric units, and inpatient pharmacies. Drug administration, particularly improper dosing, was implicated most commonly. Severity analysis showed 5% "near misses," 91% errors without harm, and 4% harmful errors, with no reported fatalities. A total of 893 medications were cited in 821 reports. Diuretics were cited most frequently, followed by antihypertensives, angiotensin inhibitors, beta-adrenergic receptor blockers, digoxin, and calcium channel blockers. Calcium channel blockers, phosphodiesterase inhibitors, antiarrhythmics, and digoxin had the largest proportions of harmful events, although the values were not statistically significantly different from those for other drug classes. Infants medication errors reaching inpatients, in a national, voluntary, error-reporting database. Proportions of harmful errors were not significantly different by age or cardiovascular medication. Most errors were related to medication administration, largely due to improper dosing.
Manias, Elizabeth; Kinney, Sharon; Cranswick, Noel; Williams, Allison
This study aims to explore the characteristics of reported medication errors occurring among children in an Australian children's hospital, and to examine the types, causes and contributing factors of medication errors. A retrospective clinical audit was undertaken of medication errors reported to an online incident facility at an Australian children's hospital over a 4-year period. A total of 2753 medication errors were reported over the 4-year period, with an overall medication error rate of 0.31% per combined admission and presentation, or 6.58 medication errors per 1000 bed days. The two most common severity outcomes were: the medication error occurred before it reached the child (n = 749, 27.2%); and the medication error reached the child who required monitoring to confirm that it resulted in no harm (n = 1519, 55.2%). Common types of medication errors included overdose (n = 579, 21.0%) and dose omission (n = 341, 12.4%). The most common cause relating to communication involved misreading or not reading medication orders (n = 804, 29.2%). Key contributing factors involved communication relating to children's transfer across different clinical settings (n = 929, 33.7%) and the lack of following policies and procedures (n = 617, 22.4%). More than half of the reports (72.5%) were made by nurses. Future research should focus on implementing and evaluating strategies aimed at reducing medication errors relating to analgesics, anti-infectives, cardiovascular agents, fluids and electrolytes and anticlotting agents, as they are consistently represented in the types of medication errors that occur. Greater attention needs to be placed on supporting health professionals in managing these medications. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
Poorolajal, Jalal; Rezaie, Shirin; Aghighi, Negar
This study was conducted to explore the prevalence of medical error underreporting and associated barriers. This cross-sectional study was performed from September to December 2012. Five hospitals, affiliated with Hamadan University of Medical Sciences, in Hamedan, Iran were investigated. A self-administered questionnaire was used for data collection. Participants consisted of physicians, nurses, midwives, residents, interns, and staffs of radiology and laboratory departments. Overall, 50.26% of subjects had committed but not reported medical errors. The main reasons mentioned for underreporting were lack of effective medical error reporting system (60.0%), lack of proper reporting form (51.8%), lack of peer supporting a person who has committed an error (56.0%), and lack of personal attention to the importance of medical errors (62.9%). The rate of committing medical errors was higher in men (71.4%), age of 50-40 years (67.6%), less-experienced personnel (58.7%), educational level of MSc (87.5%), and staff of radiology department (88.9%). This study outlined the main barriers to reporting medical errors and associated factors that may be helpful for healthcare organizations in improving medical error reporting as an essential component for patient safety enhancement.
Full Text Available Background: This study was conducted to explore the prevalence of medical error underreporting and associated barriers. Methods: This cross-sectional study was performed from September to December 2012. Five hospitals, affiliated with Hamadan University of Medical Sciences, in Hamedan,Iran were investigated. A self-administered questionnaire was used for data collection. Participants consisted of physicians, nurses, midwives, residents, interns, and staffs of radiology and laboratory departments. Results: Overall, 50.26% of subjects had committed but not reported medical errors. The main reasons mentioned for underreporting were lack of effective medical error reporting system (60.0%, lack of proper reporting form (51.8%, lack of peer supporting a person who has committed an error (56.0%, and lack of personal attention to the importance of medical errors (62.9%. The rate of committing medical errors was higher in men (71.4%, age of 50-40 years (67.6%, less-experienced personnel (58.7%, educational level of MSc (87.5%, and staff of radiology department (88.9%. Conclusions: This study outlined the main barriers to reporting medical errors and associated factors that may be helpful for healthcare organizations in improving medical error reporting as an essential component for patient safety enhancement.
Lesar, Timothy S
CONTEXT Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed. OBJECTIVE To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms . DESIGN Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital. MAIN OUTCOME MEASURES Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms. RESULTS A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially “fatal or severe” in 3 cases (0.7%), and “serious” in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%). CONCLUSIONS Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors. PMID:12213138
Benhamou, D; Nacry, R; Journois, D; Auroy, Y; Durand, D; Arnoux, A; Olier, L; Castot, A
Medication errors are a significant cause of severe healthcare-associated complications. In December 2006, the French Health Products Agency (Afssaps) has issued a protocol to harmonise labeling of injectable drugs vials. In 2007, a first change was launched for four drugs and was followed in 2008-2009 by a second wave concerning 42 active drugs. The present study describes how healthcare professionals have perceived this change and their overall appreciation of the drug harmonisation programme. A survey using an electronic questionnaire was distributed to medical and non-medical professionals in anaesthesia and intensive care and pharmacists in a representative sample of 200 French hospitals. The harmonisation procedure was felt as being overall satisfactory by 53% of professionals who had responded but it was recognised that the new procedure is associated with improved readability and understanding of drug dosage. The use of colour coding was also well accepted by the personnel of clinical units. Respondents expressed significant criticisms regarding both the communication plan and the way the plan was implemented locally in hospitals. Old and new labeling coexisted in 66% of responding hospitals and many respondents described being aware of errors or near-misses that were considered related to the transition. For many important topics, pharmacists had views that were significantly different from clinicians. This national survey describing the perception of healthcare professionals regarding the new harmonisation procedure for injectable drugs highlighted some progress but also a number of deficiencies, notably regarding communication and implementation of the change in clinical units. This survey will be used by the French Health Products Agency to improve future steps of the long-lasting campaign against medication errors. Copyright © 2011 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.
Rinke, Michael L; Bundy, David G; Shore, Andrew D; Colantuoni, Elizabeth; Morlock, Laura L; Miller, Marlene R
To describe inpatient and outpatient pediatric antidepressant medication errors. We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years. Of the 451 error reports identified, 95% reached the patient, 6.4% reached the patient and necessitated increased monitoring and/or treatment, and 77% involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30% cited dispensing, 28% cited transcribing, and 7.9% cited prescribing. The most commonly cited medications were sertraline (20%), bupropion (19%), fluoxetine (15%), and trazodone (11%). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59% vs 32%, p = .023), errors occurring in inpatient care (93% vs 68%, p = .012) and extra doses of medication (31% vs 10%, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p errors due to inaccurate or omitted transcription (p errors. Family notification of medication errors was reported in only 12% of errors. Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.
One of the strategies to enhance patient safety is the spontaneous reporting and analysis of medication errors. Sharing this information with other healthcare providers will help to prevent the reoccurrence of similar medication errors. In The Netherlands medication errors can be reported to a
Whitney, Paul D.; Young, Jonathan; Santell, John; Hicks, Rodney; Posse, Christian; Fecht, Barbara A.
In medicine, as in many areas of research, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been, however, a corresponding lag in our abilities to analyze this overwhelming mass of data, and classic forms of statistical analysis may not allow researchers to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports has been carried out based on an approach of data comparison, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. Traditionally, USP has conducted an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.
Conclusions: The Medical Error Checklists developed in this study advance the study of medical errors by proposing a comprehensive, valid and reliable self-assessment tool. The results highlight the importance of hospital organizational factors in preventing medical errors.
Introduction to Medical Device RequirementsIntroductionThe ChallengesSources of ErrorsUnderstanding the Science of Safety Overview of FDA Quality System Regulation Overview of Risk Management Standard ISO 14971 Overview of FDA Device Approval Process Overview of Regulatory Requirements for Clinical TrialsSummaryReferencesPreventing Recalls during Specification WritingIntroductionConduct Requirements Analysis to Identify Missing RequirementsSpecifications for Safety, Durability, and
To assess the prevalence and characteristics of medication errors (ME) in patients admitted to King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia. Medication errors are documented by the nurses and physicians standard reporting forms (Hospital Based Incident Report). The study was carried out in King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia and all the incident reports were collected during the period from January 2008 to December 2009. The incident reports were analyzed for age, gender, nationality, nursing unit, and time where ME was reported. The data were analyzed and the statistical significance differences between groups were determined by Student's t-test, and p-values of <0.05 using confidence interval of 95% were considered significant. There were 38 ME reported for the study period. The youngest patient was 5 days and the oldest 70 years. There were 31 Saudis, and 7 non-Saudi patients involved. The most common error was missed medication, which was seen in 15 (39.5%) patients. Over 15 (39.5%) of errors occurred in 2 units (pediatric medicine, and obstetrics and gynecology). Nineteen (50%) of the errors occurred during the 3-11 pm shift. Our study shows that the prevalence of ME in our institution is low, in comparison with the world literature. This could be due to under reporting of the errors, and we believe that ME reporting should be made less punitive so that ME can be studied and preventive measures implemented (Author).
McLennan, Stuart; Shaw, David; Leu, Agnes; Elger, Bernice
To examine medicolegal stakeholders' views about the impact of professional liability insurance in Switzerland on medical error disclosure. Purposive sample of 23 key medicolegal stakeholders in Switzerland from a range of fields between October 2012 and February 2013. Data were collected via individual, face-to-face interviews using a researcher-developed semi-structured interview guide. Interviews were transcribed and analysed using conventional content analysis. Participants, particularly those with a legal or quality background, reported that concerns relating to professional liability insurance often inhibited communication with patients after a medical error. Healthcare providers were reported to be particularly concerned about losing their liability insurance cover for apologising to harmed patients. It was reported that the attempt to limit the exchange of information and communication could lead to a conflict with patient rights law. Participants reported that hospitals could, and in some case are, moving towards self-insurance approaches, which could increase flexibility regarding error communication The reported current practice of at least some liability insurance companies in Switzerland of inhibiting communication with harmed patients after an error is concerning and requires further investigation. With a new ethic of transparency regarding medical errors now prevailing internationally, this approach is increasingly being perceived to be misguided. A move away from hospitals relying solely on liability insurance may allow greater transparency after errors. Legalisation preventing the loss of liability insurance coverage for apologising to harmed patients should also be considered.
Naunton, Mark; Nor, Kowsar; Bartholomaeus, Andrew; Thomas, Jackson; Kosari, Sam
Abstract Introduction: The World Health Organisation recognizes confusing drug names as one of the most common causes of medication errors. Other factors include spelling, phonetic, or packaging similarities. Case presentation: We presented a case report of an inadvertent administration of a non-ocular pharmaceutical product (Novasone? lotion) into the eye of an octogenarian individual, and briefly reviewed the relevant literature. Discussion: We discussed prevention strategies to avoid simil...
Weant, Kyle A; Bailey, Abby M; Baker, Stephanie N
Medication errors are an all-too-common occurrence in emergency departments across the nation. This is largely secondary to a multitude of factors that create an almost ideal environment for medication errors to thrive. To limit and mitigate these errors, it is necessary to have a thorough knowledge of the medication-use process in the emergency department and develop strategies targeted at each individual step. Some of these strategies include medication-error analysis, computerized provider-order entry systems, automated dispensing cabinets, bar-coding systems, medication reconciliation, standardizing medication-use processes, education, and emergency-medicine clinical pharmacists. Special consideration also needs to be given to the development of strategies for the pediatric population, as they can be at an elevated risk of harm. Regardless of the strategies implemented, the prevention of medication errors begins and ends with the development of a culture that promotes the reporting of medication errors, and a systematic, nonpunitive approach to their elimination.
Gaffney, Theresa A; Hatcher, Barbara J; Milligan, Renee
The aim of this study was to conduct an integrative review of the literature to fully understand nurses' role in medical error recovery. Despite focused efforts on error prevention, the prevalence of medical errors occurring in the health care system remains a concern. Patient harm can be reduced or prevented by adequate recovery processes that include identifying, interrupting and correcting medical errors in a timely fashion. Both medical error prevention and recovery are critical components in advancing patient safety, yet little is known about nurses' role in medical error recovery. An integrative review of the literature, guided by Whittmore and Knafl's (Journal of Advanced Nursing, 5, 2005, 546) five-step process, was conducted for the period between 2000-2015. A comprehensive search yielded twelve articles for this review. The level and quality of evidence of the included articles was rated using a five-level rating system and the Johns Hopkins Nursing Quality of Evidence Appraisal developed by ©The Johns Hopkins Hospital/The Johns Hopkins University. The medical error recovery rate varied across specialty nursing populations with nurses recovering, on average, as many as one error per shift to as few as one error per week. Nurses rely on knowing the patient, environment and plan of care to aid in medical error recovery. Nurses play a unique yet invisible role in identifying, interrupting and recovering medical errors. Individual and organisational factors influencing nurses' ability to recover medical errors remain unclear. Greater understanding of nurse characteristics and organisational factors that influence error recovery can foster the development of effective strategies to detect and correct medical errors and enable organisations to reduce negative outcomes. © 2016 John Wiley & Sons Ltd.
David, Guy; Gunnarsson, Candace L; Waters, Heidi C; Horblyuk, Ruslan; Kaplan, Harold S
The primary objective of this study was to estimate the occurrence and costs of medical errors from the hospital perspective. Methods from a recent actuarial study of medical errors were used to identify medical injuries. A visit qualified as an injury visit if at least 1 of 97 injury groupings occurred at that visit, and the percentage of injuries caused by medical error was estimated. Visits with more than four injuries were removed from the population to avoid overestimation of cost. Population estimates were extrapolated from the Premier hospital database to all US acute care hospitals. There were an estimated 161,655 medical errors in 2008 and 170,201 medical errors in 2009. Extrapolated to the entire US population, there were more than 4 million unique injury visits containing more than 1 million unique medical errors each year. This analysis estimated that the total annual cost of measurable medical errors in the United States was $985 million in 2008 and just over $1 billion in 2009. The median cost per error to hospitals was $892 for 2008 and rose to $939 in 2009. Nearly one third of all medical injuries were due to error in each year. Medical errors directly impact patient outcomes and hospitals' profitability, especially since 2008 when Medicare stopped reimbursing hospitals for care related to certain preventable medical errors. Hospitals must rigorously analyze causes of medical errors and implement comprehensive preventative programs to reduce their occurrence as the financial burden of medical errors shifts to hospitals. Copyright © 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.
Rutledge, Dana N; Retrosi, Tina; Ostrowski, Gary
errors, especially errors where patient harm is not apparent or where an error might be hidden. Such under-reporting impedes collection of accurate medication error data and prevents hospitals from changing harmful practices. © 2018 John Wiley & Sons Ltd.
al Tehewy, Mahi; Fahim, Hoda; Gad, Nanees Isamil; El Gafary, Maha; Rahman, Shady Abdel
To measure the rates of medication administration errors in medical wards at Ain Shams University Hospital and to identify significant determinants of medication administration errors. A descriptive direct-observational study of drug administration errors was carried out at medical wards of Ain Shams University hospital for a period of 3 months. A standardized observational checklist was used to observe the nurse during giving medications, and a medical record audit form was used to assess documentation. The error rates per observation, nurse, and patient were calculated, and the association between error rates and characteristics of each category was tested using linear regression to identify potential risk factors. The study included 237 patients and 28 nurses. The final number of drug administration observations was 2090 after excluding 310 omissions. A total of 5531 errors were observed with an average number of 2.67 errors per observation. More than 85% of the observations had at least one error, and the overall error rate was 37.68% (per hundred error opportunities). The highest error rate was detected in injections especially the intravenous route (39.58%). The most frequent errors were wrong documentation (90.96%) and wrong technique (78.90%), and the least was wrong patient (0.05%). The significant independent determinants of medication administration errors were high number of shifts taken by nurse per month, night shifts, weekends, elderly patient, and illiteracy. Medication administration errors represent a major problem in the hospital that needs urgent intervention to optimize medication administration process. The intervention should consider the identified significant determinants of medication administration errors.
Andersen, Mette Lehmann; Søndergaard, Jens; Hallas, Jesper; Pedersen, Anette; Hellebek, Annemarie
Medication order errors are frequent in Denmark. It is necessary to know the reasons why these errors happen to be able to implement initiatives limiting medication order errors. In this study we analyzed 811 medications order errors, which were reported as unintended events. The medication order errors were associated with at total of 98 medicinal product; hence nine medicinal products caused 18 errors with severe or catastrophic harm to patients. 46.0% of the errors were incorrect medicinal product, 47.7% were incorrect dosage and 6.3% of the orders were double ordering. Penicillin and warfarin were the most frequently involved medicinal products. The products that most frequently caused severe or catastrophic patient harm were insulin and warfarin. The most frequent errors were "no medicinal product prescribed" and "incorrect medicinal product". The errors with the most severe consequences for the patients were due to "medication was not discontinued" (sevoflurane and warfarin) and "poor patient compliance" (warfarin and insulin). A common feature concerning the errors' origin was incorrect handling of information. Specific initiatives should be taken to counter the above-mentioned problems and reduce the occurrence of medication order errors. Such measures may comprise control, medication reconciliation and imposition of clinical decision support.
Full Text Available Background and objectives : Medication errors can be a threat to the safety of patients. Preventing medication errors requires reporting and investigating such errors. The present study was conducted with the purpose of investigating medication errors in educational health centers of Kermanshah. Material and Methods: The present research is an applied, descriptive-analytical study and is done as a survey. Error Report of Ministry of Health and Medical Education was used for data collection. The population of the study included all the personnel (nurses, doctors, paramedics of educational health centers of Kermanshah. Among them, those who reported the committed errors were selected as the sample of the study. The data analysis was done using descriptive statistics and Chi 2 Test using SPSS version 18. Results: The findings of the study showed that most errors were related to not using medication properly, the least number of errors were related to improper dose, and the majority of errors occurred in the morning. The most frequent reason for errors was staff negligence and the least frequent was the lack of knowledge. Conclusion: The health care system should create an environment for detecting and reporting errors by the personnel, recognizing related factors causing errors, training the personnel and create a good working environment and standard workload.
Annegret F. Hannawa
Full Text Available Approximately 43 million adverse events occur across the globe each year at a cost of at least 23 million disability-adjusted life years and $132 billion in excess health care spending, ranking this safety burden among the top 10 medical causes of disability in the world.1 These findings are likely to be an understatement of the actual severity of the problem, given that the numbers merely reflect seven types of adverse events and completely neglect ambulatory care, and of course they only cover reported incidents. Furthermore, they do not include statistics on children and incidents from India and China, which host more than a third of the world’s population. Best estimates imply that about two thirds of these incidents are preventable. Thus, from a public health perspective, medical errors are a seri- ous global health burden, in fact ahead of high-profile health problems like AIDS and cancer. Interventions to date have not reduced medical errors to satisfactory rates. Even today, far too often, hand hygiene is not practiced properly (even in developed countries, surgical procedures take place in underequipped operating theaters, and checklists are missing or remain uncompleted. The healthcare system seems to be failing in managing its errors − it is costing too much, and the complexity of care causes severe safety hazards that too often harm rather than help patients. In response to this evolving discussion, the International Society for Quality in Healthcare recently nominated an Innovations Team that is now developing new strategies. One of the emerging themes is that the medical field cannot resolve this problem on its own. Instead, interdisciplinary collaborations are needed to advance effective, evidence-based interventions that will eventually result in competent changes. In March 2013, the Institute of Communication and Health at the University of Lugano organized a conference on Communicating Medical Error (COME 2013 in
Berland, Astrid; Bentsen, Signe Berit
To explore registered nurses' experiences of medication errors and patient safety in home care. The focus of care for older patients has shifted from institutional care towards a model of home care. Medication errors are common in this situation and can result in patient morbidity and mortality. An exploratory qualitative design with focus group interviews was used. Four focus group interviews were conducted with 20 registered nurses in home care. The data were analysed using content analysis. Five categories were identified as follows: lack of information, lack of competence, reporting medication errors, trade name products vs. generic name products, and improving routines. Medication errors occur frequently in home care and can threaten the safety of patients. Insufficient exchange of information and poor communication between the specialist and home-care health services, and between general practitioners and healthcare workers can lead to medication errors. A lack of competence in healthcare workers can also lead to medication errors. To prevent these, it is important that there should be up-to-date information and communication between healthcare workers during the transfer of patients from specialist to home care. Ensuring competence among healthcare workers with regard to medication is also important. In addition, there should be openness and accurate reporting of medication errors, as well as in setting routines for the preparation, alteration and administration of medicines. To prevent medication errors in home care, up-to-date information and communication between healthcare workers is important when patients are transferred from specialist to home care. It is also important to ensure adequate competence with regard to medication, and that there should be openness when medication errors occur, as well as in setting routines for the preparation, alteration and administration of medications. © 2017 John Wiley & Sons Ltd.
Ahmadipour, Habibeh; Nahid, Mortazavi
It is difficult to determine the real incidence of medical errors due to the lack of a precise definition of errors, as well as the failure to report them under certain circumstances. We carried out a cross- sectional study in Kerman University of Medical Sciences, Iran in 2013. The participants were selected through the census method. The data were collected using a self-administered questionnaire, which consisted of questions on the participants' demographic data and questions on the medical errors committed. The data were analysed by SPSS 19. It was found that 270 participants had committed medical errors. There was no significant difference in the frequency of errors committed by interns and residents. In the case of residents, the most common error was misdiagnosis and in that of interns, errors related to history-taking and physical examination. Considering that medical errors are common in the clinical setting, the education system should train interns and residents to prevent the occurrence of errors. In addition, the system should develop a positive attitude among them so that they can deal better with medical errors.
Drach-Zahavy, Anat; Pud, Dorit
This paper is a report of a study conducted to identify and test the effectiveness of learning mechanisms applied by the nursing staff of hospital wards as a means of limiting medication administration errors. Since the influential report ;To Err Is Human', research has emphasized the role of team learning in reducing medication administration errors. Nevertheless, little is known about the mechanisms underlying team learning. Thirty-two hospital wards were randomly recruited. Data were collected during 2006 in Israel by a multi-method (observations, interviews and administrative data), multi-source (head nurses, bedside nurses) approach. Medication administration error was defined as any deviation from procedures, policies and/or best practices for medication administration, and was identified using semi-structured observations of nurses administering medication. Organizational learning was measured using semi-structured interviews with head nurses, and the previous year's reported medication administration errors were assessed using administrative data. The interview data revealed four learning mechanism patterns employed in an attempt to learn from medication administration errors: integrated, non-integrated, supervisory and patchy learning. Regression analysis results demonstrated that whereas the integrated pattern of learning mechanisms was associated with decreased errors, the non-integrated pattern was associated with increased errors. Supervisory and patchy learning mechanisms were not associated with errors. Superior learning mechanisms are those that represent the whole cycle of team learning, are enacted by nurses who administer medications to patients, and emphasize a system approach to data analysis instead of analysis of individual cases.
Jorge Enrique Machado-Alba
Full Text Available Objective: this study analyzes the medication errors reported to a pharmacovigilance system by 26 hospitals for patients in the healthcare system of Colombia. Methods: this retrospective study analyzed the medication errors reported to a systematized database between 1 January 2008 and 12 September 2013. The medication is dispensed by the company Audifarma S.A. to hospitals and clinics around Colombia. Data were classified according to the taxonomy of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP. The data analysis was performed using SPSS 22.0 for Windows, considering p-values < 0.05 significant. Results: there were 9 062 medication errors in 45 hospital pharmacies. Real errors accounted for 51.9% (n = 4 707, of which 12.0% (n = 567 reached the patient (Categories C to I and caused harm (Categories E to I to 17 subjects (0.36%. The main process involved in errors that occurred (categories B to I was prescription (n = 1 758, 37.3%, followed by dispensation (n = 1 737, 36.9%, transcription (n = 970, 20.6% and administration (n = 242, 5.1%. The errors in the administration process were 45.2 times more likely to reach the patient (CI 95%: 20.2–100.9. Conclusions: medication error reporting systems and prevention strategies should be widespread in hospital settings, prioritizing efforts to address the administration process.
Full Text Available Kyle A Weant,1 Abby M Bailey,2 Stephanie N Baker2 1North Carolina Public Health Preparedness and Response, North Carolina Department of Health and Human Services, Raleigh, NC, 2University of Kentucky HealthCare, Department of Pharmacy Services, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA Abstract: Medication errors are an all-too-common occurrence in emergency departments across the nation. This is largely secondary to a multitude of factors that create an almost ideal environment for medication errors to thrive. To limit and mitigate these errors, it is necessary to have a thorough knowledge of the medication-use process in the emergency department and develop strategies targeted at each individual step. Some of these strategies include medication-error analysis, computerized provider-order entry systems, automated dispensing cabinets, bar-coding systems, medication reconciliation, standardizing medication-use processes, education, and emergency-medicine clinical pharmacists. Special consideration also needs to be given to the development of strategies for the pediatric population, as they can be at an elevated risk of harm. Regardless of the strategies implemented, the prevention of medication errors begins and ends with the development of a culture that promotes the reporting of medication errors, and a systematic, nonpunitive approach to their elimination. Keywords: emergency medicine, pharmacy, medication errors, pharmacists, pediatrics
Warholak, Terri L; Queiruga, Caryn; Roush, Rebecca; Phan, Hanna
To assess and compare prescribing error-identification rates by health professional students. Medical, pharmacy, and nursing students were asked to complete a questionnaire on which they evaluated the accuracy of 3 prescriptions and indicated the type of error found, if any. The number of correctly identified prescribing errors and the number of correct types of errors identified were compared and error identification rates for each group were calculated. One hundred seventy-five questionnaires were returned (87% response rate). Pharmacy students had a significantly higher error-identification rate than medical and nursing students (p medical and nursing students (p = 0.88). Compared to medical students, pharmacy students more often were able to identify correctly the error type for each prescription (p error-identification rate, which may be associated with the greater number of pharmacology and pharmacotherapeutics course hours that pharmacy students complete.
Brock, Douglas M; Quella, Alicia; Lipira, Lauren; Lu, Dave W; Gallagher, Thomas H
Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.
Machado-Alba, Jorge E; Moncada, Juan Carlos; Moreno-Gutiérrez, Paula Andrea
Medication errors outside the hospital have been poorly studied despite representing an important threat to patient safety. To describe the characteristics of medication errors in outpatient dispensing pharmacists reported in a pharmaco-surveillance system between 2005 and 2013 in Colombia. We conducted a descriptive study by reviewing and categorizing medication error reports from outpatient pharmacy services to a national medication dispensing company between January, 2005 and September, 2013. Variables considered included: process involved (administration, dispensing, prescription and transcription), wrong drug, time delay for the report, error type, cause and severity. The analysis was conducted in the SPSS® software, version 22.0. A total of 14,873 medication errors were reviewed, of which 67.2% in fact occurred, 15.5% reached the patient and 0.7% caused harm. Administration (OR=93.61, CI 95%: 48.510-180.655, perrors (OR=5.64; CI 95%: 3.488-9.142, perror reaching the patient. It is necessary to develop surveillance systems for medication errors in ambulatory care, focusing on the prescription, transcription and dispensation processes. Special strategies are needed for the prevention of medication errors related to anti-infective drugs.
Soydemir, Dilek; Seren Intepeler, Seyda; Mert, Hatice
The purpose of the study was to determine what barriers to error reporting exist for physicians and nurses. The study, of descriptive qualitative design, was conducted with physicians and nurses working at a training and research hospital. In-depth interviews were held with eight physicians and 15 nurses, a total of 23 participants. Physicians and nurses do not choose to report medical errors that they experience or witness. When barriers to error reporting were examined, it was seen that there were four main themes involved: fear, the attitude of administration, barriers related to the system, and the employees' perceptions of error. It is important in terms of preventing medical errors to identify the barriers that keep physicians and nurses from reporting errors.
Sullivan, Janice E; Buchino, John J
Medication errors have come to the forefront in healthcare and oversight organizations as well as to the public over the past several years. There has been an increasing focus on this area of patient care requiring more intensive evaluation and intervention to prevent these errors. Although it is difficult to ascertain the true occurrence of medication errors, they may occur as frequently as once in every 20 orders. Children are at higher risk for medication errors and adverse drug events for numerous reasons. Not only is there great variability in weight and body surface area in this population, there is also significant differences in the pharmacokinetics and pharmacodynamics of many medications when compared to adults. In addition, our knowledge of pharmacogenetics and phenotypic ontogeny must be applied. Sources of medication errors are identified, and specific examples and solutions to improve medication use in children are provided. It is critical to have 1) personnel trained in pediatrics to prescribe, prepare, dispense and administer medications, 2) a quality review system in place to review drug use and medication errors, and 3) to implement computerized physician order entry with decision support and other tools in the next decade to improve pharmacologic therapy for pediatric patients.
Lampert, Anette; Seiberth, Jasmin; Haefeli, Walter E; Seidling, Hanna M
Transdermal patches provide an attractive route of drug delivery with considerable advantages over other routes of administration, for example maintenance of constant plasma drug levels and convenient usage. However, medication administration errors abound with this dosage form and frequently result in harm or treatment failure. A systematic literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using appropriate keywords to identify articles reporting faulty transdermal patch administration. Common pitfalls and errors that were identified through the systematic literature search were discussed alongside individual steps of the transdermal patch administration process. The systematic investigation of published errors illustrated that every step in the transdermal patch administration process is prone to errors. Thereby, the lack of knowledge and awareness of the importance of a correct administration practice were a major source of risk. Based on the identified errors and causes of errors prevention strategies were developed as a first step in avoiding transdermal patch administration errors.
Yarmohammadian, Mohammad H; Mohammadinia, Leila; Tavakoli, Nahid; Ghalriz, Parvin; Haghshenas, Abbas
characteristics, and the quality of error experiences' transmission in the health-care system. Although, appropriate achievements have been assured in Shahid Beheshti Hospital, but it seems necessary that in order to immune promotion not only in this hospital, but in the other organizations, necessary infrastructures have been provided for an error reporting system performance. An appropriate medical error reporting system could be educated and prevent the occurrence of repeated errors.
Love, Peter E D; Lopez, Robert; Edwards, David J; Goh, Yang M
Design errors contribute significantly to cost and schedule growth in social infrastructure projects and to engineering failures, which can result in accidents and loss of life. Despite considerable research that has addressed their error causation in construction projects they still remain prevalent. This paper identifies the underlying conditions that contribute to design errors in social infrastructure projects (e.g. hospitals, education, law and order type buildings). A systemic model of error causation is propagated and subsequently used to develop a learning framework for design error prevention. The research suggests that a multitude of strategies should be adopted in congruence to prevent design errors from occurring and so ensure that safety and project performance are ameliorated. Copyright © 2011. Published by Elsevier Ltd.
Medication errors are one of the most common incidents leading to adverse events in healthcare worldwide. Tackling these major problems requires the implementation of a systems approach to healthcare, stating that risks should be managed proactively by improving the healthcare system. One of the recommended key strategies for learning from medication errors and risk prone processes is the establishment of local and national medication error reporting (MER) systems in healthcare. This stu...
Prescrire's analyses showed that the quality of drug packaging in 2010 still left much to be desired. Potentially dangerous packaging remains a significant problem: unclear labelling is source of medication errors; dosing devices for some psychotropic drugs create a risk of overdose; child-proof caps are often lacking; and too many patient information leaflets are misleading or difficult to understand. Everything that is needed for safe drug packaging is available; it is now up to regulatory agencies and drug companies to act responsibly. In the meantime, health professionals can help their patients by learning to identify the pitfalls of drug packaging and providing safe information to help prevent medication errors.
Honey, Brooke Lynn; Bray, Whitney M; Gomez, Michael R; Condren, Michelle
Medication errors are hazardous and costly. Children are at increased risk for medication errors because of weight-based dosing, limited FDA indications, and human calculation errors. The aim of this study is to determine the frequency and type of resident prescribing errors in a pediatric clinic and further compare error rates of residents in different training programs. Resident prescription error data from a pediatric clinic was collected for 5 months. Upon detection of an error, residents were notified/given feedback regarding the type of error, ways to remedy errors, and future prevention methods. Data were categorized based on medication involved, error type, and resident training program. The review included 2941 prescriptions, with the overall resident prescribing error rate being 5.88%. The pediatric resident error rate was 4%. Family medicine, internal medicine, and medicine/pediatrics had error rates of 11%, 8%, and 7%, respectively. The prescribing error rate showed a statistically significant difference with pediatrics compared with family medicine, internal medicine, and medicine/pediatrics (P medication error type was overdose, followed by unclear quantity. Among the medication classes, topical agents and antimicrobials were among the top prescribed. Numerous types of medication errors occur in a pediatric clinic. Prescribing errors take place among all medical trainees; however, medication error rates in the pediatric population may vary among resident specialty. Identifying the cause of prescribing errors will allow institutions to create educational programs tailored for safe medication use in children as well as systemwide changes for error reduction.
Letarte, Nathalie; Gabay, Michael P; Bressler, Linda R; Long, Katie E; Stachnik, Joan M; Villano, J Lee
The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.
Kale, Abhivyakti; Keohane, Carol A; Maviglia, Saverio; Gandhi, Tejal K; Poon, Eric G
To determine how often serious or life-threatening medication administration errors with the potential to cause harm (potential adverse drug events) result in actual harm (adverse drug events (ADEs)) in the hospital setting. Retrospective chart review of clinical events following observed medication administration errors. Medication errors are common at the medication administration stage for inpatients. While many errors can cause harm, it is unclear exactly how often. In a previous study where 14 041 medication administrations were directly observed, 1271 medication administration errors were discovered, of which 133 had the potential to cause serious or life-threatening harm and were considered serious or life-threatening potential adverse drug events. As a follow-up, clinical reviewers conducted detailed chart review of serious or life-threatening potential ADEs to determine if they caused an ADE. Reviewers assessed severity of the ADE and attribution to the error. Ten (7.5% (95% CI 6.98 to 8.01)) actual ADEs resulted from the 133 serious and life-threatening potential ADEs, of which 6 resulted in significant, three in serious, and one life threatening injury. Therefore 4 (3% (95% CI 2.12 to 3.6)) of serious or life threatening potential ADEs led to serious or life threatening ADEs. Half of the ADEs were caused by dosage or monitoring errors for anti-hypertensives. Unintercepted potential ADEs at the medication administration stage can cause serious patient harm. At hospitals where 6 million doses are administered per year, about 4000 preventable ADEs would be attributable to medication administration errors annually.
Sædder, Eva Aggerholm; Lisby, Marianne; Nielsen, Lars Peter
Medication errors (MEs) are preventable and can result in patient harm and increased expenses in the healthcare system in terms of hospitalization, prolonged hospitalizations and even death. We aimed to develop a screening tool to detect acutely admitted patients at low or high risk of MEs...
Huamaní, Charles; Pacheco-Romero, José
References are fundamental in our studies; an adequate selection is asimportant as an adequate description. To determine the number of errors in a sample of references found in Peruvian medical journals. We reviewed 515 scientific papers references selected by systematic randomized sampling and corroborated reference information with the original document or its citation in Pubmed, LILACS or SciELO-Peru. We found errors in 47,6% (245) of the references, identifying 372 types of errors; the most frequent were errors in presentation style (120), authorship (100) and title (100), mainly due to spelling mistakes (91). References error percentage was high, varied and multiple. We suggest systematic revision of references in the editorial process as well as to extend the discussion on this theme. references, periodicals, research, bibliometrics.
Hodges, Nichole L; Spiller, Henry A; Casavant, Marcel J; Chounthirath, Thiphalak; Smith, Gary A
The objective of this study is to provide an epidemiologic analysis of medication errors occurring outside of health care facilities that result in serious medical outcomes (defined by the National Poison Database System as "moderate effect," "major effect," "death," or "death, indirect report"). National Poison Database System data from 2000 through 2012 were used for this retrospective analysis of non-health care facility medication errors. From 2000 through 2012, Poison Control Centers in the United States received data on 67,603 exposures related to unintentional therapeutic pharmaceutical errors that occurred outside of health care facilities that resulted in serious medical outcomes. The overall average rate of these medication errors was 1.73 per 100,000 population, and there was a 100.0% rate increase during the 13-year study period. Medication error frequency and rates increased for all age groups except children younger than 6 years of age. Medical outcome was most commonly reported as moderate effect (93.5%), followed by major effect (5.8%) and death (0.6%). Common types of medication errors included incorrect dose, taking or administering the wrong medication, and inadvertently taking the medication twice. The medication categories most frequently associated with serious outcomes were cardiovascular drugs (20.6%) (primarily beta blockers, calcium antagonists, and clonidine), analgesics (12.0%) (most often opioids and acetaminophen, alone and combination products), and hormones/hormone antagonists (11.0%) (in particular, insulin, and sulfonylurea). This study analyzed non-health care facility medication errors resulting in serious medical outcomes. The rate of non-health care facility medication errors resulting in serious medical outcomes is increasing, and additional efforts are needed to prevent these errors.
Full Text Available This study was conducted as a descriptive study in order to determine the medical errors in hospital services and preventive measures that could be taken to reduce these errors, from the perspective of nurses. The population of the study is composed of nurses working in 2 public hospitals in center of the province of Sakarya. We haven’t selected sample and it was aimed to reach as many nurses as possible in the study. A total of 441 questionnaires were send and 324 were returned. A questionnaire as a means of data collection was prepared and used by the authors. Structural Equation Modeling, confirmatory factor analysis, descriptive statistical methods, the significance control test between compared means and ANOVA test were used in statistical analysis. Physicians, nurses, work environment and lack of communication are stated as possible causes of medical error. According to nurses, the major causes of medical errors, in order of their frequency, were inadequate number of health personnel, excessive work stress, high number of patients per nurse, the weariness due to the behavior and attitudes of superiors and the pressure to care so many patients in a very short period of time, and long time of study. Compensation of medical error is very difficult in health care. A great amount of health care is provided in hospitals and medical errors in hospital services must be prevented. In order to prevent these errors which directly affect human life, it is thought that adequate number of staff should be employed in hospitals and the attitude of superiors towards the employees should be motivating. [TAF Prev Med Bull 2012; 11(4.000: 421-430
Dibbi, Huda M; Al-Abrashy, Hanan F; Hussain, Waleed A; Fatani, Mohammad I; Karima, Talal M
To develop better understanding of Medication Errors (MEs) in the health care sector, and to improve the error prevention services in the hospital. We conducted a retrospective study at the Hera General Hospital, Makkah, Saudi Arabia. The medical records were reviewed for adult hospitalized patients from June 1, 2000 to June 30, 2002. Patients demographic data, types, and causes of MEs, were recorded. The contributing factors, frequency and patient's outcome were also analyzed. A total of 2627 patient files were analyzed, 3963 errors were studied as follows: 1559 files contain one error, 800 files with 2 errors, and 268 with >3 errors. The most common type of error found was wrong strength (concentration) in 914 patients (34.79%), 807 patients (30.7%) had wrong route of administration, and 788 (30%) had wrong dosage form. On the other hand, the most common cause identified for MEs, was human factor, which accounted in 1223 patients (46.49%). Miscommunication was the most common second cause in 920 patients (35.02%), and the third common cause was name confusion [484, (18.43%)]. Medication Errors were classified from a regulatory prospective into actual in 735 patient files (28%), potential in 1866 (71%) and serious in 26 (0.98%). The study showed that wrong strength was the most common ME found and human factors were the most common cause contributing MEs. Therefore, focusing on these factors will definitely minimize MEs in hospitalized patients.
Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi; Wan-Mohaina, W M
Reporting and analysing the data on medication errors (MEs) is important and contributes to a better understanding of the error-prone environment. This study aims to examine the characteristics of errors submitted to the National Medication Error Reporting System (MERS) in Malaysia. A retrospective review of reports received from 1 January 2009 to 31 December 2012 was undertaken. Descriptive statistics method was applied. A total of 17,357 MEs reported were reviewed. The majority of errors were from public-funded hospitals. Near misses were classified in 86.3 % of the errors. The majority of errors (98.1 %) had no harmful effects on the patients. Prescribing contributed to more than three-quarters of the overall errors (76.1 %). Pharmacists detected and reported the majority of errors (92.1 %). Cases of erroneous dosage or strength of medicine (30.75 %) were the leading type of error, whilst cardiovascular (25.4 %) was the most common category of drug found. MERS provides rich information on the characteristics of reported MEs. Low contribution to reporting from healthcare facilities other than government hospitals and non-pharmacists requires further investigation. Thus, a feasible approach to promote MERS among healthcare providers in both public and private sectors needs to be formulated and strengthened. Preventive measures to minimise MEs should be directed to improve prescribing competency among the fallible prescribers identified.
Varjavand, Nielufar; Bachegowda, Lohith S; Gracely, Edward; Novack, Dennis H
The 2000 Institute of Medicine report, 'To Err is Human: Building a Safer Health System', focused the medical community on medical error. This focus led to educational initiatives and legislation designed to minimise errors and increase their disclosure. This study aimed to investigate whether increased general awareness about medical error has affected interns' attitudes toward medical error and disclosure by comparing responses to surveys of interns carried out at either end of the last decade. Two cohorts of interns for the academic years 1999, 2000 and 2001 (n = 304) and 2008 and 2009 (n = 206) at a university hospital were presented with two hypothetical scenarios involving errors that resulted in, respectively, no permanent harm and an adverse outcome. The interns were questioned regarding their likely responses to error and disclosure. We collected 510 surveys (100% response rate). For both scenarios, the percentage of interns who would be willing to fully disclose their mistakes increased substantially from 1999-2001 to 2008-2009 ('no permanent harm': 38% and 71%, respectively [p error disclosure decreased (70% and 52%, respectively), the percentage of interns who felt that 'medical mistakes are preventable if doctors know enough' decreased (49% and 31%, respectively), belief that competent doctors keep emotions and uncertainties to themselves decreased (51% and 14%, respectively), and agreement with leaving medicine if one (as an intern) caused harm or death decreased (50% and 3%, respectively). Prior training about medical mistakes increased more than four-fold between the cohorts. This comparison of intern responses to a survey administered at either end of the last decade reveals that there may have been some important changes in interns' intended disclosure practices and attitudes toward medical error. © Blackwell Publishing Ltd 2012.
African Journal of Psychiatry. Journal Home · ABOUT · Advanced Search · Current Issue · Archives · Journal Home > Vol 5, No 2 (2002) >. Log in or Register to get access to full text downloads. Username, Password, Remember me, or Register. Medical error. Merryll Vorster, Michael Berk. Abstract. South African Psychiatry ...
Gaffney, Theresa A; Hatcher, Barbara J; Milligan, Renee; Trickey, Amber
Keeping patients safe is a core nursing duty. The dynamic nature of the healthcare environment requires that nurses practice to the full extent of their education, experience, and role to keep patients safe. Research has focused on error causation rather than error recovery, a process that occurs before patient harm ensues. In addition, little is known about the role nurses play in error recovery. A descriptive cross-sectional, correlational study using a sample of 184 nurses examined relationships between nurse characteristics, organizational factors, and recovery of medical errors among medical-surgical nurses in hospitals. In this article, we provide background information to introduce the concept of error recovery, and present our study aims and methods. Study results suggested that medical-surgical nurses recovered on average 22 medical errors and error recovery was positively associated with education and expertise. The discussion section further considers the important role of medical-surgical nurses and error recovery to enhance patient safety. In conclusion, we suggest that creating a safer healthcare system will depend on the ability of nurses to fully use their education, expertise and role to identify, interrupt, and correct medical errors; thereby, preventing patient harm.
Härkänen, Marja; Turunen, Hannele; Vehviläinen-Julkunen, Katri
This study aimed to compare medication administration errors detected by 3 different methods in terms of severity, type, and contributing factors. The study was performed in one university hospital in Finland. A convenience sample of medication administration errors (n = 451) reported on incident reports or detected by reviewing randomly selected patient records via the Global Trigger Tool method and direct observations of patient record reviews were collected for reanalysis. The severity of the medication administration errors, the types thereof, and factors contributing to such errors were reclassified using the National Coordinating Council for Medication Error Reporting and Prevention's taxonomy of medication errors. The observational method revealed fewer medication errors that were more likely to cause harm to patients than did the incident reports or the Global Trigger Tool method. The incident reports and the Global Trigger Tool method mainly revealed wrong doses, whereas most medication administration errors in the observational data were errors involving the use of the incorrect technique. In addition, each method produced different information regarding the factors contributing to medication administration errors. Based on the study's findings and the limitations of each method, a combination of different methods should be used to discover representative information concerning medication administration errors. To increase medication administration safety, advanced multiprofessional collaboration, effective communication, adequate skills, more systematic medication processes, and distraction-free work environments are needed.
