scholarly journals Pharmaceutical Care Training Increases the Ability Pharmacists to Reduce the Incidence of Medication Error

2015 ◽  
Vol 4 (2) ◽  
pp. 119
Author(s):  
Akrom Akrom ◽  
Budiyono Budiyono ◽  
Woro Supadmi

The objective of the study was to know the potential incidence of medication errors before and after the training of pharmaceutical care in the Outpatient Pharmacy Unit of general privat hospital in rural area of Yogyakarta. The observational studi used to describe the potential medication errors in prescribing phase and dispensing phase and to determine its completion. This research was conducted prior to the training of pharmaceutical care that is in May and after the training of pharmaceutical care that was in June 2014 at the Outpatient Unit of general privat hospital in rural area Yogyakarta. The data was taken from a book review of prescriptions in outpatient units for the month. The results showed that the number of potential medication errors before the training of pharmaceutical care in prescribing phase (prescribing errors) found 17 cases or 0.21% and the dispensing phase (dispensing error) as many as 36 cases or 0.45%. While the potential for medication errors after the training phase of pharmaceutical care in prescribing phase (prescribing error) is found as many as 115 cases or 1.45% and the dispensing phase (dispensing error) is found as many as 165 cases or 2.10%.

2015 ◽  
Vol 4 (2) ◽  
pp. 119
Author(s):  
Akrom Akrom ◽  
Budiyono Budiyono ◽  
Woro Supadmi

The objective of the study was to know the potential incidence of medication errors before and after the training of pharmaceutical care in the Outpatient Pharmacy Unit of general privat hospital in rural area of Yogyakarta. The observational studi used to describe the potential medication errors in prescribing phase and dispensing phase and to determine its completion. This research was conducted prior to the training of pharmaceutical care that is in May and after the training of pharmaceutical care that was in June 2014 at the Outpatient Unit of general privat hospital in rural area Yogyakarta. The data was taken from a book review of prescriptions in outpatient units for the month. The results showed that the number of potential medication errors before the training of pharmaceutical care in prescribing phase (prescribing errors) found 17 cases or 0.21% and the dispensing phase (dispensing error) as many as 36 cases or 0.45%. While the potential for medication errors after the training phase of pharmaceutical care in prescribing phase (prescribing error) is found as many as 115 cases or 1.45% and the dispensing phase (dispensing error) is found as many as 165 cases or 2.10%.


2021 ◽  
Vol 18 (5) ◽  
pp. 1119-1122
Author(s):  
Sultan M. Alshahrani ◽  
Khaled M. Alakhali ◽  
Yaser Mohammed Al-Worafi

Purpose: To identify medication errors at Aseer Central Hospital (ACH, Abha) in the southern province of Saudi Arabia. Methods: A cross-sectional retrospective study was conducted by reviewing adult patients’ records (> 15 years old) at ACH’s inpatient and outpatients settings over an 8-week period in October and November 2015. Results: We identified 113 medication errors, including 112 prescribing errors and 1 dispensing error. Most medication errors (91.2 %) in this study were for inpatient prescriptions. The most common prescribing error was medication duplication (31.2 %) followed by missing patient identifying information (25 %). Conclusion: Medication errors, mainly in inpatient prescriptions, have been fully identified at ACH. Educational interventions such as workshops could help minimize and prevent medication errors.


Author(s):  
Peter J Gates ◽  
Rae-Anne Hardie ◽  
Magdalena Z Raban ◽  
Ling Li ◽  
Johanna I Westbrook

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.


