scholarly journals What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Carita Linden-Lahti ◽  
Anna Takala ◽  
Anna-Riia Holmström ◽  
Marja Airaksinen
Keyword(s):  
Health Care ◽  
Medication Errors ◽  
Medication Safety ◽  
Supervisory Authority

Look-Alike Names and Packages Are at the Root of Most Stocking Errors in Automated Dispensing Cabinets Use Caution when Reconstituting Synagis (Palivizumab) Intrathecal Vincristine Fatal Once More Fellowship in Medication Safety Medication Safety Videos Available Free via the Internet

2003 ◽  
Vol 38 (4) ◽  
pp. 312-313
Author(s):  
Michael R. Cohen
Keyword(s):  
Health Care ◽  
Medication Errors ◽  
Medication Safety ◽  
Training Programs ◽  
Health Care Facilities ◽  
Inservice Training ◽  
The Internet ◽  
Safe Medication ◽  
Care Facilities ◽  
Procedural Safeguards

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

scholarly journals Medication safety for children with medical complexity

2020 ◽  
Vol 25 (7) ◽  
pp. 473-473
Author(s):  
Kathleen Huth ◽  
Patricia Vandecruys ◽  
Julia Orkin ◽  
Hema Patel
Keyword(s):  
Health Care ◽  
Medication Errors ◽  
Health Care Professionals ◽  
Chronic Conditions ◽  
Medication Safety ◽  
Care Utilization ◽  
Children With Medical Complexity ◽  
Technology Dependence ◽  
Medical Complexity ◽  
Care Fragmentation

Abstract Due to advances in medical care and innovations in health technology, many children with life-limiting conditions are now living longer. These children are often referred to as ‘children with medical complexity (CMC)’, and they are characterized by chronic conditions, increased health care utilization, and technology dependence. Their complexity of care and inherent fragility lead to higher risk for medication errors, both in-community and in-hospital. High rates of care fragmentation, miscommunication, and polypharmacy in CMC increase opportunities for error, particularly as children transition between health care settings and practitioners. Data on the factors contributing to higher risk of medication errors in this population and how they can be effectively addressed are lacking. This practice point provides clinical guidance for health care professionals to ensure medication safety when caring for CMC, with focus on practical strategies for outpatient and inpatient care.

Infodemiological patterns in searching medication errors: relationship with risk management and shift work (Preprint)

2019 ◽  
Author(s):  
Fabio Fabbian ◽  
Emanuele Di Simone ◽  
Sara Dionisi ◽  
Noemi Giannetta ◽  
Luigi De Gennaro ◽  
...  
Keyword(s):  
Health Care ◽  
Risk Management ◽  
Shift Work ◽  
Medication Errors ◽  
Medical Errors ◽  
World Health ◽  
Noncommunicable Diseases ◽  
Western World ◽  
The World ◽  
Google Search

BACKGROUND Western world health care systems have been trying to improve their efficiency and effectiveness in order to respond properly to the aging of the population and the epidemic of noncommunicable diseases. Errors in drugs administration is an actual important issue due to different causes. OBJECTIVE Aim of this study is to measure interest in online seeking medical errors information online related to interest in risk management and shift work. METHODS We investigated Google Trends® for popular search relating to medical errors, risk management and shift work. Relative search volumes (RSVs) were evaluated for the period November 2008-November 2018 all around the world. A comparison between RSV curves related to medical errors, risk management and shift work was carried out. Then we compared world to Italian search. RESULTS RSVs were persistently higher for risk management than for medication errors during the study period (mean RSVs 74 vs. 51%) and RSVs were stably higher for medical errors than shift work during the study period (mean RSVs 51 vs 23%). In Italy, RSVs were much lower than the rest of the world, and RSVs for medication errors during the study period were negligible. Mean RSVs for risk management and shift work were 3 and 25%, respectively. RSVs related to medication errors and clinical risk management were correlated (r=0.520, p<0.0001). CONCLUSIONS Google search query volumes related to medication errors, risk management and shift work are different. RSVs for risk management are higher, are correlated with medication errors, and the relationship with shift work appears to be even worse, by analyzing the entire world. In Italy such a relationship completely disappears, suggesting that it needs to be emphasized by health care authorities.