Full Text Available Introduction: Diagnostic errors have a natural complexity. Medical diagnoses make up a large proportion of all medical errors and cause much suffering and harm. Compared to other types of error, diagnostic errors receive little attention-a major factor in continuity of unacceptable rates of diagnostic error. Case: A 55-year-old woman presented to the emergency department (ED complaining of bone pain which has been started a month ago and increased gradually in the upper right thigh. Following the emergency evaluation she was sent home with pain medication. On the second visit, a femur neck fracture was seen in the x-ray. She underwent hemiarthroplasty and was discharged. Over several weeks she was reevaluated by many Physicians, because of her worsening pain .In the third visit after the surgery, her x-ray showed bone destruction and following bone biopsy, malignant paraganglioma was diagnosed. Discussion and solution: In all cases in which patient comes to us with skeletal pain, getting a comprehensive history and a full physical examination are prior to lab tests and x-rays. Bone metastasis which can develop severe pain and pathological fractures, is common in patients with malignant paraganglioma. Effective steps for diagnostic error prevention are: Considering the diagnostic error in the normal range of quality assurance surveillance and review, identifying the elements leading to diagnostic errors and getting feedback on the diagnoses Physicians make, in order to improve their skills. Conclusion: It is an every health system priority to identify, analyze, and prevent diagnostic errors in order to improve patient safety
Hansen, Richard A; Greene, Sandra B; Williams, Charlotte E; Blalock, Susan J; Crook, Kathleen D; Akers, Roger; Carey, Timothy S
Medication errors are an important problem in nursing homes, but little is known about the types of medications involved in errors in this setting. Gaining a better understanding of the types of medications commonly involved in medication errors in nursing homes would be an important step toward quality improvement. This study sought to describe the types of medication errors most frequently reported to a statewide repository by North Carolina nursing homes. We also examined whether nursing homes reporting an error involving a drug on the updated Beers list of medications considered potentially inappropriate for use in the elderly were likely to report a greater number of medication errors or more harmful medication errors compared with nursing homes that did not report such an error. Medication errors were defined as preventable events that had the potential to cause/lead to or actually caused/led to inappropriate medication use or patient harm. We analyzed summary reports of medication errors submitted to the State of North Carolina by licensed nursing homes for the 9-month period from January 1, 2004, to September 30, 2004, using a Web-based reporting system. Drugs commonly involved in medication errors were summarized for all nursing homes in the state. Errors involving medications on the updated Beers list also were identified. Nursing homes were profiled and compared according to the type of medication error and whether the error reached the patient and/or caused harm. Among the 384 licensed nursing homes included in our analysis, 9272 medication errors were reported. The specific medication involved was documented for 5986 of these errors. The medications most commonly involved in an error were lorazepam (457 errors [8%]), warfarin (349 [6%]), insulin (332 [6%]), hydrocodone and hydrocodone combinations (233 [4%]), furosemide (173 [3%]), and the fentanyl patch (150 [3%]). The medication errors disproportionately included central nervous system agents (16
Medical identity theft is a crime with two victims: patients and providers. It is easy to commit and lucrative because healthcare record keeping and business interactions are complex and mainly electronic. Patients whose identity has been stolen are vulnerable to both medical error and financial loss. Providers may suffer both reputation loss and financial loss. There are steps to help prevent and to respond appropriately to medical identity theft.
Conclusion: One of the effective methods for prevention of medication error is providing teaching courses for nurses to raise their knowledge in this regard and aware them of the outcomes of wrong medication prescription.
Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y
The primary goal of reducing medication errors is to eliminate those that reach the patient. We aimed to study the pattern of interceptions to tackle medication errors along the medication use processes. Tertiary care hospital in Hong Kong. The 'Swiss Cheese Model' was used to explain the interceptions targeting medication error reporting over 5 years (2006-2010). Proportions of prescribing, dispensing and drug administration errors intercepted by pharmacists and nurses; proportions of prescribing, dispensing and drug administration errors that reached the patient. Our analysis included 1,268 in-patient medication errors, of which 53.4% were related to prescribing, 29.0% to administration and 17.6% to dispensing. 34.1% of all medication errors (4.9% prescribing, 26.8% drug administration and 2.4% dispensing) were not intercepted. Pharmacy staff intercepted 85.4% of the prescribing errors. Nurses detected 83.0% of dispensing and 5.0% of prescribing errors. However, 92.4% of all drug administration errors reached the patient. Having a preventive measure at each stage of the medication use process helps to prevent most errors. Most drug administration errors reach the patient as there is no defense against these. Therefore, more interventions to prevent drug administration errors are warranted.
Rinke, Michael L; Bundy, David G; Velasquez, Christina A; Rao, Sandesh; Zerhouni, Yasmin; Lobner, Katie; Blanck, Jaime F; Miller, Marlene R
Medication errors cause appreciable morbidity and mortality in children. The objective was to determine the effectiveness of interventions to reduce pediatric medication errors, identify gaps in the literature, and perform meta-analyses on comparable studies. Relevant studies were identified from searches of PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Cumulative Index to Nursing Allied Health Literature and previous systematic reviews. Inclusion criteria were peer-reviewed original data in any language testing an intervention to reduce medication errors in children. Abstract and full-text article review were conducted by 2 independent authors with sequential data extraction. A total of 274 full-text articles were reviewed and 63 were included. Only 1% of studies were conducted at community hospitals, 11% were conducted in ambulatory populations, 10% reported preventable adverse drug events, 10% examined administering errors, 3% examined dispensing errors, and none reported cost-effectiveness data, suggesting persistent research gaps. Variation existed in the methods, definitions, outcomes, and rate denominators for all studies; and many showed an appreciable risk of bias. Although 26 studies (41%) involved computerized provider order entry, a meta-analysis was not performed because of methodologic heterogeneity. Studies of computerized provider order entry with clinical decision support compared with studies without clinical decision support reported a 36% to 87% reduction in prescribing errors; studies of preprinted order sheets revealed a 27% to 82% reduction in prescribing errors. Pediatric medication errors can be reduced, although our understanding of optimal interventions remains hampered. Research should focus on understudied areas, use standardized definitions and outcomes, and evaluate cost-effectiveness. Copyright © 2014 by the American Academy of Pediatrics.
Full Text Available Medication error is a major cause of morbidity and mortality in medical profession, and anaesthesia and critical care are no exception to it. Man, medicine, machine and modus operandi are the main contributory factors to it. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.
Leendertse, A.J.; Dijk, E.A. van; Smet, P.A.G.M. de; Egberts, T.C.; Bemt, P.M. van den
BACKGROUND: Medication errors and renal impairment contribute to severe adverse drug events, which may lead to hospital admission. OBJECTIVE: To determine whether medication errors and renal impairment contribute to hospital admission and examine these errors for strategies to prevent admissions.
An analysis was accomplished of all inpatient medication errors at a military academic medical center during the year 2000, based on the causes of medication errors as described by current research in the field...
There is evidence for a high prevalence of statistical reporting errors in psychology and other scientific fields. These errors display a systematic preference for statistically significant results, distorting the scientific literature. There are several possible causes for this systematic error
Full Text Available Desak Ketut Ernawati,1,2 Ya Ping Lee,2 Jeffery David Hughes21Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia; 2School of Pharmacy and Curtin Health Innovation and Research Institute, Curtin University, Perth, WA, AustraliaPurpose: To determine the nature and frequency of medication errors during medication delivery processes in a public teaching hospital geriatric ward in Bali, Indonesia.Methods: A 20-week prospective study on medication errors occurring during the medication delivery process was conducted in a geriatric ward in a public teaching hospital in Bali, Indonesia. Participants selected were inpatients aged more than 60 years. Patients were excluded if they had a malignancy, were undergoing surgery, or receiving chemotherapy treatment. The occurrence of medication errors in prescribing, transcribing, dispensing, and administration were detected by the investigator providing in-hospital clinical pharmacy services.Results: Seven hundred and seventy drug orders and 7,662 drug doses were reviewed as part of the study. There were 1,563 medication errors detected among the 7,662 drug doses reviewed, representing an error rate of 20.4%. Administration errors were the most frequent medication errors identified (59%, followed by transcription errors (15%, dispensing errors (14%, and prescribing errors (7%. Errors in documentation were the most common form of administration errors. Of these errors, 2.4% were classified as potentially serious and 10.3% as potentially significant.Conclusion: Medication errors occurred in every stage of the medication delivery process, with administration errors being the most frequent. The majority of errors identified in the administration stage were related to documentation. Provision of in-hospital clinical pharmacy services could potentially play a significant role in detecting and preventing medication errors.Keywords: geriatric, medication errors, inpatients, medication delivery process
Kamboj, Amrit K; Spiller, Henry A; Casavant, Marcel J; Hodges, Nichole L; Chounthirath, Thiphalak; Smith, Gary A
Prior studies have not examined national trends and characteristics of unintentional non-health care facility (HCF) medication errors associated with cardiovascular drugs. To investigate non-HCF medication errors associated with cardiovascular drugs reported to poison control centers in the United States. A retrospective analysis of non-HCF medication errors associated with cardiovascular drugs from 2000 to 2012 was conducted using the National Poison Data System database. There were 278 444 medication errors associated with cardiovascular drugs reported to US poison control centers during the study period, averaging 21 419 exposures annually. The overall rate of cardiovascular medication errors per 100 000 population increased 104.6% from 2000 to 2012 ( P medical outcomes were reported in 4.0% of exposures. The cardiovascular drugs most commonly implicated in medication errors were β-blockers (28.2%), calcium antagonists (17.7%), and angiotensin-converting enzyme inhibitors (15.9%). Most of the 114 deaths were associated with cardiac glycosides (47.4%) or calcium antagonists (29.8%). Most medication errors involved taking or being given a medication twice (52.6%). This study describes characteristics and trends of non-HCF cardiovascular medication errors over a 13-year period in the United States. The number and rate of cardiovascular medication errors increased steadily from 2000 to 2012, with the highest error rates among older adults. Further research is needed to identify prevention strategies for these errors, with a particular focus on the older adult population.
Ameer, Ahmed; Dhillon, Soraya; Peters, Mark J; Ghaleb, Maisoon
Medication administration is the last step in the medication process. It can act as a safety net to prevent unintended harm to patients if detected. However, medication administration errors (MAEs) during this process have been documented and thought to be preventable. In pediatric medicine, doses are usually administered based on the child's weight or body surface area. This in turn increases the risk of drug miscalculations and therefore MAEs. The aim of this review is to report MAEs occurring in pediatric inpatients. Twelve bibliographic databases were searched for studies published between January 2000 and February 2015 using "medication administration errors", "hospital", and "children" related terminologies. Handsearching of relevant publications was also carried out. A second reviewer screened articles for eligibility and quality in accordance with the inclusion/exclusion criteria. A total of 44 studies were systematically reviewed. MAEs were generally defined as a deviation of dose given from that prescribed; this included omitted doses and administration at the wrong time. Hospital MAEs in children accounted for a mean of 50% of all reported medication error reports (n=12,588). It was also identified in a mean of 29% of doses observed (n=8,894). The most prevalent type of MAEs related to preparation, infusion rate, dose, and time. This review has identified five types of interventions to reduce hospital MAEs in children: barcode medicine administration, electronic prescribing, education, use of smart pumps, and standard concentration. This review has identified a wide variation in the prevalence of hospital MAEs in children. This is attributed to the definition and method used to investigate MAEs. The review also illustrated the complexity and multifaceted nature of MAEs. Therefore, there is a need to develop a set of safety measures to tackle these errors in pediatric practice.
The incidence of medication errors in the NICU and paediatric wards at the teaching hospital was higher than values reported elsewhere globally. Most errors occur during prescribing and administration of medication. Dosing errors are a common problem in paediatrics. Therefore, a formalised system to record these errors ...
Taxis, K; Barber, N
Background: Intravenous (IV) medication errors are frequent events. They are associated with considerable harm, but little is known about their causes. Human error theory is increasingly used to understand adverse events in medicine, but has not yet been applied to study IV errors. Our aim was to investigate causes of errors in IV drug preparation and administration using a framework of human error theory.
Lobaugh, Lauren M Y; Martin, Lizabeth D; Schleelein, Laura E; Tyler, Donald C; Litman, Ronald S
Wake Up Safe is a quality improvement initiative of the Society for Pediatric Anesthesia that contains a deidentified registry of serious adverse events occurring in pediatric anesthesia. The aim of this study was to describe and characterize reported medication errors to find common patterns amenable to preventative strategies. In September 2016, we analyzed approximately 6 years' worth of medication error events reported to Wake Up Safe. Medication errors were classified by: (1) medication category; (2) error type by phase of administration: prescribing, preparation, or administration; (3) bolus or infusion error; (4) provider type and level of training; (5) harm as defined by the National Coordinating Council for Medication Error Reporting and Prevention; and (6) perceived preventability. From 2010 to the time of our data analysis in September 2016, 32 institutions had joined and submitted data on 2087 adverse events during 2,316,635 anesthetics. These reports contained details of 276 medication errors, which comprised the third highest category of events behind cardiac and respiratory related events. Medication errors most commonly involved opioids and sedative/hypnotics. When categorized by phase of handling, 30 events occurred during preparation, 67 during prescribing, and 179 during administration. The most common error type was accidental administration of the wrong dose (N = 84), followed by syringe swap (accidental administration of the wrong syringe, N = 49). Fifty-seven (21%) reported medication errors involved medications prepared as infusions as opposed to 1 time bolus administrations. Medication errors were committed by all types of anesthesia providers, most commonly by attendings. Over 80% of reported medication errors reached the patient and more than half of these events caused patient harm. Fifteen events (5%) required a life sustaining intervention. Nearly all cases (97%) were judged to be either likely or certainly preventable. Our findings
Hirata, Kristin M; Kang, Ann H; Ramirez, Gina V; Kimata, Chieko; Yamamoto, Loren G
An accurate weight is critical for dosing medications in children. Weight errors can lead to medication-dosing errors. This study examined the frequency and consequences of weight errors occurring at 1 children's hospital and 2 general hospitals. Using an electronic medical record database, 79,000 emergency department encounters of children younger than 5 years were analyzed. Extreme weights were first identified using weight percentiles. Encounters with potential weight errors were further evaluated using a retrospective chart review to determine whether a weight error and medication-dosing error occurred. The percentage of weight errors of total encounters at all 3 institutions was low (0.63% on average), but a large proportion of weight errors led to subsequent medication-dosing errors (34% on average). The children's hospital did not have clinically significantly lower occurrences of weight errors or weight-based medication errors. Common weight errors included the weight in pounds being substituted for the weight in kilograms and decimal placement errors. Weight errors were uncommon at the 3 emergency departments that we studied, but they led to weight-based medication-dosing errors that had the potential to cause harm.
Dehghan-Nayeri, Nahid; Bayat, Fariba; Salehi, Tahmineh; Faghihzadeh, Soghrat
Medication therapy is one of the most complex and high-risk clinical processes that nurses deal with. Medication error is the most common type of error that brings about damage and death to patients, especially pediatric ones. However, these errors are preventable. Identifying and preventing undesirable events leading to medication errors are the main risk management activities. The aim of this study was to investigate the effectiveness of a risk management program on the pediatric nurses' medication error rate. This study is a quasi-experimental one with a comparison group. In this study, 200 nurses were recruited from two main pediatric hospitals in Tehran. In the experimental hospital, we applied the risk management program for a period of 6 months. Nurses of the control hospital did the hospital routine schedule. A pre- and post-test was performed to measure the frequency of the medication error events. SPSS software, t-test, and regression analysis were used for data analysis. After the intervention, the medication error rate of nurses at the experimental hospital was significantly lower (P error-reporting rate was higher (P medical environment, applying the quality-control programs such as risk management can effectively prevent the occurrence of the hospital undesirable events. Nursing mangers can reduce the medication error rate by applying risk management programs. However, this program cannot succeed without nurses' cooperation.
Khoo Ee Ming
Full Text Available Abstract Background Patient safety is vital in patient care. There is a lack of studies on medical errors in primary care settings. The aim of the study is to determine the extent of diagnostic inaccuracies and management errors in public funded primary care clinics. Methods This was a cross-sectional study conducted in twelve public funded primary care clinics in Malaysia. A total of 1753 medical records were randomly selected in 12 primary care clinics in 2007 and were reviewed by trained family physicians for diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors. Results The majority of patient encounters (81% were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0 of medical records and management errors in 53.2% (95% CI: 46.3, 60.2. For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4 of records, investigation errors in 21.7% (95% CI: 16.5, 26.8 and decision making errors in 14.5% (95% CI: 10.8, 18.2. A total of 39.9% (95% CI: 33.1, 46.7 of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1 of records. Nearly all errors (93.5% detected were considered preventable. Conclusions The occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors.
Chamoun, Nibal R; Zeenny, Rony; Mansour, Hanine
Background Pharmacists' involvement in patient care has improved the quality of care and reduced medication errors. However, this has required a lot of work that could not have been accomplished without documentation of interventions. Several means of documenting errors have been proposed in the literature but without a consistent comprehensive process. Recently, the American College of Clinical Pharmacy (ACCP) recognized that pharmacy practice lacks a consistent process for direct patient care and discussed several options for a pharmaceutical care plan, essentially encompassing medication therapy assessment, development and implementation of a pharmaceutical care plan and finally evaluation of the outcome. Therefore, as per the recommendations of ACCP, we sought to retrospectively analyze interventions by grouping them according to medication related problems (MRP) and their nodes such as prescribing; administering; monitoring; documenting and dispensing. Objective The aim of this study is to report interventions according to medication error (ME) nodes and show the impact of pharmacy interventions in reducing MRPs. Setting The study was conducted at the cardiology and infectious diseases services at a teaching hospital located in Beirut, Lebanon. Methods Intervention documentation was completed by pharmacy students on infectious diseases and cardiology rotations then reviewed by clinical pharmacists with respective specialties. Before data analysis, a new pharmacy reporting sheet was developed in order to link interventions according to MRP. Then, MRPs were grouped in the five ME nodes. During the documentation process, whether MRP had reached the patient or not may have not been reported which prevented the classification to the corresponding medication error nodes as ME. Main outcome Reduction in medication related problems across all ME nodes. Results A total of n = 1174 interventions were documented. N = 1091 interventions were classified as MRPs
Hicks, Rodney W; Becker, Shawn C; Cousins, Diane D
Harmful pediatric medication errors are common in hospitals and health systems. Understanding what products are involved in these errors is important in the prevention of future errors. We used data from a voluntary medication error reporting system (MEDMARX) and identified 816 harmful outcomes involving 242 medications during a 5-year period. Eleven medications accounted for more than one third of reported errors (n = 261 or 34.5%). Wrong dosing and omission errors were common and were associated with therapeutic classes such as opioid analgesics (e.g., morphine and fentanyl), antimicrobial agents (e.g., vancomycin and gentamicin), and antidiabetic agents (e.g., insulin). Older commonly used agents still resulted in a substantial number of harmful pediatric medication errors and should be included in the focus of patient safety activities.
Martin, Lizabeth D; Grigg, Eliot B; Verma, Shilpa; Latham, Gregory J; Rampersad, Sally E; Martin, Lynn D
The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety. © 2017 John Wiley & Sons Ltd.
Alomari, Albara; Wilson, Val; Solman, Annette; Bajorek, Beata; Tinsley, Patricia
This study aims to outline the current workplace culture of medication practice in a pediatric medical ward. The objective is to explore the perceptions of nurses in a pediatric clinical setting as to why medication administration errors occur. As nurses have a central role in the medication process, it is essential to explore nurses' perceptions of the factors influencing the medication process. Without this understanding, it is difficult to develop effective prevention strategies aimed at reducing medication administration errors. Previous studies were limited to exploring a single and specific aspect of medication safety. The methods used in these studies were limited to survey designs which may lead to incomplete or inadequate information being provided. This study is phase 1 on an action research project. Data collection included a direct observation of nurses during medication preparation and administration, audit based on the medication policy, and guidelines and focus groups with nursing staff. A thematic analysis was undertaken by each author independently to analyze the observation notes and focus group transcripts. Simple descriptive statistics were used to analyze the audit data. The study was conducted in a specialized pediatric medical ward. Four key themes were identified from the combined quantitative and qualitative data: (1) understanding medication errors, (2) the busy-ness of nurses, (3) the physical environment, and (4) compliance with medication policy and practice guidelines. Workload, frequent interruptions to process, poor physical environment design, lack of preparation space, and impractical medication policies are identified as barriers to safe medication practice. Overcoming these barriers requires organizations to review medication process policies and engage nurses more in medication safety research and in designing clinical guidelines for their own practice.
Schnock, Kumiko O; Dykes, Patricia C; Albert, Jennifer; Ariosto, Deborah; Call, Rosemary; Cameron, Caitlin; Carroll, Diane L; Drucker, Adrienne G; Fang, Linda; Garcia-Palm, Christine A; Husch, Marla M; Maddox, Ray R; McDonald, Nicole; McGuire, Julie; Rafie, Sally; Robertson, Emilee; Saine, Deb; Sawyer, Melinda D; Smith, Lisa P; Stinger, Kristy Dixon; Vanderveen, Timothy W; Wade, Elizabeth; Yoon, Catherine S; Lipsitz, Stuart; Bates, David W
Intravenous medication errors persist despite the use of smart pumps. This suggests the need for a standardised methodology for measuring errors and highlights the importance of identifying issues around smart pump medication administration in order to improve patient safety. We conducted a multisite study to investigate the types and frequency of intravenous medication errors associated with smart pumps in the USA. 10 hospitals of various sizes using smart pumps from a range of vendors participated. Data were collected using a prospective point prevalence approach to capture errors associated with medications administered via smart pumps and evaluate their potential for harm. A total of 478 patients and 1164 medication administrations were assessed. Of the observed infusions, 699 (60%) had one or more errors associated with their administration. Identified errors such as labelling errors and bypassing the smart pump and the drug library were predominantly associated with violations of hospital policy. These types of errors can result in medication errors. Errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). 1 error of category E (0.1%), 4 of category D (0.3%) and 492 of category C (excluding deviations of hospital policy) (42%) were identified. Of these, unauthorised medication, bypassing the smart pump and wrong rate were the most frequent errors. We identified a high rate of error in the administration of intravenous medications despite the use of smart pumps. However, relatively few errors were potentially harmful. The results of this study will be useful in developing interventions to eliminate errors in the intravenous medication administration process. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
Okamoto, Sawako; Kawahara, Kazuo; Algren, Margaret
This study examines perceptions of persons who experienced a medical error and elements that may serve to open communication with those who experienced a medical error in Japan. Survey of individuals who reported a previous medical error in their care and those who did not. Tokyo, Osaka and Nagoya metropolitan areas, and in Fukuoka, Shimane and Miyagi rural townships in Japan. Questionnaires were distributed to 80 people who had experienced a medical error and 300 people who had not. Prevalence of views, expectations and psychological needs regarding medical error. Forty (50%) questionnaires from those who experienced the errors and 201 (67%) from those who did not experience a medical error were completed. Among those who experienced error, 95% (38/40) preferred to be informed of a medical error immediately by senior personnel (57.7%: 23/40). Those who had not experienced error preferred to be informed by a directly responsible provider (87.6%: 176/201). The perception differences regarding who should break bad news showed statistical significance (Pmedical error by senior medical personnel and medical providers should create an environment to continue 'communication' in order to accommodate shifting perspectives of those who experienced the error.
Hicks, Rodney W; Becker, Shawn C
Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes-product shortage, calculation errors, and tubing interconnectivity-emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.
Full Text Available Abstract Background Older people in long-term residential care are at increased risk of medication prescribing and administration errors. The main aim of this study was to measure the incidence of medication administration errors in nursing and residential homes using a barcode medication administration (BCMA system. Methods A prospective study was conducted in 13 care homes (9 residential and 4 nursing. Data on all medication administrations for a cohort of 345 older residents were recorded in real-time using a disguised observation technique. Every attempt by social care and nursing staff to administer medication over a 3-month observation period was analysed using BCMA records to determine the incidence and types of potential medication administration errors (MAEs and whether errors were averted. Error classifications included attempts to administer medication at the wrong time, to the wrong person or discontinued medication. Further analysis compared data for residential and nursing homes. In addition, staff were surveyed prior to BCMA system implementation to assess their awareness of administration errors. Results A total of 188,249 medication administration attempts were analysed using BCMA data. Typically each resident was receiving nine different drugs and was exposed to 206 medication administration episodes every month. During the observation period, 2,289 potential MAEs were recorded for the 345 residents; 90% of residents were exposed to at least one error. The most common (n = 1,021, 45% of errors was attempting to give medication at the wrong time. Over the 3-month observation period, half (52% of residents were exposed to a serious error such as attempting to give medication to the wrong resident. Error incidence rates were 1.43 as high (95% CI 1.32-1.56 p Conclusions The incidence of medication administration errors is high in long-term residential care. A barcode medication administration system can capture medication
Taib, Ibrahim Adham; McIntosh, Andrew Stuart
A reliable database on the causes and contributing factors of medication errors can inform strategies for their prevention. To form a single database from multiple databases requires a process of integration that both maximizes the utility of the new data and minimizes the loss of information. Unfortunately, the terminologies used by different studies and databases may limit integration; therefore, terminologies must be standardized prior to integration. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Taxonomy of Medication Errors was applied to standardize the different terminologies in 11 studies that reported the causes or contributing factors of medication errors. After standardization, 57% of the reported causes and contributing factors were integrated to form a database while 43% were not integrated because the terminologies could not be standardized or were not similar to the taxonomy. This study highlights the challenges to standardizing and integrating databases and the importance of adopting and applying a standardized terminology to record medical errors.
Full Text Available Ahmed Ameer,1 Soraya Dhillon,1 Mark J Peters,2 Maisoon Ghaleb11Department of Pharmacy, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK; 2Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK Objective: Medication administration is the last step in the medication process. It can act as a safety net to prevent unintended harm to patients if detected. However, medication administration errors (MAEs during this process have been documented and thought to be preventable. In pediatric medicine, doses are usually administered based on the child's weight or body surface area. This in turn increases the risk of drug miscalculations and therefore MAEs. The aim of this review is to report MAEs occurring in pediatric inpatients. Methods: Twelve bibliographic databases were searched for studies published between January 2000 and February 2015 using “medication administration errors”, “hospital”, and “children” related terminologies. Handsearching of relevant publications was also carried out. A second reviewer screened articles for eligibility and quality in accordance with the inclusion/exclusion criteria. Key findings: A total of 44 studies were systematically reviewed. MAEs were generally defined as a deviation of dose given from that prescribed; this included omitted doses and administration at the wrong time. Hospital MAEs in children accounted for a mean of 50% of all reported medication error reports (n=12,588. It was also identified in a mean of 29% of doses observed (n=8,894. The most prevalent type of MAEs related to preparation, infusion rate, dose, and time. This review has identified five types of interventions to reduce hospital MAEs in children: barcode medicine administration, electronic prescribing, education, use of smart pumps, and standard concentration. Conclusion: This review has identified a wide variation in the prevalence of hospital MAEs in children. This is attributed to
Sung, Chanho; Kim, Younggab; Joung, Sanghoun
Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses
Rinke, Michael L; Shore, Andrew D; Morlock, Laura; Hicks, Rodney W; Miller, Marlene R
Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors. The authors queried the United States Pharmacopeia MEDMARX database, a national, voluntary, Internet-accessible error reporting system, for all error reports from 1999 through 2004 that involved chemotherapy medications and patients aged error reports, 85% reached the patient, and 15.6% required additional patient monitoring or therapeutic intervention. Forty-eight percent of errors originated in the administering phase of medication delivery, and 30% originated in the drug-dispensing phase. Of the 387 medications cited, 39.5% were antimetabolites, 14.0% were alkylating agents, 9.3% were anthracyclines, and 9.3% were topoisomerase inhibitors. The most commonly involved chemotherapeutic agents were methotrexate (15.3%), cytarabine (12.1%), and etoposide (8.3%). The most common error types were improper dose/quantity (22.9% of 327 cited error types), wrong time (22.6%), omission error (14.1%), and wrong administration technique/wrong route (12.2%). The most common error causes were performance deficit (41.3% of 547 cited error causes), equipment and medication delivery devices (12.4%), communication (8.8%), knowledge deficit (6.8%), and written order errors (5.5%). Four of the 5 most serious errors occurred at community hospitals. Pediatric chemotherapy errors often reached the patient, potentially were harmful, and differed in quality between outpatient and inpatient areas. This study indicated which chemotherapeutic agents most often were involved in errors and that administering errors were common. Investigation is needed regarding targeted medication administration safeguards for these high-risk medications. Copyright (c) 2007 American Cancer Society.
Jember, Abebaw; Hailu, Mignote; Messele, Anteneh; Demeke, Tesfaye; Hassen, Mohammed
A medication error (ME) is any preventable event that may cause or lead to inappropriate medication use or patient harm. Voluntary reporting has a principal role in appreciating the extent and impact of medication errors. Thus, exploration of the proportion of medication error reporting and associated factors among nurses is important to inform service providers and program implementers so as to improve the quality of the healthcare services. Institution based quantitative cross-sectional study was conducted among 397 nurses from March 6 to May 10, 2015. Stratified sampling followed by simple random sampling technique was used to select the study participants. The data were collected using structured self-administered questionnaire which was adopted from studies conducted in Australia and Jordan. A pilot study was carried out to validate the questionnaire before data collection for this study. Bivariate and multivariate logistic regression models were fitted to identify factors associated with the proportion of medication error reporting among nurses. An adjusted odds ratio with 95% confidence interval was computed to determine the level of significance. The proportion of medication error reporting among nurses was found to be 57.4%. Regression analysis showed that sex, marital status, having made a medication error and medication error experience were significantly associated with medication error reporting. The proportion of medication error reporting among nurses in this study was found to be higher than other studies.
Zeleke, Abebe; Chanie, Tesfahun; Woldie, Mirkuzie
Medication error is common and preventable cause of medical errors and occurs as a result of either human error or a system flaw. The consequences of such errors are more harmful and frequent among pediatric patients. To assess medication prescribing errors and associated factors in the pediatric wards of Dessie Referral Hospital, Northeast Ethiopia. A cross-sectional study was carried out in the pediatric wards of Dessie Referral Hospital from February 17 to March 17, 2012. Data on the prescribed drugs were collected from patient charts and prescription papers among all patients who were admitted during the study period. Descriptive statistics was used to determine frequency, prevalence, means, and standard deviations. The relationship between dependent and independent variables were computed using logistic regression (with significance declared at p-value of 0.05 and 95% confidence interval). Out of the 384 Medication order s identified during the study, a total of 223 prescribing errors were identified. This corresponds to an overall medication prescribing error rate of 58.07%. Incomplete prescriptions and dosing errors were the two most common types of prescribing errors. Antibiotics (54.26%) were the most common classes of drugs subjected to prescribing error. Day of the week and route of administration were factors significantly associated with increased prescribing error. Medication prescribing errors are common in the pediatric wards of Dessie Referral Hospital. Improving quick access to up to date reference materials, providing regular refresher trainings and possibly including a clinical pharmacist in the healthcare team are recommended.
van der Veen, Willem; van den Bemt, Patricia M L A; Wouters, Hans; Bates, David W; Twisk, Jos W R; de Gier, Johan J; Taxis, Katja
Objective: To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors. Materials and Methods: A prospective observational study in
Gariel, C; Cogniat, B; Desgranges, F-P; Chassard, D; Bouvet, L
Medication errors are not uncommon in hospitalized patients. Paediatric patients may have increased risk for medication errors related to complexity of weight-based dosing calculations or problems with drug preparation and dilution. This study aimed to determine the incidence of medication errors in paediatric anaesthesia in a university paediatric hospital, and to identify their characteristics and potential predictive factors. This prospective incident monitoring study was conducted between November 2015 and January 2016 in an exclusively paediatric surgical centre. Children medication error (2.6%). Drugs most commonly involved in medication errors were opioids and antibiotics. Incorrect dose was the most frequently reported type of error (n=27, 67.5%), with dilution error involved in 7/27 (26%) cases of incorrect dose. Duration of procedure >120 min was the only factor independently associated with medication error [adjusted odds ratio: 4 (95% confidence interval: 2-8); P=0.0001]. Medication errors are not uncommon in paediatric anaesthesia. Identification of the mechanisms related to medication errors might allow preventive measures that can be assessed in further studies. Copyright © 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
Desai, Rishi J; Williams, Charlotte E; Greene, Sandra B; Pierson, Stephanie; Caprio, Anthony J; Hansen, Richard A
involved in medication errors in nursing home patients regardless of the extent of their use. The drug classes frequently and disproportionately involved in errors in nursing homes include anxiolytics/sedatives/hypnotics, antidiabetic agents, anticoagulants, anticonvulsants, and ophthalmic preparations. Better understanding of the causes and prevention strategies to reduce these errors may improve nursing home patient safety. Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.
Nguyen, Minh-Nha Rhylie; Mosel, Cassandra; Grzeskowiak, Luke E
Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors. A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and reference-list checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting. A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology ( n = 38; e.g. electronic prescribing), organizational ( n = 16; e.g. guidelines, policies, and procedures), personnel ( n = 13; e.g. staff education), pharmacy ( n = 9; e.g. clinical pharmacy service), hazard and risk analysis ( n = 8; e.g. error detection tools), and multifactorial ( n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50-70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors. While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the
Risør, Bettina Wulff; Lisby, Marianne; Sørensen, Jan
The objective of this study was to evaluate the effectiveness of two automated medication systems in reducing medication administration errors. The study was a controlled before-and-after study and included three observation periods with collection of data during a 3-week period as initial baseline and two subsequent follow-up periods at 10 and 20 months. The study was conducted in two Danish acute medical units. Two automated medication systems were implemented: (i) a complex automated medication system (cAMS) consisting of an automated dispensing cabinet, automated unit-dose dispensing and barcode medication administration (BCMA) and (ii) a non-patient-specific automated medication system (npsAMS) consisting of automated unit-dose dispensing and BCMA. The occurrence of administration errors and sub-types; procedural and clinical errors were observed. The proportion of errors was calculated by dividing the number of doses with one or more errors with the number of opportunities for errors. Difference-in-difference analysis using logistic regression was used to assess changes in proportion of errors. Compared with control, the cAMS reduced the overall risk of administration errors in the intervention unit, (odds ratio (OR) 0.53; 95% confidence interval (CI) 0.27-0.90) and procedural errors were significantly reduced as well (OR 0.44; 95% CI 0.126-0.94). The npsAMS effectively reduced the clinical errors in the intervention ward (OR 0.38; 95% CI 0.15-0.96). In line with previous research, this study found that technological interventions in the medication administration process could reduce the occurrence of medication errors.
Kunac, Desireé L; Tatley, Michael V
Despite the traditional focus being adverse drug reactions (ADRs), pharmacovigilance centres have recently been identified as a potentially rich and important source of medication error data. To identify medication errors in the New Zealand Pharmacovigilance database (Centre for Adverse Reactions Monitoring [CARM]), and to describe the frequency and characteristics of these events. A retrospective analysis of the CARM pharmacovigilance database operated by the New Zealand Pharmacovigilance Centre was undertaken for the year 1 January-31 December 2007. All reports, excluding those relating to vaccines, clinical trials and pharmaceutical company reports, underwent a preventability assessment using predetermined criteria. Those events deemed preventable were subsequently classified to identify the degree of patient harm, type of error, stage of medication use process where the error occurred and origin of the error. A total of 1412 reports met the inclusion criteria and were reviewed, of which 4.3% (61/1412) were deemed preventable. Not all errors resulted in patient harm: 29.5% (18/61) were 'no harm' errors but 65.5% (40/61) of errors were deemed to have been associated with some degree of patient harm (preventable adverse drug events [ADEs]). For 5.0% (3/61) of events, the degree of patient harm was unable to be determined as the patient outcome was unknown. The majority of preventable ADEs (62.5% [25/40]) occurred in adults aged 65 years and older. The medication classes most involved in preventable ADEs were antibacterials for systemic use and anti-inflammatory agents, with gastrointestinal and respiratory system disorders the most common adverse events reported. For both preventable ADEs and 'no harm' events, most errors were incorrect dose and drug therapy monitoring problems consisting of failures in detection of significant drug interactions, past allergies or lack of necessary clinical monitoring. Preventable events were mostly related to the prescribing and
Ozkan, Suzan; Kocaman, Gulseren; Ozturk, Candan; Seren, Seyda
This study examined the frequency of pediatric medication administration errors and contributing factors. This research used the undisguised observation method and Critical Incident Technique. Errors and contributing factors were classified through the Organizational Accident Model. Errors were made in 36.5% of the 2344 doses that were observed. The most frequent errors were those associated with administration at the wrong time. According to the results of this study, errors arise from problems within the system.
Stheneur, C; Armengaud, J-B; Castro, C; Chéron, G; Chevallier, B
To improve the knowledge of medication errors in paediatrics: rate of occurrence, error characteristics, risk factors. Our prospective study included nine uninformed teaching paediatric wards (general paediatrics, emergency departments, intensive care units) using a describing questionnaire built from medical reports analysis (event description, medical issues, contributing personal and structural factors) during a two-months period. Seventy-five questionnaires were collected and analysed. Medical errors reported concerned prescription: 21 cases and administration: 45 cases. Ten errors led to adverse effects. An attributable factor was noted in 39 cases. Concerning prescription errors, no respect to protocol: 11 cases, lack of knowledge: 3 cases, personal communication failure: 3 cases were noted. Concerning administration errors, human mistakes (lack of experience, miscommunication, calculation error): 8 cases, unclear prescription: 6 cases and system flaws: 6 cases were noted. Several attribuable causes were reported in 8 cases. Medication errors in paediatrics inpatients are common and contributing factors intricated. Paediatricians should help hospitals develop effective programs for safety providing medications, reporting medication errors, errors analysis strategy and creating a safe environment of medication for all hospitalised paediatric patients.
Hammoudi, Baraa M; Ismaile, Samantha; Abu Yahya, Omar
Patient safety is a significant challenge facing healthcare systems. The administration of medication is pivotal to patient safety, and errors in drug administration are associated with mortality and morbidity. In this study, we assessed the factors contributing to the occurrence and reporting of medication errors from the nurse's perspective. In this descriptive cross-sectional study, we distributed a validated questionnaire to 367 nurses at a large public hospital and obtained a response rate of 73.4%. The questionnaire comprised 65 questions, including 29 on the causes of medication errors, 16 on the reasons why medication errors are not reported and 20 that estimated the percentages of the different medication errors actually reported. Informed consent was obtained from all participants, and the anonymity and confidentiality of participants' information were preserved throughout the process. This study received institutional review board approval. Descriptive statistics were used for data analysis. The main factors associated with medication errors by nurses were related to medication packaging, nurse-physician communication, pharmacy processes, nurse staffing and transcribing issues. The main barriers to the reporting of errors by nurses were related to the administrative response, fear of reporting and disagreements regarding the definitions of errors. Medication errors by nurses are related to medication packaging, poor communication, unclear medication orders, workload and staff rotation. To prevent medication errors, teamwork must be improved. All healthcare settings should emphasise awareness of the culture of safety, provide support and guidance to nurses and improve communication skills. We also recommend the use of integrated health informatics, including computerised drug administration systems. The limitations of this study include the potential for nonresponse bias associated with the sampling method. Further research is required to explore the
Full Text Available Software defect prevention is an important way to reduce the defect introduction rate. As the primary cause of software defects, human error can be the key to understanding and preventing software defects. This paper proposes a defect prevention approach based on human error mechanisms: DPeHE. The approach includes both knowledge and regulation training in human error prevention. Knowledge training provides programmers with explicit knowledge on why programmers commit errors, what kinds of errors tend to be committed under different circumstances, and how these errors can be prevented. Regulation training further helps programmers to promote the awareness and ability to prevent human errors through practice. The practice is facilitated by a problem solving checklist and a root cause identification checklist. This paper provides a systematic framework that integrates knowledge across disciplines, e.g., cognitive science, software psychology and software engineering to defend against human errors in software development. Furthermore, we applied this approach in an international company at CMM Level 5 and a software development institution at CMM Level 1 in the Chinese Aviation Industry. The application cases show that the approach is feasible and effective in promoting developers’ ability to prevent software defects, independent of process maturity levels.
Full Text Available BACKGROUND Medical error is a continuing global phenomenon. It represents an important public health problem that poses a serious threat to patient safety. Since the time when doctors had been blindly trusted for their clinical acumen, in recent times most of them have been frequently questioned on all aspects of patients’ care clearly indicating that in certain circumstances, even their motives are not beyond reproach. OBJECTIVE To assess the frequency of the medical errors and to devise workable solutions and prevention strategies in Saudi Arabia. METHODOLOGY This paper critically reviews the literature on medical error, data compiled from Medico-Legal Committee (MLC of Ministry of Health (MOH portal, of different regions of Kingdom of Saudi Arabia and to identify key sources of errors in primary care. CONCLUSION A critical approach to bringing wide ranging changes in medical education, communication skills and evidence based practice that can reduce the risk of errors and adverse outcomes in patient care. There is a growing public perception that serious medical error is commonplace and largely tolerased by the medical profession. The Government and Medical establishments’ response to this perceived epidemic of error has included tighter controls over practicing doctors and individual stick-and-carrot reforms of medical practice. There is a growing public perception that serious medical error is commonplace and largely tolerated by the medical profession.
Full Text Available Background: To prevent medication errors in prescribing, one needs to know their types and relative occurrence. Such errors are a great cause of concern as they have the potential to cause patient harm. The aim of this study was to determine the nature and types of medication prescribing errors in an Indian setting.Methods: The medication errors were analyzed in a prospective observational study conducted in 3 medical wards of a public teaching hospital in India. The medication errors were analyzed by means of Micromedex Drug-Reax database.Results: Out of 312 patients, only 304 were included in the study. Of the 304 cases, 103 (34% cases had at least one error. The total number of errors found was 157. The drug-drug interactions were the most frequently (68.2% occurring type of error, which was followed by incorrect dosing interval (12% and dosing errors (9.5%. The medication classes involved most were antimicrobial agents (29.4%, cardiovascular agents (15.4%, GI agents (8.6% and CNS agents (8.2%. The moderate errors contributed maximum (61.8% to the total errors when compared to the major (25.5% and minor (12.7% errors. The results showed that the number of errors increases with age and number of medicines prescribed.Conclusion: The results point to the establishment of medication error reporting at each hospital and to share the data with other hospitals. The role of clinical pharmacist in this situation appears to be a strong intervention; and the clinical pharmacist, initially, could confine to identification of the medication errors.
Cheragi, Mohammad Ali; Manoocheri, Human; Mohammadnejad, Esmaeil; Ehsani, Syyedeh R
The main professional goal of nurses is to provide and improve human health. Medication errors are among the most common health threatening mistakes that affect patient care. Such mistakes are considered as a global problem which increases mortality rates, length of hospital stay, and related costs. This study was conducted to evaluate the types and causes of nursing medication errors. This cross-sectional study was conducted in 2009. A total number of 237 nurses were randomly selected from nurses working in Imam Khomeini Hospital (Tehran, Iran). They filled out a questionnaire including 10 items on demographic characteristics and 7 items about medication errors. Data were analyzed using descriptive and inferential statistics in SPSS for Windows 16.0. Medication errors had been made by 64.55% of the nurses. In addition, 31.37% of the participants reported medication errors on the verge of occurrence. The most common types of reported errors were wrong dosage and infusion rate. The most common causes were using abbreviations instead of full names of drugs and similar names of drugs. Therefore, the most important cause of medication errors was lack of pharmacological knowledge. There were no statistically significant relationships between medication errors and years of working experience, age, and working shifts. However, a significant relationship was found between errors in intravenous injections and gender. Likewise, errors in oral administration were significantly related with number of patients. Medication errors are a major problem in nursing. Since most cases of medication errors are not reported by nurses, nursing managers must demonstrate positive responses to nurses who report medication errors in order to improve patient safety.
Full Text Available The aim of this qualitative study was to determine the most important medical errors made by gynecology residents. This study used a Delphi technique in three rounds. First, a list of common errors was prepared using a questionnaire, then the most important errors were prioritized and finally, the managerial and training procedures were determined for errors. In this study, 45 common errors were detected. The most common errors were inadequate surgical homeostasis, excessive use of magnesium sulfate, managerial error of post-operative infections; undiagnosed pulmonary embolism and incorrect prescription of heparin. Specialists and residents stated that designing an instructional guideline was the best method to manage all kinds of errors. Different regulatory and training procedures should be applied to prevent and control errors. An effective method for professional practitioners is designing instructional guidelines. In this study, an instructional manual was developed for the most frequent errors observed in obstetrics and gynecology.
