Analysis of Medication Error Reports

2004 ◽  
Author(s):  
Paul Whitney ◽  
Jonathan Young ◽  
John Santell ◽  
Rodney Hicks ◽  
Christian Posse ◽  
...  
Keyword(s):  
Data Analysis ◽  
Medication Error ◽  
Medication Errors ◽  
Free Text ◽  
Area Of Interest ◽  
Analysis Tools ◽  
Depth Analysis ◽  
Reporting Programs ◽  
Types Of Information ◽  
Error Reports

In medicine, as in many areas of research and society, 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 a corresponding lag in our abilities to analyze this mass of data, and traditional forms and expressions of statistical analysis do not allow researchers and practitioners 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 are approached as data comparisons, 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. Additionally, the “types” of information objects that can be the objects of data analysis have been extended to include text [8][9]. 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. USP conducts 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.

Anticoagulant medication errors in hospitals and primary care: a cross-sectional study

2018 ◽  
Vol 31 (5) ◽  
pp. 346-352 ◽  
Author(s):  
Albert R Dreijer ◽  
Jeroen Diepstraten ◽  
Vera E Bukkems ◽  
Peter G M Mol ◽  
Frank W G Leebeek ◽  
...  
Keyword(s):  
Human Factors ◽  
Medication Error ◽  
Medication Errors ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Cross Sectional ◽  
Medication Process ◽  
Before And After ◽  
Anticoagulant Medication ◽  
Error Reports

Abstract Objective To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase). Design A cross-sectional study. Setting Medication errors reported to the Central Medication incidents Registration reporting system. Participants Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR. Intervention N/A. Main outcome measure Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline. Results Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline. Conclusions Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.

scholarly journals Risk of Medication Errors With Infusion Pumps

2019 ◽  
pp. 61-69
Author(s):  
Matthew Taylor ◽  
Rebecca Jones
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Reporting System ◽  
Risk Mitigation ◽  
Infusion Pump ◽  
Free Text ◽  
Patient Harm ◽  
Infusion Pumps ◽  
Safety Reporting ◽  
Medication Process

The risk of medication errors with infusion pumps is well established, yet a better understanding is needed of the scenarios and factors associated with the errors. Our study explored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018. Our study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, we did find that 22% of events involved a high-alert medication. Our study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, we manually reviewed a free-text narrative field in each event report to better understand the nature of errors. For example, we found that a majority of wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.

scholarly journals Patterns of medication errors involving pediatric population reported to the French Medication Error Guichet

2021 ◽  
Vol 19 (2) ◽  
pp. 2360
Author(s):  
Christine Azar ◽  
Delphine Allué ◽  
Marie B. Valnet-Rabier ◽  
Laurent Chouchana ◽  
Fanny Rocher ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Pediatric Population ◽  
Hospital Setting ◽  
Community Setting ◽  
Blood Substitutes ◽  
Community Settings ◽  
Prevention Measures ◽  
Error Type ◽  
Error Reports

Background: Medication error is a global threat to patient safety, particularly in pediatrics. Yet, this issue remains understudied in this population, in both hospital and community settings. Objectives: To characterize medication errors involving pediatrics reported to the French Medication Error Guichet, and compare them with medication errors in adults, in each of the hospital and community settings. Methods: This was a retrospective secondary data analysis of medication errors reported throughout 2013-2017. Descriptive and multivariate analyses were performed to compare actual and potential medication error reports between pediatrics (aged <18 years) and adults (aged >18 and <60 years). Two subanalyses of actual medication errors with adverse drug reaction (ADR), and serious ADR were conducted. Results:  We analyzed 4,718 medication error reports. In pediatrics, both in hospital (n=791) and community (n=1,541) settings, antibacterials for systemic use (n=121, 15.7%; n=157, 10.4%, respectively) and wrong dose error type (n=391, 49.6%; n=549, 35.7%, respectively) were frequently reported in medication errors. These characteristics were also significantly more likely to be associated with reported errors in pediatrics compared with adults. In the hospital setting, analgesics (adjusted odds ratio (aOR)=1.59; 95% confidence interval (CI) 1.03:2.45), and blood substitutes and perfusion solutions (aOR=3.74; 95%CI 2.24:6.25) were more likely to be associated with reported medication errors in pediatrics; the latter drug class (aOR=3.02; 95%CI 1.59:5.72) along with wrong technique (aOR=2.28; 95%CI 1.01:5.19) and wrong route (aOR=2.74; 95%CI 1.22:6.15) error types related more to reported medication errors with serious ADR in pediatrics. In the community setting, the most frequently reported pediatric medication errors involved vaccines (n=389, 25.7%). Psycholeptics (aOR=2.42; 95%CI 1.36:4.31) were more likely to be associated with reported medication errors with serious ADR in pediatrics. Wrong technique error type (aOR=2.71; 95%CI 1.47:5.00) related more to reported medication errors with ADR in pediatrics. Conclusions: We identified pediatric-specific medication error patterns in the hospital and community settings. Our findings inform focused error prevention measures, and pave the way for interventional research targeting the needs of this population.

