Designing an overview display for computer supported medication administration to reveal hidden dangers to patient safety

2004 ◽  
Author(s):  
Roger J. Chapman ◽  
Russell A. Carlson
2020 ◽  
Author(s):  
Bintang Marsondang Rambe

Latar Belakang Keselamatan pasien (patient safety) rumah sakit adalah suatu sistem dimana rumah sakit membuat asuhan pasien lebih aman yang meliputi assessment risiko, identifikasi dan pengelolaan hal yang berhubungan dengan risiko pasien, pelaporan dan analisis insiden, kemampuan belajar dari insiden dan tindak lanjutnya serta implementasi solusi untuk meminimalkan timbulnya risiko dan mencegah terjadinya cedera yang disebabkan oleh kesalahan akibat melaksanakan suatu tindakan atau tidak mengambil tindakan yang seharusnya diambil yang dilakukan oleh perawat (Kemenkes, 2011).Salah satu kesalahan yang dapat merugikan pasien adalah medication error. Menurut WHO (2016) medication error adalah setiap kejadian yang dapat dicegah yang menyebabkan penggunaan obat yang tidak tepat yang menyebabkan bahaya kepasien, dimana obat berada dalam kendali profesional perawatan kesehatan. proses terjadi medication error dimulai dari tahap prescribing, transcribing, dispensing,dan administration. Kesalahan peresepan (prescribing error), kesalahan penerjemahan resep (transcribing erorr), kesalahan menyiapkan dan meracik obat (dispensing erorr), dan kesalahan penyerahan obat kepada pasien (administration error). Medication error yang paling sering terjadi adalah pada fase administration / pemberian obat yang dilakukan oleh perawat.Administration error terjadi ketika pemberian obat kepada pasien tidak sesuai dengan prinsip enam benar yaitu benar obat, benar pasien, benar dosis, benar rute pemberian, benar waktu pemberian dan benar pendokumentasian. Secara global, kesalahan pemberian obat (medication errors) sampai saat ini masih menjadi isu keselamatan pasien dan kualitas pelayanan di beberapa rumah sakit (Depkes RI, 2015; AHRQ, 2015). Perawat sebagai bagian terbesar dari tenaga kesehatan di rumah sakit, mempunyai peranan dalam kejadian medication error. Perawat berkontribusi karena perawat banyak berperan dalam proses pemberian obat. Pemberian obat/ Medication Administration adalah salah satu intervensi keperawatan yang paling banyak dilakukan, dengan sekitar 5- 20% waktu perawat dialokasikan untuk kegiatan ini (Härkänen et al.,, 2019). Pemberian obat juga mencakup tugas-tugas lain, seperti menyiapkan dan memeriksa obat obatan, memantau efek obat-obatan, mengedukasi pasien tentang pengobatan, dan memperdalam pengetahuan perawat tentang obat – obatan sendiri (DrachZahavy et al., 2014 dalam Yulianti et al., 2019)Berdasarkan isu tersebut, penulis tertarik untuk melakukan literature review terkait faktor perawat dalam pelaksanakan keselamatan pasien terhadap kejadian medication administration error di Rumah Sakit.


Author(s):  
N Vicente Oliveros ◽  
T Gramage Caro ◽  
C Pérez Menendez-Conde ◽  
AMAlvarez Díaz ◽  
T Bermejo Vicedo ◽  
...  

2018 ◽  
Vol 24 (2) ◽  
pp. 116-123 ◽  
Author(s):  
Raymond L. Bonds

Current evidence reveals that surgical patients are more prone to adverse events when compared to any other population in the acute care setting. In a military training hospital, handoff communication between surgical intensive care unit (SICU) nurses, physicians, and anesthesia providers (certified registered nurse anesthetists and anesthesiologists) about patients being prepared for surgery was identified as a problem by an initial inquiry of the staff. This article discusses an evidence-based project (EBP) that utilized a standardized multidisciplinary Situation, Background, Assessment, Recommendation (SBAR) tool to improve communication, teamwork, and the perception of a patient safety culture between the SICU nurses and physicians and the anesthesia providers in preparation for surgery. The SICU and anesthesia departments received training on the SBAR tool, followed by a 7-week implementation period. Standardized handoff communication utilizing the SBAR method increased by 100%, and documentation of intraoperative antibiotics on the electronic medication administration record increased by 43%. Postimplementation results from the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture surpassed database benchmarks for handoffs and transitions, overall perception of patient safety culture, and teamwork across units. This project reinforced current evidence supporting the use of standardized handoff communication.