Kooienga, Sarah; Stewart, Valerie T
Knowledge of the patient's perspective on medical error is limited. Research efforts have centered on how best to disclose error and how patients desire to have medical error disclosed. On the basis of a qualitative descriptive component of a mixed method study, a purposive sample of 30 community members told their stories of medical error. Their experiences focused on lack of communication, missed communication, or provider's poor interpersonal style of communication, greatly contrasting with the formal definition of error as failure to follow a set standard of care. For these participants, being a patient was more important than error or how an error is disclosed. The patient's understanding of error must be a key aspect of any quality improvement strategy. © 2010 National Association for Healthcare Quality.
Bradley, Corey K; Fischer, Melissa A; Walsh, Kathleen E
The Institute of Medicine has called for physician education as a key step in medical error prevention. In our 2002 national survey, pediatric resident education about medical error prevention was sporadic. We sought to describe the amount and type of pediatric resident training about medical errors and to assess the change in training since 2002. We surveyed a national sample of 50 pediatric chief residents randomly selected from the 198 Accreditation Council for Graduate Medical Education-accredited residency programs from August to November 2010. The 31-item telephone survey was developed from the 2002 survey, with the addition of 10 items about electronic learning and resident quality improvement projects. The survey included 4 domains: current patient safety curriculum, chief resident knowledge, learning from medical errors, and demographics. We phoned 55 chief residents and contacted 51. Fifty participated (90% participation rate). Ninety-four percent of chief residents stated that their program had a formalized curriculum to discuss medical errors, compared to only 50% (P medical error should be systemic change. The primary method for educating residents about medical error reported was informal teaching. Ninety-two percent reported never or rarely discussing medical error in an outpatient setting. Seventy-four percent of chief residents reported that they never or rarely learn from an error made by an attending physician, and 50% never or rarely learned from an error made by a fellow resident. Although resident education about medical errors has improved since 2002, opportunities to model learning from mistakes are frequently missed. Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
Walsh, Kathleen E; Roblin, Douglas W; Weingart, Saul N; Houlahan, Kathleen E; Degar, Barbara; Billett, Amy; Keuker, Christopher; Biggins, Colleen; Li, Justin; Wasilewski, Karen; Mazor, Kathleen M
As home medication use increases, medications previously managed by nurses are now managed by patients and their families. Our objective was to describe the types of errors occurring in the home medication management of children with cancer. In a prospective observational study at 3 pediatric oncology clinics in the northeastern and southeastern United States, patients undergoing chemotherapy and their parents were recruited from November 2007 through April 2011. We reviewed medical records and checked prescription doses. A trained nurse visited the home, reviewed medication bottles, and observed administration. Two physicians independently made judgments regarding whether an error occurred and its severity. Overall rates of errors were weighted to account for clustering within sites. We reviewed 963 medications and observed 242 medication administrations in the homes of 92 patients. We found 72 medication errors. Four errors led to significant patient injury. An additional 40 errors had potential for injury: 2 were life-threatening, 13 were serious, and 25 were significant. Error rates varied between study sites (40-121 errors per 100 patients); the weighted overall rate was 70.2 errors per 100 patients (95% confidence interval [CI]: 58.9-81.6). The weighted rate of errors with injury was 3.6 (95% CI: 1.7-5.5) per 100 patients and with potential to injure the patient was 36.3 (95% CI: 29.3-43.3) per 100 patients. Nonchemotherapy medications were more often involved in an error than chemotherapy. Medication errors were common in this multisite study of outpatient pediatric cancer care. Rates of preventable medication-related injuries in this outpatient population were comparable or higher than those found in studies of hospitalized patients.
Stroobants, A. K.; Goldschmidt, H. M. J.; Plebani, M.
Background: Random, systematic and sporadic errors, which unfortunately are not uncommon in laboratory medicine, can have a considerable impact on the well being of patients. Although somewhat difficult to attain, our main goal should be to prevent all possible errors. A good insight on error-prone
Baril, Chantal; Gascon, Viviane; St-Pierre, Liette; Lagacé, Denis
The purpose of this paper is to study a medication distribution technology's (MDT) impact on medication errors reported in public nursing homes in Québec Province. The work was carried out in six nursing homes (800 patients). Medication error data were collected from nursing staff through a voluntary reporting process before and after MDT was implemented. The errors were analysed using: totals errors; medication error type; severity and patient consequences. A statistical analysis verified whether there was a significant difference between the variables before and after introducing MDT. The results show that the MDT detected medication errors. The authors' analysis also indicates that errors are detected more rapidly resulting in less severe consequences for patients. MDT is a step towards safer and more efficient medication processes. Our findings should convince healthcare administrators to implement technology such as electronic prescriber or bar code medication administration systems to improve medication processes and to provide better healthcare to patients. Few studies have been carried out in long-term healthcare facilities such as nursing homes. The authors' study extends what is known about MDT's impact on medication errors in nursing homes.
Itri, Jason N; Patel, Sohil H
The field of cognitive science has provided important insights into mental processes underlying the interpretation of imaging examinations. Despite these insights, diagnostic error remains a major obstacle in the goal to improve quality in radiology. In this article, we describe several types of cognitive bias that lead to diagnostic errors in imaging and discuss approaches to mitigate cognitive biases and diagnostic error. Radiologists rely on heuristic principles to reduce complex tasks of assessing probabilities and predicting values into simpler judgmental operations. These mental shortcuts allow rapid problem solving based on assumptions and past experiences. Heuristics used in the interpretation of imaging studies are generally helpful but can sometimes result in cognitive biases that lead to significant errors. An understanding of the causes of cognitive biases can lead to the development of educational content and systematic improvements that mitigate errors and improve the quality of care provided by radiologists.
Chapuis, Claire; Roustit, Matthieu; Bal, Gaëlle; Schwebel, Carole; Pansu, Pascal; David-Tchouda, Sandra; Foroni, Luc; Calop, Jean; Timsit, Jean-François; Allenet, Benoît; Bosson, Jean-Luc; Bedouch, Pierrick
We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction. Preintervention and postintervention study involving a control and an intervention medical intensive care unit. Two medical intensive care units in the same department of a 2,000-bed university hospital. Adult medical intensive care patients. After a 2-month observation period, we implemented an automated dispensing system in one of the units (study unit) chosen randomly, with the other unit being the control. The overall error rate was expressed as a percentage of total opportunities for error. The severity of errors was classified according to National Coordinating Council for Medication Error Reporting and Prevention categories by an expert committee. User satisfaction was assessed through self-administered questionnaires completed by nurses. A total of 1,476 medications for 115 patients were observed. After automated dispensing system implementation, we observed a reduced percentage of total opportunities for error in the study compared to the control unit (13.5% and 18.6%, respectively; perror (20.4% and 13.5%; perror showed a significant impact of the automated dispensing system in reducing preparation errors (perrors caused no harm (National Coordinating Council for Medication Error Reporting and Prevention category C). The automated dispensing system did not reduce errors causing harm. Finally, the mean for working conditions improved from 1.0±0.8 to 2.5±0.8 on the four-point Likert scale. The implementation of an automated dispensing system reduced overall medication errors related to picking, preparation, and administration of drugs in the intensive care unit. Furthermore, most nurses favored the new drug dispensation organization.
Ghalandarpoorattar, Seyedeh Mojgan; Kaviani, Ahmad; Asghari, Fariba
This study aims to evaluate the attending surgeons' and residents' attitudes towards error disclosure and factors that can potentially affect these tendencies in major academic hospitals affiliated with Tehran University of Medical Sciences (TUMS). In a cross-sectional study, self-administered questionnaires were delivered to all attending surgeons and second to fourth year surgical residents of TUMS during October and November 2009. The questionnaire contained two clinical scenarios and questions regarding physicians' attitudes towards disclosing medical error and their actual practice in the case of their last error. Of the 63 distributed questionnaires, 53 (84.1%) were completed and returned. Participants were less likely to disclose minor (39.6%; 21/53) than major (49.1%; 29/53) medical errors. Participants believed that their most important concerns for not disclosing errors were fear of a malpractice lawsuit (71.7%, n=38), losing patients' trust (62.3%, n=33), and emotional reactions of the patients and their relatives (56.6%, n=30). Although most physicians indicated they would disclose errors in minor and major scenarios, only 16.7% (n=8) had disclosed their last medical errors to their patients, two of which had resulted in patients taking legal action. There was an obvious gap between surgeons' intentions and actual practices concerning disclosure of medical error. Education in medical error management to professionally support error disclosure might help reduce the gap.
... errors do occur in the everyday practice of anesthetists in Nigeria as in other countries and can lead to morbidity and mortality in our patients. Routine audit and reporting of critical incidents including errors in drug administration should be encouraged. Reduction of medication errors is an important aspect of patient safety, ...
Worldwide, a large number of children are prescribed drugs on an outpatient basis. Medication errors are fairly common in these settings. Though this matter has been well recognized as a cause of concern, limited data is available from ambulatory settings. Medication errors can be defined as errors that may occur at any step, starting from ordering a medication, to dispensing, administration of the drug and the subsequent monitoring. The outcomes of such errors are variable and may range between those that are clinically insignificant to a life-threatening event. The reasons for these medication errors are multi-factorial. Children are unable to administer medications to themselves and also require a strict weight-based dosing regimen. The risk factors associated with medication errors include complex regimens with multiple medications. Overdosing and under-dosing (10-fold calculation errors), an increased or a decreased frequency of dosing or an inappropriate duration of administration of the medication, are frequently detected errors. The lack of availability of proper formulations adds to the confusion. The low level of literacy among the caregivers can aggravate this problem. There is a lack of proper reporting and monitoring mechanisms in most ambulatory settings, hence these errors remain unrecognized and often go unreported. This article summarizes the current available literature on medication errors in ambulatory settings and the possible strategies that can be adopted to reduce the burden of these errors in order to improve child care and patient safety. Voluntary, anonymous reporting can be introduced in the healthcare institutions to determine the incidence of these errors.
Pazokian, M; Zagheri Tafreshi, M; Rassouli, M
Medical errors are one of the major threats for patient safety in all countries. Medication errors are common medical mistakes that can lead to serious consequences and even death of patients. The aim of this study was to explore nurses' perspectives of factors influencing medication errors. This qualitative study based on content analysis included 20 nurses (n = 20) with at least 2 years of clinical experience working in a large teaching hospital. The nurses were selected using purposeful sampling. The data were collected using semi-structured interviews and analysed using deductive content analysis approach based on Reason's human error model. Rigor of the data was confirmed by external and member check. Two themes were identified by the participants: (1) the individual approach including personal and psychological characteristics of nurses, patient medical history and physicians' orders errors; and (2) the cultural and organizational approach including workplace conditions, learning process, risk management strategies, nurses' pharmacological knowledge, inevitable nursing errors and medication error complications. Concern about the potential consequences related to reporting of the medication errors was the major limitation of this study. Participants' concerns were handled by keeping their identity confidential and anonymous. Results show the importance of planning comprehensive educational programmes and providing constructive feedback in a favourable learning climate. Findings of this study can be beneficial to managers for nurturing a transparent organizational culture, whereby staff members freely discuss their errors in patient care and seek advice for problem solving. © 2014 International Council of Nurses.
Wholey, Douglas; Moscovice, Ira; Hietpas, Terry; Holtzman, Jeremy
The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural health care organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events…
Linthorst, G. E.; Kallimanis-King, B. L.; Douwes Dekker, I.; Hoekstra, J. B. L.; de Haes, J. C. J. M.
Background: The release of the report 'To err is human' put medical safety and the disclosure of errors to the forefront of the health care agenda. Disclosure of medical errors by physicians is vital in this process. We studied the role of background and social psychological factors in internists'
Rosenthal, Marilynn M; Cornett, Patricia L; Sutcliffe, Kathleen M; Lewton, Elizabeth
Studies before and since the 1999 Institute of Medicine report have noted the limitations of using medical record reporting for reliably quantifying and understanding medical error. Quantitative macro analyses of large datasets should be supplemented by small-scale qualitative studies to provide insight into micro-level daily events in clinical and hospital practice that contribute to errors and adverse events and how they are reported. The study design involved semistructured face-to-face interviews with residents about the medical errors in which they recently had been involved and included questions regarding how those errors were acknowledged. This paper reports the ways in which medical error is or is not reported and residents' responses to a perceived medical error. Twenty-six residents were randomly sampled from a total population of 85 residents working in a 600-bed teaching hospital. Outcome measures were based on analysis of cases residents described. Using Ethnograph and traditional methods of content analysis, cases were categorized as Documented, Discussed, and Uncertain. Of 73 cases, 30 (41.1%) were formally acknowledged and Documented in the medical record; 24 (32.9%) were addressed through Discussions but not documented; 19 cases (26%) cases were classified as Uncertain. Twelve cases involved medication errors, which were acknowledged in different categories. The supervisory discussion, the informal discussion, and near-miss contain important information for improving clinical care. Our study also shows the need to improve residents' education to prepare them to recognize and address medical errors.
Agrawal, A.; Aronson, J.K.; Britten, N.; Ferner, R.E.; Smet, P.A.G.M. de; Fialova, D.; Fitzgerald, R.J.; Likic, R.; Maxwell, S.R.; Meyboom, R.H.; Minuz, P.; Onder, G.; Schachter, M.; Velo, G.
Here we discuss 15 recommendations for reducing the risks of medication errors: 1. Provision of sufficient undergraduate learning opportunities to make medical students safe prescribers. 2. Provision of opportunities for students to practise skills that help to reduce errors. 3. Education of
Hung, Chang-Chiao; Chu, Tsui-Ping; Lee, Bih-O; Hsiao, Chia-Chi
The Aims of this study were to explore the effects of nurses' attitudes and intentions regarding medication administration error reporting on actual reporting behaviours. Underreporting of medication errors is still a common occurrence. Whether attitude and intention towards medication administration error reporting connect to actual reporting behaviours remain unclear. This study used a cross-sectional design with self-administered questionnaires, and the theory of planned behaviour was used as the framework for this study. A total of 596 staff nurses who worked in general wards and intensive care units in a hospital were invited to participate in this study. The researchers used the instruments measuring nurses' attitude, nurse managers' and co-workers' attitude, report control, and nurses' intention to predict nurses' actual reporting behaviours. Data were collected from September-November 2013. Path analyses were used to examine the hypothesized model. Of the 596 nurses invited to participate, 548 (92%) completed and returned a valid questionnaire. The findings indicated that nurse managers' and co-workers' attitudes are predictors for nurses' attitudes towards medication administration error reporting. Nurses' attitudes also influenced their intention to report medication administration errors; however, no connection was found between intention and actual reporting behaviour. The findings reflected links among colleague perspectives, nurses' attitudes, and intention to report medication administration errors. The researchers suggest that hospitals should increase nurses' awareness and recognition of error occurrence. Regardless of nurse managers' and co-workers' attitudes towards medication administration error reporting, nurses are likely to report medication administration errors if they detect them. Management of medication administration errors should focus on increasing nurses' awareness and recognition of error occurrence. © 2015 John Wiley & Sons Ltd.
Linthorst, G E; Kallimanis-King, B L; Douwes Dekker, I; Hoekstra, J B L; de Haes, J C J M
The release of the report 'To err is human' put medical safety and the disclosure of errors to the forefront of the health care agenda. Disclosure of medical errors by physicians is vital in this process. We studied the role of background and social psychological factors in internists' willingness to report medical errors. Survey among a random sample of internists from five teaching hospitals in the Netherlands, all internists and internists in training at the Departments of Internal Medicine of the participating hospitals. Questionnaires were received from 115 participants (response 51%). The willingness to disclose was related to the severity of the error, with the majority of near misses not reported to the head of department or the hospital error committees. Errors were more often reported to colleagues. Positive factors in favour of disclosing were reported more often than negative ones prohibiting disclosure. Motivation, behavioural control and social barriers were related to the disclosure of errors. Personal and social issues contributing to the will and addressed properly to stimulate disclosure. The creation of an atmosphere where disclosing errors is routine seems vital. In addition, it is essential to create a departmental culture where medical errors are discussed in a non-judgmental, safe environment. In order to improve reporting of medical errors, more emphasis should be placed on the individual barriers that preclude adequate reporting.
Full Text Available Abstract Background Medication administration errors in patient care have been shown to be frequent and serious. Such errors are particularly prevalent in highly technical specialties such as the intensive care unit (ICU. In Ethiopia, the prevalence of medication administration errors in the ICU is not studied. Objective To assess medication administration errors in the intensive care unit of Jimma University Specialized Hospital (JUSH, Southwest Ethiopia. Methods Prospective observation based cross-sectional study was conducted in the ICU of JUSH from February 7 to March 24, 2011. All medication interventions administered by the nurses to all patients admitted to the ICU during the study period were included in the study. Data were collected by directly observing drug administration by the nurses supplemented with review of medication charts. Data was edited, coded and entered in to SPSS for windows version 16.0. Descriptive statistics was used to measure the magnitude and type of the problem under study. Results Prevalence of medication administration errors in the ICU of JUSH was 621 (51.8%. Common administration errors were attributed to wrong timing (30.3%, omission due to unavailability (29.0% and missed doses (18.3% among others. Errors associated with antibiotics took the lion's share in medication administration errors (36.7%. Conclusion Medication errors at the administration phase were highly prevalent in the ICU of Jimma University Specialized Hospital. Supervision to the nurses administering medications by more experienced ICU nurses or other relevant professionals in regular intervals is helpful in ensuring that medication errors don’t occur as frequently as observed in this study.
Agalu, Asrat; Ayele, Yemane; Bedada, Worku; Woldie, Mirkuzie
Medication administration errors in patient care have been shown to be frequent and serious. Such errors are particularly prevalent in highly technical specialties such as the intensive care unit (ICU). In Ethiopia, the prevalence of medication administration errors in the ICU is not studied. To assess medication administration errors in the intensive care unit of Jimma University Specialized Hospital (JUSH), Southwest Ethiopia. Prospective observation based cross-sectional study was conducted in the ICU of JUSH from February 7 to March 24, 2011. All medication interventions administered by the nurses to all patients admitted to the ICU during the study period were included in the study. Data were collected by directly observing drug administration by the nurses supplemented with review of medication charts. Data was edited, coded and entered in to SPSS for windows version 16.0. Descriptive statistics was used to measure the magnitude and type of the problem under study. Prevalence of medication administration errors in the ICU of JUSH was 621 (51.8%). Common administration errors were attributed to wrong timing (30.3%), omission due to unavailability (29.0%) and missed doses (18.3%) among others. Errors associated with antibiotics took the lion's share in medication administration errors (36.7%). Medication errors at the administration phase were highly prevalent in the ICU of Jimma University Specialized Hospital. Supervision to the nurses administering medications by more experienced ICU nurses or other relevant professionals in regular intervals is helpful in ensuring that medication errors don't occur as frequently as observed in this study.
van der Veen, Willem; van den Bemt, Patricia M L A; Wouters, Hans; Bates, David W; Twisk, Jos W R; de Gier, Johan J; Taxis, Katja; Duyvendak, Michiel; Luttikhuis, Karen Oude; Ros, Johannes J W; Vasbinder, Erwin C; Atrafi, Maryam; Brasse, Bjorn; Mangelaars, Iris
To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors. A prospective observational study in Dutch hospitals using BCMA to administer medication. Direct observation was used to collect data. Primary outcome measure was the proportion of medication administrations with one or more medication administration errors. Secondary outcome was the frequency and types of workarounds and medication administration errors. Univariate and multivariate multilevel logistic regression analysis were used to assess the association between workarounds and medication administration errors. Descriptive statistics were used for the secondary outcomes. We included 5793 medication administrations for 1230 inpatients. Workarounds were associated with medication administration errors (adjusted odds ratio 3.06 [95% CI: 2.49-3.78]). Most commonly, procedural workarounds were observed, such as not scanning at all (36%), not scanning patients because they did not wear a wristband (28%), incorrect medication scanning, multiple medication scanning, and ignoring alert signals (11%). Common types of medication administration errors were omissions (78%), administration of non-ordered drugs (8.0%), and wrong doses given (6.0%). Workarounds are associated with medication administration errors in hospitals using BCMA. These data suggest that BCMA needs more post-implementation evaluation if it is to achieve the intended benefits for medication safety. In hospitals using barcode-assisted medication administration, workarounds occurred in 66% of medication administrations and were associated with large numbers of medication administration errors.
Full Text Available Introduction: The objective of our study was to estimate the incidence of prescribing medication errors specifically made by a trainee and identify factors associated with these errors during the simulated resuscitation of a critically ill child. Methods: The results of the simulated resuscitation are described. We analyzed data from the simulated resuscitation for the occurrence of a prescribing medication error. We compared univariate analysis of each variable to medication error rate and performed a separate multiple logistic regression analysis on the significant univariate variables to assess the association between the selected variables. Results: We reviewed 49 simulated resuscitations . The final medication error rate for the simulation was 26.5% (95% CI 13.7% - 39.3%. On univariate analysis, statistically significant findings for decreased prescribing medication error rates included senior residents in charge, presence of a pharmacist, sleeping greater than 8 hours prior to the simulation, and a visual analog scale score showing more confidence in caring for critically ill children. Multiple logistic regression analysis using the above significant variables showed only the presence of a pharmacist to remain significantly associated with decreased medication error, odds ratio of 0.09 (95% CI 0.01 - 0.64. Conclusion: Our results indicate that the presence of a clinical pharmacist during the resuscitation of a critically ill child reduces the medication errors made by resident physician trainees.
Porter, Evelyn; Barcega, Besh; Kim, Tommy Y
The objective of our study was to estimate the incidence of prescribing medication errors specifically made by a trainee and identify factors associated with these errors during the simulated resuscitation of a critically ill child. The results of the simulated resuscitation are described. We analyzed data from the simulated resuscitation for the occurrence of a prescribing medication error. We compared univariate analysis of each variable to medication error rate and performed a separate multiple logistic regression analysis on the significant univariate variables to assess the association between the selected variables. We reviewed 49 simulated resuscitations. The final medication error rate for the simulation was 26.5% (95% CI 13.7% - 39.3%). On univariate analysis, statistically significant findings for decreased prescribing medication error rates included senior residents in charge, presence of a pharmacist, sleeping greater than 8 hours prior to the simulation, and a visual analog scale score showing more confidence in caring for critically ill children. Multiple logistic regression analysis using the above significant variables showed only the presence of a pharmacist to remain significantly associated with decreased medication error, odds ratio of 0.09 (95% CI 0.01 - 0.64). Our results indicate that the presence of a clinical pharmacist during the resuscitation of a critically ill child reduces the medication errors made by resident physician trainees.
Al-Hajje, Amal; Awada, Sanaa; Rachidi, Samar; Chahine, Nazih Bou; Azar, Rania; Zein, Salam; Hneine, Anna-Maria; Dalloul, Nadia; Sili, Georges; Salameh, Pascale
Medication prescribing errors are made all over the world. However, exact data about them are lacking in Lebanon. Our objective was to describe medication errors, including drug-drug interactions in medication orders given to patients admitted to Lebanese hospitals. A prospective study was carried out on 313 patients taken from seven Lebanese hospitals; 1826 medication orders were assessed for errors and 456 drug-drug interactions were found. Data was entered and analyzed on SPSS. Around 40% of medication orders were judged to comprise at least one prescribing error, mainly no ordering of parameters monitoring (20%), unnecessary medication (9%), and no indication (7%). Errors occurred mainly in the pediatrics (50%) and internal medicine wards (40%). Having an infectious or gastrointestinal problem almost doubled the risk of medication prescribing error. Antiulcer agents, NSAIDs, antibiotics and steroidal agents were the medications mainly involved. Meanwhile, 12 adverse medication events were reported, with an odds ratio of association to a medication error of 7.4 (p = 0.004). As for drug-drug interaction (DDI), prescriptions comprised zero to 29 interactions, involving medications with low margin of safety such as acenocoumarol, amiodarone and valproate. Pharmacodynamic interactions were mainly found (60%). The majority of DDI were of high clinical significance and well documented (80%), with moderate (59%) to major (17%) severity. These results highlight the urgency of an intervention to improve patients' outcomes and avoid deleterious impact of inadequate medication use in Lebanon. The presence of a clinical pharmacist, the inclusion of computerized systems and the application of drug management policies are suggested to decrease medication prescribing errors and enhance the physician attention to DDI.
Full Text Available Background: Increasing number of reports on medication errors and relevant subsequent damages, especially in medical centers has become a growing concern for patient safety in recent decades. Patient safety and in particular, medication safety is a major concern and challenge for health care professionals around the world. Our prospective study was designed to detect prescribing, transcribing, dispensing, and administering medication errors in two major university hospitals. Materials and Methods: After choosing 20 similar hospital wards in two large teaching hospitals in the city of Isfahan, Iran, the sequence was randomly selected. Diagrams for drug distribution were drawn by the help of pharmacy directors. Direct observation technique was chosen as the method for detecting the errors. A total of 50 doses were studied in each ward to detect prescribing, transcribing and administering errors in each ward. The dispensing error was studied on 1000 doses dispensed in each hospital pharmacy. Results: A total of 8162 number of doses of medications were studied during the four stages, of which 8000 were complete data to be analyzed. 73% of prescribing orders were incomplete and did not have all six parameters (name, dosage form, dose and measuring unit, administration route, and intervals of administration. We found 15% transcribing errors. One-third of administration of medications on average was erroneous in both hospitals. Dispensing errors ranged between 1.4% and 2.2%. Conclusion: Although prescribing and administrating compromise most of the medication errors, improvements are needed in all four stages with regard to medication errors. Clear guidelines must be written and executed in both hospitals to reduce the incidence of medication errors.
Lammers, Richard; Willoughby-Byrwa, Maria; Fales, William
Systematic evaluation of the performances of prehospital providers during actual pediatric anaphylaxis cases has never been reported. Epinephrine medication errors in pediatric resuscitation are common, but the root causes of these errors are not fully understood. The primary objective of this study was to identify underlying causes of prehospital medication errors that were observed during a simulated pediatric anaphylaxis reaction. Two- and 4-person emergency medical services crews from eight geographically diverse agencies participated in a 20-minute simulation of a 5-year old child with progressive respiratory distress and hypotension from an anaphylactic reaction. Crews used their own equipment and drugs. A checklist-based scoring protocol was developed to help identify errors. A trained facilitator conducted a structured debriefing, supplemented by playback of video recordings, immediately after the simulated event to elicit underlying causes of errors. Errors were analyzed with mixed quantitative and qualitative methods. One hundred forty-two subjects participated in 62 simulation sessions. Ninety-five percent of crews (59/62) gave epinephrine, but 27 of those crews (46%) delivered the correct dose of epinephrine in an appropriate concentration and route. Twelve crews (20%) gave a dose that was ≥5 times the correct dose; 8 crews (14%) bolused epinephrine intravenously. Among the 55 crews who gave diphenhydramine, 4 delivered the protocol-based dose. Three crews provided an intravenous steroid, and 1 used the protocol-based dose. Underlying causes of errors were categorized into eight themes: faulty reasoning, weight estimation errors, faulty recall of medication dosages, problematic references, calculation errors, dose estimation, communication errors, and medication delivery errors. Simulation, followed by a structured debriefing, identified multiple, underlying causes of medication errors in the prehospital management of pediatric anaphylactic reactions
Yin, H Shonna; Dreyer, Benard P; Ugboaja, Donna C; Sanchez, Dayana C; Paul, Ian M; Moreira, Hannah A; Rodriguez, Luis; Mendelsohn, Alan L
Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship. Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site. Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2-4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03-3.5) dose; associations greater for parents with low health literacy and non-English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon-associated measurement errors. Findings support a milliliter-only standard to reduce medication errors. Copyright © 2014 by the American Academy of Pediatrics.
Nichols, Pamela; Copeland, Tandy-Sue; Craib, Ian A; Hopkins, Paul; Bruce, David G
To study the clinical contexts contributing to harmful medication errors. A qualitative study using semi-structured interviews was conducted between March and August 2005 at Fremantle Hospital, a 450-bed metropolitan teaching hospital. Twenty-six of 46 staff members (57%) identified by pharmacy staff as having contributed to a significant medication error were interviewed. Interviews were recorded and transcribed for thematic analysis. Most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. Knowledge-based mistakes (eg, failure to follow a protocol) also contributed to prescribing errors. Errors were more likely to occur during tasks being carried out after hours by busy, distracted staff, often in relation to unfamiliar patients. Communication problems with senior staff and difficulty accessing appropriate drug dosing information contributed to knowledge-based prescribing errors. Several medical staff were unaware they had committed an error until their involvement with our study. Contextual factors that contributed to slips, lapses and knowledge-based mistakes in our sample are likely to be widespread in hospitals, and their impact on medication error may be substantial. Staff need training in how to recognise and deal with error-prone clinical situations. Safe prescribing practices (eg, the absolute requirement to acquire information before prescribing unfamiliar drugs) must be emphasised. Improved access to drug information at the point of prescribing, attention to communication barriers, and increasing staffing levels in particular areas are other potential strategies for reducing error.
Hannawa, Annegret F; Beckman, Howard; Mazor, Kathleen M; Paul, Norbert; Ramsey, Joanne V
The disclosure of medical errors has attracted considerable research interest in recent years. However, the research to date has lacked interdisciplinary dialog, making translation of findings into medical practice challenging. This article lays out the disciplinary perspectives of the fields of medicine, ethics, law and communication on medical error disclosure and identifies gaps and tensions that occur at these interdisciplinary boundaries. This article summarizes the discussion of an interdisciplinary error disclosure panel at the 2012 EACH Conference in St. Andrews, Scotland, in light of the current literature across four academic disciplines. Current medical, ethical, legal and communication perspectives on medical error disclosure are presented and discussed with particular emphasis on the interdisciplinary gaps and tensions. The authors encourage interdisciplinary collaborations that strive for a functional approach to understanding and improving the disclosure of medical errors with the ultimate goal to improve quality and promote safer medical care. Interdisciplinary collaborations are needed to reconcile the needs of the stakeholders involved in medical error disclosure. A particular challenge is the effective translation of error disclosure research into practice. Concrete research questions are provided throughout the manuscript to facilitate a resolution of the tensions that currently impede interdisciplinary progress. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Lemer, Claire; Bates, David W; Yoon, Catherine; Keohane, Carol; Fitzmaurice, Garrett; Kaushal, Rainu
In the pediatric setting, adverse events occurring at the administration stage are the most common type of preventable adverse drug events. Few data are available on the effect of advice from medical professionals on medication safety. This is a prospective cohort study of 1685 pediatric patients, 6 office practices in the Boston area. Data were collected from parental interviews, review of duplicate prescriptions, and chart review. Incidents were stratified by type (medication error, near miss, or preventable adverse drug event) and stage of the medication process. Descriptive analysis was followed by a multivariable analysis to determine which factors influenced the occurrence of reported medication administration errors. Advice from both office and pharmacy was assessed to be poor in quality and limited in provision. Health care providers most often failed to offer information. Fifty-seven percent of families who did not receive information were not presented with information, rather than refusing it. Multivariable analysis did not demonstrate that advice form or location reduced the rate of medication administration errors (errors occurring during delivery of the medication, usually in the home). However, taking more than 1 medication (odds ratio = 1.68; 95% confidence interval, 1.15-2.46) and age younger than 5 years (odds ratio = 2.35; 95% confidence interval, 1.05-5.28) were correlated with risk of a medication administration error. Inadequate advice was provided. The current approach for delivering advice does not prevent against medication administration errors. Those at highest risk of such errors are the youngest children and those on multiple medications.
Acheampong, Franklin; Tetteh, Ashalley Raymond; Anto, Berko Panyin
This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana. This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes. Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems. This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.
Dharmar, Madan; Kuppermann, Nathan; Romano, Patrick S; Yang, Nikki H; Nesbitt, Thomas S; Phan, Jennifer; Nguyen, Cynthia; Parsapour, Kourosh; Marcin, James P
To compare the frequency of physician-related medication errors among seriously ill and injured children receiving telemedicine consultations, similar children receiving telephone consultations, and similar children receiving no consultations in rural emergency departments (EDs). We conducted retrospective chart reviews on seriously ill and injured children presenting to 8 rural EDs with access to pediatric critical care physicians from an academic children's hospital. Physician-related ED medication errors were independently identified by 2 pediatric pharmacists by using a previously published instrument. The unit of analysis was medication administered. The association of telemedicine consultations with ED medication errors was modeled by using hierarchical logistic regression adjusting for covariates (age, risk of admission, year of consultation, and hospital) and clustering at the patient level. Among the 234 patients in the study, 73 received telemedicine consultations, 85 received telephone consultations, and 76 received no specialist consultations. Medications for patients who received telemedicine consultations had significantly fewer physician-related errors than medications for patients who received telephone consultations or no consultations (3.4% vs. 10.8% and 12.5%, respectively; P medications for patients who received telemedicine consultations had a lower odds of physician-related errors than medications for patients who received telephone consultations (odds ratio: 0.19, P Pediatric critical care telemedicine consultations were associated with a significantly reduced risk of physician-related ED medication errors among seriously ill and injured children in rural EDs.
West, Colin P; Tan, Angelina D; Habermann, Thomas M; Sloan, Jeff A; Shanafelt, Tait D
Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown. To determine the association of fatigue and distress with self-perceived major medical errors among resident physicians using validated metrics. Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic, Rochester, Minnesota. Data were provided by 380 of 430 eligible residents (88.3%). Participants began training from 2003 to 2008 and completed surveys quarterly through February 2009. Surveys included self-assessment of medical errors, linear analog self-assessment of overall quality of life (QOL) and fatigue, the Maslach Burnout Inventory, the PRIME-MD depression screening instrument, and the Epworth Sleepiness Scale. Frequency of self-perceived, self-defined major medical errors was recorded. Associations of fatigue, QOL, burnout, and symptoms of depression with a subsequently reported major medical error were determined using generalized estimating equations for repeated measures. The mean response rate to individual surveys was 67.5%. Of the 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. In univariate analyses, there was an association of subsequent self-reported error with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03-1.16; P = .002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08-1.21; P error was also associated with burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05-1.12; P errors when adjusted for burnout or depression. Among internal medicine residents, higher levels of fatigue and distress are independently associated with self-perceived medical errors.
Rezaiamin, Abdoolkarim; Pazokian, Marzieh; Zagheri Tafreshi, Mansoureh; Nasiri, Malihe
Incidence of medication errors in intensive care unit (ICU) can cause irreparable damage for ICU patients. Therefore, it seems necessary to find the causes of medication errors in this section. Work commitment and dynamic might affect the incidence of medication errors in ICU. To assess the mentioned hypothesis, we performed a descriptive-analytical study which was carried out on 117 nurses working in ICU of educational hospitals in Tehran. Minick et al., Salyer et al., and Wakefield et al. scales were used for data gathering on work commitment, dynamic, and medication errors, respectively. Findings of the current study revealed that high work commitment in ICU nurses caused low number of medication errors, including intravenous and nonintravenous. We controlled the effects of confounding variables in detection of this relationship. In contrast, no significant association was found between work dynamic and different types of medication errors. Although the study did not observe any relationship between the dynamics and rate of medication errors, the training of nurses or nursing students to create a dynamic environment in hospitals can increase their interest in the profession and increase job satisfaction in them. Also they must have enough ability in work dynamic so that they don't confused and distracted result in frequent changes of orders, care plans, and procedures.
Full Text Available Background: Medical errors have been highlighted in recent years by different agencies, scientific bodies and research teams alike. We sought to explore the issue of medical errors in Cyprus using data from the Eurobarometer survey.Methods: Data from the special Eurobarometer survey conducted in 2005 across all European Union countries (EU-25 and the acceding countries were obtained from the corresponding EU office. Statisticalanalyses including logistic regression models were performed using SPSS.Results: A total of 502 individuals participated in the Cyprus survey. About 90% reported that they had often or sometimes heard about medical errors, while 22% reported that a family member or they had suffered a serious medical error in a local hospital. In addition, 9.4% reported a serious problem from a prescribed medicine. We also found statistically significant differences across different ages and gender and in rural versus urban residents. Finally, using multivariable-adjusted logistic regression models, wefound that residents in rural areas were more likely to have suffered a serious medical error in a local hospital or from a prescribed medicine.Conclusion: Our study shows that the vast majority of residents in Cyprus in parallel with the other Europeans worry about medical errors and a significant percentage report having suffered a serious medical error at a local hospital or from a prescribed medicine. The results of our study could help the medical community in Cyprus and the society at large to enhance its vigilance with respect to medical errors in order to improve medical care.
Ulas, Arife; Silay, Kamile; Akinci, Sema; Dede, Didem Sener; Akinci, Muhammed Bulent; Sendur, Mehmet Ali Nahit; Cubukcu, Erdem; Coskun, Hasan Senol; Degirmenci, Mustafa; Utkan, Gungor; Ozdemir, Nuriye; Isikdogan, Abdurrahman; Buyukcelik, Abdullah; Inanc, Mevlude; Bilici, Ahmet; Odabasi, Hatice; Cihan, Sener; Avci, Nilufer; Yalcin, Bulent
Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures
Anselmi, Maria Luiza; Peduzzi, Marina; Dos Santos, Claudia Benedita
To verify the frequency of errors in the preparation and administration of intravenous medication in three Brazilian hospitals in the State of Bahia. The administration of intravenous medications constitutes a central activity in Brazilian nursing. Errors in performing this activity may result in irreparable damage to patients and may compromise the quality of care. Cross-sectional study, conducted in three hospitals in the State of Bahia, Brazil. Direct observation of the nursing staff (nurse technicians, auxiliary nurses and nurse attendants), preparing and administering intravenous medication. When preparing medication, wrong patient error did not occur in any of the three hospitals, whereas omission dose was the most frequent error in all study sites. When administering medication, the most frequent errors in the three hospitals were wrong dose and omission dose. The rates of error found are considered low compared with similar studies. The most frequent types of errors were wrong dose and omission dose. The hospitals studied showed different results with the smallest rates of errors occurring in hospital 1 that presented the best working conditions. Relevance to clinical practice. Studies such as this one have the potential to improve the quality of care.
Szczepura, Ala; Wild, Deidre; Nelson, Sara
drugs reported they were aware of potential administration errors in their care home. The incidence of medication administration errors is high in long-term residential care. A barcode medication administration system can capture medication administration errors and prevent these from occurring.
Tevlin, Ruth; Doherty, Eva; Traynor, Oscar
Human error is the major causal factor of industrial and transportation accidents and healthcare is not immune to the effects of human error. Medical error can be defined as the failure of the planned action to be completed as intended or the use of a wrong plan to achieve an aim. The objective of this literature review was to explore the practices of medical error management and disclosure by surgical trainees and to examine how to better prepare and educate the surgeons of tomorrow. PubMed was searched to identify available literature. Preliminary search criteria included medical error and junior doctors, management and prevention of medical error. Fifty-two papers were included for review. Medical error is common and junior doctors are more vulnerable to err. Most serious errors occur in the emergency department, operating rooms and the intensive care unit. Improvements in patient safety result primarily from organizational and individual learning, particularly with reference to trainee doctors who present an enhanced level of risk. Junior doctors are a unique population, with a higher propensity to medical error. A transition from the current culture of 'name, blame and shame' is required. We need to ensure that the 'learning moment' is seized and that mistakes are learned from and not simply forgotten. Surgery has an opportunity to learn from high risk-industries and incorporate human factors training, into surgical training programs in order to better manage and prevent medical error. Copyright © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Kagan, Ilya; Barnoy, Sivia
To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%). The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data. Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance. This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level. A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety. © 2013 Sigma Theta Tau International.
Topcu, Ibrahim; Turkmen, Ayse Sonay; Sahiner, Nejla Canbulat; Savaser, Sevim; Sen, Hanife
To determine medical errors associated with communication failures among physicians and nurses. This cross-sectional, descriptive study was conducted at 20 state hospitals and 14 training and research hospitals affiliated with the Istanbul City Health Directorate in Turkey, and comprised physicians and nurses. Data were collected between August 2012 and February 2013. A 16-item questionnaire was used that included questions regarding socio-demographic features such as age, gender, educational status, institution, occupation and working years. Questions also aimed at determining medical errors related to communication failures. The questionnaire was completed by the participants during face-to-face interviews. Of the 2,273 participants, 1,654(72.8%) were nurses and 619(27.2%) were physicians. Besides, 340(54.9%) physicians and 811(49.03%) nurses worked in state hospitals. The mean age of the physicians was 37.76±9.20 years (range: 22-62 years), and that of the nurses was 32.61±7.38 years (range: 17-62 years). Moreover, 137(22.1%) physicians and 258(15.3%) nurses had previously experienced medical errors. Also, 74(54%) physicians and 135(52.3%) nurses had experienced medical errors due to some communication error. The most common medical errors by physicians were incorrect drug administration 45(32.8%), and delivery of drugs to the wrong patient by nurses 103(40.7%). In addition, 58(42.3%) physicians made medical errors in adult surgical clinic services while 102(39.5%) nurses made medical errors in adult internal medicine clinics. The majority of medical errors originated from communication failures.
Rishoej, Rikke Mie; Almarsdóttir, Anna Birna; Christesen, Henrik Thybo; Hallas, Jesper; Kjeldsen, Lene Juel
The aim was to describe medication errors (MEs) in hospitalized children reported to the national mandatory reporting and learning system, the Danish Patient Safety Database (DPSD). MEs were extracted from DPSD from the 5-year period of 2010-2014. We included reports from public hospitals on patients aged 0-17 years and categorized by reporters as medication-related. Reports from psychiatric wards and outpatient clinics were excluded. A ME was defined as any medication-related error occurring in the medication process whether harmful or not. MEs were categorized as harmful if they resulted in actual harm or interventions to prevent harm. MEs were further categorized according to occurrence in the medication process, type of error, and the medicines involved. A total of 2071 MEs including 487 harmful MEs were identified. Most MEs occurred during prescribing (40.8%), followed by dispensing (38.7%). Harmful MEs occurred mainly during dispensing (40.3%). Dosing errors were the most reported type of error, 47.7% of all MEs and 45.4% of harmful MEs. Antibiotics and analgesics were the most frequently reported medication classes. Common medicines associated with MEs included morphine, paracetamol, and gentamicin. MEs caused no harm (74.9%), mild (11.7%), moderate (10.5%), or severe harm (1.3%), but none were lethal. MEs in hospitalized children occur in all medication processes and mainly involve dosing errors. Strategies should be developed to prevent MEs as these still threaten medication safety in pediatric inpatients. What is known: • Hospitalized children are more likely to experience medication errors than adults. • Voluntary national and local reporting and learning systems have previously been used to describe the nature and types of medication errors. What is new: • Medication errors in hospitalized children occur in all steps of the medication process, most frequently involving dosing errors and most commonly involving morphine, paracetamol, and
Walsh, Elaine K; Hansen, Christina Raae; Sahm, Laura J; Kearney, Patricia M; Doherty, Edel; Bradley, Colin P
Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.
few errors were considered potentially fatal. Medical staff needs greater awareness of medication safety and guidelines related to the medication process. Many errors in this study might potentially be prevented by nursing staff when handling medication and observing patients for effect and side effects of medication. The nurses' role in psychiatric medication safety should be further explored as nurses appear to be in the unique position to intercept errors before they reach the patient. Keywords: medication safety, mental health disorders, medication errors, psychiatry
McKaig, Donald; Collins, Christine; Elsaid, Khaled A
A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site. During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors. Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.
Conclusion: Prescription errors are common in outpatient settings of Aluthgama and Kandy areas in. Sri Lanka. Standardized prescription writing process in relation to layout, use of abbreviations, and units and legibility, is proposed as a potential solution to overcome this problem. Keywords: Medication error, Prescriptions, ...
Background: Proper and adequate pharmacovigilance is lacking in children\\'s drug therapy, especially in developing countries. Therefore these children are at risk of developing adverse reactions to drugs as a result of medication errors. Having a better understanding of the types of error in a teaching hospital would be an ...
Silvia González Gómez
• Objective: To determine the prevalence of medication errors associated with the administration in the emergency room of University Hospital Marques de Valdecilla. • Introduction: Adverse events related to health care, are increasingly common, it is estimated that between 44000 and 98000 people served in U.S. hospitals die from adverse events related to health care. In 7000 these deaths are caused by medication errors. In Spain the studies speak of similar figures. The emergency services are...