Clinicians Often Unaware of Colchicine Dose Limits; What is a “Bolus?”; Drug Information Leaflets can Help Prevent Errors

2002 ◽  
Vol 37 (4) ◽  
pp. 355-356
Author(s):  
Michael R. Cohen
Keyword(s):  
Health Care ◽  
Medication Errors ◽  
Training Programs ◽  
Drug Information ◽  
Health Care Facilities ◽  
Inservice Training ◽  
Safe Medication ◽  
Information Leaflets ◽  
Care Facilities ◽  
Dose Limits

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

scholarly journals Pictograms for Safer Medication Management by Health Care Workers

2016 ◽  
Vol 69 (4) ◽  
Author(s):  
Régis Vaillancourt ◽  
Annie Pouliot ◽  
Kim Streitenberger ◽  
Sylvia Hyland ◽  
Pierre Thabet
Keyword(s):  
Health Care ◽  
Medication Safety ◽  
Medication Management ◽  
Medication Administration ◽  
Delphi Process ◽  
Semiotic Analysis ◽  
Safety Issues ◽  
Personnel Infirmier ◽  
Nurses And Physicians ◽  
Pharmacy Technicians

<p><strong>ABSTRACT</strong></p><p><strong>Background:</strong> Inherent risks are associated with the preparation and administration of medications. As such, a key aspect of medication safety is to ensure safe medication management practices.</p><p><strong>Objective:</strong> To identify key medication safety issues and high-alert drug classes that might benefit from implementation of pictograms, for use by health care providers, to enhance medication administration safety. This study was the first step in the development of such pictograms.</p><p><strong>Methods:</strong> Self-identified medication management experts participated in a modified Delphi process to achieve consensus on situations where safety pictograms are required for labelling to optimize safe medication management. The study was divided into 3 phases: issue generation, issue reduction, and issue selection. Issues achieving at least 80% consensus and deemed most essential were selected for future studies. Retained issues were subjected to semiotic analysis, and preliminary pictograms were developed.</p><p><strong>Results:</strong> Of the 87 health care professionals (pharmacists, pharmacy technicians, nurses, and physicians) invited to participate in the Delphi process, 30 participated in all 3 phases. A total of 55 situations that could potentially benefit from safety pictograms were generated initially. Through the Delphi process, these were narrowed down to 10 situations where medication safety might be increased with the use of safety pictograms. For most of the retained issues, between 3 and 6 pictograms were designed, based on the results of the semiotic analysis.</p><p><strong>Conclusions:</strong> The pharmacists, pharmacy technicians, nurses, and physicians participating in this study reached consensus and identified 10 medication administration safety issues that might benefit from the development and implementation of safety pictograms. Pictograms were developed for a total of 9 issues. In follow-up studies, these pictograms will be validated for comprehension and evaluated for effectiveness.</p><p><strong>RÉSUMÉ</strong></p><p><strong>Contexte :</strong> Il y a des risques inhérents associés à la préparation et à l’administration de médicaments. Pour cette raison, l’un des principaux aspects de la sécurité des médicaments est d’assurer des pratiques de gestion des médicaments sécuritaires.</p><p><strong>Objectif :</strong> Déterminer les principales questions de sécurité des médicaments et les classes de médicaments de niveau d’alerte élevé pour lesquelles l’ajout de pictogrammes, destinés aux fournisseurs de soins de santé, permettrait de rendre l’administration de médicaments plus sécuritaire. La présente étude représentait la première étape dans l’élaboration de ces pictogrammes.</p><p><strong>Méthodes :</strong> Des professionnels qui se définissaient comme experts en gestion de médicaments ont participé à un processus Delphi modifié dans le but d’arriver à un consensus à propos des situations où des pictogrammes de sécurité doivent être ajoutés à l’étiquette afin d’optimiser la gestion sécuritaire des médicaments. L’étude a été divisée en trois phases : génération de questions de sécurité, élimination de questions de sécurité et sélection de questions de sécurité. Les questions qui atteignaient un consensus d’au moins 80 % et qui étaient considérées comme les plus essentielles ont été retenues pour des études ultérieures. Les questions de sécurité retenues ont été soumises à une analyse sémiotique, puis des ébauches de pictogrammes ont été créées.</p><p><strong>Résultats :</strong> Parmi les 87 professionnels de la santé (notamment des pharmaciens, des techniciens en pharmacie, du personnel infirmier et des médecins) invités à participer au processus Delphi, 30 ont pris part aux trois étapes. Au total, 55 situations pour lesquelles il pourrait être avantageux d’utiliser des pictogrammes de sécurité ont été générées au départ. Grâce au processus Delphi, ce nombre a été réduit à 10 situations pour lesquelles la sécurité des médicaments pourrait être accrue à l’aide de pictogrammes de sécurité. Pour la plupart des questions retenues, entre trois et six pictogrammes ont été conçus à l’aide des résultats de l’analyse sémiotique.</p><p><strong>Conclusion :</strong> Les pharmaciens, les techniciens en pharmacie, le personnel infirmier et les médecins qui ont participé à l’étude ont atteint un consensus sur dix questions au sujet de l’administration sécuritaire des médicaments pour lesquelles l’élaboration et la mise en place de pictogrammes de sécurité pourraient être avantageuses. Ensuite, des pictogrammes ont été conçus pour neuf questions au total. Dans les études ultérieures, il faudra évaluer l’efficacité des pictogrammes et s’assurer qu’ils sont interprétés correctement.</p>

