Necrotising fasciitis following accidental injection of intraoral xylene: a preventable medication error

2020 ◽  
Vol 13 (11) ◽  
pp. e236018
Author(s):  
Sudhagar Eswaran ◽  
Anupriya Ayyaswamy ◽  
Prasanna Kumar Saravanam
Keyword(s):  
Medication Error ◽  
Healthcare System ◽  
Medication Errors ◽  
Anaesthetic Agent ◽  
Drug Prescription ◽  
Physician Education ◽  
Mortality And Morbidity ◽  
Delivery Problem ◽  
Wrong Drug ◽  
Patient Health

The most common cause of preventable mortality and morbidity to the patient in a healthcare system is medication error. Medication errors have got a significant impact on the patient health and healthcare system. These errors are multidisciplinary and can occur at various stages of drug therapy. Physicians, nursing staff, pharmacists, hospital administration all have an important role in preventing medication errors from recurring. The most common causes include wrong patient, wrong drug prescription, look-alike sound-alike drugs, faulty drug administration, wrong dosage, drug storage, delivery problem, lack of staff, patient and physician education and failure to monitor closely. This case illustrates the importance of incorporating protocol and cross-checking before administering a drug during the procedure. Here, we discuss a case of accidental intraoral injection of xylene instead of xylocaine (local anaesthetic agent), which was a sound-alike drug that resulted in significant morbidity to the patient.

Prevalence and factors contributing to medication errors in a referral hospital in Iran: A retrospective study

2021 ◽  
Vol 15 (6) ◽  
pp. 1785-1789
Author(s):  
Meisam Moezzi ◽  
Golshan Afshari ◽  
Fakher Rahim
Keyword(s):  
Quality Improvement ◽  
Medication Error ◽  
Medication Errors ◽  
Drug Administration ◽  
Referral Hospital ◽  
Error Reporting ◽  
Inappropriate Drug ◽  
Wrong Drug ◽  
Significant Difference ◽  
Qualitative Variables

Background: A medication error is defined as any inappropriate drug administration that can harm the patient while being preventable and equally occurring under the supervision of a medical team. Objectives: The current study was conducted to clarify the error status, evaluate the regularity of medical mistakes in a referral hospital in the South West of Iran. Methods: Data were gathered from multiple wards at various shift works based on an optional error reporting form, either self-reporting or colleague-reporting, and then it has been made available to the "Quality Improvement Office" experts. Since the current study was retrospective, the samples were calculated from 2017 to 2019. The average and standard deviations were implemented to describe qualitative variables, and ANOVA to determine any statistically significant differences between groups. Results: Of 305 medication errors reported to the Quality Improvement Office, the "Administering the wrong drug" rate was 32.5%, and it has dedicated the most significant percentage of mistake types. The most-reported medication errors occurred in the general ward, and there was no significant difference in the number of mistakes in other shifts. Conclusion: Results suggest there is an association between the incidence of medication errors and the therapeutic ward. Although the most prevalent medication error in this study was "Administering the wrong drug. Keywords: medical error, error reporting, drug administration, mistakes, hospital

scholarly journals THE NATURAL AND PREVALENCE OF MEDICATION ERRORS IN A TERTIARY HOSPITAL IN INDONESIA

2021 ◽  
pp. 55-58
Author(s):  
ANDIKA DWI MAHENDRA
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Improve Patient Safety ◽  
Medical Center ◽  
Hospital Setting ◽  
Tertiary Hospital ◽  
Prescribing Error ◽  
Electronic Prescription ◽  
Mortality And Morbidity ◽  
Medication Error Reporting