Melnyk, Bernadette Mazurek; Orsolini, Liana; Tan, Alai; Arslanian-Engoren, Cynthia; Melkus, Gail D'Eramo; Dunbar-Jacob, Jacqueline; Rice, Virginia Hill; Millan, Angelica; Dunbar, Sandra B; Braun, Lynne T; Wilbur, JoEllen; Chyun, Deborah A; Gawlik, Kate; Lewis, Lisa M
The aim of this study was to describe (1) nurses' physical and mental health; (2) the relationship between health and medical errors; and (3) the association between nurses' perceptions of wellness support and their health. A cross-sectional descriptive survey was conducted with 1790 nurses across the U.S. Over half of the nurses reported suboptimal physical and mental health. Approximately half of the nurses reported having medical errors in the past 5 years. Compared with nurses with better health, those with worse health were associated with 26% to 71% higher likelihood of having medical errors. There also was a significant relationship between greater perceived worksite wellness and better health. Wellness must be a high priority for health care systems to optimize health in clinicians to enhance high-quality care and decrease the odds of costly preventable medical errors.
Oğuzhan Özcan; A. Semra Güreser
Objectives: We aimed to analyze the preanalytical errorsand the role of training in the prevention of error insamples sent to the biochemistry and microbiology laboratories.Materials and methods: All samples accepted in thecentral laboratory during eight-month period were evaluatedretrospectively. Distribution of rejected sampleswere classified according to preanalytical error categories(wrong sample, improper sample, incorrect barcode,insufficient volume, exceeded volume, clotted sample,hemo...
Li, Qi; Kirkendall, Eric S; Hall, Eric S; Ni, Yizhao; Lingren, Todd; Kaiser, Megan; Lingren, Nataline; Zhai, Haijun; Solti, Imre; Melton, Kristin
To improve neonatal patient safety through automated detection of medication administration errors (MAEs) in high alert medications including narcotics, vasoactive medication, intravenous fluids, parenteral nutrition, and insulin using the electronic health record (EHR); to evaluate rates of MAEs in neonatal care; and to compare the performance of computerized algorithms to traditional incident reporting for error detection. We developed novel computerized algorithms to identify MAEs within the EHR of all neonatal patients treated in a level four neonatal intensive care unit (NICU) in 2011 and 2012. We evaluated the rates and types of MAEs identified by the automated algorithms and compared their performance to incident reporting. Performance was evaluated by physician chart review. In the combined 2011 and 2012 NICU data sets, the automated algorithms identified MAEs at the following rates: fentanyl, 0.4% (4 errors/1005 fentanyl administration records); morphine, 0.3% (11/4009); dobutamine, 0 (0/10); and milrinone, 0.3% (5/1925). We found higher MAE rates for other vasoactive medications including: dopamine, 11.6% (5/43); epinephrine, 10.0% (289/2890); and vasopressin, 12.8% (54/421). Fluid administration error rates were similar: intravenous fluids, 3.2% (273/8567); parenteral nutrition, 3.2% (649/20124); and lipid administration, 1.3% (203/15227). We also found 13 insulin administration errors with a resulting rate of 2.9% (13/456). MAE rates were higher for medications that were adjusted frequently and fluids administered concurrently. The algorithms identified many previously unidentified errors, demonstrating significantly better sensitivity (82% vs. 5%) and precision (70% vs. 50%) than incident reporting for error recognition. Automated detection of medication administration errors through the EHR is feasible and performs better than currently used incident reporting systems. Automated algorithms may be useful for real-time error identification and
Drach-Zahavy, A; Somech, A; Admi, H; Peterfreund, I; Peker, H; Priente, O
Attention in the ward should shift from preventing medication administration errors to managing them. Nevertheless, little is known in regard with the practices nursing wards apply to learn from medication administration errors as a means of limiting them. To test the effectiveness of four types of learning practices, namely, non-integrated, integrated, supervisory and patchy learning practices in limiting medication administration errors. Data were collected from a convenient sample of 4 hospitals in Israel by multiple methods (observations and self-report questionnaires) at two time points. The sample included 76 wards (360 nurses). Medication administration error was defined as any deviation from prescribed medication processes and measured by a validated structured observation sheet. Wards' use of medication administration technologies, location of the medication station, and workload were observed; learning practices and demographics were measured by validated questionnaires. Results of the mixed linear model analysis indicated that the use of technology and quiet location of the medication cabinet were significantly associated with reduced medication administration errors (estimate=.03, perrors (estimate=.04, plearning practices, supervisory learning was the only practice significantly linked to reduced medication administration errors (estimate=-.04, plearning were significantly linked to higher levels of medication administration errors (estimate=-.03, plearning was not associated with it (p>.05). How wards manage errors might have implications for medication administration errors beyond the effects of typical individual, organizational and technology risk factors. Head nurse can facilitate learning from errors by "management by walking around" and monitoring nurses' medication administration behaviors. Copyright © 2013 Elsevier Ltd. All rights reserved.
There are a variety of factors that make the pediatric population more susceptible to medication errors and potential complications resulting from medication administration including the availability of different dosage forms of the same medication, incorrect dosing, lack of standardized dosing regimen, and organ system maturity. A systematic literature search on medication administration errors in the pediatric population was conducted. Five themes obtained from the systematic literature search include incidence rate of medication administration errors; specific medications involved in medication administration errors and classification of the errors; why medication administration errors occur; medication error reporting; and interventions to reduce medication errors. Copyright © 2010 Elsevier Inc. All rights reserved.
Björkstén, Karin Sparring; Bergqvist, Monica; Andersén-Karlsson, Eva; Benson, Lina; Ulfvarson, Johanna
Many studies address the prevalence of medication errors but few address medication errors serious enough to be regarded as malpractice. Other studies have analyzed the individual and system contributory factor leading to a medication error. Nurses have a key role in medication administration, and there are contradictory reports on the nurses' work experience in relation to the risk and type for medication errors. All medication errors where a nurse was held responsible for malpractice (n = 585) during 11 years in Sweden were included. A qualitative content analysis and classification according to the type and the individual and system contributory factors was made. In order to test for possible differences between nurses' work experience and associations within and between the errors and contributory factors, Fisher's exact test was used, and Cohen's kappa (k) was performed to estimate the magnitude and direction of the associations. There were a total of 613 medication errors in the 585 cases, the most common being "Wrong dose" (41 %), "Wrong patient" (13 %) and "Omission of drug" (12 %). In 95 % of the cases, an average of 1.4 individual contributory factors was found; the most common being "Negligence, forgetfulness or lack of attentiveness" (68 %), "Proper protocol not followed" (25 %), "Lack of knowledge" (13 %) and "Practice beyond scope" (12 %). In 78 % of the cases, an average of 1.7 system contributory factors was found; the most common being "Role overload" (36 %), "Unclear communication or orders" (30 %) and "Lack of adequate access to guidelines or unclear organisational routines" (30 %). The errors "Wrong patient due to mix-up of patients" and "Wrong route" and the contributory factors "Lack of knowledge" and "Negligence, forgetfulness or lack of attentiveness" were more common in less experienced nurses. The experienced nurses were more prone to "Practice beyond scope of practice" and to make errors in spite of "Lack of adequate
Kronman, Andrea C; Paasche-Orlow, Michael; Orlander, Jay D
Attributes of the organisational culture of residency training programmes may impact patient safety. Training environments are complex, composed of clinical teams, residency programmes, and clinical units. We examined the relationship between residents' perceptions of their training environment and disclosure of or apology for their worst error. Anonymous, self-administered surveys were distributed to Medicine and Surgery residents at Boston Medical Center in 2005. Surveys asked residents to describe their worst medical error, and to answer selected questions from validated surveys measuring elements of working environments that promote learning from error. Subscales measured the microenvironments of the clinical team, residency programme, and clinical unit. Univariate and bivariate statistical analyses examined relationships between trainee characteristics, their perceived learning environment(s), and their responses to the error. Out of 109 surveys distributed to residents, 99 surveys were returned (91% overall response rate), two incomplete surveys were excluded, leaving 97: 61% internal medicine, 39% surgery, 59% male residents. While 31% reported apologising for the situation associated with the error, only 17% reported disclosing the error to patients and/or family. More male residents disclosed the error than female residents (p=0.04). Surgery residents scored higher on the subscales of safety culture pertaining to the residency programme (p=0.02) and managerial commitment to safety (p=0.05). Our Medical Culture Summary score was positively associated with disclosure (p=0.04) and apology (p=0.05). Factors in the learning environments of residents are associated with responses to medical errors. Organisational safety culture can be measured, and used to evaluate environmental attributes of clinical training that are associated with disclosure of, and apology for, medical error.
Fatemeh Rangraz Jeddi
Full Text Available Medical errors are unintentional acts that take place due to the negligence or lead to undesirable consequences in medical practice. The purpose of this study was to design a conceptual model for medical error reporting system. This applied descriptive cross-sectional research employed Delphi method carried out from 2012 to 2013. The study population was medical and paramedical personnel of health workers and paramedical personnel of hospitals, deputy of treatment, faculty members of Kashan University of Medical Sciences in addition to the internet and library resources. Sample size included 30 expert individuals in the field of medical errors. The one-stage stratified sampling procedure was used. The items with opposition ranging 0 to 25 were confirmed and those exceeding 50 were rejected whereas the items with the opposition 25 to 50 were reevaluated in the second session. This process continued for three times and the items that failed to be approved were eliminated in the model. Based on the results of this research, repeated informing about and reporting operation at on-line bases that have access to the incidence of error detected on time, identifying cause and damage due to the incidence reported confidential and anonymously immediately after the occurrence is necessary. Analysis of data quantitatively and qualitatively by using computer software is needed. Classifying the errors reports based on feedback provision according to the cause of error is needed. In addition, confidential report and possible manual retrieval were suggested It is essential to determine the means of reporting and items in the reporting form including time, cause and damage of medical error, media of reporting and method of recording and analysis.
Full Text Available Medications are mostly taken in patients' own homes, increasingly administered by carers, yet studies of medication safety have been largely conducted in the hospital setting. We aimed to review studies of how carers cause and/or prevent medication administration errors (MAEs within the patient's home; to identify types, prevalence and causes of these MAEs and any interventions to prevent them.A narrative systematic review of literature published between 1 Jan 1946 and 23 Sep 2013 was carried out across the databases EMBASE, MEDLINE, PSYCHINFO, COCHRANE and CINAHL. Empirical studies were included where carers were responsible for preventing/causing MAEs in the home and standardised tools used for data extraction and quality assessment.Thirty-six papers met the criteria for narrative review, 33 of which included parents caring for children, two predominantly comprised adult children and spouses caring for older parents/partners, and one focused on paid carers mostly looking after older adults. The carer administration error rate ranged from 1.9 to 33% of medications administered and from 12 to 92.7% of carers administering medication. These included dosage errors, omitted administration, wrong medication and wrong time or route of administration. Contributory factors included individual carer factors (e.g. carer age, environmental factors (e.g. storage, medication factors (e.g. number of medicines, prescription communication factors (e.g. comprehensibility of instructions, psychosocial factors (e.g. carer-to-carer communication, and care-recipient factors (e.g. recipient age. The few interventions effective in preventing MAEs involved carer training and tailored equipment.This review shows that home medication administration errors made by carers are a potentially serious patient safety issue. Carers made similar errors to those made by professionals in other contexts and a wide variety of contributory factors were identified. The home care
Parand, Anam; Garfield, Sara; Vincent, Charles; Franklin, Bryony Dean
Medications are mostly taken in patients' own homes, increasingly administered by carers, yet studies of medication safety have been largely conducted in the hospital setting. We aimed to review studies of how carers cause and/or prevent medication administration errors (MAEs) within the patient's home; to identify types, prevalence and causes of these MAEs and any interventions to prevent them. A narrative systematic review of literature published between 1 Jan 1946 and 23 Sep 2013 was carried out across the databases EMBASE, MEDLINE, PSYCHINFO, COCHRANE and CINAHL. Empirical studies were included where carers were responsible for preventing/causing MAEs in the home and standardised tools used for data extraction and quality assessment. Thirty-six papers met the criteria for narrative review, 33 of which included parents caring for children, two predominantly comprised adult children and spouses caring for older parents/partners, and one focused on paid carers mostly looking after older adults. The carer administration error rate ranged from 1.9 to 33% of medications administered and from 12 to 92.7% of carers administering medication. These included dosage errors, omitted administration, wrong medication and wrong time or route of administration. Contributory factors included individual carer factors (e.g. carer age), environmental factors (e.g. storage), medication factors (e.g. number of medicines), prescription communication factors (e.g. comprehensibility of instructions), psychosocial factors (e.g. carer-to-carer communication), and care-recipient factors (e.g. recipient age). The few interventions effective in preventing MAEs involved carer training and tailored equipment. This review shows that home medication administration errors made by carers are a potentially serious patient safety issue. Carers made similar errors to those made by professionals in other contexts and a wide variety of contributory factors were identified. The home care setting should
A.J. Leendertse (Anne); E.A. van Dijk (Elisabeth); P.A. de Smet (Peter); T.C.G. Egberts (Toine); P.M.L.A. van den Bemt (Patricia)
textabstractBackground: Medication errors and renal impairment contribute to severe adverse drug events, which may lead to hospital admission. Objective: To determine whether medication errors and renal impairment contribute to hospital admission and examine these errors for strategies to prevent
Gallagher, Thomas H; Bell, Sigall K; Smith, Kelly M; Mello, Michelle M; McDonald, Timothy B
A gap exists between recommendations to disclose errors to patients and current practice. This gap may reflect important, yet unanswered questions about implementing disclosure principles. We explore some of these unanswered questions by presenting three real cases that pose challenging disclosure dilemmas. The first case involves a pancreas transplant that failed due to the pancreas graft being discarded, an error that was not disclosed partly because the family did not ask clarifying questions. Relying on patient or family questions to determine the content of disclosure is problematic. We propose a standard of materiality that can help clinicians to decide what information to disclose. The second case involves a fatal diagnostic error that the patient's widower was unaware had happened. The error was not disclosed out of concern that disclosure would cause the widower more harm than good. This case highlights how institutions can overlook patients' and families' needs following errors and emphasizes that benevolent deception has little role in disclosure. Institutions should consider whether involving neutral third parties could make disclosures more patient centered. The third case presents an intraoperative cardiac arrest due to a large air embolism where uncertainty around the clinical event was high and complicated the disclosure. Uncertainty is common to many medical errors but should not deter open conversations with patients and families about what is and is not known about the event. Continued discussion within the medical profession about applying disclosure principles to real-world cases can help to better meet patients' and families' needs following medical errors.
Supporting patients and families in circumstances where medical error has caused significant harm is said to be governed by the principles of ordinary treatment: honest, open communication, empathy and respect. By and large, harmed patients look for acknowledgment of the events that occurred including errors, acceptance of responsibility, a sincere apology, and assurance that lessons learned will be put to preventive use. Australia's National Open Disclosure Standard purports to respond to these reasonable expectations, yet it advises health care professionals that while they may express regret for what has occurred, they should take care not to state or agree that they, or other health care professionals, or health care organisations, are liable for the harm caused to the patient. The National Open Disclosure Standard is currently being reviewed, and the Consultation Draft of the Australian Open Disclosure Framework appears to move things closer to its stated finding that ethical practice prioritises organisational and individual learning from error, rather than an organisational risk-management approach. However, it remains the case that the sense of apology in the Consultation Draft is one of stating regret, not of accepting responsibility This dissonance in the Draft Framework wording may represent a continuing disingenuousness on the part of health professionals and their institutions regarding the kind of apologies that patients look for. Following Berlinger, the current author argues that expressions of regret are not apologies, since an apology presupposes the fault that health professionals are advised they avoid admitting. But honest, open communication surely implies both materially relevant disclosure, which would include acknowledgment of fault where that is known, and a genuine apology, as part of the continuing doctor-patient relationship. To the extent that open disclosure policies and practices fudge complete disclosure, admission of fault and
Yin, H Shonna; Parker, Ruth M; Sanders, Lee M; Dreyer, Benard P; Mendelsohn, Alan L; Bailey, Stacy; Patel, Deesha A; Jimenez, Jessica J; Kim, Kwang-Youn A; Jacobson, Kara; Hedlund, Laurie; Smith, Michelle C J; Maness Harris, Leslie; McFadden, Terri; Wolf, Michael S
Poorly designed labels and packaging are key contributors to medication errors. To identify attributes of labels and dosing tools that could be improved, we examined the extent to which dosing error rates are affected by tool characteristics (ie, type, marking complexity) and discordance between units of measurement on labels and dosing tools; along with differences by health literacy and language. Randomized controlled experiment in 3 urban pediatric clinics. English- or Spanish-speaking parents (n = 2110) of children ≤8 years old were randomly assigned to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. Each parent measured 9 doses of medication (3 amounts [2.5, 5, and 7.5 mL] and 3 tools [1 cup, 2 syringes (0.2- and 0.5-mL increments)]), in random order. Outcome assessed was dosing error (>20% deviation; large error defined as > 2 times the dose). A total of 84.4% of parents made ≥1 dosing error (21.0% ≥1 large error). More errors were seen with cups than syringes (adjusted odds ratio = 4.6; 95% confidence interval, 4.2-5.1) across health literacy and language groups (P error rates were seen between the 2 syringe types. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used (adjusted odds ratio = 1.2; 95% confidence interval, 1.01-1.4). Recommending oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors. Copyright © 2016 by the American Academy of Pediatrics.
Smorti, Andrea; Cappelli, Francesco; Zarantonello, Roberta; Tani, Franca; Gensini, Gian Franco
In recent years the issue of patient safety has been the subject of detailed investigations, particularly as a result of the increasing attention from the patients and the public on the problem of medical error. The purpose of this work is firstly to define the classification of medical errors, which are distinguished between two perspectives: those that are personal, and those that are caused by the system. Furthermore we will briefly review some of the main methods used by healthcare organizations to identify and analyze errors. During this discussion it has been determined that, in order to constitute a practical, coordinated and shared action to counteract the error, it is necessary to promote an analysis that considers all elements (human, technological and organizational) that contribute to the occurrence of a critical event. Therefore, it is essential to create a culture of constructive confrontation that encourages an open and non-punitive debate about the causes that led to error. In conclusion we have thus underlined that in health it is essential to affirm a system discussion that considers the error as a learning source, and as a result of the interaction between the individual and the organization. In this way, one should encourage a non-guilt bearing discussion on evident errors and on those which are not immediately identifiable, in order to create the conditions that recognize and corrects the error even before it produces negative consequences.
Kamel, Hani Fouad
Despite many efforts to structure the development and design processes of embedded systems, errors are discovered at the final stages of production and sometimes after the delivery of the products. The cost of such errors can be prohibitive.Different design techniques to detect such errors...... systems, a formal model for such systems is introduced. The main characteristics of embedded systems design and the interaction of these properties are described. A taxonomy for the structure of the software developed for such systems based on the amount of processes and processors involved is presented...... will be presented. Moreover, we will try to describe the causes of these errors and the countermeasures that can be taken to avoid them. The main theme is that prevention is better than cure.The presentation is structured in three parts. The first part deals with an introduction to the subject area of embedded...
Stroud, Lynfa; McIlroy, Jodi; Levinson, Wendy
To determine internal medicine (IM) residents' ability to disclose a medical error using standardized patients (SPs) and to survey residents' experiences of disclosure. In 2005, 42 second-year IM residents at the University of Toronto participated in the study. Each resident disclosed one medical error (insulin overdose) to an SP. The SP and a physician observer scored performance using a rating scale (1 = not performed, 2 = performed somewhat, and 3 = performed well) that measures error disclosure on five specific component skills and that provides an overall assessment score (scored on a five-point scale, 5 = high). Residents also completed a questionnaire. The mean scores on the five components were explanation of medical facts (2.60), honesty (2.31), empathy (2.47), future error prevention (1.99), and general communication skills (2.47). The residents' mean overall disclosure score was 3.53. Although 27 of 42 residents (64%) reported previous experience in disclosing an error to a patient during their training, only 7 (27%) of these residents reported receiving any feedback about their performance. Of 41 residents, 21 (51%) had received some prior training in disclosure, and 38 (93%) thought additional training would be useful and relevant. Disclosing medical error is now a standard practice. Experience with medical error begins early in training, and preparing trainees to discuss these errors is essential. Areas exist for improvement in residents' disclosure abilities, particularly regarding the prevention of future errors. Curricula to increase residents' skills and comfort in disclosure need to be implemented. Most residents would welcome further training.
Mekonnen, Alemayehu B; Alhawassi, Tariq M; McLachlan, Andrew J; Brien, Jo-Anne E
Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5-20.1%), while adverse drug events causing admission were reported in 2.8% (0.7-6.4%) of patients but it was reported that a median of 43.5% (20.0-47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0-0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8-72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5-50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge
Korb-Savoldelli, Virginie; Boussadi, Abdelali; Durieux, Pierre; Sabatier, Brigitte
The positive impact of computerized physician order entry (CPOE) systems on prescription safety must be considered in light of the persistence of certain types of medication-prescription errors. We performed a systematic review, based on the PRISMA statement, to analyze the prevalence of prescription errors related to the use of CPOE systems. We searched MEDLINE, EMBASE, CENTRAL, DBLP, the International Clinical Trials Registry, the ISI Web of Science, and reference lists of relevant articles from March 1982 to August 2017. We included original peer-reviewed studies which quantitatively reported medication-prescription errors related to CPOE. We analyzed the prevalence of medication-prescription errors according to an adapted version of the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) taxonomy and assessed the mechanisms responsible for each type of prescription error due to CPOE. Fourteen studies were included. The prevalence of CPOE systems-related medication errors relative to all prescription medication errors ranged from 6.1 to 77.7% (median = 26.1% [IQR:17.6-42,1]) and was less than 6.3% relative to the number of prescriptions reviewed. All studies reported "wrong dose" and "wrong drug" errors. The "wrong dose" error was the most frequently reported (from 7 to 67.4%, median = 31.5% [IQR:20.5-44.5]). We report the associated mechanism for each type of medication described (those due to CPOE or those occurring despite CPOE). We observed very heterogeneous results, probably due to the definition of error, the type of health information system used for the study, and the data collection method used. Each data collection method provides valuable and useful information concerning the prevalence and specific types of errors related to CPOE systems. The reporting of prescription errors should be continued because the weaknesses of CPOE systems are potential sources of error. Analysis of the mechanisms behind CPOE
Kim, Jeongeun; Bates, David W
Medication administration errors represent one of the major concerns in patient safety. We aimed to study the rate using more robust methods for the correct results. Very few studies have been carried out on medication administration error frequency. Previous studies of medication error frequency have used mainly surveys of clinical nurses, which may result in substantial undercounts. We developed a checklist using basic medication guidelines including the Five Rights, infection recommendations and medication recording rules. After validity and reliability were confirmed, we performed direct observation using a checklist to evaluate the medication activities of clinical nurses. We observed total 293 cases of medication activities, collected data and calculated adherence ratios per item. Only 45·6% of nurses verified the amount of medication indicated on the vial at least once for at least one-second. In addition, only 6·5% read the name of the patient from the wristband. Administering the medication at the correct time guideline was observed 41·0% of the time. The guideline regarding hand washing before external and oral medications was followed only 4·5% of the time, although this figure was much higher for intravenous medications at 96·6%. Overall, among 31 categories regarding drug administration, 17·2 (± 3·6) items per person were followed, whereas 5·7 (± 1·2) items per person were violated. Thus, the results overall showed low rates of adherence to guidelines, suggesting that many medication administration guidelines are not strictly followed. We found key instances in which nurses did not follow the guidelines, including many from the Five Rights. About one in four elements were violated overall. The results of this study could be adopted to make guidelines of medication administration more practical for the clinical nurses to adhere. © 2012 Blackwell Publishing Ltd.
Ambrosio, L; Pumar-Méndez, M J
The incidence of medication administration errors (MAE) is high and costly for patients and health institutions. Human factors and factors relating to the work context intervene in their occurrence. The aim of this article is to identify the role of factors in the work setting related to occurrence of MAEs in the hospital field. A narrative review of the literature. Eight articles were included following a review of MEDLINE, CINAHL and COCHRANE LIBRARY databases for the 2002-2012 period. Distractions and interruptions, work overload, design of units and characteristics of the material stood out amongst the work context factors intervening in the occurrence of medication administration errors. The creation of organizational artefacts to reduce interruptions; patient involvement in medication administration; the introduction of new technologies and improving the labelling of medications can help reduce the incidence of medication administration errors. To advance in identifying and managing factors that are precursors of medication administration errors, we recommend the carrying out of studies or reviews of prospective cohorts.
Wu, Shuhua; Chen, Kefei; Zhu, Yuefei
Quite recently, Yu et al. presented a real lightweight binding proof protocol to guard patient safety and prevent medication errors. In this paper, we first show their protocol is still vulnerable to impersonation attacks. Thereafter we propose a new lightweight binding proof protocol to overcome these weaknesses and securely achieve the goal of proving that two tags exist in the field simultaneously.
Lane, R; Stanton, NA; Harrison, DJ
Medication use in hospitals is a complex process and is dependent on the successful interaction of health professionals functioning within different disciplines. Errors can occur at any one of the five main stages of prescribing, documenting, dispensing or preparation, administering and monitoring. The responsibility for the error is often placed on the nurse, as she or he is the last person in the drug administration chain whilst more pressing underlying causal factors remain unresolved. ...
Sears, Kim; Goodman, William M.
Patients' risks from medication errors are widely acknowledged. Yet not all errors, if they occur, have the same risks for severe consequences. Facing resource constraints, policy makers could prioritize factors having the greatest severe–outcome risks. This study assists such prioritization by identifying work-related risk factors most clearly associated with more severe consequences. Data from three Canadian paediatric centres were collected, without identifiers, on actual or potential erro...
Plews-Ogan, Margaret; May, Natalie; Owens, Justine; Ardelt, Monika; Shapiro, Jo; Bell, Sigall K
Confronting medical error openly is critical to organizational learning, but less is known about what helps individual clinicians learn and adapt positively after making a harmful mistake. Understanding what factors help doctors gain wisdom can inform educational and peer support programs, and may facilitate the development of specific tools to assist doctors after harmful errors occur. Using "posttraumatic growth" as a model, the authors conducted semistructured interviews (2009-2011) with 61 physicians who had made a serious medical error. Interviews were recorded, professionally transcribed, and coded by two study team members (kappa 0.8) using principles of grounded theory and NVivo software. Coders also scored interviewees as wisdom exemplars or nonexemplars based on Ardelt's three-dimensional wisdom model. Of the 61 physicians interviewed, 33 (54%) were male, and on average, eight years had elapsed since the error. Wisdom exemplars were more likely to report disclosing the error to the patient/family (69%) than nonexemplars (38%); P medical error highlights specific ways to help clinicians move through this difficult experience so that they avoid devastating professional outcomes and have the best chance of not just recovery but positive growth.
Vilà-de-Muga, Mònica; Colom-Ferrer, Laura; Gonzàlez-Herrero, Mariona; Luaces-Cubells, Carles
To describe the prevalence, type, and factors associated with medication errors in a pediatric emergency department. This is a descriptive retrospective study about the treatments administered in the pediatric emergency department during a week in November 2007. We used the protocols and clinical guides at our center as pattern of reference. The errors were classified as follows: (1) prescription error: drug involved, indication, dose, and route of administration; (2) severity of the error; and (3) associated factors: triage category, age of the patient, training level of the physician, day of the week, and hour of the day. In 377 of 1906 checked reports, some treatments were prescribed. A total of 92 errors (15%) were detected and all of them were prescription errors: 50 (8%) for inappropriate indication and 42 (7 %) for inadequate dose. Also, 87 were considered insignificant errors, 5 were moderate and none were severe. There was a higher rate of errors among residents with less experience. We did not find differences in the triage category neither in the age of the patient. In the weekends and holidays, we commit more errors compared in weekdays (28% vs 18 %, P=0.02). Between 24 and 8 hours, we registered more errors than between 8 and 16 and between 16 and 24 hours (32.3% vs 17.9% vs 21.2%; P=0.03). Error rates in drugs administered exclusively in the emergency department are slightly higher than others evaluating house orders and emergency department treatments. The high assistance pressure during weekends and holidays and the tiredness during the night are risk factors of prescribing errors. Periodical evaluation of the prescriptions is necessary to develop the best strategies to apply every time. Copyright © 2011 by Lippincott Williams & Wilkins
Plessen, Kerstin J; Allen, Elena A; Eichele, Heike
BACKGROUND: We examined the blood-oxygen level-dependent (BOLD) activation in brain regions that signal errors and their association with intraindividual behavioural variability and adaptation to errors in children with attention-deficit/hyperactivity disorder (ADHD). METHODS: We acquired...... functional MRI data during a Flanker task in medication-naive children with ADHD and healthy controls aged 8-12 years and analyzed the data using independent component analysis. For components corresponding to performance monitoring networks, we compared activations across groups and conditions...... performance monitoring problems to specific brain regions and operations in error processing may help to guide the targets of future treatments for ADHD....
Aguirre-Gas, Héctor Gerardo; Zavala-Villavicencio, Jesús Antonio; Hernández-Torres, Francisco; Fajardo-Dolci, Germán
over time, a significant number of definitions and concepts on quality of care have been identified. This study focuses on quality of care from the perspective of medical patients. quality of medical care includes different areas: opportunity, professional qualifications, safety, respect for ethical principles of medical practice and satisfaction with care outcomes. In this regard, at the Conamed (National Commission for Medical Arbitration), 8062 complaints have been followed, analyzed and completed between June 1996 and December 2008: in 16.8% of the complaints there were insufficient data to determine whether or not there was evidence of malpractice; 20.8% of the complaints had evidence of malpractice and in 62.4% of complaints the existence of good practice was determined according to the lex artis. Among the surgical specialties with the highest malpractice cases were the following: general surgery, gynecology, orthopedics, ophthalmology, emergency surgery, urology and traumatology. acknowledgment of the concept of quality of health care provides a starting point to determine the source of errors, malpractice and professional responsibility in order to resolve and prevent them. Conamed offers alternative means for conflict resolution related to physician-patient relationship by means of conciliation and arbitration, favoring patient and family, as well as the medical profession.
Hoyle, John D; Davis, Alan T; Putman, Kevin K; Trytko, Jeff A; Fales, William D
Medication dosing errors occur in up to 17.8% of hospitalized children. There are limited data to describe pediatric medication errors by emergency medical services (EMS) paramedics. It has been shown that paramedics have infrequent encounters with pediatric patients. To characterize medication dosing errors in children treated by EMS. We studied patients aged ≤11 years who were treated by paramedics from eight Michigan EMS agencies from January 2004 through March 2006. We defined a medication dosing error as ≥20% deviation from the weight-appropriate dose, as determined by the patient's reported weight in the prehospital medical record or by use of the Broselow-Luten tape (BLT). We studied errors in administering six EMS medications commonly given to children: albuterol, atropine, dextrose, diphenhydramine, epinephrine, and naloxone. There were 5,547 children aged ≤11 years who were treated during the study period, of whom 230 (4.1%) received drugs and had a documented weight. These patients received a total of 360 medication administrations. Multiple drug administrations occurred in 73 cases. Medication dosing errors occurred in 125 of the 360 drug administrations (34.7%; 95% confidence interval [CI] 30.0, 39.8). Relative drug dosage errors (with 95% CI) were as follows: albuterol 23.3% (18.4, 29.1), atropine 48.8% (34.3, 63.5), diphenhydramine 53.8% (29.1, 76.8), and epinephrine 60.9% (49.9, 73.9). The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine overdoses was 808% ± 428%. The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine underdoses was 35.5% ± 27.4%. Medications delivered in the prehospital care of children were frequently administered outside of the proper dose range when compared with patient weights recorded in the prehospital medical record. EMS systems should develop strategies to reduce pediatric medication dosing errors.
Full Text Available The purpose of this study was (1 to determine frequency and type of medication errors (MEs, (2 to assess the number of MEs prevented by registered nurses, (3 to assess the consequences of ME for patients, and (4 to compare the number of MEs reported by a newly developed medication error self-reporting tool to the number reported by the traditional incident reporting system. We conducted a cross-sectional study on ME in the Cardiovascular Surgery Department of Bern University Hospital in Switzerland. Eligible registered nurses ( involving in the medication process were included. Data on ME were collected using an investigator-developed medication error self reporting tool (MESRT that asked about the occurrence and characteristics of ME. Registered nurses were instructed to complete a MESRT at the end of each shift even if there was no ME. All MESRTs were completed anonymously. During the one-month study period, a total of 987 MESRTs were returned. Of the 987 completed MESRTs, 288 (29% indicated that there had been an ME. Registered nurses reported preventing 49 (5% MEs. Overall, eight (2.8% MEs had patient consequences. The high response rate suggests that this new method may be a very effective approach to detect, report, and describe ME in hospitals.
The use of bar-code medication administration technology is on the rise in acute care facilities in the United States. The technology is purported to decrease medication errors that occur at the point of administration. How significantly this technology affects actual rate and severity of error is unknown. This descriptive, longitudinal research…
Muroi, Maki; Shen, Jay J; Angosta, Alona
Registered nurses (RNs) play an important role in safe medication administration and patient safety. This study examined a total of 1276 medication error (ME) incident reports made by RNs in hospital inpatient settings in the southwestern region of the United States. The most common drug class associated with MEs was cardiovascular drugs (24.7%). Among this class, anticoagulants had the most errors (11.3%). The antimicrobials was the second most common drug class associated with errors (19.1%) and vancomycin was the most common antimicrobial that caused errors in this category (6.1%). MEs occurred more frequently in the medical-surgical and intensive care units than any other hospital units. Ten percent of MEs reached the patients with harm and 11% reached the patients with increased monitoring. Understanding the contributing factors related to MEs, addressing and eliminating risk of errors across hospital units, and providing education and resources for nurses may help reduce MEs. Copyright © 2016 Elsevier Inc. All rights reserved.
Charboneau, Aubri L; Shelton, Penny S; Brickley, Jan B; Rich, Wesley
To determine the percentage of medication-related proposed penalties for licensed assisted living facilities in North Carolina. This retrospective, cross-sectional study examined all proposed penalties and related case-file narratives stemming from annual surveys of licensed assisted living facilities conducted by the state between July 2007 and December 2008. The percentage of medication-related deficiencies and proposed penalties were calculated. Associations between the medication-related proposed penalties and facility size, location, and penalty type were explored using chi-square tests. Assisted living facilities in North Carolina. Percentage of medication- and non-medication-related penalties. A total of 1,256 licensed assisted living facilities (51% adult care homes, 59% metropolitan) were surveyed during the study period. There were 88 proposed penalties (51% medication-related) among 60 facilities. No association between medication-related proposed penalties and facility size or location was detected. However, an association (P = 0.002) was found between type of penalty (A or B) and whether the proposed penalty was medication- or non-medication-related (37.3% and 70.3% of Type A and B penalties, respectively, were medication related). Medications commonly cited were insulin, cardiovascular agents, supplements, anticonvulsants, and antipsychotics. Common categories of medication errors were drug not administered and wrong dose administered. Medication errors, regardless of facility size or location, were contributing factors in approximately one-half of violations sufficient enough to warrant a penalty proposal among the licensed assisted living facilities in North Carolina. These findings demonstrate a need for continued regulation and increased pharmacist involvement to improve medication safety.
Full Text Available Medication error (ME is a worldwide issue, but most studies on ME have been undertaken in developed countries and very little is known about ME in Southeast Asian countries. This study aimed systematically to identify and review research done on ME in Southeast Asian countries in order to identify common types of ME and estimate its prevalence in this region.The literature relating to MEs in Southeast Asian countries was systematically reviewed in December 2014 by using; Embase, Medline, Pubmed, ProQuest Central and the CINAHL. Inclusion criteria were studies (in any languages that investigated the incidence and the contributing factors of ME in patients of all ages.The 17 included studies reported data from six of the eleven Southeast Asian countries: five studies in Singapore, four in Malaysia, three in Thailand, three in Vietnam, one in the Philippines and one in Indonesia. There was no data on MEs in Brunei, Laos, Cambodia, Myanmar and Timor. Of the seventeen included studies, eleven measured administration errors, four focused on prescribing errors, three were done on preparation errors, three on dispensing errors and two on transcribing errors. There was only one study of reconciliation error. Three studies were interventional.The most frequently reported types of administration error were incorrect time, omission error and incorrect dose. Staff shortages, and hence heavy workload for nurses, doctor/nurse distraction, and misinterpretation of the prescription/medication chart, were identified as contributing factors of ME. There is a serious lack of studies on this topic in this region which needs to be addressed if the issue of ME is to be fully understood and addressed.
Salmasi, Shahrzad; Khan, Tahir Mehmood; Hong, Yet Hoi; Ming, Long Chiau; Wong, Tin Wui
Medication error (ME) is a worldwide issue, but most studies on ME have been undertaken in developed countries and very little is known about ME in Southeast Asian countries. This study aimed systematically to identify and review research done on ME in Southeast Asian countries in order to identify common types of ME and estimate its prevalence in this region. The literature relating to MEs in Southeast Asian countries was systematically reviewed in December 2014 by using; Embase, Medline, Pubmed, ProQuest Central and the CINAHL. Inclusion criteria were studies (in any languages) that investigated the incidence and the contributing factors of ME in patients of all ages. The 17 included studies reported data from six of the eleven Southeast Asian countries: five studies in Singapore, four in Malaysia, three in Thailand, three in Vietnam, one in the Philippines and one in Indonesia. There was no data on MEs in Brunei, Laos, Cambodia, Myanmar and Timor. Of the seventeen included studies, eleven measured administration errors, four focused on prescribing errors, three were done on preparation errors, three on dispensing errors and two on transcribing errors. There was only one study of reconciliation error. Three studies were interventional. The most frequently reported types of administration error were incorrect time, omission error and incorrect dose. Staff shortages, and hence heavy workload for nurses, doctor/nurse distraction, and misinterpretation of the prescription/medication chart, were identified as contributing factors of ME. There is a serious lack of studies on this topic in this region which needs to be addressed if the issue of ME is to be fully understood and addressed.
Zientek, David M
This essay reviews and defines avoidable medical error, malpractice and complication. The relevant ethical principles pertaining to unanticipated medical outcomes are identified. In light of these principles I critically review the moral culpability of the agents in each circumstance and the resulting obligations to patients, their families, and the health care system in general. While I touch on some legal implications, a full discussion of legal obligations and liability issues is beyond the scope of this paper.
da Silva, Brianna A; Krishnamurthy, Mahesh
A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs) account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Medication reconciliation including an 'indication review' for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider-patient relationship.
Brianna A. da Silva
Full Text Available Case description: A 71-year-old female accidentally received thiothixene (Navane, an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Discussion: Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Conclusion: Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider–patient relationship.
Shah, Kanan; Barker, Kimberly A
Previous research and reporting has focused on the incidence and prevention of medication errors in the hospital setting; however, no previous study has reported the frequencies, characteristics and outcomes of out-of-hospital medication (OHME) errors. Data from the National Poison Data System (NPDS) was collected for 2000-2005 and information regarding out-of-hospital medication errors reported to Poison Control Centers (PCC) was collected by a trained investigator. From 2000-2005 there were 1,166,116 OHME reported to PCC. Of these patients, 88,451 (7.5%) received medical evaluation by a healthcare provided and 229 (0.01%) deaths reported. The most common drug classes involved included cough/cold medications, analgesics, cardiovascular agents, antihistamines, antidepressants and antimicrobial agents. The most common error reported in both children and adults was taking or giving medication twice. OHME occur frequently and the NPDS may be a useful resource for data collection and evaluation in this previously overlooked population. The majority of OHME reported did not result in any significant morbidity or mortality and were managed at home without need for healthcare referrral. Further study of OHME is needed, and in particular whether healthcare professionals can target educational instruction to patients so as to effectively reduce the frequency of the most common or injurious errors. (c) 2009 John Wiley & Sons, Ltd.
Bielić, Toni; Hasanspahić, Nermin; Čulin, Jelena
The objective of embedding technology on board ships, to improve safety, is not fully accomplished. The paper studies marine accidents caused by human error resulting from improper human-technology interaction. The aim of the paper is to propose measures to prevent reoccurrence of such accidents. This study analyses the marine accident reports issued by Marine Accidents Investigation Branch covering the period from 2012 to 2014. The factors that caused these accidents are examined and categor...
Adverse events involving psychotropic drugs are common and some may be due to errors in clinical decision making of a type not detected by the studies reviewed. These are potentially preventable. On the basis of this, it is recommended that medicine management in mental health settings should be a priority for future ...
Flin, Rhona; Patey, Rona; Jackson, Jeanette; Mearns, Kathryn; Dissanayaka, Upul
To improve patient safety, medical students should be taught about human error and the factors influencing adverse events. The optimal evaluation of new curricula for patient safety requires tools for baseline measurement of medical students' attitudes and knowledge. The aim of the study was to design and evaluate a questionnaire for measuring the attitudes of Year 1 medical students to patient safety and medical error. A questionnaire entitled 'Medical Students' Patient Safety Questionnaire (Year 1)' was designed to assess Year 1 medical students' attitudes and anticipated behaviours relating to medical error and patient safety. This was administered to two cohorts of Year 1 medical students in a UK medical school during 2008 (n = 296) and the data subjected to psychometric analyses. Medical students' attitudes to good patient safety practices were generally positive, but the students had little knowledge of how to report errors and were unsure about what to do if a colleague made an error or if a patient indicated that an error had been made. On the five scales of the questionnaire, Cronbach's alpha values ranged from 0.59 (Attitudes to patient safety scale) to 0.88 (Knowledge of error and patient safety scale) and three scales showed internal consistencies below the recommended value of 0.70. Exploratory factor analysis showed that the five factors explain 51.7% of variance. With some minor item trimming and re-allocation, the Medical Students' Patient Safety Questionnaire (Year 1) can function as an instrument with which to assess the attitudes of new medical students to patient safety and medical error. To assess the suitability of the instrument beyond the UK would require additional work.
Thyroid-stimulating hormone (TSH) is a first-line thyroid function test and, if abnormal, reflex thyroxine (T4) or tri-iodothyronine (T3) testing is requested, depending on clinical and medication data provided. Interpretative comments are added to all TFT results. Objectives. In view of the paucity of articles describing such errors ...
Conclusions: The results show that many of the manuscripts had remarkable errors and demonstrate the need for attention to detail in study design and manuscript preparation and for further training of medical scientists in the techniques of manuscript writing for journal publication. Key words: Academic writing, Africa, Asia, ...
A comparative study of voluntarily reported medication errors among adult patients in intensive care (IC) and non- IC settings in Riyadh, Saudi Arabia. Shmeylan A. Al Harbi, Nasser Mahdi Al-Qhtani, Rami Bustami, Hind Almodaimegh, Abdulmalik M. Alkatheri, Hind A. Al Badali, Yousef H. Al Awlah, Saleh Aldekhael, Waleed ...
Plessen, Kerstin J; Allen, Elena A; Eichele, Heike
BACKGROUND: We examined the blood-oxygen level-dependent (BOLD) activation in brain regions that signal errors and their association with intraindividual behavioural variability and adaptation to errors in children with attention-deficit/hyperactivity disorder (ADHD). METHODS: We acquired...... functional MRI data during a Flanker task in medication-naive children with ADHD and healthy controls aged 8-12 years and analyzed the data using independent component analysis. For components corresponding to performance monitoring networks, we compared activations across groups and conditions...... and correlated them with reaction times (RT). Additionally, we analyzed post-error adaptations in behaviour and motor component activations. RESULTS: We included 25 children with ADHD and 29 controls in our analysis. Children with ADHD displayed reduced activation to errors in cingulo-opercular regions...
Hardmeier, Anna; Tsourounis, Candy; Moore, Mary; Abbott, Wendy E; Guglielmo, B Joseph
Direct observation was used to detect medication errors and Bar Code Medication Administration (BCMA) workarounds on two pediatric units and one neonatal unit at UCSF Benioff Children's Hospital. The study (1) measured the frequency of nursing medication administration-related errors, (2) characterized the types of medication errors, (3) assessed compliance with the institution's six medication administration safety processes, and (4) identified observed workarounds following BCMA implementation. The results of the direct observation were compared to medication administration-related incident reports (IRs) for the same period. The frequency of medication errors was 5% for the three units. Compliance with the process measures was achieved 86% of the time (range 23-100%). Seven medication administration-related IRs were submitted during the same observation period. Three BCMA workarounds were identified; (1) failure to visually confirm patient's identification, (2) failure to compare the medication to the electronic medication administration record at least twice before administration, and (3) charting administration of medication before actual administration. The direct observation methodology identified a low frequency of medication administration errors (MAEs) consistent with post-BCMA implementation. The incident reporting system identified different MAEs than direct observation suggesting that both methods should be used to better characterize the scope of MAEs. © 2014 National Association for Healthcare Quality.