Adverse Drug Reaction and Medication Error Reporting by Pharmacy Students

2005 ◽  
Vol 39 (3) ◽  
pp. 452-459 ◽  
Author(s):  
Erin L Sears ◽  
Joyce A Generali
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Work Experience ◽  
Adverse Event Reporting System ◽  
Adverse Event Reporting ◽  
Pharmacy Students ◽  
Error Reporting ◽  
Positive Trend ◽  
Medication Error Reporting ◽  
Reporting Programs

BACKGROUND: The reporting of adverse drug reactions (ADRs) and medication errors is the responsibility of all who are involved, particularly pharmacists. Since pharmacists are often privy to information surrounding ADRs and medication errors, it is of utmost importance that they are educated regarding the procedures of reporting. OBJECTIVE: To determine pharmacy students' knowledge of and ability to report ADRs and medication errors. METHODS: A total of 1322 students from 9 colleges of pharmacy were surveyed. RESULTS: The largest group of respondents was fifth-year pharmacy students (38%) followed by third-, fourth-, and sixth-year students (28%, 26%, and 8%, respectively). The majority of students reported learning about ADR and medication error reporting programs via didactic experiences. In comparison, fewer students cited alternative mechanisms of learning, including experiential rotations and work experience. Overall, respondents demonstrated the most experience with MedWatch and the least experience with the Vaccine Adverse Event Reporting System (VAERS). As students progressed through pharmacy curricula, there was a positive trend in the ability to locate and complete MedWatch forms. For VAERS and Medication Error Reporting (MER) program forms, however, this positive trend was broken at year 4. For all programs, significantly fewer students demonstrated appropriate use of the forms compared with those indicating familiarity with the programs. CONCLUSIONS: This study demonstrated that students are becoming familiar with ADR and MER programs via the college curriculum; however, there is opportunity for greater exposure and understanding. Colleges of pharmacy should continually seek methods to strengthen the education provided to pharmacy students regarding these programs.

How Useful Are Voluntary Medication Error Reports? The Case of Warfarin-Related Medication Errors

2008 ◽  
Vol 34 (1) ◽  
pp. 36-45 ◽  
Author(s):  
Chunliu Zhan ◽  
Scott R. Smith ◽  
Margaret A. Keyes ◽  
Rodney W. Hicks ◽  
Diane D. Cousins ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Error Reports

Analisis Faktor Perawat Dalam Pelaksanakan Keselamatan Pasien Terhadap Kejadian Medication Administration Error di Rumah Sakit

2020 ◽  
Author(s):  
Bintang Marsondang Rambe
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Prescribing Error ◽  
Medication Administration Error ◽  
Administration Error

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.

scholarly journals Downscaled Finite Element Modeling of Metal Targets for Surface Roughness Level under Pulsed Laser Irradiation

2021 ◽  
Vol 11 (3) ◽  
pp. 1253
Author(s):  
Evaggelos Kaselouris ◽  
Kyriaki Kosma ◽  
Yannis Orphanos ◽  
Alexandros Skoulakis ◽  
Ioannis Fitilis ◽  
...  
Keyword(s):  
Surface Roughness ◽  
Finite Element ◽  
Surface Acoustic Waves ◽  
Pulsed Laser ◽  
Multiscale Simulation ◽  
Experimental Methodology ◽  
Computational Domain ◽  
Area Of Interest ◽  
Depth Analysis ◽  
Laser Solid Interactions

A three-dimensional, thermal-structural finite element model, originally developed for the study of laser–solid interactions and the generation and propagation of surface acoustic waves in the macroscopic level, was downscaled for the investigation of the surface roughness influence on pulsed laser–solid interactions. The dimensions of the computational domain were reduced to include the laser-heated area of interest. The initially flat surface was progressively downscaled to model the spatial roughness profile characteristics with increasing geometrical accuracy. Since we focused on the plastic and melting regimes, where structural changes occur in the submicrometer scale, the proposed downscaling approach allowed for their accurate positioning. Additionally, the multiscale simulation results were discussed in relation to experimental findings based on white light interferometry. The combination of this multiscale modeling approach with the experimental methodology presented in this study provides a multilevel scientific tool for an in-depth analysis of the influence of heat parameters on the surface roughness of solid materials and can be further extended to various laser–solid interaction applications.

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