Reducing Medication Errors and Increasing Patient Safety: Case Studies in Clinical Pharmacology

2003 ◽  
Vol 43 (7) ◽  
pp. 768-783 ◽  
Author(s):  
David M. Benjamin
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.


Author(s):  
Graham Brack ◽  
Penny Franklin ◽  
Jill Caldwell

Medicines Management for Nursing Practice: Pharmacology, Patient Safety, and Procedures is a friendly guide designed to equip pre-registration and newly qualified nurses with the medicines management knowledge and skills to provide safe patient-centred care. Balancing theory with practical advice, this accessible text covers basic pharmacology, drug calculations, key legislation and standards, and patient safety. Drawing from the most up-to-date sources of evidence and advice, including NMC and BNF guidelines, Medicines Management for Nursing Practice prepares nurses to promote their patients' safety, concordance, understanding of medicines, and wellbeing. This book takes a lively and straightforward approach to a vital set of nursing skills. Learning features such as reflection points, exercises, and further reading help readers to develop and consolidate their knowledge. Chapters on pharmacology and drug calculations take a step-by-step approach and are supported by diagrams and examples to aid understanding. Case studies relate guidelines and theories to the common practical scenarios that nurses encounter on a day-to-day basis.


2019 ◽  
Vol 58 (4) ◽  
pp. 413-416
Author(s):  
Brian Murray ◽  
Matthew J. Streitz ◽  
Michael Hilliard ◽  
Joseph K. Maddry

Introduction. Adverse medication events are a potential source of significant morbidity and mortality in pediatric patients, where dosages frequently rely on weight-based formulas. The most frequent occurrence of medication errors occurs during the ordering phase. Methods. Through a prospective cohort analysis, we followed medication errors through patient safety reports (PSRs) to determine if the use of a medication dosage calculator would reduce the number of PSRs per patient visits. Results. The number of PSRs for medication errors per patient visit occurring due to errors in ordering decreased from 10/28 417 to 1/17 940, a decrease by a factor of 6.31, with a χ2 value of 4.063, P = .0463. Conclusion. We conclude that the use of an electronic dosing calculator is able to reduce the number of medication errors, thereby reducing the potential for serious pediatric adverse medication events.


2011 ◽  
Vol 36 (5) ◽  
pp. 2743-2749 ◽  
Author(s):  
Shuhua Wu ◽  
Kefei Chen ◽  
Yuefei Zhu

2020 ◽  
Vol 11 (4) ◽  
pp. 23
Author(s):  
Jennifer Mazan ◽  
Margaret Lett ◽  
Ana Quiñones-Boex

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.


2002 ◽  
Vol 37 (11) ◽  
pp. 1140-1146
Author(s):  
Michael R. Cohen

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.


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