Hutton, Kevin; Ding, Qian; Wellman, Gregory
The bar-coding technology adoptions have risen drastically in U.S. health systems in the past decade. However, few studies have addressed the impact of bar-coding technology with strong prospective methodologies and the research, which has been conducted from both in-pharmacy and bedside implementations. This systematic literature review is to examine the effectiveness of bar-coding technology on preventing medication errors and what types of medication errors may be prevented in the hospital setting. A systematic search of databases was performed from 1998 to December 2016. Studies measuring the effect of bar-coding technology on medication errors were included in a full-text review. Studies with the outcomes other than medication errors such as efficiency or workarounds were excluded. The outcomes were measured and findings were summarized for each retained study. A total of 2603 articles were initially identified and 10 studies, which used prospective before-and-after study design, were fully reviewed in this article. Of the 10 included studies, 9 took place in the United States, whereas the remaining was conducted in the United Kingdom. One research article focused on bar-coding implementation in a pharmacy setting, whereas the other 9 focused on bar coding within patient care areas. All 10 studies showed overall positive effects associated with bar-coding implementation. The results of this review show that bar-coding technology may reduce medication errors in hospital settings, particularly on preventing targeted wrong dose, wrong drug, wrong patient, unauthorized drug, and wrong route errors.
Pinto, Jose Miguel; Arrieta, Cristobal; Andia, Marcelo E; Uribe, Sergio; Ramos-Grez, Jorge; Vargas, Alex; Irarrazaval, Pablo; Tejos, Cristian
Additive manufacturing (AM) models are used in medical applications for surgical planning, prosthesis design and teaching. For these applications, the accuracy of the AM models is essential. Unfortunately, this accuracy is compromised due to errors introduced by each of the building steps: image acquisition, segmentation, triangulation, printing and infiltration. However, the contribution of each step to the final error remains unclear. We performed a sensitivity analysis comparing errors obtained from a reference with those obtained modifying parameters of each building step. Our analysis considered global indexes to evaluate the overall error, and local indexes to show how this error is distributed along the surface of the AM models. Our results show that the standard building process tends to overestimate the AM models, i.e. models are larger than the original structures. They also show that the triangulation resolution and the segmentation threshold are critical factors, and that the errors are concentrated at regions with high curvatures. Errors could be reduced choosing better triangulation and printing resolutions, but there is an important need for modifying some of the standard building processes, particularly the segmentation algorithms. Copyright © 2015 IPEM. Published by Elsevier Ltd. All rights reserved.
Oshikoya, K A; Oreagba, I A; Ogunleye, O O; Senbanjo, I O; MacEbong, G L; Olayemi, S O
There is paucity of data on paediatric medicine administration error (MAE) in developing countries. This study aimed to investigate the experience of MAEs among paediatric nurses working in public hospitals in Lagos, Nigeria. A confidential, self-reporting questionnaire was the instrument for the study. Public hospitals in Lagos, Nigeria with established paediatric services and departments. Paediatric nurses. The questionnaire was administered to 75 nurses working in public hospitals in Lagos to obtain information on the experience of medication errors during their entire career, as well as to know their views on the nature of MAEs and the contributing factors. Fifty nurses responded to give a response rate of 66.7%. All the participants were females with a mean ± s.d age of 35.3 ± 10.7 years. Thirty two (64%) had committed at least one medication error over the course of their career. Wrong dose error (24; 48%) and wrong timing of medicine administration (20; 40%) were the MAEs frequently committed by the participants. The consequences of the errors included shock (23; 46%), restlessness (21; 42%), disorientation (11; 22%), and respiratory depression (10; 20%). Increased workload (26; 52%) and not double checking medicine doses (12; 24%) were the major factors the nurses perceived to be contributing to MAEs. Only 15(30%) nurses had reported MAEs to their superiors. Fear of intimidation, retribution or being punished (11; 22%) and lack of policies in place to report errors (13; 26%) were the two major barriers to reporting MAEs. Half (50%) of the nurses indicated that policies were available in their work places to prevent medication errors. Medication administration errors were frequently committed by the participants and resulted in some inconsequential effects, morbidity and deaths. Appropriate measures should be implemented to prevent future occurrences of MAEs.
Risør, Bettina Wulff; Lisby, Marianne; Sørensen, Jan
the medication administration error rate in comparison with current practice. Material and methods This was a controlled before and after study with follow-up after 7 and 14 months. The study was conducted in two acute medical hospital wards. Two automated medication systems were tested: (1) automated dispensing...... cabinet, automated dispensing and barcode medication administration; (2) non-patient specific automated dispensing and barcode medication administration. The occurrence of administration errors was observed in three 3 week periods. The error rates were calculated by dividing the number of doses with one....... The complex automated medication system effectively reduced the overall risk of administration errors in the intervention ward (OR 0.53, 95% CI 0.27–0.90), and the procedural error rate was also significantly reduced (OR 0.44, 95% CI 0.126–0.94). The non-patient specific automated medication system...
Maaskant, Jolanda M; Vermeulen, Hester; Apampa, Bugewa; Fernando, Bernard; Ghaleb, Maisoon A; Neubert, Antje; Thayyil, Sudhin; Soe, Aung
Many hospitalised patients are affected by medication errors (MEs) that may cause discomfort, harm and even death. Children are at especially high risk of harm as the result of MEs because such errors are potentially more hazardous to them than to adults. Until now, interventions to reduce MEs have led to only limited improvements. To determine the effectiveness of interventions aimed at reducing MEs and related harm in hospitalised children. The Effective Practice and Organisation of Care Group (EPOC) Trials Search Co-ordinator searched the following sources for primary studies: The Cochrane Library, including the Cochrane Central Register of Controlled Trials (CENTRAL), the Economic Evaluation Database (EED) and the Health Technology Assessments (HTA) database; MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Proquest Dissertations & Theses, Web of Science (citation indexes and conference proceedings) and the EPOC Register of Studies. Related reviews were identified by searching the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE). Review authors searched grey literature sources and trial registries. They handsearched selected journals, contacted researchers in the field and scanned reference lists of relevant reviews. They conducted searches in November 2013 and November 2014. They applied neither language nor date limits. Randomised controlled trials, controlled before-after studies and interrupted time series investigating interventions to improve medication safety in hospitalised children (≤ 18 years). Participants were healthcare professionals authorised to prescribe, dispense or administer medications. Outcome measures included MEs, (potential) patient harm, resource utilisation and unintended consequences of the interventions. Two review authors independently selected studies, extracted data and assessed study quality using the EPOC data collection
van Doormaal, J.E.; Lenderink, A.W.; Mol, P.G.M.; Kosterink, J.G.W.; Egberts, T.C.G.; Haaijer-Ruskamp, F.M.; van den Bemt, P.M.L.A.; Zaal, Rianne J.
Purpose To compare determinants for medication errors leading to patient harm with determinants for medication errors without patient harm. Methods A two-way case-control design was used to identify determinants for medication errors without harm (substudy I) and determinants for medication errors
Costello, Jennifer L; Torowicz, Deborah Lloyd; Yeh, Timothy S
The effects of a pharmacist-led pediatrics medication safety team (PMST) on the frequency and severity of medication errors reported were studied. This study was conducted in a pediatric critical care center (PCCC) in three phases. Phase 1 consisted of retrospective collection of medication-error reports before any interventions were made. Phases 2 and 3 included prospective collection of medication-error reports after several interventions. Phase 2 introduced a pediatrics clinical pharmacist to the PCCC. A pediatrics clinical pharmacist-led PMST (including a pediatrics critical care nurse and pediatrics intensivist), a new reporting form, and educational forums were added during phase 3 of the study. In addition, education focus groups were held for all intensive care unit staff. Outcomes for all phases were measured by the number of medication-error reports processed, the number of incidents, error severity, and the specialty of the reporter. Medication-error reporting increased twofold, threefold, and sixfold between phases 1 and 2, phases 2 and 3, and phases 1 and 3, respectively. Error severity decreased over the three time periods. In phases 1, 2, and 3, 46%, 8%, and 0% of the errors were classified as category D or E, respectively. Conversely, the reporting of near-miss errors increased from 9% in phase 1 to 38% in phase 2 and to 51% in phase 3. An increase in the number of medication errors reported and a decrease in the severity of errors reported were observed in a PCCC after implementation of a PMST, provision of education to health care providers, and addition of a clinical pharmacist.
Purpose. - The fast modifications in French medical legislation, the increasing number of litigations and the professional consequences for the practitioner warrant the necessity to recall the 'how to manage' a claim for medical error. Patients and methods. - Four cases of legal action against oncologists are presented. Results and discussion. - The importance of quality and traceability of the given information, the essential pieces of the medical file, the description of the different process steps and of the contradictory meeting are presented and discussed. Conclusion. - Beyond the control of medical and technical risks, the practitioners in general and the radiation oncologist in particular should learn on the daily management of the risk related to medical claim. (authors)
Campanella, Nando; Morosini, Pierpaolo; Sampaolo, Guido; Catozzo, Vania; Caso, Andrea; Ferretti, Maurizio; Giovagnoli, Moreno; Torniai, Mariangela; Antico, Ettore
e-Health strategies are supposed to improve the performance of national health systems. Medical teleconsultation (MT) is an important component of such e-Health strategies. The outcome of MT was evaluated with regard to the impact on the medical error vulnerability (MEV) of internal medicine patients. A team of internal medicine doctors plus a network of forty specialists was set-up in one health district belonging to a unified and universal national health system of a country of Western Europe, in order to provide free-of-charge MT to support general practitioners in solving internal medicine cases. In this observational study, the case series of 2013 is reviewed. a) Only 21% of the MT fell short to the general practitioner's expectations about the case solving focus; b) throughout the medical care process of the patient, 49% of the cases met with one or more of the five MEVs, namely: 1) clinical test mishandling; 2) inaccurate differential diagnosis; 3) inadequate information flow between health providers at different levels of care (transition care); 4) poor coordination between health providers; and 5) poor reconciliation of medications or hazardous therapies. c) MT canceled or prevented MEVs in 56% and mitigate MEVs in 15% of the cases; d) MT canceled or prevented 85% of MEV caused by poor information exchange in transition care, therefore improving patient referral and counter-referral. MT reduces MEV and therefore, whenever implemented to a large extent, may improve the quality of health care delivery and the performance of national health systems. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Rivière, A; Piriou, V; Durand, D; Arnoux, A; Castot-Villepelet, A
The purpose of this study was to assess medication errors and risks of medication errors during anaesthetic practice reported at the French Health Products Agency (Afssaps) from 2005 to 2010. Descriptive study. The data are issued of "Medication errors and risks of medication errors" file which group together all cases received by the Medication Errors Unit at Afssaps since 2005. A total of 263 cases were observed by the Medication Errors Unit at Afssaps. Among them, 159 cases were risks of medication errors, 76 cases were patent medication errors and 28 were near misses. Among the 76 cases of patent medication errors, out of which 47 cases were appreciated with adverse reaction and 35 cases were classified as serious. Adverse events were classified as haemodynamic, respiratory and neurologic events. Most of the errors occurred during administration (65%), followed by dispensing errors (14%), storage errors (15%) or preparation errors (4%). Sixty-nine percent of cases of wrong drug errors were found, followed by 26% of errors of strength, 3% of incorrect route of administration errors and 2% of patient errors. In most of cases, similarity in packaging was underlined (n=83). This study showed that the majority of medication errors and risks of medication errors during anaesthetic practice, underline similarity in packaging. Results highlighted the importance of vial labeling presentation (readability and mention understanding) in anaesthetic practice. Copyright © 2011. Published by Elsevier SAS.
Perregaard, Helene; Aronson, Jeffrey K; Dalhoff, Kim
AIMS: We have looked for medication errors involving the use of low-dose methotrexate, by extracting information from Danish sources other than traditional pharmacovigilance databases. We used the data to establish the relative frequencies of different types of errors. METHODS: We searched four...... databases for cases involving low-dose methotrexate between 1999 and 2011: the Danish Patient Safety Databases (DPSD), controlled by the Danish National Agency for Patients' Rights and Complaints, the Patient Compensation Association (PCA), the Danish Poison and Information Centre (DPIC), and the online...
Full Text Available Reporting on adverse events is essential to create a culture of safety, which focuses on protecting doctors and patients from medical errors. We present a fatal case of Streptococcus C pharyngitis in a 56-year-old man. The clinical course and the results of additional diagnostics and autopsy showed that sepsis followed by multiple organ failure was the ultimate cause of death. The clinical course appeared fatal due to a chain of adverse events, including errors made by the physicians caring for the patient for 10 days.
Wu, Hsiang-Feng; Yu, Shu; Lan, Ya-Hui; Tang, Fu-In
Medication safety is a major concern worldwide that directly relates to patient care quality and safety. Reducing medication error incidents is a critical medication safety issue. This literature review article summarizes medication error issues related specifically to three hospital units, namely emergency rooms (ERs), intensive care units (ICUs), and pediatric wards. Time constrains, lack of patient history details and the frequent need to use rapid response life-saving medications are key factors behind high ER medication error rates. Patient hypo-responsiveness, complex medication administration and frequent need to use high-alert medications are key factors behind high ICU medication error rates. Medication error in pediatric wards are often linked to errors made by nurses in calculating dosage based on patient body weight. This article summarizes the major types of medication errors reported by these three units in order to increase nurse awareness of medication errors and further encourage nurses to apply proper standard operational procedures to medication administration.
Skinner, Stan; Holdefer, Robert; McAuliffe, John J; Sala, Francesco
Error avoidance in medicine follows similar rules that apply within the design and operation of other complex systems. The error-reduction concepts that best fit the conduct of testing during intraoperative neuromonitoring are forgiving design (reversibility of signal loss to avoid/prevent injury) and system redundancy (reduction of false reports by the multiplication of the error rate of tests independently assessing the same structure). However, error reduction in intraoperative neuromonitoring is complicated by the dichotomous roles (and biases) of the neurophysiologist (test recording and interpretation) and surgeon (intervention). This "interventional cascade" can be given as follows: test → interpretation → communication → intervention → outcome. Observational and controlled trials within operating rooms demonstrate that optimized communication, collaboration, and situational awareness result in fewer errors. Well-functioning operating room collaboration depends on familiarity and trust among colleagues. Checklists represent one method to initially enhance communication and avoid obvious errors. All intraoperative neuromonitoring supervisors should strive to use sufficient means to secure situational awareness and trusted communication/collaboration. Face-to-face audiovisual teleconnections may help repair deficiencies when a particular practice model disallows personal operating room availability. All supervising intraoperative neurophysiologists need to reject an insular or deferential or distant mindset.
Sears, Kim; Goodman, William M
Patients' risks from medication errors are widely acknowledged. Yet not all errors, if they occur, have the same risks for severe consequences. Facing resource constraints, policy makers could prioritize factors having the greatest severe-outcome risks. This study assists such prioritization by identifying work-related risk factors most clearly associated with more severe consequences. Data from three Canadian paediatric centres were collected, without identifiers, on actual or potential errors that occurred. Three hundred seventy-two errors were reported, with outcome severities ranging from time delays up to fatalities. Four factors correlated significantly with increased risk for more severe outcomes: insufficient training; overtime; precepting a student; and off-service patient. Factors' impacts on severity also vary with error class: for wrong-time errors, the factors precepting a student or working overtime significantly increase severe-outcomes risk. For other types, caring for an off-service patient has greatest severity risk. To expand such research, better standardization is needed for categorizing outcome severities. Copyright © 2012 Longwoods Publishing.
It is indispensable to decrease human errors as far as possible in view of the importance of nuclear power generation for Japan. From the viewpoint like this, the Central Research Institute of Electric Power Industry organized Human Factor Research Center in 1987, and the research on the prevention of human errors in nuclear power stations has been advanced together with electric power companies. For initial five years, the research centering around individual human behavior was advanced, and the establishment of the technique for the analysis of the cause and the plan of countermeasures on the occurred accidents and troubles from the aspect of human factors, the development of human behavior prediction system, the collection of the data on the state of research regarding human factors, the proposal of the concrete supporting technology for reducing human errors in maintenance works, the development of the technique for determining the probability of trouble occurrence, the development of the equipment for measuring and analyzing human visual sense, behavior and physiology, and the proposal of the technology for supporting the formation of knowledge and education system were carried out. In the second five-year period to 1996, the team errors in operation and maintenance, the development of a man-machine simulator, the practical use of the concrete supporting technology and so on are taken up. The human behavior prediction system is explained. (K.I.)
Gilmartin-Thomas, Julia Fiona-Maree; Smith, Felicity; Wolfe, Rory; Jani, Yogini
systems (RR=4.3, 95%CI 2.7 to 6.8, ppackaging and multi-compartment compliance aids supports the use of the latter in care homes, as well as local investigation of tablet and capsule impact on medication administration errors and staff training to prevent errors occurring. As a significant difference in error rate was not observed between use of a single or combination medication administration system, common practice of using both multi-compartment compliance aids (for most medications) and original packaging (for medications with stability issues) is supported. Copyright © 2017 Elsevier Ltd. All rights reserved.
Ida Bagus N. Maharjana
Full Text Available Hospital as a last line of health services shall provide quality service and oriented on patient safety, one responsibility in preventing medication errors. Effective collaboration and communication between the profession needed to achieve patient safety. Read-back is one way of doing effective communication. Before-after study with PDCA TQM approach. The samples were on the medication chart patient medical rd rd records in the 3 week of May (before and the 3 week in July (after 2013. Treatment using the check list, asked for time 2 minutes to read-back by the doctors and nurses after the visit together. Obtained 57 samples (before and 64 samples (after. Before charging 45.54% incomplete medication chart on patient medical records that have the potential risk of medication error to 10.17% after treatment with a read back check list for 10 weeks, with 77.78% based on the achievement of the PDCA TQM approach. Checklist usage as a guidance on Read-back as an effective communication can reduce charging incompleteness drug records on medical records that have the potential risk of medication errors, 45.54% to 10.17%.
van den Bemt, Patricia M.L.A.; Idzinga, Jetske C.; Robertz, Hans; Kormelink, Dennis Groot; Pels, Neske
Objective To identify the frequency of medication administration errors as well as their potential risk factors in nursing homes using a distribution robot. Design The study was a prospective, observational study conducted within three nursing homes in the Netherlands caring for 180 individuals. Measurements Medication errors were measured using the disguised observation technique. Types of medication errors were described. The correlation between several potential risk factors and the occurrence of medication errors was studied to identify potential causes for the errors. Results In total 2,025 medication administrations to 127 clients were observed. In these administrations 428 errors were observed (21.2%). The most frequently occurring types of errors were use of wrong administration techniques (especially incorrect crushing of medication and not supervising the intake of medication) and wrong time errors (administering the medication at least 1 h early or late).The potential risk factors female gender (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.05–1.83), ATC medication class antibiotics (OR 11.11; 95% CI 2.66–46.50), medication crushed (OR 7.83; 95% CI 5.40–11.36), number of dosages/day/client (OR 1.03; 95% CI 1.01–1.05), nursing home 2 (OR 3.97; 95% CI 2.86–5.50), medication not supplied by distribution robot (OR 2.92; 95% CI 2.04–4.18), time classes “7–10 am” (OR 2.28; 95% CI 1.50–3.47) and “10 am-2 pm” (OR 1.96; 1.18–3.27) and day of the week “Wednesday” (OR 1.46; 95% CI 1.03–2.07) are associated with a higher risk of administration errors. Conclusions Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload. PMID:19390109
Full Text Available Background. Paediatric patients are particularly prone to medication errors as they are classified as the most fragile population in ahospital setting. Paediatric medication errors in the South African healthcare setting are comparatively understudied.Objectives. To determine the incidence of medication errors in neonatal and paediatric inpatients, investigate the origin of medicationerrors that occurred and describe and categorise the types of medication errors made in both the neonatal intensive care unit (NICU andpaediatric wards.Methods. The study followed a prospective, quantitative design with a descriptive approach. A prospective record review of inpatients’medication charts was undertaken to determine what was prescribed by the physician, dispensed by the pharmacy and administered bythe nurses. The researcher also directly observed the preparation and administration techniques as performed by the nurses. A medicationerror checklist was used to collect the data.Results. A total of 663 medication errors were detected in 227 patients over the study period of 16 weeks, of which 177 (78% patients hadone or more error(s. There were 338 (51% administration errors and 309 (47% prescribing errors. Incorrect dosing was the most frequenttype of error (34%, followed by omission of medication (18.5% and medication given at the incorrect time (12%. The causes of thesemedication errors were mostly due to miscalculation (26%, failure to monitor (15% and procedures not followed (15%. Anti-infectives(43% and analgesics (25% had the most errors.In 118 (67% patients the errors resulted in no harm to the patient, whereas in 59 (33%patients the medication error resulted in some level of harm.Conclusion. The incidence of medication errors in the NICU and paediatric wards at the teaching hospital was higher than values reportedelsewhere globally. Most errors occur during prescribing and administration of medication. Dosing errors are a common problem
Given the complexity of the intravenous medication process, systematic thinking is essential to reduce medication errors. Two thousand eight hundred cases of 'Hiyari-Hatto' were analyzed. Eight important factors which cause intravenous medication error were clarified as a result. In the following I summarize the systematic approach for each factor. 1. Failed communication of information: illegible handwritten orders, and inaccurate verbal orders and copying cause medication error. Rules must be established to prevent miscommunication. 2. Error-prone design of the hardware: Look-alike packaging and labeling of drugs and the poor design of infusion pumps cause errors. The human-hardware interface should be improved by error-resistant design by manufacturers. 3. Patient names similar to simultaneously operating surgical procedures and interventions: This factor causes patient misidentification. Automated identification devices should be introduced into health care settings. 4. Interruption in the middle of tasks: The efficient assignment of medical work and business work should be made. 5. Inaccurate mixing procedure and insufficient mixing space: Mixing procedures must be standardized and the layout of the working space must be examined. 6. Time pressure: Mismatch between workload and manpower should be improved by reconsidering the work to be done. 7. Lack of information about high alert medications: The pharmacist should play a greater role in the medication process overall. 8. Poor knowledge and skill of recent graduates: Training methods and tools to prevent medication errors must be developed.
Rodriguez-Gonzalez, Carmen Guadalupe; Herranz-Alonso, Ana; Martin-Barbero, Maria Luisa; Duran-Garcia, Esther; Durango-Limarquez, Maria Isabel; Hernández-Sampelayo, Paloma; Sanjurjo-Saez, Maria
To identify the frequency of medication administration errors and their potential risk factors in units using a computerized prescription order entry program and profiled automated dispensing cabinets. Prospective observational study conducted within two clinical units of the Gastroenterology Department in a 1537-bed tertiary teaching hospital in Madrid (Spain). Medication errors were measured using the disguised observation technique. Types of medication errors and their potential severity were described. The correlation between potential risk factors and medication errors was studied to identify potential causes. In total, 2314 medication administrations to 73 patients were observed: 509 errors were recorded (22.0%)-68 (13.4%) in preparation and 441 (86.6%) in administration. The most frequent errors were use of wrong administration techniques (especially concerning food intake (13.9%)), wrong reconstitution/dilution (1.7%), omission (1.4%), and wrong infusion speed (1.2%). Errors were classified as no damage (95.7%), no damage but monitoring required (2.3%), and temporary damage (0.4%). Potential clinical severity could not be assessed in 1.6% of cases. The potential risk factors morning shift, evening shift, Anatomical Therapeutic Chemical medication class antacids, prokinetics, antibiotics and immunosuppressants, oral administration, and intravenous administration were associated with a higher risk of administration errors. No association was found with variables related to understaffing or nurse's experience. Medication administration errors persist in units with automated prescription and dispensing. We identified a need to improve nurses' working procedures and to implement a Clinical Decision Support tool that generates recommendations about scheduling according to dietary restrictions, preparation of medication before parenteral administration, and adequate infusion rates.
Shehata, Zahraa Hassan Abdelrahman; Sabri, Nagwa Ali; Elmelegy, Ahmed Abdelsalam
This study analyzes reports to the Egyptian medication error (ME) reporting system from June to December 2014. Fifty hospital pharmacists received training on ME reporting using the national reporting system. All received reports were reviewed and analyzed. The pieces of data analyzed were patient age, gender, clinical setting, stage, type, medication(s), outcome, cause(s), and recommendation(s). Over the course of 6 months, 12,000 valid reports were gathered and included in this analysis. The majority (66%) came from inpatient settings, while 23% came from intensive care units, and 11% came from outpatient departments. Prescribing errors were the most common type of MEs (54%), followed by monitoring (25%) and administration errors (16%). The most frequent error was incorrect dose (20%) followed by drug interactions, incorrect drug, and incorrect frequency. Most reports were potential (25%), prevented (11%), or harmless (51%) errors; only 13% of reported errors lead to patient harm. The top three medication classes involved in reported MEs were antibiotics, drugs acting on the central nervous system, and drugs acting on the cardiovascular system. Causes of MEs were mostly lack of knowledge, environmental factors, lack of drug information sources, and incomplete prescribing. Recommendations for addressing MEs were mainly staff training, local ME reporting, and improving work environment. There are common problems among different healthcare systems, so that sharing experiences on the national level is essential to enable learning from MEs. Internationally, there is a great need for standardizing ME terminology, to facilitate knowledge transfer. Underreporting, inaccurate reporting, and a lack of reporter diversity are some limitations of this study. Egypt now has a national database of MEs that allows researchers and decision makers to assess the problem, identify its root causes, and develop preventive strategies. © The Author 2015. Published by Oxford University
Deshpande, Girish G.; Torres, Adalberto; Buchanan, David L.; Shane Gray, Susan C.; Brown, Suzanne C.; Hoadley, Theresa; Ruppel, Patricia L.; Tobias, Joseph D.
OBJECTIVE Medication errors involving intravenous medications continue to be a significant problem, particularly in the pediatric population due to the high rate of point-of-care and weight-adjusted dosing. The pharmaceutical algorithm computerized calculator (pac2) assists in converting physician medication orders to correct volumes and rates of administration for intravenous medications. This study was designed to assess the efficacy of the pac2 in simulated clinical scenarios of point-of-care dosing. Methods The study design was a within-subject controlled study in which 33 nurses from pediatrics, pediatric critical care, or critical care (mean nursing experience of 10.9 years) carried out various point-of-care medication-dosing scenarios with and without the aid of the pac2. RESULTS Use of the pac2 resulted in a significantly higher percentage (mean [95% CI]) of medication volumes calculated and drawn accurately (91% [87–95%] versus 61% [52–70%], p<0.0001), a higher percentage of correct recall of essential medication information (97% [95–99%] versus 45% [36–53%], p<0.0001), and better recognition of unsafe doses (93% [87–99%] versus 19% [12–27%], p<0.0001) as compared to usual practice. The pac2 also significantly reduced average medication calculation times (1.5 minutes [1.3–1.7 minutes] versus 1.9 minutes [1.6–2.2 minutes], p=0.0028) as compared to usual practice. CONCLUSIONS The pac2 significantly improved the performance of drug calculations by pediatric and critical care nurses during simulated clinical scenarios designed to mimic point-of-care dosing. These results suggest that the pac2 addresses an area of safety vulnerability for point-of-care dosing practices and could be a useful addition to a hospital's overall program to minimize medication errors. PMID:22477815
Allison, Geneve M; Weigel, Bernard; Holcroft, Christina
Medication errors are an important patient safety issue. Electronic medication reconciliation is a system designed to correct medication discrepancies at transitions in healthcare. The purpose of this paper is to measure types and prevalence of intravenous antibiotic errors at hospital discharge before and after the addition of an electronic discharge medication reconciliation tool (EDMRT). A retrospective study was conducted at a tertiary hospital where house officers order discharge medications. In total, 100 pre-EDMRT and 100 post-EDMRT subjects were randomly recruited from the study center's clinical Outpatient Parenteral Antimicrobial Therapy (OPAT) program. Using infectious disease consultant recommendations as gold standard, each antibiotic listed in these consultant notes was compared to the hospital discharge orders to ascertain the primary outcome: presence of an intravenous antibiotic error in the discharge orders. The primary covariate of interest was pre- vs post-EDMRT group. After generating the crude prevalence of antibiotic errors, logistic regression accounted for potential confounding: discharge day (weekend vs weekday), average years of practice by prescribing physician, inpatient service (medicine vs surgery) and number of discharge mediations per patient. Prevalence of medication errors decreased from 30 percent (30/100) among pre-EDMRT subjects to 15 percent (15/100) errors among post-EDMRT subjects. Dosage errors were the most common type of medication error. The adjusted odds ratio of discharge with intravenous antibiotic error in the post-EDMRT era was 0.39 (0.18, 0.87) compared to the pre-EDMRT era. In the adjusted model, the total number of discharge medications was associated with increased OR of discharge error. To the authors' knowledge, no other study has examined the impact of reconciliation on types and prevalence of medication errors at hospital discharge. The focus on intravenous antibiotics as a class of high-stakes medications
Huong-Thao Nguyen, [Unknown; Tuan-Dung Nguyen, [No Value; van den Heuvel, Edwin R.; Haaijer-Ruskamp, Flora M.; Taxis, Katja
Background Evidence from developed countries showed that medication errors are common and harmful. Little is known about medication errors in resource-restricted settings, including Vietnam. Objectives To determine the prevalence and potential clinical outcome of medication preparation and
Scott, David M; Friesner, Daniel L; Rathke, Ann M; Peterson, Charles D; Anderson, Howard C
To examine differences in dispensing errors within community telepharmacy practices by comparing error rates across central sites (community telepharmacy sites with pharmacists present) and the corresponding remote sites, which are staffed by registered technicians and overseen by the central site pharmacist. Cross-sectional pilot study with a test group (remote sites) and comparison group (central sites). 24 rural community telepharmacies (14 remote sites and 10 central sites). Pharmacy staff. The Pharmacy Quality Commitment (PQC) reporting system was integrated into the North Dakota Telepharmacy Project and used to track dispensing errors over a 45-month period. Both pharmacists and pharmacy technicians were trained on the use of the PQC system. The PQC system focused on two quality-related events (QREs): a "near miss" (i.e., a mistake discovered by the pharmacy staff before a medication reaches the patient) and an "error" (i.e., a mistake discovered after the patient leaves the pharmacy with the medication). The distribution of QREs across central and remote sites. The remote (central) telepharmacy group reported 47,078 (62,480) prescriptions and a QRE rate of 1.34% (1.43%). QREs at the remote sites were more likely than at the central sites to be caught at the final pharmacist check (58.2% vs. 40.8%, P differences between central and remote sites existed based on how QREs arose and how they were caught. Pharmacists must recognize this fact and use diligence when working in a telepharmacy setting.
Background: Medication administration errors (MAEs) occur in about 5% of all doses given in UK hospitals. However, there are several reasons why existing methods for studying MAEs are inadequate. The aims of this research were to investigate the use of mathematical modelling to study MAEs and to develop a method for assessing MAE severity. Methods: A discrete-event simulation model was developed to represent the hospital drug distribution system. The model was used to investigate the effec...
Manias, Elizabeth; Kinney, Sharon; Cranswick, Noel; Williams, Allison; Borrott, Narelle
To systematically examine the research literature to identify which interventions reduce medication errors in pediatric intensive care units. Databases were searched from inception to April 2014. Studies were included if they involved the conduct of an intervention with the intent of reducing medication errors. In all, 34 relevant articles were identified. Apart from 1 study, all involved single-arm, before-and-after designs without a comparative, concurrent control group. A total of 6 types of interventions were utilized: computerized physician order entry (CPOE), intravenous systems (ISs), modes of education (MEs), protocols and guidelines (PGs), pharmacist involvement (PI), and support systems for clinical decision making (SSCDs). Statistically significant reductions in medication errors were achieved in 7/8 studies for CPOE, 2/5 studies for ISs, 9/11 studies for MEs, 1/2 studies for PGs, 2/3 studies for PI, and 3/5 studies for SSCDs. The test for subgroup differences showed that there was no statistically significant difference among the 6 subgroups of interventions, χ(2)(5) = 1.88, P = 0.87. The following risk ratio results for meta-analysis were obtained: CPOE: 0.47 (95% CI = 0.28, 0.79); IS: 0.37 (95% CI = 0.19, 0.73); ME: 0.36 (95% CI = 0.22, 0.58); PG: 0.82 (95% CI = 0.21, 3.25); PI: 0.39 (95% CI = 0.10, 1.51), and SSCD: 0.49 (95% CI = 0.23, 1.03). Available evidence suggests some aspects of CPOE with decision support, ME, and IS may help in reducing medication errors. Good quality, prospective, observational studies are needed for institutions to determine the most effective interventions. © The Author(s) 2014.
Weant KA; Bailey AM; Baker SN
Kyle A Weant,1 Abby M Bailey,2 Stephanie N Baker2 1North Carolina Public Health Preparedness and Response, North Carolina Department of Health and Human Services, Raleigh, NC, 2University of Kentucky HealthCare, Department of Pharmacy Services, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA Abstract: Medication errors are an all-too-common occurrence in emergency departments across the nation. This is largely secondary to a multitu...
Dreisinger, Naomi; Zapolsky, Nathan
The emergency department (ED) is an environment that is conducive to medical errors. The ED is a time-pressured environment where physicians aim to rapidly evaluate and treat patients. Quick thinking and problem-based solutions are often used to assist in evaluation and diagnosis. Error analysis leads to an understanding of the cause of a medical error and is important to prevent future errors. Research suggests mechanisms to prevent medical errors in the pediatric ED, but prevention is not always possible. Transparency about errors is necessary to assure a trusting doctor-patient relationship. Patients want to be informed about all errors, and apologies are hard. Apologizing for a significant medical error that may have caused a complication is even harder. Having a systematic way to go about apologizing makes the process easier, and helps assure that the right information is relayed to the patient and his or her family. This creates an environment of autonomy and shared decision making that is ultimately beneficial to all aspects of patient care.
Cabilan, C J; Hughes, James A; Shannon, Carl
To describe the contextual, modal and psychological classification of medication errors in the emergency department to know the factors associated with the reported medication errors. The causes of medication errors are unique in every clinical setting; hence, error minimisation strategies are not always effective. For this reason, it is fundamental to understand the causes specific to the emergency department so that targeted strategies can be implemented. Retrospective analysis of reported medication errors in the emergency department. All voluntarily staff-reported medication-related incidents from 2010-2015 from the hospital's electronic incident management system were retrieved for analysis. Contextual classification involved the time, place and the type of medications involved. Modal classification pertained to the stage and issue (e.g. wrong medication, wrong patient). Psychological classification categorised the errors in planning (knowledge-based and rule-based errors) and skill (slips and lapses). There were 405 errors reported. Most errors occurred in the acute care area, short-stay unit and resuscitation area, during the busiest shifts (0800-1559, 1600-2259). Half of the errors involved high-alert medications. Many of the errors occurred during administration (62·7%), prescribing (28·6%) and commonly during both stages (18·5%). Wrong dose, wrong medication and omission were the issues that dominated. Knowledge-based errors characterised the errors that occurred in prescribing and administration. The highest proportion of slips (79·5%) and lapses (76·1%) occurred during medication administration. It is likely that some of the errors occurred due to the lack of adherence to safety protocols. Technology such as computerised prescribing, barcode medication administration and reminder systems could potentially decrease the medication errors in the emergency department. There was a possibility that some of the errors could be prevented if safety
Full Text Available Objective: To promote first year (P1 pharmacy students’ awareness of medication error prevention and to support student learning in biomedical and pharmaceutical sciences. Innovation: A novel curricular activity was created and referred to as “Medication Errors and Sciences Applications (MESA”. The MESA activity encouraged discussions of patient safety among students and faculty to link medication errors to biomedical and pharmaceutical sciences, which ultimately reinforced student learning in P1 curricular topics. Critical Analysis: Three P1 cohorts implemented the MESA activity and approximately 75% of students from each cohort completed a reliable assessment instrument. Each P1 cohort had at least 14 student teams who generated professional reports analyzing authentic medication errors. The quantitative assessment results indicated that 70-85% of students believed that the MESA activity improved student learning in biomedical and pharmaceutical sciences. More than 95% of students agreed that the MESA activity introduced them to medication errors. Approximately 90% of students agreed that the MESA activity integrated the knowledge and skills they developed through the P1 curriculum, promoted active learning and critical thinking, and encouraged students to be self-directed learners. Furthermore, our data indicated that approximately 90% of students stated that the achievement of Bloom’s taxonomy's six learning objectives was promoted by completing the MESA activity. Next Steps: Pharmacy students’ awareness of medication errors is a critical component of pharmacy education, which pharmacy educators can integrate with biomedical and pharmaceutical sciences to enhance student learning in the P1 year. Treatment of Human Subjects: IRB exemption granted Type: Note License: CC BY
Byrne, Eamonn; Bury, Gerard
Incident reporting is vital to identifying pre-hospital medication safety issues because literature suggests that the majority of errors pre-hospital are self-identified. In 2016, the National Ambulance Service (NAS) reported 11 medication errors to the national body with responsibility for risk management and insurance cover. The Health Information and Quality Authority in 2014 stated that reporting of clinical incidents, of which medication errors are a subset, was not felt to be representative of the actual events occurring. Even though reporting systems are in place, the levels appear to be well below what might be expected. Little data is available to explain this apparent discrepancy. To identify, investigate and document the barriers to medication error reporting within the NAS. An independent moderator led four focus groups in March of 2016. A convenience sample of 18 frontline Paramedics and Advanced Paramedics from Cork City and County discussed medication errors and the medication error reporting process. The sessions were recorded and anonymised, and the data was analysed using a process of thematic analysis. Practitioners understood the value of reporting errors. Barriers to reporting included fear of consequences and ridicule, procedural ambiguity, lack of feedback and a perceived lack of both consistency and confidentiality. The perceived consequences for making an error included professional, financial, litigious and psychological. Staff appeared willing to admit errors in a psychologically safe environment. Barriers to reporting are in line with international evidence. Time constraints prevented achievement of thematic saturation. Further study is warranted.
Haw, C; Stubbs, J; Dickens, G L
Medication administration errors and near misses are common including in mental health settings. Nurses should report all errors and near misses so that lessons can be learned and future mistakes avoided. We interviewed 50 nurses to find out if they would report an error that a colleague had made or if they would report a near-miss that they had. Less than half of nurses said they would report an error made by a colleague or a near-miss involving themselves. Nurses commonly said they would not report the errors or near misses because there was a good excuse for the error/near miss, because they lacked knowledge about whether it was an error/near miss or how to report it, because they feared the consequences of reporting it, or because reporting it was too much work. Mental health nurses mostly report similar reasons for not reporting errors and near misses as nurses working in general medical settings. We have not seen another study where nurses would not report an error or near miss because they thought there was a good excuse for it. Training programmes and policies should address all the reasons that prevent reporting of errors and near misses. Medication errors are a common and preventable cause of patient harm. Guidance for nurses indicates that all errors and near misses should be immediately reported in order to facilitate the development of a learning culture. However, medication errors and near misses have been under-researched in mental health settings. This study explored the reasons given by psychiatric nurses for not reporting a medication error made by a colleague, and the perceived barriers to near-miss reporting. We presented 50 nurses with clinical vignettes about error and near-miss reporting and interviewed them about their likely actions and about their views and perceptions. Less than half of participants would report an error made by a colleague (48%) or a near-miss involving themselves (40%). Thematic analysis revealed common themes for both
Niemann, D; Bertsche, A; Meyrath, D; Oelsner, S; Ewen, A L; Pickardt, B; Henhapl, T; Hoffmann, G; Meyburg, J; Bertsche, T
Drug handling in paediatric intensive care units (PICU) is prone to medication errors. We aimed to identify type and prevalence of those errors and to assess preventative interventions. Prospective intervention study investigating a 3-step intervention for preventing errors in drug handling in a 10-bed PICU of a university hospital. Nurses' drug handling was monitored in daily routine to identify the number of patients affected by errors and overall prevalence and types of errors in drug handling. We implemented a comprehensive intervention consisting of an information handout, a training course, and a 76-page reference book tailored to reduce the prevalence. The prevalence of errors in drug handling decreased from 83 % (555 errors/668 processes)to 63 % (554/883; p drugs (1.33 errors/process) were more error-prone than intravenous (IV) drugs(0.64), despite being used less frequently (27 % vs.73 % of all processes, p drugs (p = 0.025). Errors in drug handling were alarmingly frequent. PO drugs were frequently subject to errors, even though being used less frequently. The implementation of a comprehensive intervention succeeded in reducing the prevalence of errors. Yet further refinements are necessary to decrease also the number of affected patients. © Georg Thieme Verlag KG Stuttgart · New York.
Full Text Available Medication errors account for about 78% of serious medical errors in intensive care unit (ICU. So far no study has been performed in Iran to evaluate all type of possible medication errors in ICU. Therefore the objective of this study was to reveal the frequency, type and consequences of all type of errors in an ICU of a large teaching hospital. The prospective observational study was conducted in an 11 bed internal ICU of a university hospital in Shiraz. In each shift all processes that were performed on one selected patient was observed and recorded by a trained pharmacist. Observer would intervene only if medication error would cause substantial harm. The data was evaluated and then were entered in a form that was designed for this purpose. The study continued for 38 shifts. During this period, a total of 442 errors per 5785 opportunities for errors (7.6% occurred. Of those, there were 9.8% administration errors, 6.8% prescribing errors, 3.3% transcription errors and, 2.3% dispensing errors. Totally 45 interventions were made, 40% of interventions result in the correction of errors. The most common causes of errors were observed to be: rule violations, slip and memory lapses and lack of drug knowledge. According to our results, the rate of errors is alarming and requires implementation of a serious solution. Since our system lacks a well-organize detection and reporting mechanism, there is no means for preventing errors in the first place. Hence, as the first step we must implement a system where errors are routinely detected and reported.
Ohashi, Kumiko; Dalleur, Olivia; Dykes, Patricia C; Bates, David W
Smart infusion pumps have been introduced to prevent medication errors and have been widely adopted nationally in the USA, though they are not always used in Europe or other regions. Despite widespread usage of smart pumps, intravenous medication errors have not been fully eliminated. Through a systematic review of recent studies and reports regarding smart pump implementation and use, we aimed to identify the impact of smart pumps on error reduction and on the complex process of medication administration, and strategies to maximize the benefits of smart pumps. The medical literature related to the effects of smart pumps for improving patient safety was searched in PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (2000-2014) and relevant papers were selected by two researchers. After the literature search, 231 papers were identified and the full texts of 138 articles were assessed for eligibility. Of these, 22 were included after removal of papers that did not meet the inclusion criteria. We assessed both the benefits and negative effects of smart pumps from these studies. One of the benefits of using smart pumps was intercepting errors such as the wrong rate, wrong dose, and pump setting errors. Other benefits include reduction of adverse drug event rates, practice improvements, and cost effectiveness. Meanwhile, the current issues or negative effects related to using smart pumps were lower compliance rates of using smart pumps, the overriding of soft alerts, non-intercepted errors, or the possibility of using the wrong drug library. The literature suggests that smart pumps reduce but do not eliminate programming errors. Although the hard limits of a drug library play a main role in intercepting medication errors, soft limits were still not as effective as hard limits because of high override rates. Compliance in using smart pumps is key towards effectively preventing errors. Opportunities for improvement include upgrading drug
Huckels-Baumgart, Saskia; Manser, Tanja
Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process-oriented approach to medication incident analysis focusing on medication error chains. Our study was conducted across a 900-bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009-2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). "Non-consideration of documentation/prescribing" during the drug preparation was the most frequent contributor for "wrong dose" during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety. © 2014, The American College of Clinical Pharmacology.
Laura K Barger
Full Text Available A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (> or =24 h reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States.We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3-3.7 and 7.5 (95% CI, 7.2-7.8, respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4-22 and 7.0 (95% CI, 4.3-11, were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality.In our survey, extended-duration work shifts were associated with an increased risk of significant medical
Although mistakes are inevitable, even in the best-run organizations, the tools used for care coordination--such as clinical pathways, standing order sets, algorithms, and other "point of care" reminders--are among the most important weapons in the fight against medical errors in hospitals. For example, establish maximum doses for high-risk drugs, and incorporate these criteria into pathways or standing orders. Preprinted order sets and protocols allow staff to focus their attention on relevant patient care issues, rather than spending time rewriting orders and possibly introducing errors into the system. Case managers can be particularly effective in helping other caregivers catch and correct mistakes before the patient is harmed.