scholarly journals Non-health Care Facility Medication Errors Associated with Hormones and Hormone Antagonists in the United States

2017 ◽  
Vol 13 (4) ◽  
pp. 293-302
Author(s):  
Pranav Magal ◽  
Henry A. Spiller ◽  
Marcel J. Casavant ◽  
Thitphalak Chounthirath ◽  
Nichole L. Hodges ◽  
...  
Keyword(s):  
United States ◽  
Health Care ◽  
Medication Errors ◽  
Care Facility ◽  
Health Care Facility ◽  
The United States ◽  
Hormone Antagonists

Improving Medication Safety Through the Use of Metrics

2013 ◽  
Vol 27 (1) ◽  
pp. 61-64
Author(s):  
Robert D. Beckett ◽  
Marina Yazdi ◽  
Laura J. Hanson ◽  
Ross W. Thompson
Keyword(s):  
Medication Errors ◽  
Medication Safety ◽  
Adverse Drug Events ◽  
Safety Information ◽  
Medication Use ◽  
Cross Sectional Study ◽  
Survey Instrument ◽  
Sectional Study ◽  
Cross Sectional ◽  
Safety Metrics

Purpose: Describe medication safety metrics used at University HealthSystem Consortium (UHC) institutions and recommend a meaningful way to report and communicate medication safety information across an organization. Methods: A cross-sectional study was conducted using an electronically distributed, open-ended survey instrument. Results: Twenty percent of the UHC institutions responded to our survey. Seventy-seven percent of those institutions responding to our survey reported their organization has defined metrics to measure medication safety; an additional 21% of the institutions were still in the process of defining metrics. Of metrics that were reported, 33% were true medication safety metrics. Results are distributed to a wide variety of institutional venues. Conclusion: Institutions should take several actions related to medication safety including defining local metrics; building metrics addressing preventable adverse drug events, medication errors, and technology; and reporting results to a variety of venues in order to design specific interventions to improve local medication use.

scholarly journals Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 2

2020 ◽  
Vol 67 (1) ◽  
pp. 48-59
Author(s):  
Daniel S. Sarasin ◽  
Jason W. Brady ◽  
Roy L. Stevens
Keyword(s):  
General Anesthesia ◽  
Medication Errors ◽  
Medication Safety ◽  
Adverse Drug Events ◽  
Contributing Factors ◽  
Full Spectrum ◽  
Dental Profession ◽  
Novel Method ◽  
Dental Providers ◽  
Preventive Methods

For decades, the dental profession has provided the full spectrum of anesthesia services ranging from local anesthesia to general anesthesia in the office-based ambulatory environment to alleviate pain and anxiety. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article illuminated the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medical anesthesia has implemented to manage such problems that may have utility in dentistry, and introduce a novel method for addressing these issues within dentistry known as the Dental Anesthesia Medication Safety Paradigm (DAMSP).

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