An Overview of Intravenous-related Medication Administration Errors as Reported to MEDMARX®, a National Medication Error-reporting Program

2006 ◽  
Vol 29 (1) ◽  
pp. 20-27 ◽  
Author(s):  
Rodney W. Hicks ◽  
Shawn C. Becker
Keyword(s):  
Medication Error ◽  
Medication Administration ◽  
Error Reporting ◽  
Medication Error Reporting ◽  
Medication Administration Errors

scholarly journals Improving patient safety through identifying barriers to reporting medication errors among nurses: an integrative review

2021 ◽  
Author(s):  
Agani Afaya ◽  
Kennedy Diema Konlan ◽  
Hyunok Kim Do
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Feedback System ◽  
Medication Administration ◽  
Integrative Review ◽  
Error Reporting ◽  
Medication Error Reporting ◽  
Inadequate Knowledge ◽  
Uniform Definition ◽  
Definition Of

Abstract Background: The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the next five years. To achieve this goal, comprehensive identification of barriers to reporting medication errors is imperative.Objective: This review aimed to identify studies that investigated barriers to reporting medication administration errors among nurses, systematically summarize the findings to make recommendations for improving error reporting, and for future investigation.Design: An integrative review Review methods: PubMed, Web of Science, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) including Google scholar were searched to identify published studies on barriers to medication error reporting from January 2016 to December 2020. The reviewers independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018.Results: Of the 10937 articles reviewed, 14 studies were included. The main themes and subthemes identified after the integration of results from qualitative and quantitative studies were; organizational barriers (inadequate reporting systems, management behavior, and unclear definition of medication error), and professional and individual barriers (fear of management/colleagues/lawsuit, individual reasons and inadequate knowledge of errors).Conclusion: It is not expected that nurses will freely report medication errors in a fearful, punitive, and blaming culture. Providing an enabling environment void of punitive measures and blame culture is imperative for nurses to report medication errors. To minimize the burden on nurses reporting medication errors, an effective, non-time consuming, and uncomplicated anonymous system is required. An open feedback system for motivating or rewarding nurses for reporting medication errors is imperative and will therefore increase the rate of error reporting. Policymakers, managers, and nurses should agree on a uniform definition of what constitutes medication error to enhance nurses' ability to report.

scholarly journals Kesalahan Penggunaan Obat Ibu dan Balita Peserta Posyandu di Kecamatan Sukolilo, Surabaya

2017 ◽  
Vol 1 (1) ◽  
pp. 35-44
Author(s):  
Anita Purnamayanti ◽  
Agnes Nuniek Winantari ◽  
Nani Parfati ◽  
Ida Diana ◽  
Nurul Latifah ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Administration ◽  
Error Reporting ◽  
Medication Administration Error ◽  
Medication Error Reporting ◽  
Administration Error

Kesalahan penggunaan obat (Medication Administration Error, MAE) pada ibu hamil dan anak merupakanjenis kesalahan penggunaan obat yang lazim dijumpai di komunitas. Orang tua berperan pentingdalampemberian obat bagi anak, terutama pada balita. Pos Pelayanan Terpadu (Posyandu) di Indonesia merupakanUpaya Kesehatan Berbasis Masyarakat (UKBM) yang secara terpadu meningkatkan kesehatan ibu dan balita,yang bertujuan untuk mengatasi ketimpangan akses terhadap fasilitas pelayanan kesehatan maupun terhadaptenaga kesehatan. Penelitian observasional yang dilaksanakan di Posyandu di Kecamatan Sukolilo secara prospektifini dirancang untuk mengkaji kesalahan penggunaan obat yang mungkin terjadi di masyarakat. Sukolilomerupakan Kecamatan yang unik, karena keragaman di bidang sosioekonomi, maupun kemampuan masyarakatnyauntuk mengakses tenaga kesehatan dan fasilitas pelayanan kesehatan. Penelitian ini berlangsung selamabulan Januari sampai Mei 2013, dengan metode wawancara penggunaan obat oleh ibu hamil dan orang tua untukanak balitanya. Hasil penelitian dikelompokkan berdasarkan algoritma dan diagram National CoordinatingCouncil for Medication Error Reporting and Prevention. Terdapat MAE pada penggunaan obat ibu hamil dan balita.Jenis kesalahan penggunaan obat yang tersering adalah “Terjadi kesalahan, tidak membahayakan” kategori“B”, “C”, dan “D”. Selain itu, “Terjadi kesalahan, Membahayakan” kategori “E” dan “F” juga terdapat, namun tidakada “Terjadi Kesalahan, Mematikan”. Jenis MAE tersering adalah “obat tidak diberikan”, dan “dosis dan frekuensiobat tidak tepat”, terutama pada penggunaan antibiotik. Kesalahan ini dapat dicegah melalui pemberian edukasikepada orang tua untuk meningkatkan pemahaman mengenai cara penggunaan obat.

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy

2021 ◽  
pp. 107815522199431
Author(s):  
Jennifer P Booth ◽  
Julie M Kennerly-Shah ◽  
Amber D Hartman
Keyword(s):  
Cancer Therapy ◽  
Medication Error ◽  
Retrospective Analysis ◽  
Error Reporting ◽  
Single Center ◽  
Medication Error Reporting ◽  
Anti Cancer ◽  
Secondary Endpoints ◽  
Type Frequency

Introduction To describe pharmacist interventions as a result of an independent double check during cognitive order verification of outpatient parenteral anti-cancer therapy. Methods A single-center, retrospective analysis of all individual orders for outpatient, parenteral anti-cancer agents within a hematology/oncology infusion center during a 30 day period was conducted. The primary endpoint was error identification rates during first and second verification. Secondary endpoints included the type, frequency, and severity of errors identified during second verification using a modified National Coordinating Council for Medication Error Reporting and Prevention Index. Results A total of 1970 anti-cancer parenteral orders were screened, from which 1645 received an independent double check and were included. The number of errors identified during first and second verification were 30 (1.8%) and 10 (0.6%) respectively; second verification resulted in a 33.3% increase in corrected errors. The 10 errors identified during second verification included: four rate transcriptions to optimize pump interoperability, three rate and/or volume modifications, two dosage adjustments, and one treatment deferral due to toxicity. The severity was classified as Category A for four (40%), Category C for three (30%), and Category D for three (30%) errors. This correlated to a low capacity for harm for seven (70%) and a serious capacity for three (30%) errors. Conclusions Second verification of outpatient, parenteral anti-cancer medication orders resulted in a 33.3% increase in corrected errors. Three errors detected during second verification were determined to have a serious capacity for harm, supporting the value of independent double checks during pharmacist cognitive order verification.

Medication Error Reduction: The Pharmacy Technician's Role

1998 ◽  
Vol 14 (2) ◽  
pp. 70-77 ◽  
Author(s):  
Eddie B Dunn ◽  
Jonathan J Wolfe
Keyword(s):  
Public Health ◽  
Medication Error ◽  
Error Reduction ◽  
Error Reporting ◽  
Health Issue ◽  
Public Health Issue ◽  
Pharmacy Technician ◽  
Medication Error Reporting ◽  
The Us ◽  
Coordinating Council

This article presents medication error reduction as a public health issue relevant to the pharmacy technician. The chief types of errors are presented, and opportunities for technicians to identify errors and factors that promote errors are described. The article then discusses the importance of medication error reporting by technicians. Emphasis is placed on the necessity of examining the reason why errors occur rather than assigning blame. The US Pharmacopeia Practitioners' Reporting Network is described in detail, along with the newer National Coordinating Council for Medication Error Reporting and Prevention.

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