Akakpo, Patrick K; Awuku, Yaw A; Derkyi-Kwarteng, Leonard; Gyamera, Kelvin A; Eliason, Sebastian
Reliable mortality statistics are useful in determining national policies on preventive and interventional medicine. This study reviews, completed medical certificates of cause of death at the Cape Coast Teaching Hospital, in order to determine their accuracy and reliability. A one-year review of Medical Certificates of Cause of Death (MCCD) signed between 01-01-2013 and 31-12-2013 in the medical, pediatric, surgical and obstetrics/gynecology departments of Cape Coast Teaching Hospital were done, analyzing for errors using the WHO/ICD-10 guidelines as the standard. The errors were grouped into minor and major errors. In all, 337 medical certificates of cause of death were audited. Majority, 212(62.9%) were issued in the internal medicine and therapeutics department. 30.86% (104) MCCDs were completed by specialists while 69.14% (233) were completed by non-specialist medical officers. Over half (56.68%) of the MCCDs had major errors while all (100%) had at least one minor error. Our study showed significant errors in MCCD records, with the errors more likely in certificates issued by non-specialist medical officers. All the certificates audited had at least one minor error. Training of doctors on proper completion of MCCDs is strongly advocated. None of the authors received any financial support for this study.
You, Mi-Ae; Choe, Mi-Hyeon; Park, Geun-Ok; Kim, Sang-Hee; Son, Youn-Jung
To identify reasons for medication administration errors (MAEs) and why they are unreported, and estimate the percentage of MAEs actually reported among hospital nurses. A cross-sectional survey design. Three university hospitals in three South Korean provinces. A total of 312 hospital staff nurses were included in this study. Medication administration errors. Actual MAEs were experienced by 217 nurses (69.6%) during their clinical career, whereas 149 nurses (47.8%) perceived that MAEs only occur less than 20% rate. MAEs occurred mostly during intravenous (IV) administrations. Nurses perceived that the most common reasons for MAEs were inadequate number of nurses in each working shift (4.88 ± 1.05) and administering drugs with similar names or labels (4.49 ± 0.94). The most prevalent reasons for unreported MAEs included fears of being blamed (4.36 ± 1.10) and having too much emphasis on MAEs as a measure of nursing care quality (4.32 ± 1.02). The three most frequent errors perceived by nurses for non-IV related MAEs included administering medications to the incorrect patients and incorrect medication doses and drug choices. The three most frequent IV related MAEs included incorrect infusion rates, patients and medication doses. Nurse-staffing adequacy could be helpful to prevent MAEs among nurses as well ongoing education, and training regarding safe medication administration using the problem-based simulation education. In addition, encouraging nurses to identify and report work related errors in a non-punitive milieu will increase error reporting. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.
Cassidy, Nicola; Duggan, Edel; Williams, David J P; Tracey, Joseph A
Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication
INTRODUCTION: Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. AIM: The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. METHODS: A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. RESULTS: Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (>\\/= 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for
Payne, Christopher H; Smith, Christopher R; Newkirk, Laura E; Hicks, Rodney W
Medication errors involving pediatric patients in the postanesthesia care unit may occur as frequently as one in every 20 medication orders and are more likely to cause harm when compared to medication errors in the overall population. Researchers examined six years of records from the MEDMARX database and used consecutive nonprobability sampling and descriptive statistics to compare medication errors in the pediatric data set to those occurring in the total population data set. Nineteen different causes of error involving 28 different products were identified. The results of the study indicate that an organization can focus on causes of errors and products involved in errors to mitigate future error occurrence.
Almutary, Hayfa H; Lewis, Peter A
Reporting of medication administration errors (MAEs) is one means by which health care facilities monitor their practice in an attempt to maintain the safest patient environment. This study examined the likelihood of registered nurses (RNs) reporting MAEs when working in Saudi Arabia. It also attempted to identify potential barriers in the reporting of MAE. This study found that 63% of RNs raised concerns about reporting of MAEs in Saudi Arabia-nursing administration was the largest impediment affecting nurses' willingness to report MAEs. Changing attitude to a non-blame system and implementation of anonymous reporting systems may encourage a greater reporting of MAEs.
Matin, Behzad Karami; Hajizadeh, Mohammad; Nouri, Bijan; Rezaeian, Shahab; Mohammadi, Masoud; Rezaei, Satar
To estimate the 1-year period prevalence of medication errors and the reporting rate to nurse managers among nurses working in hospitals in Iran. Medication errors are one of the main factors affecting the quality of hospital services and reducing patient safety in health care systems. A literature search from Iranian and international scientific databases was developed to find relevant studies. Meta-regression was used to identify which characteristics may have a confounding effect on the pooled prevalence estimates. Based on the final 22 studies with 3556 samples, the overall estimated 1-year period prevalence of medication errors and its reporting rate to nurse managers among nurses were 53% (95% confidence interval, 41%-60%) and 36% (95% confidence interval, 23%-50%), respectively. The meta-regression analyses indicated that the sex (female/male) ratio was a statistically significant predictor of the prevalence of medication errors (p medication errors to nurse managers. The period prevalence of medication errors among nurses working in hospitals was high in Iran, whereas its reporting rate to nurse managers was low. Continuous training programmes are required to reduce and prevent medication errors among nursing staff and to improve the reporting rate to nurse managers in in Iran. © 2018 John Wiley & Sons Ltd.
Shultz, Jonas; Strosher, Lisa; Nathoo, Shaheen Nenshi; Manley, Jim
Pharmaceutical companies use a variety of abbreviations to denote short- and long-acting medications. Errors involving the administration of these medications are frequently reported. To evaluate comprehension rates for abbreviations used to denote short- and long-acting medications and to evaluate whether changes to medication labels could reduce potential errors in the selection and administration of medications. In phase 1 of the study, nursing staff were asked to define 4 abbreviations and then to categorize them by release rate. In phase 2, a simulation exercise, nursing staff were asked if it would be appropriate to administer a medication illustrated in a photograph (oxycodone CR 5-mg blister pack) on the basis of information highlighted in a screen shot of an electronic medication administration record (order for oxycodone 5 mg). Three different presentations were used to identify the medication in the medication administration record and on the drug label. In phase 1, 10 (28%) of 36 nursing staff members knew what all 4 abbreviations meant, and 14 (39%) correctly classified all 4 abbreviations as indicating a short- or a long-acting medication. In the simulation exercise (phase 2), labelling changes reduced the likelihood of a potential medication administration error. Most abbreviations used to indicate short- versus long-acting medications were not correctly understood by study participants. Of more concern was the incorrect interpretation of some abbreviations as indicating the opposite release rate (e.g., "ER" interpreted as meaning "emergency release", rather than "extended release", with incorrect classification as a short-acting medication). This evaluation highlighted the potential consequences of using non-intuitive abbreviations to differentiate high-risk medications having different release rates.
Full Text Available Background Medication errors are among the most common medical errors which are used as an indicator to assess patients’ safety in hospitals. Thereby the aim of this study was to investigate the frequency, type and causes of medication errors in children's ward at hospitals in Yazd- Iran. Materials and Methods This descriptive-analytical study was conducted during 6 months from Jan to Jun 2015. A total number of 63 nurses working in the pediatric ward of the hospitals in Yazd city were enrolled in this study using census method. Data collection tools included demographic questionnaire and "Wakefield medication administration errors" questionnaire. Data were analyzed using SPSS-18. Results Medication errors had been made by 44.4% of the nurses once to twice in the 6 months preceding the study. 30.2% of the errors had occurred on the night shift. Errors with high incidence in non-injectable medication included wrong patient (1.6%,wrong dosage (7.9% , drug adminstration without doctors ordedr (1.6% and in injectable medication included wrong dosage (7.9%,mistake in medication calculation (6.4% and wrong infusion rate (9.5%. The most common causes were communication, packaging, transcription, working conditions and pharmacy conditions respectively. Conclusion Considering the frequency of errors on the night shift, dosage calculation and administration as well as the identified causes, it is necessary that nursing managers to negotiate with medical and pharmaceutical professionals in order to design and implement operational guidelines for preventing medication errors.
Ghaleb, Maisoon Abdullah; Barber, Nick; Franklin, Bryony Dean; Wong, Ian Chi Kei
To determine the incidence and nature of prescribing and medication administration errors in paediatric inpatients. Prospective review of drug charts to identify prescribing errors and prospective observation of nurses preparing and administering drugs to identify medication administration errors. In addition, incident reports were collected for each ward studied. Paediatric patients admitted to hospitals and nurses administering medications to these patients. 11 wards (prescribing errors) and 10 wards (medication administration errors) across five hospitals (one specialist children's teaching hospital, one nonteaching hospital and three teaching hospitals) in the London area (UK). Number, types and incidence of prescribing and medication administration errors, using practitioner-based definitions. 391 prescribing errors were identified, giving an overall prescribing error rate of 13.2% of medication orders (95% CI 12.0 to 14.5). There was great variation in prescribing error rates between wards. Incomplete prescriptions were the most common type of prescribing error, and dosing errors the third most common. 429 medication administration errors were identified; giving an overall incidence of 19.1% (95% CI 17.5% to 20.7%) erroneous administrations. Errors in drug preparation were the most common, followed by incorrect rates of intravenous administration. Prescribing and medication administration errors are not uncommon in paediatrics, partly as a result of the extra challenges in prescribing and administering medication to this patient group. The causes and extent of these errors need to be explored locally and improvement strategies pursued.
da Cruz, Hellen Lilliane; Mota, Flávia Karla da Cruz; Araújo, Lorena Ulhôa; Bodevan, Emerson Cotta; Seixas, Sérgio Ricardo Stuckert; Santos, Delba Fonseca
ABSTRACT Objective: This study describes the development of the medication history of the medical records to measure factors associated with medication errors among chronic diseases patients in Diamantina, Minas Gerais. Methods: retrospective, descriptive observational study of secondary data, through the review of medical records of hypertensive and diabetic patients, from March to October 2016. Results: The patients the mean age of patient was 62.1 ± 14.3 years. The number of basic nursing care (95.5%) prevailed and physician consultations were 82.6%. Polypharmacy was recorded in 54% of sample, and review of the medication lists by a pharmacist revealed that 67.0% drug included at least one risk. The most common risks were: drug-drug interaction (57.8%), renal risk (29.8%), risk of falling (12.9%) and duplicate therapies (11.9%). Factors associated with medications errors history were chronic diseases and polypharmacy, that persisted in multivariate analysis, with adjusted RP chronic diseases, diabetes RP 1.55 (95%IC 1.04-1.94), diabetes/hypertension RP 1.6 (95%CI 1.09-1.23) and polypharmacy RP 1.61 (95%IC 1.41-1.85), respectively. Conclusion: Medication errors are known to compromise patient safety. This has led to the suggestion that medication reconciliation an entry point into the systems health, ongoing care coordination and a person focused approach for people and their families. PMID:29236841
Bjeldbak-Olesen, Mette; Danielsen, Anja Gadsbølle; Tomsen, Dorthe Vilstrup
Introduction: The objective of this study was to compare medication reconciliation and medication review based on number, type and severity of discrepancies and drug-related problems (DRPs), denoted errors. Material and methods: This was a retrospective study conducted at the Department of Cardi......Introduction: The objective of this study was to compare medication reconciliation and medication review based on number, type and severity of discrepancies and drug-related problems (DRPs), denoted errors. Material and methods: This was a retrospective study conducted at the Department...... of Cardiology, Hillerød Hospital. Medication reconciliation compared the prescriptions in patient records, an electronic medication system (EMS) and in discharge summaries (DS). The medication review was based on the EMS. The two methods were performed on the same data material. To assess the clinical...... importance of the errors, a four-point scale was applied. Results: A total of 75 patient records were included. In all, 198 discrepancies were identified by medication reconciliation, 2.6 per patient. The most frequent discrepancies were omission of a drug in the DS and discrepancy between the drugs noted...
Durham, Marianne L; Suhayda, Rosemarie; Normand, Patricia; Jankiewicz, Ann; Fogg, Louis
The aim of this medication safety pilot program was to increase RN sensitivity to potential error risk, improve behaviors, and reduce observed medication administration errors (MAEs). MAEs are common and preventable and may lead to adverse drug events, costing the patient and organization. MAEs are low visibility, rarely intercepted, and underreported. An interprofessional team used process improvement methodology to develop a human factors-based medication safety pilot program to address identified issues. An observational time-series design study monitored the effect of the program. After the program, error interception practices during administration increased, and some nurses reported using a mindfulness strategy to gain situational awareness before administration. Process behaviors were performed more consistently, and the risk of MAE decreased. Familiarity and complexity were identified as additional variables affecting MAE outcome. Strategies to support safe medication administration may reduce error and be of interest to nurse leaders.
Full Text Available Medication errors are common, fatal, costly but preventable. Location of drugs on the shelves and wrong drug names in prescriptions can cause errors during dispensing process. Therefore, a good drug-shelf arrangement system in pharmacies is crucial for preventing medication errors, increasing patient’s safety, evaluating pharmacy performance, and improving patient outcomes. The main purpose of this study to suggest a new drug-shelf arrangement for the pharmacy to prevent wrong drug selection from shelves by the pharmacist. The study proposes an integrated structure with three-stage data mining method using patient prescription records in database. In the first stage, drugs on prescriptions were clustered depending on the Anatomical Therapeutic Chemical (ATC classification system to determine associations of drug utilizations. In the second stage association rule mining (ARM, well-known data mining technique, was applied to obtain frequent association rules between drugs which tend to be purchased together. In the third stage, the generated rules from ARM were used in multidimensional scaling (MDS analysis to create a map displaying the relative location of drug groups on pharmacy shelves. The results of study showed that data mining is a valuable and very efficient tool which provides a basis for potential future investigation to enhance patient safety.
Küng, Kaspar; Aeschbacher, Katrin; Rütsche, Adrian; Goette, Jeannette
Background: Prospective observational studies from Swiss university hospitals, focusing on the frequency of medication preparation and medication administration errors using direct observation, are still missing. To close this gap, we have conducted a scientific evaluation of an electronically assisted medication preparation and administration process in a Swiss university hospital. Aim: The aim of this study was to measure the frequency of medication preparation and medication administration errors in two units in a Swiss university hospital before the implementation of an electronically assisted medication preparation and administration process. Method: To fulfil the study aims we used direct observation of medical staff during the medication process, the gold standard to detect medication errors. Furthermore, we measured the time that medical staff used in order to prepare and administer medications. Results: During the baseline measure, we observed a total of 14 571 medication doses. Errors in the medication preparation stage occurred between 1 % and 7.6 % depending on unit and type of error. Medication administration errors ranged between 21 % and 27 %. The most frequent administration errors were due to wrong administration time (84.1 %). Conclusions: This is the first study conducted in a Swiss university hospital using direct observation to detect medication preparation and medication administration errors. The current study offers important basic data to evaluate the effect of an electronically assisted medication preparation and administration process scientifically.
Kłys, Małgorzata; Kowalski, Piotr
Problems of patient safety within the system of health care are defined by prescriptive and ethical regulations; a breach of such regulations is associated with entering a complex category of situations covered by the term "medical error" or "appropriateness of medical management". In order to minimize the sources of diagnostic errors, with the knowledge on such errors largely originating from medico-legal practice, numerous initiatives emerge, according to which monitoring of adverse events and subjecting such events to a profound discussion is the most important element of prevention. The problem discussed in the paper is illustrated by the case of a 13-year old boy, in whom opioid poisoning was mistakenly diagnosed instead of a neurological condition in consequence of the physician disregarding significant symptoms of the disease and accepting his subjective suspicion of poisoning. The erroneous diagnosis was further compounded by lack of verification of the preliminary diagnosis and failure to perform further laboratory diagnostic management addressing the neurological status of the patient. The presented case supports data from publications found in the literature on the subject that describe a high risk of diagnostics errors in neurological conditions; such errors are often committed by emergency physicians other than neurologists.
Lisby, Marianne; Nielsen, L P; Brock, Birgitte
Multiplicity in terminology has been suggested as a possible explanation for the variation in the prevalence of medication errors. So far, few empirical studies have challenged this assertion. The objective of this review was, therefore, to describe the extent and characteristics of medication...... error definitions in hospitals and to consider the consequences for measuring the prevalence of medication errors....
...] Developing Guidance on Naming, Labeling, and Packaging Practices to Reduce Medication Errors; Public Workshop... entitled ``Developing Guidance on Naming, Labeling, and Packaging Practices to Reduce Medication Errors..., labeling, and packaging drugs and biologics to reduce medication errors. The April 12, 2010, notice invited...
Thomas, Lily; Donohue-Porter, Patricia; Stein Fishbein, Joanna
Medication administration errors are difficult to intercept since they occur at the end of the process. The study describes interruptions, distractions, and cognitive load experienced by registered nurses during medication administration and explores their impact on procedure failures and medication administration errors. The focus of this study was unique as it investigated how known individual and environmental factors interacted and culminated in errors.
Robert, Marie-Claude; Choi, Catherine J; Shapiro, Fred E; Urman, Richard D; Melki, Samir
To implement and measure the effect of a surgical safety checklist on the prevention of serious medical errors (never-events). Boston Eye Group, Boston, Massachusetts, USA. Retrospective cohort study. A safety checklist incorporating 28 sources of error was designed and implemented in December 2011 at the Boston Eye Group's refractive surgical center. Consecutive patients who had primary or enhancement laser vision correction (LVC) between July 2009 and February 2014 were included in this study. Before that date, a general checklist fashioned around the World Health Organization time-out procedure was used. The latter subjects were recruited as controls. The perioperative characteristics of both groups were retrospectively compared. The study comprised 2951 consecutive patients who had primary or enhancement LVC between July 2009 and February 2014; of these, 1417 patients (2744 eyes) had LVC after the implementation of a presurgical safety checklist. The general checklist fashioned around the World Health Organization time-out procedure was used for 1534 patients (2969 eyes). Both groups were comparable in patient age. The most common surgical procedures were laser in situ keratomileusis (78%) and laser-assisted subepithelial keratectomy with mitomycin-C (16%). Although there were 2 (0.07%) serious errors in the prechecklist cohort, none occurred following implementation of the safety checklist protocol (P = .23). The medical errors involved wrong refractive aim in 1 patient and wrong person-wrong procedure-wrong aim in another. Multiple potential sources of error exist in refractive surgery. The broad-scale implementation of a detailed presurgical safety checklist was helpful in minimizing and preventing serious errors (never-events) during LVC. Drs. Shapiro and Urman are members of the Institute for Safety in Office-Based Surgery, a nonprofit organization whose aims are to implement safety checklists for office-based surgery. No author has a financial or
Kohda, Takehisa; Inoue, Koichi
The accidents originated in human errors have occurred as ever in recent large accidents such as the TMI accident and the Chernobyl accident. The proportion of the accidents originated in human errors is unexpectedly high, therefore, the reliability and safety of hardware are improved hereafter, but the improvement of human reliability cannot be expected. Human errors arise by the difference between the function required for men and the function actually accomplished by men, and the results exert some adverse effect to systems. Human errors are classified into design error, manufacture error, operation error, maintenance error, checkup error and general handling error. In terms of behavior, human errors are classified into forget to do, fail to do, do that must not be done, mistake in order and do at improper time. The factors in human error occurrence are circumstantial factor, personal factor and stress factor. As the method of analyzing and evaluating human errors, system engineering method such as probabilistic risk assessment is used. The technique for human error rate prediction, the method for human cognitive reliability, confusion matrix and SLIM-MAUD are also used. (K.I.)
Chang, YunKyung; Mark, Barbara
Despite increasing recognition of the significance of learning from errors, little is known about how learning climate contributes to error reduction. The purpose of this study was to investigate whether learning climate moderates the relationship between error-producing conditions and medication errors. A cross-sectional descriptive study was done using data from 279 nursing units in 146 randomly selected hospitals in the United States. Error-producing conditions included work environment factors (work dynamics and nurse mix), team factors (communication with physicians and nurses' expertise), personal factors (nurses' education and experience), patient factors (age, health status, and previous hospitalization), and medication-related support services. Poisson models with random effects were used with the nursing unit as the unit of analysis. A significant negative relationship was found between learning climate and medication errors. It also moderated the relationship between nurse mix and medication errors: When learning climate was negative, having more registered nurses was associated with fewer medication errors. However, no relationship was found between nurse mix and medication errors at either positive or average levels of learning climate. Learning climate did not moderate the relationship between work dynamics and medication errors. The way nurse mix affects medication errors depends on the level of learning climate. Nursing units with fewer registered nurses and frequent medication errors should examine their learning climate. Future research should be focused on the role of learning climate as related to the relationships between nurse mix and medication errors.
The drug mostly associated with error was gentamicin with 29 errors (1.2 %). Conclusion: During the study, a high frequency of error was observed. There is a need to modify the way information is handled and shared by professionals as wrong time error was the most implicated error. Attention should also be given to IV ...
Smith, Maxwell D; Spiller, Henry A; Casavant, Marcel J; Chounthirath, Thiphalak; Brophy, Todd J; Xiang, Huiyun
To investigate out-of-hospital medication errors among young children in the United States. Using data from the National Poison Database System, a retrospective analysis of out-of-hospital medication errors among children medication errors, averaging 63,358 episodes per year, or 1 child every 8 minutes. The average annual rate of medication errors was 26.42 per 10,000 population. Cough and cold medication errors decreased significantly, whereas the number (42.9% increase) and rate (37.2% increase) of all other medication errors rose significantly during the 11-year study period. The number and rate of medication error events decreased with increasing child age, with children medication errors, followed by cough and cold preparations (24.6%). Ingestion accounted for 96.2% of events, and 27.0% of medication errors were attributed to inadvertently taking or being given medication twice. Most (93.5%) cases were managed outside of a health care facility; 4.4% were treated and released from a health care facility; 0.4% were admitted to a non-critical care unit; 0.3% were admitted to a critical care unit; and 25 children died. This is the first comprehensive study to evaluate the epidemiologic characteristics of out-of-hospital medication errors among children medication errors, especially those involving non-cough and cold preparations, among young children. Copyright © 2014 by the American Academy of Pediatrics.
Kim, Chan Woong; Myung, Sun Jung; Eo, Eun Kyung; Chang, Yerim
Although physicians believe that medical errors should be disclosed to patients and their families, they often hesitate to do so. In this study, we assessed the effectiveness of an education program for medical error disclosure. In 2015, six medical interns and 79 fourth-year medical students participated in this study. The education program included practice of error disclosure using a standardized patient scenario, feedback, and short didactic sessions. Participant performance was evaluated with a previously developed rating scale that measures error disclosure performance on five specific component skills. Following education program, we surveyed participant perceptions of medical error disclosure with varying severity of error outcome and their satisfaction with the education program using a 5-point Likert scale. We also surveyed the change of attitude or confidence of participants after education program. The performance score was not significantly different between medical interns and medical students (p = 0.840). Following the education program, 65% of participants said that they had become more confident in coping with medical errors, and most participants (79.7%) were satisfied with the education program. They also indicated that they felt a greater duty to disclose medical errors and deliver an apology when the medical error outcome is more severe. An education program for disclosing medical errors was helpful in improving confidence in medical error disclosure. Extending the program to more diverse scenarios and a more diverse group of physicians is needed.
Comer, Rachel; Lizer, Mitsi
A 69-year-old Caucasian male with a 25-year history of paranoid schizophrenia was brought to the emergency department because of violence toward the staff in his nursing facility. He was diagnosed with a urinary tract infection and was admitted to the behavioral health unit for medication stabilization. History included a five-year state psychiatric hospital admission and nursing facility placement. Because of poor cognitive function, the patient was unable to corroborate medication history, so the pharmacy student on rotation performed an in-depth chart review. The review revealed a transcription error in 2003 deleting amantadine 100 mg twice daily and adding amiodarone 100 mg twice daily. Subsequent hospitalization resulted in another transcription error increasing the amiodarone to 200 mg twice daily. All electrocardiograms conducted were negative for atrial fibrillation. Once detected, the consulted cardiologist discontinued the amiodarone, and the primary care provider was notified via letter and discharge papers. An admission four months later revealed that the nursing facility restarted the amiodarone. Amiodarone was discontinued and the facility was again notified. This case reviews how a 10-year-old medication error went undetected in the electronic medical records through numerous medication reconciliations, but was uncovered when a single comprehensive medication review was conducted.
Holmberg, Ola; McClean, Brendan
The aim of this work is to study the effectiveness of a multilayered error prevention system by analysing both the near misses found at calculation-check stations and the actual treatment errors originating in the treatment preparation chain
Eluri, Madhulika; Spiller, Henry A; Casavant, Marcel J; Chounthirath, Thitphalak; Conner, Kristen A; Smith, Gary A
This study investigates the characteristics and trends of medication errors involving analgesic medications. A retrospective analysis was conducted of analgesic-related medication errors reported to the National Poison Data System (NPDS) from 2000 through 2012. From 2000 through 2012, the NPDS received 533,763 reports of analgesic-related medication errors, averaging 41,059 medication errors annually. Overall, the rate of analgesic-related medication errors reported to the NPDS increased significantly by 82.6% from 2000 to 2009, followed by a 5.7% nonsignificant decrease from 2009 to 2012. Among the analgesic categories, rates of both acetaminophen-related and opioid-related medication errors reported to the NPDS increased during 2000-2009, but the opioid error rate leveled off during 2009-2012, while the acetaminophen error rate decreased by 17.9%. Analgesic-related medication errors involved nonsteroidal anti-inflammatory drugs (37.0%), acetaminophen (35.5%), and opioids (23.2%). Children five years or younger accounted for 38.8% of analgesics-related medication errors. Most (90.2%) analgesic-related medication errors were managed on-site, rather than at a health care facility; 1.6% were admitted to a hospital, and 1.5% experienced serious medical outcomes, including 145 deaths. The most common type of medication error was inadvertently taking/given the medication twice (26.6%). Analgesic-related medication errors are common, and although most do not result in clinical consequences, they can have serious adverse outcomes. Initiatives associated with the decrease in acetaminophen-related medication errors among young children merit additional research and potential replication as a model combining government policy and multisectoral collaboration.
Estratégias para prevenção de erros na medicação no setor de emergência Estrategias para prevenir errores en la medicación en el sector de urgencia Strategies for prevention of medication errors in emergengy services
Regina Célia de Oliveira
Full Text Available O estudo identificou as situações indicativas de erro ou quase erro na medicação através da análise das prescrições de medicamentos e evoluções de enfermagem. A partir dos dados obtidos foram implementados um ciclo de palestras e um curso sobre a segurança na administração de medicamentos para profissionais do setor de emergência de um hospital do nordeste. Os resultados revelaram que das 1.585 prescrições analisadas, 83,9% não explicitava a apresentação do medicamento e 84,6% a dose do medicamento. Dos medicamentos prescritos 34,2% apresentaram horários em que não havia registro da administração de medicamentos e 22,5% tinham o horário circulado. Dentre os medicamentos não-administrados 26% eram antibióticos e anticoagulantes; 15% analgésicos. As estratégias implementadas tiveram participação dos profissionais com bons índices de freqüência.El estudio identificó las situaciones indicadoras de errores o probables errores en la medicación, a de las prescripciones de medicamentos y fichas de evolución de enfermería. Además se llevó a cabo un ciclo de conferencias y un curso sobre seguridad en la administración de medicamentos, para los profesionales del Sector de Emergencia. Los resultados revelaron que de las 1.585 prescripciones analizadas, un 83,9% no expresaban con claridad la presentación del medicamento y un 84,6% la dosis del medicamento. De los medicamentos prescritos, un 34,2% no presentaban registro de la administración de los fármacos y un 22,5% tenían el horario circulado. Dentro de los medicamentos no administrados, un 26% eran antibióticos y anticoagulantes y un 15% analgésicos. Las estrategias implementadas tuvieron la participación de los profesionales, con buenos índices de frecuencia.This study identified situations indicating medication errors or near misses by analyzing medication orders and the nursing staff's performance. It also implemented a cycle of lectures and a course on
Full Text Available Reducing the number of preventable adverse events has become a public health issue. The paper discusses in which ways the law can contribute to that goal, especially by encouraging a culture of safety among healthcare professionals. It assesses the need or the usefulness to pass so-called disclosure laws and apology laws, to adopt mandatory but strictly confidential Critical Incidents Reporting Systems in hospitals, to change the fault-based system of medical liability or to amend the rules on criminal liability. The paper eventually calls for adding the law to the present agenda of patient safety.
When preparing radiation treatment, the prescribed dose and irradiation geometry must be translated into physical machine parameters. An error in the calculations or machine settings can negatively affect the intended treatment outcome. Analysing incidents originating in the treatment preparation chain makes it possible to find weak links and prevent treatment errors. The aim of this work is to study the effectiveness of a multilayered error prevention system by analysing both near misses and actual treatment errors.
Brock, J F
A familiar medical contrast is presented as part of a modern medical problem. The problem it reflects is the relative importance of preventive and curative services for medical practitioners, which is already, or will shortly resolve itself into, a dilemma of whether medical men should stress preventive medicine to the possible detriment of curative medicine. It is submitted that the solution to both problem and dilemma should be sought against the background of history and philosophy, where they are seen to be expressions of an eternal paradox--that of the relative value of the individual in relation to the family, group, or community. If the submission is valid, then the answer to the problem is not a purely medical exercise, nor is the dilemma purely a 'doctor's dilemma'. The paradox, being eternal, is not soluble in our time, but the community must, on the urging of the medical profession, find a general solution to the problem--'a public consensus for out time'. This must be followed by public demand for a parliamentary solution--'decision-making ex consensus'. It is argued that although the latter programme does not come easily to democracy, it can be achieved through public consensus if action is taken by the leaders of thought in appropriate categories. Initiative must be exercised by the medical profession, but public consensus can only be achieved in consultation with the leaders of all learned professions, civil servants and legislators. It must then be presented fairly and without bias to the public. In the meantime, the medical profession must formulate its own 'medical consensus' and the doctor must resolve his personal dilemma according to formulated law, public or medical consensus or, in the last resort, according to his conviction and conscience. This method of solving a problem will almost certainly be applicable to other and more recent medical problems such as the population explosion, selective abortion and euthanasia.
Alsulami, Zayed; Conroy, Sharon; Choonara, Imti
Medication errors are a significant global concern and can cause serious medical consequences for patients. Little is known about medication errors in Middle Eastern countries. The objectives of this systematic review were to review studies of the incidence and types of medication errors in Middle Eastern countries and to identify the main contributory factors involved. A systematic review of the literature related to medication errors in Middle Eastern countries was conducted in October 2011 using the following databases: Embase, Medline, Pubmed, the British Nursing Index and the Cumulative Index to Nursing & Allied Health Literature. The search strategy included all ages and languages. Inclusion criteria were that the studies assessed or discussed the incidence of medication errors and contributory factors to medication errors during the medication treatment process in adults or in children. Forty-five studies from 10 of the 15 Middle Eastern countries met the inclusion criteria. Nine (20 %) studies focused on medication errors in paediatric patients. Twenty-one focused on prescribing errors, 11 measured administration errors, 12 were interventional studies and one assessed transcribing errors. Dispensing and documentation errors were inadequately evaluated. Error rates varied from 7.1 % to 90.5 % for prescribing and from 9.4 % to 80 % for administration. The most common types of prescribing errors reported were incorrect dose (with an incidence rate from 0.15 % to 34.8 % of prescriptions), wrong frequency and wrong strength. Computerised physician rder entry and clinical pharmacist input were the main interventions evaluated. Poor knowledge of medicines was identified as a contributory factor for errors by both doctors (prescribers) and nurses (when administering drugs). Most studies did not assess the clinical severity of the medication errors. Studies related to medication errors in the Middle Eastern countries were relatively few in number and of poor quality
Mira, José Joaquín; Lorenzo, Susana; Guilabert, Mercedes; Navarro, Isabel; Pérez-Jover, Virtudes
Medication errors have been analyzed as a health professionals' responsibility (due to mistakes in prescription, preparation or dispensing). However, sometimes, patients themselves (or their caregivers) make mistakes in the administration of the medication. The epidemiology of patient medication errors (PEs) has been scarcely reviewed in spite of its impact on people, on therapeutic effectiveness and on incremental cost for the health systems. This study reviews and describes the methodological approaches and results of published studies on the frequency, causes and consequences of medication errors committed by patients at home. A review of research articles published between 1990 and 2014 was carried out using MEDLINE, Web-of-Knowledge, Scopus, Tripdatabase and Index Medicus. The frequency of PE was situated between 19 and 59%. The elderly and the preschooler population constituted a higher number of mistakes than others. The most common were: incorrect dosage, forgetting, mixing up medications, failing to recall indications and taking out-of-date or inappropriately stored drugs. The majority of these mistakes have no negative consequences. Health literacy, information and communication and complexity of use of dispensing devices were identified as causes of PEs. Apps and other new technologies offer several opportunities for improving drug safety.
Pierluissi, Edgar; Fischer, Melissa A; Campbell, Andre R; Landefeld, C Seth
Morbidity and mortality conferences in residency programs are intended to discuss adverse events and errors with a goal to improve patient care. Little is known about whether residency training programs are accomplishing this goal. To determine the frequency at which morbidity and mortality conference case presentations include adverse events and errors and whether the errors are discussed and attributed to a particular cause. Prospective survey conducted by trained physician observers from July 2000 through April 2001 on 332 morbidity and mortality conference case presentations and discussions in internal medicine (n = 100) and surgery (n = 232) at 4 US academic hospitals. Frequencies of presentation of adverse events and errors, discussion of errors, and attribution of errors. In internal medicine morbidity and mortality conferences, case presentations and discussions were 3 times longer than in surgery conferences (34.1 minutes vs 11.7 minutes; P =.001), more time was spent listening to invited speakers (43.1% vs 0%; Pinternal medicine case presentations included adverse events (37 [37%] vs 166 surgery case presentations [72%]; Perrors causing an adverse event (18 [18%] vs 98 [42%], respectively; P =.001). When an error caused an adverse event, the error was discussed as an error less often in internal medicine (10 errors [48%] vs 85 errors in surgery [77%]; P =.02). Errors were attributed to a particular cause less often in medicine than in surgery conferences (8 [38%] of 21 medicine errors vs 88 [79%] of 112 surgery errors; Perrors, conference leaders in both internal medicine and surgery infrequently used explicit language to signal that an error was being discussed and infrequently acknowledged having made an error. Our findings call into question whether adverse events and errors are routinely discussed in internal medicine training programs. Although adverse events and errors were discussed frequently in surgery cases, teachers in both surgery and internal
Patient safety requires optimal management of medications. Electronic systems are encouraged to reduce medication errors. Near field communications (NFC) is an emerging technology that may be used to develop novel medication management systems.
Lolita Dopico da Silva
Full Text Available This study aimed to identify the characteristics of nurses’ publications about medication errors. It was used an Integrative methodology review covering January 2005 to October 2010 with "medication errors" and "nursing" descriptors and it was also collected data from electronic databases via “Capes Portal”. Results show four categories, the conduct of health professionals in medication errors, types and rates of errors, medication system weaknesses, and barriers to error. Discussion of the prevalent practice was not to notify the error. The prevalent error type was administration and error rates which ranged from 14.8 to 56.7%. Ilegible handwriting, communication failures among professionals, and lack of technical knowledge were weaknesses. Among the barriers, the civility from patient, nurses and technology were evident. Advances in researches for testing barriers were found and some gaps were apparent concerning lack of study that address pharmacodynamics or pharmacokinetic aspects of drugs involved in errors.
Sørensen, Ann Lykkegaard; Mainz, Jan; Lisby, Marianne
-hospital patients (n=67), physicians prescribing drugs and ward staff (nurses and nurses assistants) dispensing and administering drugs. The study was carried out using 3 methods of investigation – an observational study, an unannounced control visit and an audit of medical records. Medication errors were evaluated...... for error. In total, 434 errors were detected in 1333 opportunities for error (33%). The rate of medication errors (with potential to harm patients) was 8% and 0.3% were considered potentially fatal. The frequency of errors was: Prescription: A) Computerized physician order entry (CPOE): 10/267 (4%), B...
Isik, Oguz; Bayin, Gamze; Ugurluoglu, Ozgur
This study was performed with the aim of identifying how news on medical errors have be transmitted, and how the types, reasons, and conclusions of medical errors have been reflected to by the media in Turkey. A content analysis method was used in the study, and in this context, the data for the study was acquired by scanning five newspapers with the top editions on the national basis between the years 2012 and 2015 for the news about medical errors. Some specific selection criteria was used for the scanning of resulted news, and 116 news items acquired as a result of all the eliminations. According to the results of the study; the vast majority of medical errors (40.5%) transmitted by the news resulted from the negligence of the medical staff. The medical errors were caused by physicians in the ratio of 74.1%, they most commonly occurred in state hospitals (31.9%). Another important result of the research was that medical errors resulted in either patient death to a large extent (51.7%), or permanent damage and disability to patients (25.0%). The news concerning medical errors provided information about the types, causes, and the results of these medical errors. It also reflected the media point of view on the issue. The examination of the content of the medical errors reported by the media were important which calls for appropriate interventions to avoid and minimize the occurrence of medical errors by improving the healthcare delivery system.
Armstrong, Gail E; Dietrich, Mary; Norman, Linda; Barnsteiner, Jane; Mion, Lorraine
Approximately a quarter of medication errors in the hospital occur at the administration phase, which is solely under the purview of the bedside nurse. The purpose of this study was to assess bedside nurses' perceived skills and attitudes about updated safety concepts and examine their impact on medication administration errors and adherence to safe medication administration practices. Findings support the premise that medication administration errors result from an interplay among system-, unit-, and nurse-level factors.
Wright, Whitney; Khatri, Naresh
that bullying behaviors exist and affect psychological/behavioral responses of nurses such as stress and anxiety and medical errors. Health care organizations should identify bullying behaviors and implement bullying prevention strategies to reduce those behaviors and the adverse effects that they may have on psychological/behavioral responses of nurses and medical errors.
Yu, Yao-Chang; Hou, Ting-Wei; Chiang, Tzu-Chiang
An Institute of Medicine Report stated there are 98,000 people annually who die due to medication related errors in the United States, and hospitals and other medical institutions are thus being pressed to use technologies to reduce such errors. One approach is to provide a suitable protocol that can cooperate with low cost RFID tags in order to identify patients. However, existing low cost RFID tags lack computational power and it is almost impossible to equip them with security functions, such as keyed hash function. To address this issue, a so a real lightweight binding proof protocol is proposed in this paper. The proposed protocol uses only logic gates (e.g. AND, XOR, ADD) to achieve the goal of proving that two tags exist in the field simultaneously, without the need for any complicated security algorithms. In addition, various scenarios are provider to explain the process of adopting this binding proof protocol with regard to guarding patient safety and preventing medication errors.
R.J. Zaal (Rianne); J.E. van Doormaal (Jasperien); A.W. Lenderink (Albert); P.G.M. Mol; J.G.W. Kosterink (Jos); T.C.G. Egberts (Toine); F.M. Haaijer-Ruskamp (Flora); P.M.L.A. van den Bemt (Patricia)
textabstractPurpose: To compare determinants for medication errors leading to patient harm with determinants for medication errors without patient harm. Methods: A two-way case-control design was used to identify determinants formedication errors without harm (substudy 1) and determinants for
Zernikow, B; Michel, E; Fleischhack, G; Bode, U
Drug errors are quite common. Many of them become harmful only if they remain undetected, ultimately resulting in injury to the patient. Errors with cytotoxic drugs are especially dangerous because of the highly toxic potential of the drugs involved. For medico-legal reasons, only 1 case of accidental iatrogenic intoxication by cytotoxic drugs tends to be investigated at a time, because the focus is placed on individual responsibility rather than on system errors. The aim of our study was to investigate whether accidental iatrogenic intoxications by cytotoxic drugs are faults of either the individual or the system. The statistical analysis of distribution and quality of such errors, and the in-depth analysis of contributing factors delivered a rational basis for the development of practical preventive strategies. A total of 134 cases of accidental iatrogenic intoxication by a cytotoxic drug (from literature reports since 1966 identified by an electronic literature survey, as well as our own unpublished cases) underwent a systematic error analysis based on a 2-dimensional model of error generation. Incidents were classified by error characteristics and point in time of occurrence, and their distribution was statistically evaluated. The theories of error research, informatics, sensory physiology, cognitive psychology, occupational medicine and management have helped to classify and depict potential sources of error as well as reveal clues for error prevention. Monocausal errors were the exception. In the majority of cases, a confluence of unfavourable circumstances either brought about the error, or prevented its timely interception. Most cases with a fatal outcome involved erroneous drug administration. Object-inherent factors were the predominant causes. A lack of expert as well as general knowledge was a contributing element. In error detection and prevention of error sequelae, supervision and back-checking are essential. Improvement of both the individual
Blignaut, Alwiena J; Coetzee, Siedine K; Klopper, Hester C; Ellis, Suria M
To determine the incidence of medication administration errors, medication administration-related deviations from safe practice as well as factors associated with these errors in medical and surgical units of public hospitals in the Gauteng Province of South Africa. Several studies have been published on the incidence of medication administration errors, but only a few have studied the incidence of medication administration-related deviations from safe practice. Context-specific research on the incidence of medication administration errors and associated factors (patient acuity, bed occupancy, staffing levels, medication administrators' qualifications, dose calculation skills, level of hospital, unit type, medication administration route and interruptions) within the continent of Africa is lacking. A cross-sectional, observational design. Direct observation was conducted incorporating a previously validated checklist based on basic medication guidelines including the five rights, asepsis and medication documentation. In addition, a knowledge test on dose calculations was performed. Medication administration to 315 patients (1847 medications administered) was observed between February-August 2015 in medical and surgical units from eight public hospitals. Twenty-five medication administrators completed dose calculations. In total, 296 medication errors were identified, of which most were wrong-time errors and omissions. Interruptions and patient acuity were significantly associated with wrong-dose and wrong-route errors, respectively. Most medication administration-related deviations from safe practice were related to patient identification or asepsis. Sixteen of 50 dosage calculations were answered incorrectly. Incorrect answers most often occurred in the calculation of parenteral dosages. Medication administration errors, especially wrong-time errors and omissions, are prevalent in public hospitals in the Gauteng Province. Interruptions lower the risk of wrong
Full Text Available Suboptimal adherence with preventive medication is common and often unrecognised as a cause of poor asthma control. A number of risk factors for nonadherence have emerged from well-conducted studies. Unfortunately, patient report a physician's estimation of adherence and knowledge of these risk factors may not assist in determining whether non-adherence is a significant factor. Electronic monitoring devices are likely to be more frequently used to remind patients to take medication, as a strategy to motivate patients to maintain adherence, and a tool to evaluate adherence in subjects with poor disease control. The aim of this paper is to review non-adherence with preventive medication in childhood asthma, its impact on asthma control, methods of evaluating non-adherence, risk factors for suboptimal adherence, and strategies to enhance adherence.
Hartnell, Nicole; MacKinnon, Neil; Sketris, Ingrid; Fleming, Mark
The under-reporting of medication errors can compromise patient safety. A qualitative study was conducted to enhance the understanding of barriers to medication error reporting in healthcare organisations. Focus groups (with physicians, pharmacists and nurses) and in-depth interviews (with risk managers) were used to identify medication error reporting beliefs and practices at four community hospitals in Nova Scotia, Canada. Audio tapes were transcribed verbatim and analysed for thematic content using the template style of analysis. The development and analysis of this study were guided by Safety Culture Theory. Incentives for medication error reporting were thematised into three categories: patient protection, provider protection and professional compliance. Barriers to medication error reporting were thematised into five categories: reporter burden, professional identity, information gap, organisational factors and fear. Facilitators to encourage medication error reporting were classified into three categories: reducing reporter burden, closing the communication gap and educating for success. Participants indicated they would report medication errors more frequently if reporting were made easier, if they were adequately educated about reporting, and if they received timely feedback. Study results may lead to a better understanding of the barriers to medication error reporting, why these barriers exist and what can be done to successfully overcome them. These results could be used by hospitals to encourage reporting of medication errors and ultimately make organisational changes leading to a reduction in the incidence of medication errors and an improvement in patient safety.
Doherty, Catherine; Mc Donnell, Conor
Tenfold medication errors are a significant source of risk to pediatric patients. This may be because of wide variations in age, weight, dosing ranges, and off-label practices, but few studies exclusively devoted to examining pediatric 10-fold error have identified the circumstances and mechanisms that lead to such errors. We examined all 10-fold medication errors reported within an academic, university-affiliated pediatric hospital to make recommendations for future initiatives that could improve medication safety in pediatric practice. We retrospectively evaluated all medication-related incident reports submitted to a voluntary safety-reporting database over a 5-year period for reports describing 10-fold medication error. Main outcome measures comprised severity of error, drugs and drug classes involved, 10-fold medication error enablers, mechanisms, and contributing causes. From 6643 medication-related safety reports, 252 10-fold medication errors were identified at a mean reporting rate of 0.062 per 100 total patient days. Morphine was the most frequently reported medication, and opioids were the most frequently reported drug class. Twenty-two reports described patient harm. Intravenous formulations, paper ordering, and drug-delivery pumps were frequent error enablers. Errors of dose calculation, documentation of decimal points, and confusion with zeroes were frequent contributing causes to 10-fold medication error. This study exclusively and comprehensively examined 10-fold medication errors over a prolonged time in pediatric inpatients. We discuss recommendations of vigilance for specific drugs and standardized order sets for opioids and antibiotics, and identify the administering phase of the medication process as a high-risk practice that can result in pediatric 10-fold medication error.
