Reporting frequency of three near-miss error types among hospital pharmacists and associations with hospital pharmacists’ perceptions of their work environment

2021 ◽  
Vol 17 (2) ◽  
pp. 381-387
Author(s):  
Marwa Noureldin ◽  
Maryam A. Noureldin
Pharmacy ◽  
2019 ◽  
Vol 7 (1) ◽  
pp. 7 ◽  
Author(s):  
Kimberly Galt ◽  
Kevin Fuji ◽  
Ted Kaufman ◽  
Shweta Shah

This study aimed to describe the impact of 13 different health information technologies (HITs) on patient safety across pharmacy practice settings from the viewpoint of the working pharmacist. A cross-sectional mixed methods survey of all licensed practicing pharmacists in 2008 in Nebraska (n = 2195) was developed, pilot-tested and IRB approved. One-fourth responded (24.4%). A database of pharmacists’ responses to closed-ended quantitative questions and in vivo qualitative responses to open-ended questions was built. Qualitative data was coded and thematically analyzed, transformed to quantitative data and descriptive and relational statistics performed. One-third were involved in an error of any kind in the six months preceding the survey, and half observed an error or “near miss”. Most errors or near misses were attributed to workload. When asked specifically about the 13 HITs, these participants reported 3252 observations about the types of errors that were associated with each. These were reports about either error types reduced or eliminated by integration of HIT (n = 1908) or occurring in association with a specific technology’s use (n = 1344). Integration of HIT into pharmacy practice also introduced new error types such as excessive alert programming in the pharmacy computer systems clinical information support causing pharmacists to experience alert fatigue and ignore warnings or bar code scanners mismatching NDC codes of products resulting in wrong drug product identification. Continued vigilance is essential to identifying patient safety issues and implementing safety strategies specific to each HIT.


2020 ◽  
Vol 8 (E) ◽  
pp. 209-212
Author(s):  
Amjad Al-Harkan ◽  
Njood Al-Harkan ◽  
Amal Al-Najjar ◽  
Alaa Al-Hunti ◽  
Ahmed Al-Rashidi ◽  
...  

BACKGROUND: Medication errors (MEs) have been defined as “any preventable event that may cause or lead to inappropriate medication or patient harm when the medication is in the control of the health care professional, patient, or consumer.” AIM: The aim of this study is to identify, analyze, and compare the common types of errors encountered in prescriptions, as well as the factors associated with the root causes of these errors, in a large tertiary hospital in the Qassim region of Saudi Arabia. METHODS: The design used is a retrospective cross-sectional analysis conducted in tertiary care hospitals in the Al-Qassim region of the Kingdom of Saudi Arabia. MEs were reported by nurses, pharmacist, and physicians through “hospital-based incident medication error reports” collected from January 2016 to December 2016. RESULTS: During the study period, 2123 MEs were reported for 213,489 prescriptions, of which 1282 (60.38%) were errors by a physician followed by nurses and then pharmacists. Analysis of the outcome of error types revealed that error types B and C were the most common, with only few type A errors identified (0.14%). The most common type of error was incomplete data (34.27%) followed by prescription in illegible handwriting (14.88%). The least common ME was prescription of the wrong strength (0.17%). CONCLUSION: This study revealed multiple prescription errors across 213,489 prescriptions, most commonly originating with physicians. The incidence of serious errors was low at 0.14%, and the major outcome of prescription errors was “Near miss.” “Incomplete data” and “Illegible handwriting” were the most common types of MEs detected. Despite the low number of MEs recorded during the study period, some of the errors were indeed serious. Based on the findings of this study, policy-makers should consider strategies for increasing efficiency in the hospital setting.


2019 ◽  
Vol 8 (2) ◽  
pp. e000558
Author(s):  
Syed Umer Mohsin ◽  
Yahya Ibrahim ◽  
Diane Levine

BackgroundMedical student error reporting can potentially be increased through patient safety education, culture change and by teaching students how to report errors. There is scant literature on what kinds of errors students see during clinical rotations. The authors developed an intervention to better understand what kinds of errors students see and to train them to identify and report errors.MethodsA safety curriculum was delivered during the Medicine clerkship for the academic year 2015–2016. Prior to the workshop, students completed a preintervention survey to determine whether they had reported a clinical error. Subsequently, they participated in an educational workshop. Facilitated discussions about conditions contributing to errors, types of errors, prevention of errors and importance of reporting followed. Students were required to submit a simulated error report about an error they personally observed. An end-of-year survey was sent to students who participated in the curriculum to determine clinical error reporting frequency.ResultsStudents submitted 282 reports. Near miss errors were seen in 64% and adverse events in 36%. National Quality Forum serious events were reported in 14%, including one death. Recommendations to prevent similar events were weak (62%). Students correctly categorised 93% near miss, 88% adverse events, 67% diagnostic, 81% treatment and 78% preventative errors. On the preintervention survey, 8.5% stated they submitted an error report to their clinical site. On the end-of-year survey, 18% confirmed submitting a formal error report.ConclusionTraining students to recognise and report errors can be successfully integrated into a clinical clerkship and impact clinical error reporting.


2006 ◽  
Vol 19 (5) ◽  
pp. 306-312 ◽  
Author(s):  
Ann M. Kerschen ◽  
Edward P. Armstrong ◽  
Tara N. Hillman

Purpose: To determine whether staff, clinical, or integrated hospital pharmacists have greater job satisfaction and if sex, years worked as a pharmacist, or having children changes job satisfaction. Methods: A prospective study was performed by distributing a 63-item questionnaire to inpatient pharmacists working at 2 hospitals. Respondents mailed the completed questionnaires to the investigators. Results: Questionnaires were completed by 38 participants (mean age [SD]= 38.36 [10.97]). Fourteen (36.85%) participants who spent 0% to 40% of their time in clinical activities were categorized as staff, 10 (26.30%) who spent 41% to 60% of their time in clinical activities were integrated, and 14 (36.85%) who spent greater than 61% of their time in clinical activities were clinical pharmacists. All pharmacists reported mean satisfaction scores above 2.5, indicating that all were satisfied in their jobs. Differences were noted in the amount of satisfaction. For work environment and professional interaction, integrated pharmacists were more satisfied than staff (P < .05). For professional interaction and personal outlook, clinical pharmacists were more satisfied than staff (P < .05). Conclusion: Job satisfaction was directly related to the number of clinical activities performed. Integrated and clinical pharmacists were both more satisfied than staff pharmacists.


2006 ◽  
Author(s):  
Cheryl Cook-Auerbach ◽  
Sarah Croushler ◽  
Elizabeth Hagerman ◽  
Andree M. Schillesci

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