2017 ◽  
Vol 23 (4) ◽  
pp. 888-894 ◽  
Author(s):  
Noelia Vicente Oliveros ◽  
Teresa Gramage Caro ◽  
Covadonga Pérez Menendez-Conde ◽  
Ana María Álvarez-Díaz ◽  
Sagrario Martín-Aragón Álvarez ◽  
...  

2020 ◽  
Vol 8 (12) ◽  
Author(s):  
Eceberil Ozturk ◽  
Ilker Kose ◽  
Beytiye Elmas

Medication management in inpatient facilities is a crucial issue for patient safety. In inpatient conventional drug management, a common problem relates to drugs prescribed and delivered to patients being returned to the pharmacy without reason for the return. When reasons are given, they are not often regularly and correctly recorded. Closed Loop Medication Administration (CLMA) protects patient safety by managing all processes, including intake of the drug to the hospital's stock, administering the drug to the patient, and disposal of unused drugs using technology. CLMA is known to contribute positively to patient safety. However, there is no study on the effect of CLMA on the return of non-administered drugs. This study aims to analyze the effect of CLMA on drug return rates and investigate the data quality of reasons for drug returns. The research was carried out in three inpatient clinics of a Turkish state hospital (Bolu İzzet Baysal Public Hospital) where the CLMA was implemented in May of 2017. The data set obtained from the hospital information system (HIS) is anonymized. The study showed a significant increase in drug return rates after CLMA, and the data quality of drug return reasons is also significantly improved. These results show that CLMA contributes positively to drug return rates and the data quality of drug return reason records.


Author(s):  
Seham Sahal Aloufi

Patient safety is considered as an essential feature of healthcare system. Many trials have been conducted in order to find ways to improve patient safety, and many reports indicate that medication errors pose a threat to patient safety. Thus, some studies have investigated the impact of bar code medication administration (BCMA) system on medication error reduction during the medication administration procedure. This systematic review (SR) reports the impact of BCMA system on reducing medication errors to improve patient safety; it also compares traditional medication administration with the BCMA system. The review concentrates on the effectiveness of BCMA technology on medication administration errors, and on the accuracy of medication administration. This review also focused on different designs of quantitative studies, as they are more effective at investigating the impact of the intervention than qualitative studies. The findings from this systematic review show various results depending on the nature of the hospital setting. Most of the studies agree that the BCMA system enhances compliance with the 'five rights’' requirement (right drug, right patient, right dose, right time and right route) of medication administration. In addition, BCMA technology identified medication error types that could not be identified with the traditional approach which is applying the 'five rights' of medication administration. The findings of this systematic review also confirm the impact of BCMA system in reducing medication error, preventing adverse events and increasing the accuracy of the medication administration rate. However, BCMA technology did not consistently reduce the overall errors of medication administration. Keyword: Patient Safety, Impact, BCMA, eMAR


2011 ◽  
Vol 02 (02) ◽  
pp. 202-224 ◽  
Author(s):  
S. Iribarren ◽  
S. Kapsandoy ◽  
S. Perri ◽  
N. Staggers ◽  
J. Guo

SummaryBackground: Electronic medication administration records (eMARs) have been widely used in recent years. However, formal usability evaluations are not yet available for these vendor applications, especially from the perspective of nurses, the largest group of eMAR users.Objective: To conduct a formal usability evaluation of an implemented eMAR.Methods: Four evaluators examined a commercial vendor eMAR using heuristic evaluation techniques. The evaluators defined seven tasks typical of eMAR use and independently evaluated the application. Consensus techniques were used to obtain 100% agreement of identified usability problems and severity ratings. Findings were reviewed with 5 clinical staff nurses and the Director of Clinical Informatics who verified findings with a small group of clinical nurses.Results: Evaluators found 60 usability problems categorized into 233 heuristic violations. Match, Error, and Visibility heuristics were the most frequently violated. Administer Medication and Order and Modify Medications tasks had the highest number of heuristic violations and usability problems rated as major or catastrophic.Conclusion: The high number of usability problems could impact the effectiveness, efficiency and satisfaction of nurses’ medication administration activities and may include concerns about patient safety. Usability is a joint responsibility between sites and vendors. We offer a call to action for usability evaluations at all sites and eMAR application redesign as necessary to improve the user experience and promote patient safety.


2010 ◽  
Vol 55 (5) ◽  
pp. 366-367
Author(s):  
Jonathon R. B. Halbesleben ◽  
Grant T. Savage ◽  
Douglas S. Wakefield ◽  
Bonnie J. Wakefield

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