Kolaitis, Irini N; Schinasi, Dana Aronson; Ross, Lainie Friedman
Limited data exist on medical error disclosure in pediatrics. We sought to assess physicians' attitudes toward error disclosure to parents and pediatric patients. An anonymous survey was distributed to 1200 members of the American Academy of Pediatrics. Surveys included 1 of 4 possible cases that only varied by patient age (16 or 9 years old) and by whether the medical error resulted in reversible or irreversible harm. Statistical analyses included chi-square, Bonferroni-adjusted P values, Fisher's exact test, Wilcoxon signed rank test, and logistic regressions including key demographic factors, patient age, and error reversibility. The response rate was 40% (474 of 1186). Overall, 98% of respondents believed it was very important to disclose medical errors to parents versus 57% to pediatric patients (P < .0001). Respondents believed that medical errors could be disclosed to developmentally appropriate pediatric patients at a mean age of 12.15 years old (SD 3.33), but not below a mean age of 10.25 years old (SD 3.55). Most respondents (72%) believed that physicians and parents should jointly decide whether to disclose to pediatric patients. When disclosing to pediatric patients, 88% of respondents believed that physicians should disclose with the parents present. Logistic regressions found only patient age (odds ratio 18.65, 95% confidence interval 9.20-37.8) and error reversibility (odds ratio 2.90, 95% confidence interval 1.73-4.86) to affect attitudes toward disclosure to pediatric patients. Respondent sex, year of medical school graduation, and area of practice had no effect on disclosure attitudes. Most respondents endorse disclosing medical errors to parents and older pediatric patients, particularly when irreversible harm occurs. Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
Patanwala, Asad E; Sanders, Arthur B; Thomas, Michael C; Acquisto, Nicole M; Weant, Kyle A; Baker, Stephanie N; Merritt, Erica M; Erstad, Brian L
The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED). This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables. A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%). Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities. Copyright © 2011. Published by Mosby, Inc.
Tamang, S; Kopec, D; Shagas, G; Levy, K
Chronic and terminally ill patients are disproportionately affected by medical errors. In addition, the elderly suffer more preventable adverse events than younger patients. Targeting system wide "error-reducing" reforms to vulnerable populations can significantly reduce the incidence and prevalence of human error in medical practice. Recent developments in health informatics, particularly the application of artificial intelligence (AI) techniques such as data mining, neural networks, and case-based reasoning (CBR), presents tremendous opportunities for mitigating error in disease diagnosis and patient management. Additionally, the ubiquity of the Internet creates the possibility of an almost ideal network for the dissemination of medical information. We explore the capacity and limitations of web-based palliative information systems (IS) to transform the delivery of care, streamline processes and improve the efficiency and appropriateness of medical treatment. As a result, medical error(s) that occur with patients dealing with severe, chronic illness and the frail elderly can be reduced.The palliative model grew out of the need for pain relief and comfort measures for patients diagnosed with cancer. Applied definitions of palliative care extend this convention, but there is no widely accepted definition. This research will discuss the development life cycle of two palliative information systems: the CONFER QOLP management information system (MIS), currently used by a community-based palliative care program in Brooklyn, New York, and the CAREN case-based reasoning prototype. CONFER is a web platform based on the idea of "eCare". CONFER uses XML (extensible mark-up language), a W3C-endorced standard mark up to define systems data. The second system, CAREN, is a CBR prototype designed for palliative care patients in the cancer trajectory. CBR is a technique, which tries to exploit the similarities of two situations and match decision-making to the best
Full Text Available Many hospitalized children are suffered from medical errors that may cause serious injuries. The aim of this study was to evaluate medical errors in hospitalized children in khorramabad Madani hospital in the first half of 2008. Materials and Methods: This study was a cross sectional that was performed for all medical errors in hospitalized children in khorramabad Madani hospital from 21/3/2008 to 21/9/2008. The sampling method was census. Studied variables included: age, sex, weight, kinds of errers, education of parents, job of parents. Data was collected by questionnaire and analyzed by SPSS software. Results: In this study out of 2250 records, 151 (6/3% had medical errors. 53%were girls and 47% were boys that there was a significant relation between sex and medical errors. 46/4%were related to age group lower than 2 years old. Most of the errors were occurred in weight group of 6kg. Types of medical errors included drug ordering 46/3% (involved incorrect dosage of drug (37%, frequency 28%, rout 19% and others 16%, transcribing10%, administering32/4%, dispensing11/3%. Most errors related to liquid therapy 76/2% and intravenous rout 85/4%. Most errors were occurred during night 47% and during weekend 56/6%. Conclusion: Medical errors are common in hospitalized patients, and in our study the rate of medical errors was 6/3%. So further efforts are needed to reduce them.
Fischer, Melissa A; Mazor, Kathleen M; Baril, Joann; Alper, Eric; DeMarco, Deborah; Pugnaire, Michele
Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. To identify major factors and areas of tension in trainees' learning from medical errors. Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.
Pape, Tess M.
Causal factors contributing to errors in medication administration should be thoroughly investigated, focusing on systems rather than individual nurses. Unless systemic causes are addressed, many errors will go unreported for fear of reprisal. (Contains 42 references.) (SK)
...) and pharmaceutical errors combined are the second or third leading killer of Americans annually: approximately 300,000 die from a combination of medical errors, hospital acquired infections (HAIs...
Shaha, Steven H; Brodsky, Linda; Leonard, Michael S; Cimino, Michael A; McDougal, Sandra A; Pilliod, Joann M; Martin, Kristen E
.... This paper will detail the means used at one hospital facility to make medication errors and their reduction a primary staff focus, and how a highly generalizable, low-tech, and cost-conscious error...
Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila
Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.
Breuker, C; Macioce, V; Mura, T; Audurier, Y; Boegner, C; Jalabert, A; Villiet, M; Castet-Nicolas, A; Avignon, A; Sultan, A
To assess the prevalence and characteristics of medication errors at hospital admission and discharge in people with Type 1 and Type 2 diabetes, and identify potential risk factors for these errors. This prospective observational study included all people with Type 1 (n = 163) and Type 2 diabetes (n = 508) admitted to the Diabetology-Department of the University Hospital of Montpellier, France, between 2013 and 2015. Pharmacists conducted medication reconciliation within 24 h of admission and at hospital discharge. Medication history collected from different sources (patient/family interviews, prescriptions/medical records, contact with community pharmacies/general practitioners/nurses) was compared with admission and discharge prescriptions to detect unintentional discrepancies in medication indicating involuntary medication changes. Medication errors were defined as unintentional medication discrepancies corrected by physicians. Risk factors for medication errors and serious errors (i.e. errors that may cause harm) were assessed using logistic regression. A total of 322 medication errors were identified and were mainly omissions. Prevalence of medication errors in Type 1 and Type 2 diabetes was 21.5% and 22.2% respectively at admission, and 9.0% and 12.2% at discharge. After adjusting for age and number of treatments, people with Type 1 diabetes had nearly a twofold higher odds of having medication errors (odds ratio (OR) 1.72, 95% confidence interval (CI) 1.02-2.94) and serious errors (OR 2.17, 95% CI 1.02-4.76) at admission compared with those with Type 2 diabetes. Medication reconciliation identified medication errors in one third of individuals. Clinical pharmacists should focus on poly-medicated individuals, but also on other high-risk people, for example, those with Type 1 diabetes. © 2017 Diabetes UK.
Eva, Kevin W.
This paper examines diagnostic error from an educational perspective. Rather than addressing the question of how educators in the health professions can help learners avoid error, however, the literature reviewed leads to the conclusion that educators should be working to induce error in learners, leading them to short term pain for long term…
Teunissen, R.; Bos, J.; Pot, H.; Pluim, M.; Kramers, C.
PURPOSE: The clinical relevance of and risk factors associated with errors related to medication administration time were studied. METHODS: In this explorative study, 66 medication administration rounds were studied on two wards (surgery and neurology) of a hospital. Data on medication errors were
Jay J. Shen
Full Text Available Medication errors can be detrimental to patient safety and contribute to additional costs in healthcare. The United States has seen a steady increase in internationally-educated nurses (IENs entering the nursing workforce. The current study builds upon the existing research examining the relationship between IENs and medication errors by controlling for confounding factors and testing whether IENs were more likely to make multiple medication errors compared to USENs. This study was a quasi-case control study. The 2006 and 2010 medication error incident data from hospital risk management departments were used. The final sample was 1,773, representing 788 registered nurse in the case group and 985 registered nurses in the control group. Multivariable analyses were conducted to examine single medication error, multiple errors, and consequence of medication errors, in comparing the IENs to USENs. IENs tended to have multiple errors more often than USENs in 2006 (31.7% for IENs and 20.5% for USENs, p = 0.03, but these differences became marginally significant after combining both years of data and completing the multivariable models adjusting for covariates (Odds ratio = 1.38, p = 0.06. No significant differences in making a single error and medication error consequences were observed between IENs and USENs. Although no significant differences between IENs and USENs in having medication error incidents were observed, IENs might be more likely to have multiple medication error incidents in a year compared to USENs. Policies that encourage targeted orientation addressing implicit belief systems about the nursing role and explains patient safety expectations as well as procedures for medication administration may be beneficial for IENs. Supportive leadership that is culturally competent, ensures ongoing continuing education in pharmacology, and provides culturally appropriate incentives for self-reporting medication errors are important.
... TM Help Prevent Errors in Your Care Behavioral Health Care To prevent health care errors, patients are urged to... SpeakUP TM Service ... individuals should be involved in their own behavioral health care. These efforts to increase consumer awareness and involvement ...
Ningsih, Yunita; Maidin, Alimin; Kapalawi, Irwandy
Kejadian medication error merupakan indikator penting keselamatan pasien. Medication error yang terjadi di Rumah Sakit Universitas Hasanuddin tahun 2013 terdapat 4 kasus dan tahun 2014 terdapat 1 kasus. Penelitian ini bertujuan mengetahui gambaran risiko kejadian medication error.Jenis penelitian yang digunakan penelitian deskriptif. Teknik pengambilan sampel yang digunakan yaitu teknik total sampling sebanyak 115 responden. Analisis data yang dilakukan adalah analisis univariat. Hasil peneli...
Thakur, Heenopama; Thawani, Vijay; Raina, Rangeel Singh; Kothiyal, Gitanjali; Chakarabarty, Mrinmoy
Objective: To study the medication errors leading to noncompliance in a tertiary care teaching hospital. Materials and Methods: This study was conducted in a tertiary care hospital of a teaching institution from Srikot, Garhwal, Uttarakhand to analyze the medication errors in 500 indoor prescriptions from medicine, surgery, obstetrics and gynecology, pediatrics and ENT departments over five months and 100 outdoor patients of medicine department. Results: Medication error rate for indo...
Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y
Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Mirco, Ana; Campos, Luís; Falcão, Fátima; Nunes, João Silva; Aleixo, Ana
Evaluation of a computerized physician order entry in an Internal Medicine Department, with a unit-dose distribution system. Pharmacy Department, Internal Medicine Department. S. Francisco Xavier Hospital, Lisbon, Portugal. This study was carried out in December 2001 and January 2002. After two years experience of the CPOE system, medication errors were evaluated prospectively, in an internal medical department of a 360-bed academic hospital. Data were collected once a week. Pharmacists reviewed all medical prescriptions as part of their routine work. Medication errors detected were recorded on a data collection form with a design based on the types of errors as defined by the American Society of Hospital Pharmacists (ASHP). Completed forms were reviewed and medication errors were classed according to ASHP guidelines. A total of 2268 orders were monitored (162 patients). In these orders, 73 medication errors (22.4% of the patients) were detected and documented (59 prescribing errors and 14 monitoring errors). The most common prescribing errors were deficiencies related to the right class but wrong drug (28.3%): omeprazole vs. ranitidine/sucralfate in stress ulcer prophylaxis; incorrect dose (30%) and unclear orders (13.3%). Errors related to incorrect frequency of administration (5%); maintenance of IV route (5%); duplicated drug therapy (11.7%); drug interactions (1.7%) and length of therapy (3.3%) were also detected. The 14 monitoring errors detected were failures to review a prescribed regimen for appropriateness and detection of problems. Computerized prescription order entry has demonstrated effectiveness in eliminating medication errors related to transcribing and patient identification. Nevertheless, medication errors related to prescription and monitoring still occur. The use of clinical decision support systems and pharmacist involvement is vital to achieve maximum medication safety and reduce medication error rates.
Thakur, Heenopama; Thawani, Vijay; Raina, Rangeel Singh; Kothiyal, Gitanjali; Chakarabarty, Mrinmoy
To study the medication errors leading to noncompliance in a tertiary care teaching hospital. This study was conducted in a tertiary care hospital of a teaching institution from Srikot, Garhwal, Uttarakhand to analyze the medication errors in 500 indoor prescriptions from medicine, surgery, obstetrics and gynecology, pediatrics and ENT departments over five months and 100 outdoor patients of medicine department. Medication error rate for indoor patients was found to be 22.4 % and 11.4% for outdoor patients as against the standard acceptable error rate 3%. Maximum errors were observed in the indoor prescriptions of the surgery department accounting for 44 errors followed by medicine 32 and gynecology 25 in the 500 cases studied leading to faulty administration of medicines. Many medication errors were noted which go against the practice of rational therapeutics. Such studies can be directed to usher in the rational use of medicines for increasing compliance and therapeutic benefits.
Mendonça, Vitor Silva; Custódio, Eda Marconi
Medical error stems from inadequate professional conduct that is capable of producing harm to life or exacerbating the health of another, whether through act or omission. This situation has become increasingly common in Brazil and worldwide. In this study, the aim was to understand what being the victim of medical error is like and to investigate the circumstances imposed on this condition of victims in Brazil. A semi-structured interview was conducted with twelve people who had gone through situations of medical error in their lives, creating a space for narratives of their experiences and deep reflection on the phenomenon. The concept of medical error has a negative connotation, often being associated with the incompetence of a medical professional. Medical error in Brazil is demonstrated by low-quality professional performance and represents the current reality of the country because of the common lack of respect and consideration for patients. Victims often remark on their loss of identity, as their social functions have been interrupted and they do not expect to regain such. It was found, however, little assumption of error in the involved doctors' discourses and attitudes, which felt a need to judge the medical conduct in an attempt to assert their rights. Medical error in Brazil presents a punitive character and is little discussed in medical and scientific circles. The stigma of medical error is closely connected to the value and cultural judgments of the country, making it difficult to accept, both by victims and professionals.
Guerrero-Aznar, M D; Jiménez-Mesa, E; Cotrina-Luque, J; Villalba-Moreno, A; Cumplido-Corbacho, R; Fernández-Fernández, L
To analyze the impact of a multidisciplinary and decentralized safety committee in the pediatric management unit, and the joint implementation of a computing network application for reporting medication errors, monitoring the follow-up of the errors, and an analysis of the improvements introduced. An observational, descriptive, cross-sectional, pre-post intervention study was performed. An analysis was made of medication errors reported to the central safety committee in the twelve months prior to introduction, and those reported to the decentralized safety committee in the management unit in the nine months after implementation, using the computer application, and the strategies generated by the analysis of reported errors. Number of reported errors/10,000 days of stay, number of reported errors with harm per 10,000 days of stay, types of error, categories based on severity, stage of the process, and groups involved in the notification of medication errors. Reported medication errors increased 4.6 -fold, from 7.6 notifications of medication errors per 10,000 days of stay in the pre-intervention period to 36 in the post-intervention, rate ratio 0.21 (95% CI; 0.11-0.39) (P.05). The notification of potential errors or errors without harm per 10,000 days of stay increased 17.4-fold (rate ratio 0.005., 95% CI; 0.001-0.026, Pde Pediatría. Published by Elsevier Espana. All rights reserved.
White, Andrew A; Bell, Sigall K; Krauss, Melissa J; Garbutt, Jane; Dunagan, W Claiborne; Fraser, Victoria J; Levinson, Wendy; Larson, Eric B; Gallagher, Thomas H
The disclosure of harmful errors to patients is recommended, but appears to be uncommon. Understanding how trainees disclose errors and how their practices evolve during training could help educators design programmes to address this gap. This study was conducted to determine how trainees would disclose medical errors. We surveyed 758 trainees (488 students and 270 residents) in internal medicine at two academic medical centres. Surveys depicted one of two harmful error scenarios that varied by how apparent the error would be to the patient. We measured attitudes and disclosure content using scripted responses. Trainees reported their intent to disclose the error as 'definitely' (43%), 'probably' (47%), 'only if asked by patient' (9%), and 'definitely not' (1%). Trainees were more likely to disclose obvious errors than errors that patients were unlikely to recognise (55% versus 30%; p error rather than only an adverse event had occurred. Regarding apologies, trainees were split between conveying a general expression of regret (52%) and making an explicit apology (46%). Respondents at higher levels of training were less likely to use explicit apologies (trend p errors (odds ratio 1.40, p = 0.03). Trainees may not be prepared to disclose medical errors to patients and worrisome trends in trainee apology practices were observed across levels of training. Medical educators should intensify efforts to enhance trainees' skills in meeting patients' expectations for the open disclosure of harmful medical errors. © Blackwell Publishing Ltd 2011.
Full Text Available Objective: This study compares medical errors in pediatric trauma patients with and without chronic conditions. Methods: The 2009 Kids’ Inpatient Database, which included 123,303 trauma discharges, was analyzed. Medical errors were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The medical error rates per 100 discharges and per 1000 hospital days were calculated and compared between inpatients with and without chronic conditions. Results: Pediatric trauma patients with chronic conditions experienced a higher medical error rate compared with patients without chronic conditions: 4.04 (95% confidence interval: 3.75–4.33 versus 1.07 (95% confidence interval: 0.98–1.16 per 100 discharges. The rate of medical error differed by type of chronic condition. After controlling for confounding factors, the presence of a chronic condition increased the adjusted odds ratio of medical error by 37% if one chronic condition existed (adjusted odds ratio: 1.37, 95% confidence interval: 1.21–1.5, and 69% if more than one chronic condition existed (adjusted odds ratio: 1.69, 95% confidence interval: 1.48–1.53. In the adjusted model, length of stay had the strongest association with medical error, but the adjusted odds ratio for chronic conditions and medical error remained significantly elevated even when accounting for the length of stay, suggesting that medical complexity has a role in medical error. Higher adjusted odds ratios were seen in other subgroups. Conclusion: Chronic conditions are associated with significantly higher rate of medical errors in pediatric trauma patients. Future research should evaluate interventions or guidelines for reducing the risk of medical errors in pediatric trauma patients with chronic conditions.
Farag, Amany; Blegen, Mary; Gedney-Lose, Amalia; Lose, Daniel; Perkhounkova, Yelena
Medication errors are one of the most frequently occurring errors in health care settings. The complexity of the ED work environment places patients at risk for medication errors. Most hospitals rely on nurses' voluntary medication error reporting, but these errors are under-reported. The purpose of this study was to examine the relationship among work environment (nurse manager leadership style and safety climate), social capital (warmth and belonging relationships and organizational trust), and nurses' willingness to report medication errors. A cross-sectional descriptive design using a questionnaire with a convenience sample of emergency nurses was used. Data were analyzed using descriptive, correlation, Mann-Whitney U, and Kruskal-Wallis statistics. A total of 71 emergency nurses were included in the study. Emergency nurses' willingness to report errors decreased as the nurses' years of experience increased (r = -0.25, P = .03). Their willingness to report errors increased when they received more feedback about errors (r = 0.25, P = .03) and when their managers used a transactional leadership style (r = 0.28, P = .01). ED nurse managers can modify their leadership style to encourage error reporting. Timely feedback after an error report is particularly important. Engaging experienced nurses to understand error root causes could increase voluntary error reporting. Published by Elsevier Inc.
Pegahan, Saeed; Byrd, Mark S.; Reddy Chinni, Karthik
Decoherence-free, or noiseless subsystems, are used to encode spin qubits in quantum dots in order to achieve universal quantum computing using only the exchange interaction. We investigate the use of dynamical decoupling controls for the purposes of eliminating leakage for a logical qubit encoded using three physical qubits. These leakage elimination operators (LEOs) can be used to eliminate all leakage errors using exchange interactions between the physical spin qubits. Depending on the encoding and the decoupling control, different types of errors can be eliminated. We show several different possible controls and the consequential noise reduction for different encodings as well as our general method for determining the effectiveness of these pulses.
Diehl, S.E.; Ochoa, A. Jr.; Dressendorfer, P.V.; Koga, R.; Kolasinski, W.A.
Cosmic ray interactions with memory cells are known to cause temporary, random, bit errors in some designs. The sensitivity of polysilicon gate CMOS static RAM designs to logic upset by impinging ions has been studied using computer simulations and experimental heavy ion bombardment. Results of the simulations are confirmed by experimental upset cross-section data. Analytical models have been extended to determine and evaluate design modifications which reduce memory cell sensitivity to cosmic ions. A simple design modification, the addition of decoupling resistance in the feedback path, is shown to produce static RAMs immune to cosmic ray-induced bit errors
Urban, Michal; Leššo, Roman; Pelclová, Daniela
The purpose of the article was to study unintentional pharmaceutical-related poisonings committed by laypersons that were reported to the Toxicological Information Centre in the Czech Republic. Identifying frequency, sources, reasons and consequences of the medication errors in laypersons could help to reduce the overall rate of medication errors. Records of medication error enquiries from 2013 to 2014 were extracted from the electronic database, and the following variables were reviewed: drug class, dosage form, dose, age of the subject, cause of the error, time interval from ingestion to the call, symptoms, prognosis at the time of the call and first aid recommended. Of the calls, 1354 met the inclusion criteria. Among them, central nervous system-affecting drugs (23.6%), respiratory drugs (18.5%) and alimentary drugs (16.2%) were the most common drug classes involved in the medication errors. The highest proportion of the patients was in the youngest age subgroup 0-5 year-old (46%). The reasons for the medication errors involved the leaflet misinterpretation and mistaken dose (53.6%), mixing up medications (19.2%), attempting to reduce pain with repeated doses (6.4%), erroneous routes of administration (2.2%), psychiatric/elderly patients (2.7%), others (9.0%) or unknown (6.9%). A high proportion of children among the patients may be due to the fact that children's dosages for many drugs vary by their weight, and more medications come in a variety of concentrations. Most overdoses could be prevented by safer labelling, proper cap closure systems for liquid products and medication reconciliation by both physicians and pharmacists. © 2016 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).
This study compared registered nurses' perceptions of safety climate and attitude toward medication error reporting before and after completing a hospital accreditation program. Medication errors are the most prevalent adverse events threatening patient safety; reducing underreporting of medication errors significantly improves patient safety. Safety climate in hospitals may affect medication error reporting. This study employed a longitudinal, descriptive design. Data were collected using questionnaires. A tertiary acute hospital in South Korea undergoing a hospital accreditation program. Nurses, pre- and post-accreditation (217 and 373); response rate: 58% and 87%, respectively. Hospital accreditation program. Perceived safety climate and attitude toward medication error reporting. The level of safety climate and attitude toward medication error reporting increased significantly following accreditation; however, measures of institutional leadership and management did not improve significantly. Participants' perception of safety climate was positively correlated with their attitude toward medication error reporting; this correlation strengthened following completion of the program. Improving hospitals' safety climate increased nurses' medication error reporting; interventions that help hospital administration and managers to provide more supportive leadership may facilitate safety climate improvement. Hospitals and their units should develop more friendly and intimate working environments that remove nurses' fear of penalties. Administration and managers should support nurses who report their own errors. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Nosek, Ronald A., Jr; McMeekin, Judy; Rake, Geoffrey W
...) began an aggressive examination of medical errors and the strategies for minimizing them. A primary goal was the creation of a standardized medication event reporting system, including a central registry for the compilation of reported data...
To identify differences in what nurses consider as medication administration errors, to examine their willingness to report these errors and to identify barriers to reporting medication errors by hospital type. Cross-sectional, descriptive design. The questionnaire comprised six medication administration error scenarios and items related to the reasons for not reporting medication errors. Two tertiary and three general hospitals in a metropolitan area, and five general hospitals in K province, in South Korea. Registered nurses working at tertiary and general hospitals in South Korea (n = 467). Consideration of medication administration errors, intention to report medication errors and reasoning for not file an incident report. There were no significant differences in what nurses considered as medication administration errors between nurses working different in hospital types. The rate of incident reporting was very low; it ranged from 6.3% to 29.9%, regardless of hospital type. Korean nurses were more likely to report an error to a physician than file an incident report. The primary reason for not reporting medication errors was fear of the negative consequences of reporting the error and subsequent legal action. The rate of filing an incident report among nurses was very low, regardless of hospital type or whether nurses perceived the incident as a medication administration error. These results may have significant implications for improving medication safety in hospitals, and more efforts are needed at the organizational level to improve incident reporting by nurses. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: email@example.com
Anand, K; Saini, Sk; Singh, Bk; Veermaram, C
In the medical device field, there are a number of players, having quite different responsibilities and levels of understanding of the processes, but all with one common interest, that of ensuring the availability of sound medical devices to the general public. To assist in this very important process, there is a need for a common method for describing and identifying these medical devices in an unambiguous manner. The Global Medical Device Nomenclature (GMDN) now provides, for the first time, an international tool for identifying all medical devices, at the generic level, in a meaningful manner that can be understood by all users. Prior to the GMDN, many nomenclature systems existed, all built upon different structures, and used locally or nationally for special purposes, with unusual approaches. These diverse systems, although often workable in their own right, have had no impact on improving the overall situation of providing a common platform, whereby, medical devices could be correctly identified and the related data safely exchanged between the involved parties. Work by standard organizations such as, CEN (European Committee for Standardization) and ISO (International Organization for Standardization), from 1993 to 1996, resulted in a standard that specified a structure for a new nomenclature, for medical devices. In this article we are trying to explain GMDN as the prime method to reduce medical device errors, and to understand the concept of GMDN, to regulate the medical device throughout the globe. Here we also make an attempt to explain various aspects of the GMDN system, such as, the process of development of the GMDN-CEN report, purpose, benefits, and their structural considerations. In addition, there will be an explanation of the coding system, role of the GMDN agency, and their utilization in the unique device identification (UDI) System. Finally, the current area of focus and vision for the future are also mentioned.
Bolandianbafghi, Shahnaz; Salimi, Tahere; Rassouli, Maryam; Faraji, Reza; Sarebanhassanabadi, Mohammadtaghi
Medication errors which can cause several medical malfunctions, have been in the spotlight recently. Job satisfaction and fatigue seems to be related to the increase of medication errors in nursing. This study aimed to determine the correlation between the amount and type of medication errors with job satisfaction and fatigue of nurses working in Shahid Sadoughi hospital in Yazd-Iran. This is a descriptive study by a cross-sectional and correlational approach conducted on all the nurses working in an educational hospital who have characteristics of samples. Participants were 170 nurses working in Shahid Sadooghi hospital in Yazd, Iran in 2012. The questionnaires of demographic characteristics, medication administration error and nurses' job satisfaction and fatigue by purposive sampling were used for gathering data. Validity and reliability were checked for internal consistency and stability. Data were analysed by SPSS version 17 using Pearson correlation coefficient and Independent-samples t-test. The findings did not illustrate a significant relationship between job satisfaction and fatigue with medication errors. Among the demographic characteristics, age of nurses was significantly associated with the frequency of medication errors (p=0.037). However, others were not significantly correlated (p>0.05). In spite of the findings, based on no significant statistical relationship between job satisfaction and fatigue with the type and amount of medication errors in nursing, the effect of these variables on medication errors cannot be disregarded; thus further studies in this area are suggested.
MacCourt, Duncan; Bernstein, Joseph
physicians cede their implicit "right to remain silent", even if some injured patients will receive less than they do today. Likewise, physicians will be happier with a system that avoids blame-even if this system placed strict requirements for high quality care and disclosure of error. We therefore conceive of de facto trade between patients and physicians, a Pareto improvement, taking form via the establishment of "Societies of Quality Medicine." Physicians working within these societies would consent to onerous processes for disclosing, rectifying and preventing medical error. Patients would in turn contractually agree to assert their claims in arbitration and with limits on recovery. The role of plaintiffs' lawyers would be unchanged, but due to increased disclosure, discovery costs would diminish and the likelihood of prevailing will more than triple. This article examines the legal and policy issues surrounding the establishment of Societies of Quality Medicine, particularly the issues of contracting over liability, and outlines a means of overcoming the theoretical and practical difficulties with enterprise liability, alternative dispute resolution and the imposition of limits on recovery for non-pecuniary damages. We aim to build a welfare enhancing system that rebuffs the culture of silence and promotes error reduction, a system that is at the same time legally sound, fiscally prudent and politically possible.
Iurasov, V V; Smakhtin, R E
The current practice of expertise of the adequacy of organization of the provision of medical aid introduces a new aspect of the notion of "medical error" that is widely employed in medical profession, among lawyers, patients, and their relatives as well as in mass media. The universally accepted meaning of this notion has not thus far been proposed. The authors consider the medico-legal concept of "medical error" reconciling the contradictory opinions.
Esqué Ruiz, M T; Moretones Suñol, M G; Rodríguez Miguélez, J M; Sánchez Ortiz, E; Izco Urroz, M; de Lamo Camino, M; Figueras Aloy, J
Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. An analysis was performed on the ME declared in a neonatal unit. A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.
Yung, Hai-Peng; Yu, Shu; Chu, Chi; Hou, I-Ching; Tang, Fu-In
(1) To explore the attitudes and perceived barriers to reporting medication administration errors and (2) to understand the characteristics of - and nurses' feelings - about error reports. Under-reporting of medication administration errors is a global concern related to the safety of patient care. Understanding nurses' attitudes and perceived barriers to error reporting is the initial step to increasing the reporting rate. A cross-sectional, descriptive survey with a self-administered questionnaire was completed by the nurses of a medical centre hospital in Taiwan. A total of 306 nurses participated in the study. Nurses' attitudes towards medication administration error reporting were inclined towards positive. The major perceived barrier was fear of the consequences after reporting. The results demonstrated that 88.9% of medication administration errors were reported orally, whereas 19.0% were reported through the hospital internet system. Self-recrimination was the common feeling of nurses after the commission of an medication administration error. Even if hospital management encourages errors to be reported without recrimination, nurses' attitudes toward medication administration error reporting are not very positive and fear is the most prominent barrier contributing to underreporting. Nursing managers should establish anonymous reporting systems and counselling classes to create a secure atmosphere to reduce nurses' fear and provide incentives to encourage reporting. © 2016 John Wiley & Sons Ltd.
Manoel de Carvalho
sistema, e encarados como oportunidade de revisão do processo e aprimoramento da assistência prestada ao paciente.Objective: to review the current literature and to discuss medical errors in hospitalized patients emphasizing its incidence, predisposing factors and prevention mechanism. Special attention is given to medication errors and adverse drug events in newborn infants and pediatric patients. Sources: bibliographic review of the current literature through electronic search in Medline data-base, with selection of the most relevant articles. Summary of the findings: even though most medical errors are not reported, it is important to notice that its incidence is greater than previously assumed. In the USA, approximately one million of patients/year are victims of medical errors and adverse drug events. Today, deaths resulting from these episodes are the fourth cause of mortality in the USA. In neonatal and pediatric intensive care units, where the complexity and frequency of technical procedures are high, medical errors are frequent. Fifteen percent of all admissions to a neonatal intensive care unit is followed by medical errors. Most of these errors occur during night shifts and include incorrect administration of drugs (35% and errors regarding the interpretation of medical prescription (26%. Environmental factors (noise, heat, psychological factors (anxiety, stress and physiologic factors (fatigue, absence of sleep contribute to the occurrence of errors. Recent study shows that after working 24 hours without sleeping, the performance of a health professional is similar to a legally drunk person (serum alcohol level > 0.08%. Conclusions: errors are part of human behavior. The prevention of errors should include a careful review of the organizational system. Medical errors should be seen as an opportunity to change or re-structure the system and to improve the quality of health care delivered and patient safety.
Zimmerman, Sheryl; Love, Karen; Sloane, Philip D; Cohen, Lauren W; Reed, David; Carder, Paula C
To compare rates of medication errors committed by assisted living staff with different training and to examine characteristics of errors. Observation of medication preparation and passes, chart review, interviews, and questionnaires. Stratified random sample of 11 assisted living communities in South Carolina (which permits nonnurses to administer medications) and Tennessee (which does not). All staff who prepared or passed medications: nurses (one registered nurse and six licensed practical nurses (LPNs)); medication aides (n=10); and others (n=19), including those with more and less training. Rates of errors related to medication, dose and form, preparation, route, and timing. Medication preparation and administration were observed for 4,957 administrations during 83 passes for 301 residents. The error rate was 42% (20% when omitting timing errors). Of all administrations, 7% were errors with moderate or high potential for harm. The odds of such an error by a medication aide were no more likely than by a LPN, but the odds of one by staff with less training was more than two times as great (odds ratio=2.10, 95% confidence interval=1.27-3.49). A review of state regulations found that 20 states restrict nonnurses to assisting with self-administration of medications. Medication aides do not commit more errors than LPNs, but other nonnurses who administered a significant number of medications and assisted with self-administration committed more errors. Consequently, all staff who handle medications should be trained to the level of a medication aide. © 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.
Full Text Available Background: Medication error is the most common adverse event for hospitalised children and can lead to significant harm. Despite decades of research and implementation of a number of initiatives, the error rates continue to rise, particularly those associated with administration. Objectives: The objective of this literature review is to explore the factors involving nurses, families and healthcare systems that impact on medication administration errors in paediatric patients. Design: A review was undertaken of studies that reported on factors that contribute to a rise or fall in medication administration errors, from family, nurse and organisational perspectives. The following databases were searched: Medline, Embase, CINAHL and the Cochrane library. The title, abstract and full article were reviewed for relevance. Articles were excluded if they were not research studies, they related to medications and not medication administration errors or they referred to medical errors rather than medication errors. Results: A total of 15 studies met the inclusion criteria. The factors contributing to medication administration errors are communication failure between the parents and healthcare professionals, nurse workload, failure to adhere to policy and guidelines, interruptions, inexperience and insufficient nurse education from organisations. Strategies that were reported to reduce errors were doublechecking by two nurses, implementing educational sessions, use of computerised prescribing and barcoding administration systems. Yet despite such interventions, errors persist. The review highlighted families that have a central role in caring for the child and therefore are key to the administration process, but have largely been ignored in research studies relating to medication administration. Conclusions: While there is a consensus about the factors that contribute to errors, sustainable and effective solutions remain elusive. To date, families have not
José Joaquín Mira
Full Text Available OBJETIVO: Analizar la frecuencia de errores de medicación que son cometidos e informados por los pacientes. MÉTODOS: Estudio descriptivo basado en encuestas telefónicas a una muestra aleatoria de pacientes adultos del nivel primario de salud del sistema público español. Respondieron un total de 1 247 pacientes (tasa de respuesta, 75%. El 63% eran mujeres y 29% eran mayores de 70 años. RESULTADOS: Mientras 37 pacientes (3%, IC 95%: 2-4 sufrieron complicaciones asociadas a la medicación en el curso del tratamiento, 241 (19,4%, IC 95%: 17-21 informaron haber cometido algún error con la medicación. Un menor tiempo de consulta (P OBJECTIVE: Analyze the frequency of medication errors committed and reported by patients. METHODS: Descriptive study based on a telephone survey of a random sample of adult patients from the primary care level of the Spanish public health care system. A total of 1 247 patients responded (75% response rate; 63% were women and 29% were older than 70 years. RESULTS: While 37 patients (3%, 95% CI: 2-4 experienced complications associated with medication in the course of treatment, 241 (19.4%, 95% CI: 17-21 reported having made some mistake with their medication. A shorter consultation time (P < 0.01 and a worse assessment of the information provided by the physician (P < 0.01 were associated with the fact that during pharmacy dispensing the patient was told that the prescribed treatment was not appropriate. CONCLUSIONS: In addition to the known risks of an adverse event due to a health intervention resulting from a system or practitioner error, there are risks associated with patient errors in the self-administration of medication. Patients who were unsatisfied with the information provided by the physician reported a greater number of errors.
The importance of learning from medical error has recently received increasing emphasis. This paper focuses on prescribing errors and argues that, while learning from prescribing errors is a laudable goal, there are currently barriers that can prevent this occurring. Learning from errors can take place on an individual level, at a team level, and across an organisation. Barriers to learning from prescribing errors include the non-discovery of many prescribing errors, lack of feedback to th...
Full Text Available Background: Medication reconciliation is a major component of safe patient care. One of the main problems in the implementation of a medication reconciliation process is the lack of human resources. With limited resources, it is better to target medication reconciliation resources to patients who will derive the most benefit from it. Objective: The primary objective of this study was to determine the frequency and types of medication reconciliation errors identified by pharmacists performing medication reconciliation at admission. Each medication error was rated for its potential to cause patient harm during hospitalization. A secondary objective was to determine risk factors associated with medication reconciliation errors. Methods: This was a prospective, single-center pilot study conducted in the internal medicine and surgical wards of a tertiary care teaching hospital in the Eastern province of Saudi Arabia. A clinical pharmacist took the best possible medication history of patients admitted to medical and surgical services and compared with the medication orders at hospital admission; any identified discrepancies were noted and analyzed for reconciliation errors. Multivariate logistic regression was performed to determine the risk factors related to reconciliation errors. Results: A total of 328 patients (138 in surgical and 198 in medical were included in the study. For the 1419 medications recorded, 1091 discrepancies were discovered out of which 491 (41.6% were reconciliation errors. The errors affected 177 patients (54%. The incidence of reconciliation errors in the medical patient group was 25.1% and 32.0% in the surgical group (p<0.001. In both groups, the most frequent reconciliation error was the omission (43.5% and 51.2%. Lipid-lowering (12.4% and antihypertensive agents were most commonly involved. If undetected, 43.6% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 17
Vialle, V; Tiphine, T; Poirier, Y; Raingeard, E; Feldman, D; Freville, J-C
The aim of the study is to identify medication errors related to computerized physician order entry in our hospital. At the end of this 1-year study (2008 to 2009), 378 beds were computerized by a business software. Medication errors were identified from notifications sent to the publisher of the software, feedback of health professionals and the analysis of Pharmacists' interventions formulate following prescription errors due to computerization. They were qualified according to the medication error's French dictionary of the French Society of Clinical Pharmacy. Thirty-five categories of medication errors were found. Most of them appear during prescription. Dosage and concentration errors, dose errors, omission errors and drug errors are the most frequent. Three main causes were found: human factor, closely related to the software settings and the quality of user training; communication problems, related to the ergonomics; conception problems, related to intuitiveness and intricacy of the software. These results confirm the existence of medication errors induced by computerized physician order entry systems. They highlight the need to involve initial and ongoing training of users, relevance and scalability of the setup and use of mature and certified software to minimized them. Copyright © 2011 Elsevier Masson SAS. All rights reserved.
O processo de preparo e administração de medicamentos: identificação de problemas para propor melhorias e prevenir erros de medicação El proceso de preparación y administración de medicamentos: identificación de problemas para proponer mejoras y prevenir errores de medicación The medication preparation and administration process: problem identification in order to propose improvements and prevent medication errors
Adriana Inocenti Miasso
capacitación continua y presencia efectiva de la enfermera en el proceso, son algunas de las sugerencias para mejorar la calidad y la seguridad en la atención a los pacientes.This exploratory study analyzed the medication preparation and administration process in medical-clinical units at four Brazilian hospitals located in the Southeast, Central-West and Northeast, identified problems that can contribute to the occurrence of medication errors and proposed improvement measures. Data were collected through non-participant and direct observation of nursing professionals' activities during one week. The results revealed the following main problems: the environment in Hospital B; preparation errors related to technique and anticipated medication preparation in C and D; technical, communication and patient identification mistakes in Hospital A. Suggestions to achieve greater quality and safety in patient care include the constitution of a multidisciplinary commission to evaluate the system, nursing discussion groups, environmental improvements, permanent courses and training and actual presence of a nurse during the process.
Berdot, Sarah; Roudot, Marjorie; Schramm, Catherine; Katsahian, Sandrine; Durieux, Pierre; Sabatier, Brigitte
Serious medication administration errors are common in hospitals. Various interventions, including barcode-based technologies, have been developed to help prevent such errors. This systematic review and this meta-analysis focus on the efficacy of interventions for reducing medication administration errors. The types of error and their gravity were also studied. MEDLINE, EMBASE, the Cochrane Library and reference lists of relevant articles published between January 1975 and August 2014 were searched, without language restriction. Randomized controlled trials, interrupted time-series studies, non-randomized controlled trials and controlled before-and-after studies were included. Studies evaluating interventions for decreasing administration errors based on total opportunity for error method were included. Nurses administering medications to adult or child inpatients were considered eligible as participants. Two reviewers independently assessed studies for eligibility, extracted data and assessed the risk of bias. The main outcome was the error rate without wrong-time errors measured at study level. A random effects model was used to evaluate the effects of interventions on administration errors. 5312 records from electronic database searches were identified. Seven studies were included: five were randomized controlled trials (including one crossover trial) and two were non-randomized controlled trials. Interventions were training-related (n=4; dedicated medication nurses, interactive CD-ROM program, simulation-based learning, pharmacist-led training program), and technology-related (n=3; computerized prescribing and automated medication dispensing systems). All studies were subject to a high risk of bias, mostly due to a lack of blinding to outcome assessment and a risk of contamination. No difference between the control group and the intervention group was found (OR=0.72 [0.39; 1.34], p=0.3). No fatal error was observed in the three studies evaluating the gravity of
Cottney, Alan; Innes, James
In the present study, we aimed to identify the incidence, type, and potential clinical consequence of medication-administration errors made in a mental health hospital, and to investigate factors that might increase the risk of error. A prospective, direct observational technique was used to collect data from nurse medication rounds on each of the hospital's 43 inpatient wards. Regression analysis was used to identify potential error predictors. During the 172 medication rounds observed, 139 errors were detected in 4177 (3.3%) opportunities. The most common error was incorrect dose omission (52/139, 37%). Other common errors included incorrect dose (25/139, 18%), incorrect form (16/139, 12%), and incorrect time (12/139, 9%). Fifteen (11%) of the errors were of serious clinical severity; the rest were of negligible or minor severity. Factors that increased the risk of error included the nurse interrupting the medication round to attend to another activity, an increased number of 'when required' doses of medication administered, a higher number of patients on the ward, and an increased number of doses of medication due. These findings suggest that providers of inpatient mental health-care services should adopt medicine-administration systems that minimize task interruption and the use of 'when required' medication, as well as taking steps to reduce nursing workload. © 2014 Australian College of Mental Health Nurses Inc.
Full Text Available Medication error (ME is the most common single preventable cause of adverse drug events which negatively affects patient safety. ME prevalence is a valuable safety indicator in healthcare system. Inadequate studies on ME, shortage of high-quality studies and wide variations in estimations from developing countries including Iran, decreases the reliability of ME evaluations. In order to clarify the status of MEs, we aimed to review current available literature on this subject from Iran. We searched Scopus, Web of Science, PubMed, CINAHL, EBSCOHOST and also Persian databases (IranMedex, and SID up to October 2012 to find studies on adults and children about prescription, transcription, dispensing, and administration errors. Two authors independently selected and one of them reviewed and extracted data for types, definitions and severity of MEs. The results were classified based on different stages of drug delivery process. Eighteen articles (11 Persian and 7 English were included in our review. All study designs were cross-sectional and conducted in hospital settings. Nursing staff and students were the most frequent populations under observation (12 studies; 66.7%. Most of studies did not report the overall frequency of MEs aside from ME types. Most of studies (15; 83.3% reported prevalence of administration errors between 14.3%-70.0%. Prescribing error prevalence ranged from 29.8%-47.8%. The prevalence of dispensing and transcribing errors were from 11.3%-33.6% and 10.0%-51.8% respectively. We did not find any follow up or repeated studies. Only three studies reported findings on severity of MEs. The most reported types of and the highest percentages for any type of ME in Iran were administration errors. Studying ME in Iran is a new area considering the duration and number of publications. Wide ranges of estimations for MEs in different stages may be because of the poor quality of studies with diversity in definitions, methods, and populations
Nnaemeka G. Okafor
Full Text Available Introduction: Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remediation, is essential for continuous quality improvement. The emergency department (ED is recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design and implementation of a web-based ED-specific incident reporting system using an iterative process. Methods: A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. Results: The utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers reported 24% and 16% respectively. The most commonly reported incidents were delays in care and management concerns. Conclusion: Error reporting frequency can be dramatically improved by using a web-based, userfriendly, voluntary, and non-punitive reporting system.