2020 ◽  
Vol 105 (9) ◽  
pp. e26.1-e26
Author(s):  
Kate Morgan

BackgroundA prescribing error is a preventable error that may lead to inappropriate medication use and patient harm(1). Prescribing errors are particularly important in paediatrics where dose calculations are complicated and small errors can result in significant morbidity and mortality.1 In 2017 pharmacy data showed that paediatric prescribing errors were an issue at our Hospital regarding the severity and high numbers of errors, especially for antibiotics and analgesia.ObjectivesTo achieve a zero prescribing error rate for paediatric within the hospital.MethodForm the Paediatric Medication Errors Prevention (PMEP) group consisting of the Paediatric Consultant, Paediatric Pharmacist, Children’s Assessment Unit Sister and Practice Education Senior Nurse.Paediatric Pharmacist to record and feedback all paediatric prescribing errors weekly at Doctors’ handover.Paediatric Pharmacist/Nurses to DATIX report all significant medication prescribing errorsPaediatric Pharmacist to produce and communicate monthly pharmacy prescribing newsletter.Paediatric Pharmacist to produce quick reference charts for the drugs with the most common prescribing errors e.g. antibiotics and analgesiaPaediatric Doctors to request a second check from another Doctor or Ward Sister when prescribing any medication on the drug chart of take home prescription.Paediatric Pharmacist to target Doctors’ induction to improve prescribing and implement a prescribing test.Doctors to complete reflections for errors with their educationsal supervisors.This study did not require ethics approval.ResultsFollowing implementation of the above strategies, there was a 33% reduction in the number of prescribing errors recorded by the Paediatric Pharmacist daily intervention log from 2017/2018 to 2018/2019. There were 163 prescribing errors for 2017/2018 compared to 110 for 2018/2019.ConclusionThe formation of the PMEP group and implementation of strategies to reduce paediatric prescribing errors has positively impacted on reducing the error rate at the hospital. It has also raised awareness of the necessity to report all errors and actively find ways to prevent these from re-occurring. Further work is required to reduce these errors to zero including targeting non paediatric teams prescribing on paediatrics and implementing Pharmacists prescribing on consultant ward rounds. Future work would also include replicating this model in other specialities e.g. neonatal intensive care to achieve the same success rate in reducing medication errors.ReferenceDavis T. Paediatric prescribing errors. Arch Dis Child. 2011;96:489–91. Accessed via http://adc.bmj.com on 2/4/19.


2018 ◽  
Vol 103 (2) ◽  
pp. e2.33-e2
Author(s):  
Peter Cook ◽  
Andy Fox

IntroductionPrescribing of medication in children is a very complex process that involves an understanding of paediatric physiology, disease states, medication used and pharmacokinetics as well as patient specific details, their co-morbidities and their clinical condition. The most common medication errors have been identified as dosing, route of administration, and frequency of administration. Computerised provider order entry has been shown to reduce the number of prescribing errors related to chemotherapy as well as the likelihood of dose and calculation errors in paediatric chemotherapy prescribing. Locally, paediatric chemotherapy is prescribed on pre-printed paper prescriptions. Adaptation and implementation of ARIA electronic prescribing (EP) system for use in paediatric chemotherapy was undertaken by a Specialist Paediatric Oncology Pharmacist and was rolled out for use in January 2016 for patients with acute lymphoblastic leukaemia.MethodThe United Kingdom National Randomised Trial for Children and Young Adults with Acute Lymphoblastic Leukaemia and Lymphoma 2011 (UKALL, 2011) was developed for use on EP, with prescribing of all other chemotherapy remaining on paper. The number and type of prescribing errors were collected during a pre-implementation phase from January 2015 to June 2015. After the introduction of EP and following a 2 month acclimatisation period, a second period of data collection took place between March 2016 and July 2016. Overall prescribing error rates and the frequency of each error type were calculated both before and after implementation.ResultsBefore the introduction of EP for paediatric chemotherapy, the overall error rate was 18.4% with a total of 16 different errors seen. Post implementation, overall error rate increased to 25.7% (p<0.001) with a total of 10 different errors seen. After introduction of EP, prescribing error rates on paper were 30.6% and on EP were 7.0% (p<0.001). Only 5 different error types were seen with electronic prescribing. The most commonly seen errors in prescribing with paper, both before and after were almost eliminated with the introduction of EP.ConclusionThe introduction of EP has resulted in a significant reduction in prescribing error rates compared to paper based prescribing for paediatric chemotherapy. Overall the prescribing error rate increased after the introduction of EP but this was related to an increased rate on the paper prescriptions. One possible reason for this was the use of dual systems for prescribing. In addition there was unforeseen relocation and building work within the paediatric cancer unit, which affected prescribing time allocation. There were also several staff shortages within the prescribing team after implementation and this resulted in an increased workload on the remaining chemotherapy prescribers. All these issues could have attributed to the increase in error rates. The most common errors seen with chemotherapy prescribing have been reduced with EP as protocols have been developed with a focus on prescribing safety. Further work is needed as more prescribing takes place on EP to assess the full impact it has on paediatric chemotherapy error rates.