Objective: Medication error is the most common errors in a hospital setting and a serious issue that intimidate the safety of the patient and may cause mortality and morbidity. The aim of this study is to explore the rate of medication errors reporting in an Indonesian hospital. Methods: This study is retrospective and descriptive. This research was conducted at dr. Soeradji Tirtonegoro General Hospital Medical Center from January to June 2020. Medication error reporting, which was reported for six months, was the sample of the study. Results: On the period, 105,171 prescribing sheets were collected. 9.5% of the total prescribing sheets are categorized as Medication Error (ME). The highest incident of ME was prescribing error (88.24%), then followed by transcribing error (7.61%), dispensing error (4.02%), and the last was administration error (0.13%). Conclusion: The most common incident occurred at prescribing stage because the hospital is not supported by electronic prescription. Medication error is an inevitable event during the medication process. But, the incidents can be minimized by implementing some preventive strategies to improve patient safety and safe drug use.

scholarly journals Medication Errors among Physician-Assistants Anaesthesia

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
G. Amponsah ◽  
A. Antwi-Kusi ◽  
W. Addison ◽  
B. Abaidoo
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Physician Assistants ◽  
Contributing Factors ◽  
Safety Issues ◽  
Contributory Factors ◽  
Wrong Drug ◽  
Quality Of Patient Care ◽  
Government Hospitals

Background. Safety issues in anaesthesia are currently being discussed widely. Anaesthetists have a unique cross-specialty opportunity to influence the safety and quality of patient care. Anaesthetists administer very potent drugs, in rapid succession, during the course of one anaesthesia event. Methodology. The study was done in April 2013 at the annual refresher course of the Physician-Assistants Anaesthesia using a questionnaire which was completed by the participants on the course. The data was analysed using IBM SPSS Statistics software version 20. Results. There were 164 completed questionnaires, with 92 (62.2%) males and 56 (37.8%) females with a mean age of 32.3 years. The majority of them (66.5%) work in government hospitals. One hundred and seven (65.3%) have had an episode of medication error with 101 (94.4%) experiencing it between 1 and 5 times. The incident occurred in the afternoon or at night in 73 (71.7%) cases. The commonest type of incident was the administration of wrong drug which occurred on 64 (71.9%) occasions resulting in 3 deaths. The contributing factors included distraction, tiredness, and overreliance on vial/ampoule colour. Conclusion. Medication errors among Physician-Assistants Anaesthesia are not uncommon leading to harm and even death of patients. The rate of medication errors can be minimised by addressing some of the contributory factors raised by the respondents.

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 How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

2020 ◽  
Author(s):  
Peter J Gates ◽  
Rae-Anne Hardie ◽  
Magdalena Z Raban ◽  
Ling Li ◽  
Johanna I Westbrook
Keyword(s):  
Systematic Review ◽  
Medication Error ◽  
Medication Errors ◽  
Meta Analysis ◽  
Error Rates ◽  
Prescribing Error ◽  
Before And After ◽  
Actual Harm ◽  
Computer Based ◽  
Wide Scale

Abstract Objective To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS. Materials and Methods We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed. Results There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18–8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72–0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence. Discussion and Conclusion Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.

scholarly journals Medication Error in Anaesthesia – A Review

2016 ◽  
Vol 27 (1) ◽  
pp. 31-35
Author(s):  
Montosh Kumar Mondal ◽  
Beauty Rani Roy ◽  
Shibani Banik ◽  
Debabrata Banik
Keyword(s):  
Public Health ◽  
Risk Factors ◽  
Medication Error ◽  
Medication Errors ◽  
Health Problem ◽  
Preventive Measures ◽  
Medical Profession ◽  
Public Health Problem ◽  
Global Public Health ◽  
Global Public Health Problem

Medication error is a major cause of morbidity and mortality in medical profession . There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers.Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 31-35

scholarly journals Medication Errors: Scope and prevention strategies

2012 ◽  
Vol 1 (2) ◽  
pp. 54 ◽  
Author(s):  
Luigi Brunetti ◽  
Dong-Churl Suh
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Health Concern ◽  
Prevention Strategies ◽  
Error Prevention ◽  
Integration Of Technology ◽  
Significant Public Health Concern ◽  
Significant Public Health ◽  
Safety Systems ◽  
Improve Patient