... informed member of your health care team. The “Speak Up” program is sponsored by The Joint Commission. ... prevent health care mistakes, patients are urged to “Speak Up.” S peak up if you have questions or ...
... informed member of your health care team. The “Speak Up” program is sponsored by The Joint Commission. ... prevent health care mistakes, patients are urged to “Speak Up.” S peak up if you have questions or ...
Ravichandran, K.; Arulchelvan, S.
This research study brings out the factors behind the increase in medical malpractices in the Indian subcontinent in the present day environment and impacts of television media awareness towards it. Increased media reporting of medical malpractices and errors lead to hospitals taking corrective action and improve the quality of medical services that they provide. The model of Cultivation Theory can be used to measure the influence of media in creating awareness of medical errors. The patient's perceptions of various errors rendered by the medical industry from different parts of India were taken up for this study. Bayesian method was used for data analysis and it gives absolute values to indicate satisfaction of the recommended values. To find out the impact of maintaining medical records of a family online by the family doctor in reducing medical malpractices which creates the importance of service quality in medical industry through the ICT.
Hutchinson, Alison M; Sales, Anne E; Brotto, Vanessa; Bucknall, Tracey K
Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals' medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change
Mazhar, Faizan; Akram, Shahzad; Al-Osaimi, Yousif A; Haider, Nafis
Medication reconciliation is a major component of safe patient care. One of the main problems in the implementation of a medication reconciliation process is the lack of human resources. With limited resources, it is better to target medication reconciliation resources to patients who will derive the most benefit from it. The primary objective of this study was to determine the frequency and types of medication reconciliation errors identified by pharmacists performing medication reconciliation at admission. Each medication error was rated for its potential to cause patient harm during hospitalization. A secondary objective was to determine risk factors associated with medication reconciliation errors. This was a prospective, single-center pilot study conducted in the internal medicine and surgical wards of a tertiary care teaching hospital in the Eastern province of Saudi Arabia. A clinical pharmacist took the best possible medication history of patients admitted to medical and surgical services and compared with the medication orders at hospital admission; any identified discrepancies were noted and analyzed for reconciliation errors. Multivariate logistic regression was performed to determine the risk factors related to reconciliation errors. A total of 328 patients (138 in surgical and 198 in medical) were included in the study. For the 1419 medications recorded, 1091 discrepancies were discovered out of which 491 (41.6%) were reconciliation errors. The errors affected 177 patients (54%). The incidence of reconciliation errors in the medical patient group was 25.1% and 32.0% in the surgical group (perror was the omission (43.5% and 51.2%). Lipid-lowering (12.4%) and antihypertensive agents were most commonly involved. If undetected, 43.6% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 17.7% were rated as potentially harmful. A multivariate logistic regression model showed that patients aged ≥65 years
Onatade, Raliat; Sawieres, Sara; Veck, Alexandra; Smith, Lindsay; Gore, Shivani; Al-Azeib, Sumiah
Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists' medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routinely write discharge medication orders as part of the clinical pharmacy service. Convenient days, based on researcher availability, between October 2013 and January 2014 were selected. Pre-registration pharmacists reviewed all discharge medication orders written by pharmacists on these days and identified discrepancies between the medication history, inpatient chart, patient records and discharge summary. A senior clinical pharmacist confirmed the presence of an error. Each error was assigned a potential clinical significance rating (based on the NCCMERP scale) by a physician and an independent senior clinical pharmacist, working separately. Main outcome measure Incidence of errors in pharmacist-written discharge medication orders. Results 509 prescriptions, written by 51 pharmacists, containing 4258 discharge medication orders were assessed (8.4 orders per prescription). Ten prescriptions (2%), contained a total of ten erroneous orders (order error rate-0.2%). The pharmacist considered that one error had the potential to cause temporary harm (0.02% of all orders). The physician did not rate any of the errors with the potential to cause harm. Conclusion The incidence of errors in pharmacists' discharge medication orders was low. The quality, safety and policy implications of pharmacists routinely writing discharge medication orders should be further explored.
Helmons, Pieter J; Dalton, Ashley J; Daniels, Charles E
The effects of a direct refill program for automated dispensing cabinets (ADCs) on medication-refill errors were studied. This study was conducted in designated acute care areas of a 386-bed academic medical center. A wholesaler-to-ADC direct refill program, consisting of prepackaged delivery of medications and bar-code-assisted ADC refilling, was implemented in the inpatient pharmacy of the medical center in September 2009. Medication-refill errors in 26 ADCs from the general medicine units, the infant special care unit, the surgical and burn intensive care units, and intermediate units were assessed before and after the implementation of this program. Medication-refill errors were defined as an ADC pocket containing the wrong drug, wrong strength, or wrong dosage form. ADC refill errors decreased by 77%, from 62 errors per 6829 refilled pockets (0.91%) to 8 errors per 3855 refilled pockets (0.21%) (p error type detected before the intervention was the incorrect medication (wrong drug, wrong strength, or wrong dosage form) in the ADC pocket. Of the 54 incorrect medications found before the intervention, 38 (70%) were loaded in a multiple-drug drawer. After the implementation of the new refill process, 3 of the 5 incorrect medications were loaded in a multiple-drug drawer. There were 3 instances of expired medications before and only 1 expired medication after implementation of the program. A redesign of the ADC refill process using a wholesaler-to-ADC direct refill program that included delivery of prepackaged medication and bar-code-assisted refill significantly decreased the occurrence of ADC refill errors.
Schnoor, Jörg; Rogalski, Christina; Frontini, Roberto; Engelmann, Nils; Heyde, Christoph-Eckhardt
Background: The acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of medication error jeopardizing patient safety are LASA as well as high workload. Case presentation: A critical incident report of medication errors of opioids for postoperative analgesia by lookalike packaging highlights the LASA aspects in everyday scenarios. A change to a generic brand of medication saved costs of up to 16% per ...
Martinez, William; Hickson, Gerald B; Miller, Bonnie M; Doukas, David J; Buckley, John D; Song, John; Sehgal, Niraj L; Deitz, Jennifer; Braddock, Clarence H; Lehmann, Lisa Soleymani
To measure trainees' exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees' attitudes and behaviors regarding error disclosure. Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error. The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P error (OR 1.37, 95% CI 1.15-1.64; P errors. Negative role models may be a significant impediment to disclosure among trainees.
Full Text Available Afsaneh Vazin,1 Zahra Zamani,1 Nahid Hatam2 1Department of Clinical Pharmacy, Faculty of Pharmacy, 2School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran Abstract: This study was conducted with the purpose of determining the frequency of medication errors (MEs occurring in tertiary care emergency department (ED of a large academic hospital in Iran. The incidence of MEs was determined through the disguised direct observation method conducted by a trained observer. A total of 1,031 medication doses administered to 202 patients admitted to the tertiary care ED were observed over a course of 54 6-hour shifts. Following collection of the data and analysis of the errors with the assistance of a clinical pharmacist, frequency of errors in the different stages was reported and analyzed in SPSS-21 software. For the 202 patients and the 1,031 medication doses evaluated in the present study, 707 (68.5% MEs were recorded in total. In other words, 3.5 errors per patient and almost 0.69 errors per medication are reported to have occurred, with the highest frequency of errors pertaining to cardiovascular (27.2% and antimicrobial (23.6% medications. The highest rate of errors occurred during the administration phase of the medication use process with a share of 37.6%, followed by errors of prescription and transcription with a share of 21.1% and 10% of errors, respectively. Omission (7.6% and wrong time error (4.4% were the most frequent administration errors. The less-experienced nurses (P=0.04, higher patient-to-nurse ratio (P=0.017, and the morning shifts (P=0.035 were positively related to administration errors. Administration errors marked the highest share of MEs occurring in the different medication use processes. Increasing the number of nurses and employing the more experienced of them in EDs can help reduce nursing errors. Addressing the shortcomings with further research should result in reduction
.5%, and adequate information about medications (69.8% were reported as the most important ways to prevent medication errors. Also 62.8% of the cases had moderate knowledge regarding medication error and its prophylactic ways. Conclusion: The data analysis showed that from the nurses viewpoints, some interventions including increasing adequate nurse to patient ratio, improving environmental conditions of work, reducing environmental distractions such as interruptions and stressors, increasing staffs’ information about medications, increasing the role of clinical pharmacologists, creating medication error reporting systems, supportive attitude of nursing officials, focusing on causes of errors, and improving controlling and supervising systems can have remarkable effects on reducing medication errors. Moreover, both individuals and systems have to be taken into consideration when rules and regulations concerning medication error reporting and prevention are made.
Shawahna, Ramzi; Masri, Dina; Al-Gharabeh, Rawan; Deek, Rawan; Al-Thayba, Lama; Halaweh, Masa
To develop and achieve formal consensus on a definition of medication administration errors and scenarios that should or should not be considered as medication administration errors in hospitalised patient settings. Medication administration errors occur frequently in hospitalised patient settings. Currently, there is no formal consensus on a definition of medication administration errors or scenarios that should or should not be considered as medication administration errors. This was a descriptive study using Delphi technique. A panel of experts (n = 50) recruited from major hospitals, nursing schools and universities in Palestine took part in the study. Three Delphi rounds were followed to achieve consensus on a proposed definition of medication administration errors and a series of 61 scenarios representing potential medication administration error situations formulated into a questionnaire. In the first Delphi round, key contact nurses' views on medication administration errors were explored. In the second Delphi round, consensus was achieved to accept the proposed definition of medication administration errors and to include 36 (59%) scenarios and exclude 1 (1·6%) as medication administration errors. In the third Delphi round, consensus was achieved to consider further 14 (23%) and exclude 2 (3·3%) as medication administration errors while the remaining eight (13·1%) were considered equivocal. Of the 61 scenarios included in the Delphi process, experts decided to include 50 scenarios as medication administration errors, exclude three scenarios and include or exclude eight scenarios depending on the individual clinical situation. Consensus on a definition and scenarios representing medication administration errors can be achieved using formal consensus techniques. Researchers should be aware that using different definitions of medication administration errors, inclusion or exclusion of medication administration error situations could significantly affect
Theissen, A; Orban, J-C; Fuz, F; Guerin, J-P; Flavin, P; Albertini, S; Maricic, S; Saquet, D; Niccolai, P
The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications. The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010). Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy. The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management. Copyright © 2014 Elsevier Masson SAS. All rights reserved.
May, Natalie; Plews-Ogan, Margaret
The aim was to examine the role of talking (or remaining silent) in the physician's experience of coping with medical error. Sixty-one physicians participated in in-depth interviews about their experience of coping with a serious medical error. We analyzed verbatim transcripts to develop a taxonomic analysis of talking domains to capture the physician experience of talking and coping with error. Talking (or not talking) about a medical error was an important aspect of the physicians' experience. After an error, honest conversations with patients and families, the medical team, colleagues, mentors, and others were critical early steps toward healing. Talking with others was important for processing and finding meaning. Many physicians used their stories to teach and help others. Some types of conversation were unhelpful, such as those that were cruel, insensitive, self-serving, and dishonest. Talking with well-intentioned colleagues and family members was often unhelpful if they minimized the error. Physicians' opportunities to talk about their experience in a meaningful way is associated with their ability to recover after a serious medical error. This work may inform institutional policies, practices, and training to help physicians effectively prepare for and cope with medical error. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Lederman, Reeva; Dreyfus, Suelette; Matchan, Jessica; Knott, Jonathan C; Milton, Simon K
Underreporting of errors in hospitals persists despite the claims of technology companies that electronic systems will facilitate reporting. This study builds on previous analyses to examine error reporting by nurses in hospitals using electronic media. This research asks whether the electronic media creates additional barriers to error reporting, and, if so, what practical steps can all hospitals take to reduce these barriers. This is a mixed-method case study nurses' use of an error reporting system, RiskMan, in two hospitals. The case study involved one large private hospital and one large public hospital in Victoria, Australia, both of which use the RiskMan medical error reporting system. Information technology-based error reporting systems have unique access problems and time demands and can encourage nurses to develop alternative reporting mechanisms. This research focuses on nurses and raises important findings for hospitals using such systems or considering installation. This article suggests organizational and technical responses that could reduce some of the identified barriers. Crown Copyright © 2013. Published by Mosby, Inc. All rights reserved.
Martinez, William; Lehmann, Lisa Soleymani
The "hidden curriculum" and role models for responding to medical errors might play a central role in influencing residents' attitudes about disclosure. We sought to compare surgical and nonsurgical residents' exposure to role modeling for responding to medical errors and their attitudes about error disclosure. We conducted a cross-sectional, electronic survey of surgical and nonsurgical residents at 2 large academic medical centers. The questionnaire asked respondents about personal experience with medical errors; training for responding to errors; frequency of exposure to role modeling related to disclosure; and attitudes about disclosure. Descriptive statistics were used to describe frequencies. Chi-square and Fisher's exact test were used to compare proportions between surgical and nonsurgical trainees. The response rate was 58% (253 of 435). Surgical residents reported more frequently observing a colleague be treated harshly (eg, humiliated or verbally abused) for an error than nonsurgical residents (sometimes or often, 39% [26 of 66] vs 20% [37 of 187]; p = 0.002). Surgical residents were more likely than nonsurgical residents to believe they would be treated harshly by others if they acknowledged making a medical error (35% [23 of 66] vs 12% [23 of 187]; p medical errors at their institution (11% [7 of 66] vs 2% [4 of 187]; p = 0.008). Surgical residents were less likely than nonsurgical residents to feel free to express concerns to other members of the team about medical errors in patient care (70% [46 of 66] vs 83% [115 of 187]; p = 0.02). The punitive response to error by senior members of the health care team might be an impediment to the transparent disclosure of errors among residents that might disproportionally affect surgical training programs. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Severity of error (88.5%) and the perception of negligence mediated intention to litigate. Voluntary disclosure significantly reduced patients' intention to litigate caregivers (chi2=3.584; df=1; P=0.053). Frustration/anger was not more likely to influence patient to litigate than feelings of resignation/forgiveness (chi2=2.156; df=1; ...
Tariq, Amina; Georgiou, Andrew; Westbrook, Johanna
Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding
Full Text Available The objective of the study is to assess the medication errors and adherence to WHO prescription writing guidelines in a tertiary care hospital. A prospective observational study was carried out for a period of 8 months from June 2015 to February 2016 at tertiary care hospital. At inpatient department regular chart review of patient case records was carried out to assess the medication errors. The observed medication errors were assessed for level of harm by using NCCMERP index. The outpatient prescriptions were screened for adherence to WHO prescription writing guidelines. Out of 200 patients, 40 patients developed medication errors. Most of the medication errors were observed in the age group above 61 years (40%. Majority of the medication errors were observed with drug class of antibiotics 9 (22.5% and bronchodilators 9 (22.5%. Most of the errors were under the NCCMERP index category C. Out of 545 outpatient prescriptions, 51 (9.37% prescriptions did not have prescriber’s name and all of the prescriptions lack prescriber’s personal contact number. Eighteen prescriptions did not have patient’s name and 426 (78.2% prescriptions did not have patient’s age. The prevalence of medication errors in this study was relatively low (20% without any fatal outcome. Omission error was the most frequently observed medication errors 31 (77.5%. In the present study, the patient’s age was missing in 78.2% of the prescriptions and none of the prescriptions had patient’s address and the drug names were not mentioned by their generic names.
Medical errors are an inevitable outcome of the human cognitive system working within the environment and demands of practicing medicine. Training can play a pivotal role in minimizing error, but the prevailing training is not as effective because it directly focuses on error reduction. Based on an understanding of cognitive architecture and how the brain processes information, a new approach is suggested: focusing training on error recovery. This entails specific training in error detection and error mitigation. Such training will not only enable better responses when errors occur, but it is also a more effective way to achieve error reduction. The suggested design for error recovery training is to begin with detecting errors in others. Starting off with highly visible and even exaggerated errors, and advancing to more challenging detections and finally requiring to detect errors within oneself rather than in others. The error mitigation training starts with providing the learners with the correct remedial actions (after they have detected the error). With training, the learners are required to select the appropriate actions within multiple choice alternatives, and eventually are required to generate the appropriate remedial responses themselves. These can be used for instruction as well as for assessment purposes. Time pressure, distractions, competitions and other elements are included so as to make the training more challenging and interactive.
Bagheri-Nesami, Masoumeh; Esmaeili, Ravanbakhsh; Tajari, Mojdeh
The dangerous events caused by medication errors are one of the main challenges faced in critical care units. The present study was conducted to determine the frequency of intravenous medication administration errors and their causes in cardiac critical care units in Iran. The present descriptive study was conducted in the critical care units (CCUs and cardiac surgery intensive care units) of 12 teaching hospitals. Of the total of 240 nurses working in these departments, 190 participated in the present study. The data collection tools used in this study included the "nurses' demographic data questionnaire", the "patients' medical and demographic data questionnaire" and the "nurses' self-reporting questionnaire about the frequency of intravenous medication administration errors and their causes". The data obtained were analyzed in SPSS-20 using descriptive statistics such as the absolute and relative frequency. During the 2 months in which this study was being conducted, 2542 patients were admitted to these departments and 20240 doses of intravenous medications were administered to these patients. The nurses reported 262 intravenous medication administration errors. The most common intravenous medication error pertained to administering the wrong medication (n=71 and 27.1%). As for the causes of intravenous medication administration errors, 51.5% of the errors were associated with work conditions, 24% with packaging, 13.4% with communication, 9.9% with transcription and 1.2% with pharmacies. According to the results, strategies are recommended to be adopted for reducing or limiting medication errors, such as building a stronger pharmacology knowledge base in nurses and nursing students, improving work conditions and improving communication between the nurses and physicians.
Mc Donnell, Conor
Opioids are the most common source of drug error that leads to harm in pediatric hospitals. To undertake a comprehensive review of experience with voluntary safety reports describing pediatric opioid medication errors at The Hospital for Sick Children (Toronto, Ontario), and to characterize the specific opioids involved, severity and type of error described, hospital location and time of day that the error occurred. All medication-related safety reports submitted to an anonymous, voluntary electronic safety reporting database in a university-affiliated pediatric hospital during the first four years of its use were examined. A database of opioid error reports was created for further analysis. A total of 5,935 medication-related safety reports were collected, 507 of which described opioids. Morphine was the most frequently reported opioid, administration was the most frequently reported stage of the medication process (192 errors) and surgical wards were the location from which opioid error was most frequently reported (128 reports). Twenty-two reports described patient harm requiring urgent treatment and intervention. Errors with codeine or hydromorphone resulted in the most significant harm reported. A total of 162 reports described problems with inappropriate opioid disposal, missing opioids, or incorrect opioid counts and checks. Future opportunities for improvement in opioid safety should focus on morphine, opioid administration errors in general, the safe disposal of opioids in the hospital environment and the identification of pain as an adverse event.
Full Text Available Purpose: the aim of this study is to research applied models of air traffic controllers’ errors prevention in terminal control areas (TMA under uncertainty conditions. In this work the theoretical framework descripting safety events and errors of air traffic controllers connected with the operations in TMA is proposed. Methods: optimisation of terminal control area formal description based on the Threat and Error management model and the TMA network model of air traffic flows. Results: the human factors variables associated with safety events in work of air traffic controllers under uncertainty conditions were obtained. The Threat and Error management model application principles to air traffic controller operations and the TMA network model of air traffic flows were proposed. Discussion: Information processing context for preventing air traffic controller errors, examples of threats in work of air traffic controllers, which are relevant for TMA operations under uncertainty conditions.
Navarrete Campos, S.; Hernandez Vitoria, A.; Canellas Anoz, M.; Millan Cebrian, E.; Garcia Romero, A.
Computerized record-and-verify systems (RVS) are being used increasingly to improve the precision of radiotherapy treatments. With the introduction of new treatment devices, such as multileaf or asymmetric collimators and virtual wedges, the responsibility to ensure correct treatment has increased. The purpose of this paper is to present the method that we are following to prevent some potential radiotherapy errors and to point out some errors that can be easily detected using a RVS, through a check of the daily recorded treatment information. We conclude that a RVS prevents the occurrence of many errors, when the settings of the treatment machine do not match the intended parameters within some maximal authorized deviation, and allows to detect easily other potential errors related with a incorrect selection of the treatment patient data. A quality assurance program, including a check of all beam data and a weekly control of the manual and electronic chart, has helped reduce errors. (author)
Schwappach, David L B; Hochreutener, Marc-Anton; Wernli, Martin
To explore oncology nurses' perceptions and experiences with patient involvement in chemotherapy error prevention. Qualitative descriptive study. In- and outpatient oncology units of a community hospital in Switzerland. 11 actively practicing oncology nurses working in an ambulatory infusion unit or on wards. Oncology nurses participated in two focus groups on two occasions. Participants discussed their personal experiences with patients intervening to intercept errors, attitudes toward patient involvement in error prevention, and changes in relationships with patients. A content-analysis framework was applied to the transcripts and analytical categories were generated. Perceptions about patient involvement in error prevention. Participants shared affirmative attitudes and overwhelmingly reported positive experiences with engaging patients in safety behaviors, although engaging patients was described as a challenge. Nurses intuitively chose among a set of strategies and patterns of language to engage patients and switch between participative and authoritative models of education. Patient involvement in error prevention was perceived to be compatible with trustful relationships. Efforts to get patients involved have the potential for frustration if preventable errors reach patients. Considerable differences exist among organizational barriers encountered by nurses. Nurses acknowledged the diverse needs of patients and deliberately used different strategies to involve patients in safety. Patient participation in safety is perceived as a complex learning process that requires cultural change. Oncology nurses perceive patient education in safety as a core element of their professional role and are receptive to advancing their expertise in this area.
Full Text Available Background Medication errors (MEs are the most common types of medical errors which effecting on pediatric safety. For decrease MEs, we should to have information about difference aspects of MEs. We have no study which assessed the frequency, types and causes of MEs made by pediatric nurses, in Iran. Material and Methods This was a cross-sectional study, which performed on 53 Pediatric Nurses. Data were collected by a self-structured questionnaire for assessment of MEs contained 3 parts: 1- one question about the fact that, do you had MEs in past 3 months; 2- types of MEs occurred (12 items; 3- causes of MEs from nurses’ perspective (20 items. The MEs in past 3 months gathered through pediatric nurses’ self-report. Descriptive statistics and Chi-square test were used for analysis. Data were analyzed using the SPSS. Results The majority of participants were female (77.3%, and initial (novice nurses (33.9%. The results showed that, 31 (58.4% of nurses were reported at least one MEs history and totally, 131 MEs were occurred in past 3 months. Most prevalent of MEs types were reported: wrong dose (36.6% and wrong drug preparation (14.5%. Also, most prevalent of MEs causes from Nurses’ perspective were reported: poor medication knowledge (96.2% and poor calculation skills (73.5%. Conclusion With using of this study results, we can program for prevention/decrease MEs and enhancing pediatric safety. On the basis of this study, actually we should enhancing level of nurses knowledge by education and to carry out special courses for pediatric nurses.
Hwang, Yeonsoo; Yoon, Dukyong; Ahn, Eun Kyoung; Hwang, Hee; Park, Rae Woong
To determine the risk factors and rate of medication administration error (MAE) alerts by analyzing large-scale medication administration data and related error logs automatically recorded in a closed-loop medication administration system using radio-frequency identification and barcodes. The subject hospital adopted a closed-loop medication administration system. All medication administrations in the general wards were automatically recorded in real-time using radio-frequency identification, barcodes, and hand-held point-of-care devices. MAE alert logs recorded during a full 1 year of 2012. We evaluated risk factors for MAE alerts including administration time, order type, medication route, the number of medication doses administered, and factors associated with nurse practices by logistic regression analysis. A total of 2 874 539 medication dose records from 30 232 patients (882.6 patient-years) were included in 2012. We identified 35 082 MAE alerts (1.22% of total medication doses). The MAE alerts were significantly related to administration at non-standard time [odds ratio (OR) 1.559, 95% confidence interval (CI) 1.515-1.604], emergency order (OR 1.527, 95%CI 1.464-1.594), and the number of medication doses administered (OR 0.993, 95%CI 0.992-0.993). Medication route, nurse's employment duration, and working schedule were also significantly related. The MAE alert rate was 1.22% over the 1-year observation period in the hospital examined in this study. The MAE alerts were significantly related to administration time, order type, medication route, the number of medication doses administered, nurse's employment duration, and working schedule. The real-time closed-loop medication administration system contributed to improving patient safety by preventing potential MAEs. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.
Wallace, Darlene; Woolley, Torres; Martin, David; Rasalam, Roy; Bellei, Maria
Medication errors are the second most frequently reported hospital incident in Australia and are a global concern. A "Medication Calculation and Administration" workshop followed by a "hurdle" assessment (compulsory task mandating a minimum level of performance as a condition of passing the course) was introduced into Year 2 of the James Cook University medical curriculum to decrease dosage calculation and administration errors among graduates. This study evaluates the effectiveness of this educational activity as a long-term strategy to teach medical students' essential skills in calculating and administering medications. This longitudinal study used a pre- and post-test design to determine whether medical students retained their calculation and administration skills over a period of 4 years. The ability to apply basic mathematical skills to medication dose calculation, principles of safe administration (Part 1), and ability to access reference materials to check indications, contraindications, and writing the medication order with correct abbreviations (Part 2) were compared between Year 2 and 6 assessments. Scores for Parts 1, 2 and total scores were nearly identical from Year 2 to Year 6 (P = 0.663, 0.408, and 0.472, respectively), indicating minimal loss of knowledge by students in this period. Most Year 6 students (86%) were able to recall at least 5 of the "6 Rights of Medication Administration" while 84% reported accessing reference material and 91% reported checking their medical calculations. The "Medication Calculation and Administration" workshop with a combined formative and summative assessment - a "hurdle" - promotes long-term retention of essential clinical skills for medical students. These skills and an awareness of the problem are strategies to assist medical graduates in preventing future medication-related adverse events.
The aim of this study was to investigate the influence of medical error case reporting by national newspapers on inpatient volume at acute care hospitals. A case-control study was conducted using the article databases of 3 major Japanese newspapers with nationwide circulation between fiscal years 2012 and 2013. Data on inpatient volume at acute care hospitals were obtained from a Japanese government survey between fiscal years 2011 and 2014. Panel data were constructed and analyzed using a difference-in-differences design. Acute care hospitals in Japan. Hospitals named in articles that included the terms "medical error" and "hospital" were designated case hospitals, which were matched with control hospitals using corresponding locations, nurse-to-patient ratios, and bed numbers. Medical error case reporting in newspapers. Changes to hospital inpatient volume after error reports. The sample comprised 40 case hospitals and 40 control hospitals. Difference-in-differences analyses indicated that newspaper reporting of medical errors was not significantly associated (P = 0.122) with overall inpatient volume. Medical error case reporting by newspapers showed no influence on inpatient volume. Hospitals therefore have little incentive to respond adequately and proactively to medical errors. There may be a need for government intervention to improve the posterror response and encourage better health care safety.
Wolf, Dwayne A; Drake, Stacy A; Snow, Francine K
In the course of fulfilling their statutory role, physicians performing medicolegal investigations may recognize clinical colleagues' medical errors. If the error is found to have led directly to the patient's death (missed diagnosis or incorrect diagnosis, for example), then the forensic pathologist has a professional responsibility to include the information in the autopsy report and make sure that the family is appropriately informed. When the error is significant but did not lead directly to the patient's demise, ethical questions may arise regarding the obligations of the medical examiner to disclose the error to the clinicians or to the family. This case depicts the discovery of medical error likely unrelated to the cause of death and describes one possible ethical approach to disclosure derived from an ethical reasoning model addressing ethical principles of respect for persons/autonomy, beneficence, nonmaleficence, and justice.
Lehmann, Lion; Wesselmann, Ulrich; Weber, Beate; Smentkowski, Ulrich
Patient safety is a central issue of health care provision. There are various approaches geared towards improving health care provision and patient safety. By conducting a systematic retrospective error analysis, the present article aims to identify the most common complaints brought forth within the field of dermatology over a period of ten years. The reports of the Expert Committee for Medical Malpractice Claims of the North Rhine Medical Association (from 2004 to 2013) on dermatological procedures were analyzed (n = 247 reports in the field of dermatology). Expert medical assessments in the field of dermatology are most frequently commissioned for nonsurgical therapies (e.g. laser therapy, phototherapy). While suspected diagnostic errors constitute the second most common reason for complaints, presumed dermatosurgery-related errors represent the least common reason for commissioning expert medical assessments. The most common and easily avoidable sources of medical errors include failure to take a biopsy despite suspicious clinical findings, or incorrect clinicopathological correlations resulting in deleterious effects for the patient. Furthermore, given the potential for incorrect indications and the inadequate selection of devices to be used as well as their parameter settings, laser and phototherapies harbor an increased risk in the treatment of dermatological patients. The fourth major source of error leading to complaints relates to incorrect indications as well as incorrect dosage and administration of drugs. Analysis of expert medical assessment reports on treatment errors in dermatology as well as other medical specialties is helpful and provides an opportunity to identify common sources of error and error-prone structures. © 2015 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.
Mankaka, Cindy Ottiger; Waeber, Gérard; Gachoud, David
BACKGROUND: Doctors, especially doctors-in-training such as residents, make errors. They have to face the consequences even though today's approach to errors emphasizes systemic factors. Doctors' individual characteristics play a role in how medical errors are experienced and dealt with. The role of gender has previously been examined in a few quantitative studies that have yielded conflicting results. In the present study, we sought to qualitatively explore the experience of female residents...
Pozmogov, A.I.; Petruk, D.A.
Reasons for errors in medical and computerized diagnostics of spherical lung neoplasms are studied based on material of 212 case records and clinicoroentgenological data; it should promote improvement of their diagnostics
Abdelbaset M. Saleh
Conclusions: Medication administration errors, fatigue and depression were all significantly affected by circadian sleep disorders. An administration’s control of work flow to provide convenient sleep hours will help in improving sleep circadian rhythms and consequently minimize these problems.
Review of errors in the issue of medical certificates of cause of death in a tertiary hospital in Ghana. Patrick K. Akakpo, Yaw A. Awuku, Leonard Derkyi-Kwarteng, Kelvin A. Gyamera, Sebastian Eliason ...
Hwang, Jee-In; Park, Hyeoun-Ae
We examined nurses' perceptions of the ethical climate of their workplace and the relationships among the perceptions, medical error experience and intent to leave through a cross-sectional survey of 1826 nurses in 33 Korean public hospitals. Ethical climate was measured using the Hospital Ethical Climate Survey. Although the sampled nurses perceived their workplace ethical climate positively, 19% reported making at least one medical error during the previous year, and 25% intended to leave their jobs in the near future. Controlling for individual and organizational characteristics, we found that nurses with a more positive perception of the 'patient' dimension of ethical climate were less likely to have made medical errors. Nurses with a more positive perception of the 'patient', 'manager', 'hospital' and 'physician' dimensions of ethical climate were less likely to leave their current job. Enhancing workplace ethical climate could reduce medical errors and improve nurses' retention in public hospitals.
Woolever, Donald R
...: To determine the impact of a patient safety program on patterns of medical error reporting. Methods: This study was a retrospective review of 1,102 incident reports filed at Eglin USAF Regional Hospital in Florida between 1997 and 2001...
Kannampallil, Thomas G; Abraham, Joanna; Solotskaya, Anna; Philip, Sneha G; Lambert, Bruce L; Schiff, Gordon D; Wright, Adam; Galanter, William L
Medication order voiding allows clinicians to indicate that an existing order was placed in error. We explored whether the order voiding function could be used to record and study medication ordering errors. We examined medication orders from an academic medical center for a 6-year period (2006-2011; n = 5 804 150). We categorized orders based on status (void, not void) and clinician-provided reasons for voiding. We used multivariable logistic regression to investigate the association between order voiding and clinician, patient, and order characteristics. We conducted chart reviews on a random sample of voided orders ( n = 198) to investigate the rate of medication ordering errors among voided orders, and the accuracy of clinician-provided reasons for voiding. We found that 0.49% of all orders were voided. Order voiding was associated with clinician type (physician, pharmacist, nurse, student, other) and order type (inpatient, prescription, home medications by history). An estimated 70 ± 10% of voided orders were due to medication ordering errors. Clinician-provided reasons for voiding were reasonably predictive of the actual cause of error for duplicate orders (72%), but not for other reasons. Medication safety initiatives require availability of error data to create repositories for learning and training. The voiding function is available in several electronic health record systems, so order voiding could provide a low-effort mechanism for self-reporting of medication ordering errors. Additional clinician training could help increase the quality of such reporting. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: firstname.lastname@example.org
Sohrevardi, Seyed Mojtaba; Jarahzadeh, Mohammad Hossein; Mirzaei, Ehsan; Mirjalili, Mahtabalsadat; Tafti, Arefeh Dehghani; Heydari, Behrooz
Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients' pharmacotherapy, and more attention should be paid to this issue.
Conclusion: Incidence and types of medication errors committed in Tikur Anbesa Specialized Hospital Adult Emergency Unit were substantiated; moreover, necessary information on factors within the healthcare delivery system that predispose healthcare professionals to commit errors have been pointed, which should be addressed by healthcare professionals through multidisciplinary efforts and involvement of decision makers at national level.
Young, Heather M.; Gray, Shelly L.; McCormick, Wayne C.; Sikma, Suzanne K.; Reinhard, Susan; Trippett, Linda Johnson; Christlieb, Carol; Allen, Tiffany
OBJECTIVES To describe the types and potential clinical significance of medication administration errors in assisted living (AL). DESIGN Cross-sectional observational study. SETTING This study was conducted in 12 AL settings in three states (Oregon, Washington, and New Jersey). PARTICIPANTS Participants included 29 unlicensed assistive personnel and 510 AL residents. MEASUREMENTS Medication administration observations, chart review, and determination of rates, types, and potential clinical significance of errors using standardized methodology. RESULTS Of 4,866 observations, 1,373 errors were observed (28.2% error rate). Of these, 70.8% were wrong time, 12.9% wrong dose, 11.1% omitted dose, 3.5% extra dose, 1.5% unauthorized drug, and 0.2% wrong drug. Excluding wrong time, the overall error rate dropped to 8.2%. Of the 1,373 errors, three were rated as having potential clinical significance. CONCLUSION A high number of daily medications are given in AL. Wrong time accounted for the majority of the errors. The bulk of the medications are low risk and routine; to promote optimal care delivery, clinicians need to focus on high-risk medications and residents with complex health problems. PMID:18482296
Dedefo, Mohammed Gebre; Mitike, Abraham Haileamlak; Angamo, Mulugeta Tarekegn
Background Medication errors cause a large number of adverse drug events with negative patient health outcomes and are a major public-health burden contributing to 18.7?56?% of all adverse drug events among hospitalized patients. The aim of this study was to assess the incidence and determinants of medication errors and adverse drug events among hospitalized children. Methods A prospective observational study was conducted among hospitalized children in the pediatrics ward of Nekemte Referral...
Pharmacovigilance has been described as 'the science and activities relating to the ... 1 Department of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine,. University ..... Hand-held devices such as smartphones with medication dosage applications.
Oberst, Robert J.; Johnson, Janet A.
Effective Medical Information Systems (MIS) are characterized by an ability to consistently provide users with information that agrees with their expectations. When a system does not perform as expected it is assumed that this system contains at least one, generally more than one, error. A significant improvement in the Software Development Staff's (SDS) ability to quickly identify errors in a MIS will certainly shorten the development cycle. Errors may be roughly divided into three types: specification errors, logical design errors, and programming language errors. We present procedures that are effective in the detection of many kinds of programming language errors. An example of an implementation of these procedures is demonstrated for a MUMPS multiuser system (Tandem NonStop System).
Valiani, Mahboubeh; Majidi, Jamileh; Beigi, Marjan
Committing an error is part of the human nature. No health care provider, despite the mastery of their skills, is immune from committing it. Medical error in the labor and obstetrics wards as well as other health units is inevitable and reduces the quality of health care, leading to accident. Sometimes these events, like the death of mother, fetus, and newborn, would be beyond repair. The purpose of this study was to investigate the perspective of gynecological ward providers about medical errors. This was a descriptive-analytical study. Sample size was 94 participants selected using census sampling. The study population included all midwives of four hospitals (Al-Zahra, Beheshti, Isa Ben Maryam, and Amin). Data were collected by a self-administered questionnaire and analyzed using SPSS software. This study shows that three factors (human, structural, and managerial) have affected medical errors in the labor and obstetrics wards. From the midwifery perspective, human factors were the most important factors with an average score of 73.26% and the lowest score was related to structural factors with an average score of 65.36%. Intervention strategies to reduce errors, service training program tailored to the needs of the service provider, distribution of the tasks at different levels, and attempts to reform the system instead of punishing the wrongdoer were set in priority list. Based on the results of this study on the perspectives of participants, among the three factors of medical errors (human factors, structural factors, and management factors), human factors are the biggest threat in committing medical errors. Modification in the pattern of teaching by the midwifery professors and their presence in the hospitals, creating a no-blame culture, and sharing of alerts in medical errors are among appropriate actions in the dimensions of human, structural, and managerial factors.
van der Veen, Willem; van den Bemt, Patricia Mla; Bijlsma, Maarten; de Gier, Han J; Taxis, Katja
BACKGROUND: Information technology-based methods such as bar code-assisted medication administration (BCMA) systems have the potential to reduce medication administration errors (MAEs) in hospitalized patients. In practice, however, systems are often not used as intended, leading to workarounds.
Bourne, Richard S; Shulman, Rob; Jennings, Jennifer K
Medication errors are the most common type of medical errors critical care patients experience. Critical care units utilise a variety of resources to reduce medication errors; it is unknown which resources or combinations thereof are most effective in improving medication safety. To obtain UK critical care pharmacist group consensus on the most important interventions/resources that reduce medication errors. To then classify units that participated in the PROTECTED UK study to investigate if there were significant differences in the reported pharmacist prescription intervention type, clinical impact and rates according to unit resource classification. An e-Delphi process (three rounds) obtained pharmacist consensus on which interventions/resources were most important in the reduction of medication errors in critical care patients. The 21 units involved in the PROTECTED UK study (multicentre study of UK critical care pharmacist medicines interventions), were categorised as high-, medium- and low-resource units based on routine delivery of the final Top 5 interventions/ resources. High and low units were compared according to type, clinical impact and rate of medication interventions reported during the PROTECTED UK study. Consensus on the Top 5 combined medication error reduction resources was established: advanced-level clinical pharmacist embedded in critical care being ranked most important. Pharmacists working on units with high resources made significantly more clinically significant medicines optimisations compared to those on low-resourced units (OR 3.09; P = 0.035). Critical care pharmacist group consensus on the most important medication error reduction resources was established. Pharmacists working on high-resourced units made more clinically significant medicines optimisations. © 2018 Royal Pharmaceutical Society.
María Antonieta Arbesú Michelena
Full Text Available El error es inherente a la conducta humana y se debe a la concatenación de múltiples factores o fallos vinculados a los procesos y a los fallos latentes relacionados con los procederes de trabajo, los medios tecnológicos, las condiciones laborales, entre otras. Los errores de medicación son frecuentes, por lo que en este trabajo se realizó una descripción de reportes bibliográficos actualizados nacionales e internacionales con definiciones relacionadas con la temática, que demostró la importancia y la gravedad del problema para la seguridad del sistema sanitario, pues su detección y accionar mediante variadas iniciativas podrían disminuir su ocurrencia, ya que se sabe que una gran cantidad de los errores de medicación son triviales y no causan daño al paciente, sin embargo, sí constituyen un indicador de baja calidad de la asistencia sanitaria y por tanto, un problema sanitario.Errors are inherent to human behavior and they result from the concatenation of multiple factors or failures linked with the latent processes and deficiencies related to working procedures, technological means, labor conditions, etc. As the medication errors are common, a description of national and international updated bibliographic reports with definitions connected with this topic was made to show the importance and seriousness of the problem for the safety of the health system, since their detection and action by various initiatives could reduce their occurrence. It is known that a lot of errors are trivial and that they do not damage the patient; however, they are an indicator of low quality health care and, therefore, a health problem.
Sandars, John; Esmail, Aneez
The identification and reduction of medical error has become a major priority for all health care providers, including primary care. Understanding the frequency and nature of medical error in primary care is a first step in developing a policy to reduce harm and improve patient safety. There has been scant research into this area. This review had two objectives; first, to identify the frequency and nature of error in primary care, and, secondly, to consider the possible causes for the diversity in the stated rates and nature of error in primary care. Literature searches of English language studies identified in the National Patient Safety Foundation bibliography database, in Medline and in Embase were carried out. Studies that were relevant to the purpose of the study were included. Additional information was obtained from a specialist medico-legal database. Studies identified that medical error occurs between five and 80 times per 100000 consultations, mainly related to the processes involved in diagnosis and treatment. Prescribing and prescription errors have been identified to occur in up to 11% of all prescriptions, mainly related to errors in dose. There are a wide variety of definitions and methods used to identify the frequency and nature of medical error. Incident reporting, systematic identification and medico-legal databases reveal differing aspects, and there are additional perspectives obtained from GPs, primary health care workers and patients. An understanding of the true frequency and nature of medical error is complicated by the different definitions and methods used in the studies. Further research is warranted to understand the complex nature and causes of such errors that occur in primary care so that appropriate policy decisions to improve patient safety can be made.
Rishoej, Rikke Mie; Hallas, Jesper; Juel Kjeldsen, Lene; Thybo Christesen, Henrik; Almarsdóttir, Anna Birna
Hospitalized children are at risk of medication errors (MEs) due to complex dosage calculations and preparations. Incident reporting systems may facilitate prevention of MEs but underreporting potentially undermines this system. We aimed to examine whether scenarios involving medications should be reported to a national mandatory incident reporting system and the likelihood of self- and peer-reporting these scenarios among paediatric nurses and physicians. Participants' reporting of MEs was explored through a questionnaire involving 20 medication scenarios. The scenarios represented different steps in the medication process, types of error, patient outcomes and medications. Reporting rates and odds ratios with 95% confidence interval [OR, (95% CI)] were calculated. Barriers to and enablers of reporting were identified through content analysis of participants' comments. The response rate was 42% (291/689). Overall, 61% of participants reported that scenarios should be reported. The likelihood of reporting was 60% for self-reporting and 37% for peer-reporting. Nurses versus physicians, and healthcare professionals with versus without patient safety responsibilities assessed to a larger extent that the scenarios should be reported [OR = 1.34 (1.05-1.70) and OR = 1.41 (1.12-1.78), respectively]; were more likely to self-report, [OR = 2.81 (1.71-4.62) and OR = 2.93 (1.47-5.84), respectively]; and were more likely to peer-report [OR = 1.89 (1.36-2.63) and OR = 3.61 (2.57-5.06), respectively].Healthcare professionals with versus without management responsibilities were more likely to peer-report [OR = 5.16 (3.44-7.72)]. Participants reported that scenarios resulting in actual injury or incidents considered to have a learning potential should be reported. The likelihood of underreporting scenarios was high among paediatric nurses and physicians. Nurses and staff with patient safety responsibilities were more likely to assess that scenarios should be reported and to report
Dollinger, Cecile; Schwiertz, Vérane; Sarfati, Laura; Gourc-Berthod, Chloé; Guédat, Marie-Gabrielle; Alloux, Céline; Vantard, Nicolas; Gauthier, Noémie; He, Sophie; Kiouris, Elena; Caffin, Anne-Gaelle; Bernard, Delphine; Ranchon, Florence; Rioufol, Catherine
To assess the impact of investigational drug labels on the risk of medication error in drug dispensing. A simulation-based learning program focusing on investigational drug dispensing was conducted. The study was undertaken in an Investigational Drugs Dispensing Unit of a University Hospital of Lyon, France. Sixty-three pharmacy workers (pharmacists, residents, technicians or students) were enrolled. Ten risk factors were selected concerning label information or the risk of confusion with another clinical trial. Each risk factor was scored independently out of 5: the higher the score, the greater the risk of error. From 400 labels analyzed, two groups were selected for the dispensing simulation: 27 labels with high risk (score ≥3) and 27 with low risk (score ≤2). Each question in the learning program was displayed as a simulated clinical trial prescription. Medication error was defined as at least one err