2018 ◽  
Vol 103 (2) ◽  
pp. e1.28-e1
Author(s):  
Bayliss Emily ◽  
Vittery Emma ◽  
Thomas Matthew

AimAssess the incidence, type and severity of prescribing errorsAssess the use and efficacy of a pre–existing prescribing aidReduce the number and severity profile of prescribing errors through increased use of the prescribing aid.MethodTwenty cystic fibrosis (CF) patients, admitted consecutively to a tertiary paediatric centre, were included in the study. Use of the pre-existing CF prescribing aid and prescribing errors were detected prospectively by daily pharmacist review of electronic drug charts. A doctor and a pharmacist then retrospectively assigned a severity score (A-I), using a standardised tool.1 Ten patients were evaluated initially. Following this, paediatric CF patients were tagged on the electronic prescribing system, creating a pop-up alert to direct prescribers to the CF prescribing aid when those patients’ electronic medicine records were opened.ResultsTen patients (163 medication orders) were evaluated in phase I pre-intervention, and ten patients (157 medication orders) were evaluated in phase II post-intervention.In total 127 prescribing errors were recorded. The most common types of prescribing error were: failing to prescribe a patient’s regular medicine (27%); prescribing the wrong formulation (19%); prescribing the wrong dose (14%).No errors, in either phase of the study, caused patient harm. The highest severity score in this study was awarded to prescribing errors that reached the patient, did not cause harm but required intervention to preclude harm or required extra monitoring (category D).1Throughout both phases, 32% of error containing orders were related to medicines that were not included in the CF prescribing aid, the error rate was comparable in both phases (30%; 35%). These medicines were non-CF specific drugs therefore not appropriate to be included in the prescribing aid. These medication orders were excluded from further pre- and post- intervention analysis.In the pre-intervention group, 100 CF medication orders were prescribed. The prescribing aid was used in 42% of orders. 43% of medication orders had at least one prescribing error. 27% of errors were of severity category D.In the post-intervention group, 104 CF medication orders were prescribed. The prescribing aid was used in 70% of orders. 27% of medication orders had at least one prescribing error. 15% of errors were of severity category D.ConclusionIntroducing a paediatric CF alert system successfully increased prescriber utilisation of the CF prescribing aid, with subsequent reduction in error rate and severity of CF specific medicines. We are confident that this improvement reflects our intervention, although without in-depth statistical analysis we cannot attribute causality. However, errors still occurred despite the use of the prescribing aid and errors occurred in non-CF specific medicines. A continuous quality improvement approach is being adopted to explore alternative causes for error and further interventions that can be made, with focus on dovetailing inpatient and outpatient prescribing and medication recording. Further study is required in this complex high-risk patient group where polypharmacy is unavoidable.ReferenceNational Coordinating Council for Medication Error Reporting and Prevention. NCC MERP index for categorising medication errors2001. http://www.nccmerp.org/types-medication-errors [Accessed: 30/07/2017].


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.


2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 443-444
Author(s):  
Joy Douglas ◽  
Christine Ferguson ◽  
Beth Nolan

Abstract Research supports the need for healthcare providers who are trained in providing care to older adults with dementia. However, few training options exist for Registered Dietitians (RDs) seeking dementia care training that is specific to nutrition. The purpose of this project was to adapt an existing dementia care training curriculum to meet the learning needs of RDs. The development team included two experts in dementia training and two RDs with expertise in gerontological nutrition. The new training module was based on the existing Positive Approach to Care™ (PAC) curriculum, which incorporates Kolb’s Experiential Learning Theory and the Adult Experiential Learning Cycle. The development team first identified learning objectives for content that would be relevant to RDs who work with persons living with dementia, and modified components of the existing PAC curriculum to meet these objectives. After a preliminary pilot, the 2-hour program was presented to 20 RDs using a combination of lecture presentation, experiential learning, and skill-building techniques. Participants were provided written materials to reinforce the concepts presented. Participants answered five dementia-specific questions before and after the training, and overall, the average percentage of correct answers improved following the training. Two weeks following the training, participants completed an open-ended survey to provide feedback on the training. Participants responded favorably to the mixed learning formats in the training. When asked to rank their preferred learning methods, participants indicated lecture-based learning and experiential learning as their top preferred methods. These findings indicate that the adapted curriculum may improve dementia knowledge among RDs.


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