Background: Medication errors are a significant public health concern.  Although significant advances have been made, errors are still relatively common and represent an opportunity for healthcare improvement.Methodology/Principal Findings: Since the publication of To Err is Human, medication errors have been under tremendous scrutiny.  Organizations have moved towards a non-punitive approach to evaluating errors.  This approach to medication errors has aided in identifying common pathways to medication errors and improving understanding regarding the anatomy of a medication error.  As a result, prevention strategies have been developed to target common themes contributing to errors.  Error prevention strategies may target common contributors of medication errors, broadly grouped as performance lapses, lack of knowledge, and lack or failure of safety systems.  Strategies to thwart medication errors range from process improvement to integration of technology in the health care environment.Conclusions/Significance:  Organizations should devote resources to address medication error prevention strategies in an effort to improve patient outcomes and decrease morbidity and mortality associated with medication errors.

scholarly journals Observational Study of Medication Error in Outpatient Pharmacy RSUP Dr. Hasan Sadikin Bandung

2017 ◽  
Vol 15 (2) ◽  
pp. 210
Author(s):  
Viki Hestiarini ◽  
Lia Amalia ◽  
Eni Margayani
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Drug Information ◽  
Data Entry ◽  
Care Process ◽  
Analysis Method ◽  
Risk Priority Number ◽  
Effect Analysis ◽  
Root Cause ◽  
Cause Of Failure

Medication error can occur at all stages, starting from prescribing, dispensing and administration of drugs. This study aims to assess the medication errors that occur in the pharmaceutical care process and analyze the cause of failure using the root cause analysis method, to improvement action and decrease the incidence of medication errors. The data were completeness prescription, frequency of dispensing error and completeness of drug information. The number of sample was 1100 prescriptions Prescribing errors were found the potential injury 15.69±11.51% and near missed error 0.5±0.55%. At dispensing stage, occur 427 incidences (9.71%), consist of two incidences (0.04%) for validation assessment regulations, 224 incidences (5.09%) of data entry, 113 incidences (2.57%) of retrieval of drugs, 19 incidences (0.43%) of fi ll in drugs, 69 incidences (1.57%) of fi nal check. At dispensing stage, near missed 330 incidences (7.51%) of near missed and 97 incidences (2.21%) of potential injury. Failure mode and effect analysis calculate of risk priority number, the drug retrieval (RPN 210) and data entry (RPN 126) were analyzed root cause of the analysis for man, material, method, facility and environment.

scholarly journals GAMBARAN KEJADIAN MEDICATION ERROR DI INSTALASI GAWAT DARURAT RSU ELIM RANTEPAO

PHARMACON ◽  
2019 ◽  
Vol 8 (1) ◽  
pp. 152
Author(s):  
Priskha Widiastuti ◽  
Gayatri Citraningtyas ◽  
Jainer P Siampa
Keyword(s):  
Data Collection ◽  
Medication Error ◽  
Medication Errors ◽  
Health Personnel ◽  
Dosage Form ◽  
Emergency Services ◽  
Descriptive Analysis ◽  
Medical Record Number ◽  
Prospective Data ◽  
Prescription Date

ABSTRACT Medication Error is an event that is detrimental to the patient due to errors in the administration of drugs during the handling of health personnel, which can actually be prevented. Data on incidents of medication errors at Elim Hospital, Rantepao in 2017 were 85 cases (0.085% of the total 98,892 prescription sheets served). This study aims to determine the incidence and the percentage of medication errors during the prescribing and dispensing phase in the Emergency Installation of Elim Hospital ,Rantepao. This research is a descriptive analysis with prospective data collection. The results showed that medication errors which occurred at prescribing stage included no prescription doctor's name was 9.19%, no medical record number was 6.13%, no doctor's initial was 99.61%, patient's name was not clear was 0.57% , there was no patient age, was 6.89%, no concentration / dosage was 2.68%, no dosage form was 52.10%, and no prescription date was  1.72%. While medication errors at the dispensing stage include taking the drug was 0.38% and the lack of drug prepared was 0.19%. Based on the results of the study, it can be concluded that the biggest occurrence of medication errors in Emergency Services at Elim Hospital, Rantepao was occurred in the prescribing phase.Keywords: medication error, prescribing, dispensing, Emergency Installation ABSTRAKMedication Error adalah kejadian yang merugikan pasien akibat kesalahan dalam pemberian obat selama penanganan tenaga kesehatan, yang sebetulnya dapat dicegah.  Data insiden kejadian medication error RSU Elim Rantepao pada tahun 2017 yaitu sebanyak 85 kasus (0,085 % dari total 98.892 lembar resep yang dilayani). Penelitian ini bertujuan menentukan kejadian dan persentase medication error pada fase prescribing dan dispensing di Instalasi Gawat Darurat RSU Elim Rantepao. Penelitian ini merupakan penelitian yang bersifat analisis deskriptif dengan pengumpulan data secara prospektif. Hasil penelitian menunjukkan bahwa medication error yang terjadi pada tahap prescribing meliputi tidak ada nama dokter penulis resep 9,19%, tidak ada nomor rekam medik 6,13%, tidak ada paraf dokter 99,61%, nama pasien tidak jelas 0,57%, tidak ada usia pasien 6,89%, tidak ada konsentrasi/dosis sediaan 2,68%, tidak ada bentuk sediaan 52,10 %, dan tidak ada tanggal pembuatan resep 1,72%. Sedangkan medication error pada tahap dispensing meliputi salah pengambilan obat 0,38% dan obat ada yang kurang 0,19%. Berdasarkan hasil penelitian maka dapat disimpulkan bahwa kejadian medication error di Instalasi Gawat Darurat RSU Elim Rantepao terbesar yaitu terjadi pada fase prescribing.Kata-kata kunci : medication error , prescribing, dispensing, Instalasi Gawat Darurat

scholarly journals American Pharmacists Attitudes and Behaviors Regarding Medication Error Disclosure

2020 ◽  
Vol 11 (4) ◽  
pp. 23
Author(s):  
Jennifer Mazan ◽  
Margaret Lett ◽  
Ana Quiñones-Boex
Keyword(s):  
Patient Safety ◽  
Medication Error ◽  
Random Sample ◽  
Medication Errors ◽  
Response Rate ◽  
Community Pharmacists ◽  
Full Disclosure ◽  
Attitudes And Behaviors ◽  
Error Disclosure ◽  
And Behaviors

Background: Patient safety places emphasis on full disclosure, transparency, and a commitment to prevent future errors. Studies addressing the disclosure of medication errors in the profession of pharmacy are lacking. Objective: This study examined attitudes and behaviors of American pharmacists regarding medication errors and their disclosure to patients. Methods: A 4-page questionnaire was mailed to a nationwide random sample of 2,002 pharmacists. It included items to assess pharmacists’ knowledge of and experience with medication errors and their disclosure. The data was collected over three months and analyzed using IBM SPSS 22.0. The study received IRB exempt status. Results: The response rate was 12.6% (n = 252). The average pharmacist respondent was a 57-year old (+ 12.1 years), Caucasian (79.8%), male (59.9%), with a BS Pharmacy degree (73.8%), and licensed for 33 years (+ 12.8 years). Most respondents were employed in a hospital (26.4%) or community (31.0 %) setting and held staff (30.9%), manager (29.1%), or clinical staff (20.6%) positions.  Respondents reported having been involved in a medication error as a patient (31.0%) or a pharmacist (95.5%). The data suggest that full disclosure is not being achieved by pharmacists. Significant differences in some attitudes and behaviors were uncovered when community pharmacists were compared to their hospital counterparts.  Conclusion: There is room for improvement regarding proper medication error disclosure by pharmacists.

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