scholarly journals Medication errors involving intravenous patient-controlled analgesia: results from the 2005–2015 MEDMARX database

2018 ◽  
Vol 9 (8) ◽  
pp. 389-404 ◽  
Author(s):  
Maitreyee Mohanty ◽  
Oluwadolapo D. Lawal ◽  
Margie Skeer ◽  
Ryan Lanier ◽  
Nathalie Erpelding ◽  
...  
Keyword(s):  
Medication Errors ◽  
Human Error ◽  
Human Performance ◽  
Descriptive Analysis ◽  
Clinical Intervention ◽  
Patient Controlled Analgesia ◽  
Error Type ◽  
Medication Error Reporting ◽  
Improper Use ◽  
Cause Of Error

Background: The aim of this study was to determine the current magnitude and characteristics of intravenous patient-controlled analgesia (IV-PCA) errors, and to identify opportunities for improving the PCA modality. Methods: We conducted a descriptive analysis of IV-PCA medication errors submitted to the MEDMARX database. Events were restricted to those occurring in inpatient hospital settings between 1 January 2005 and 31 December 2015. IV-PCA errors were classified by error category, cause of error, error type, level of care rendered, and actions taken. Results: A total of 1948 IV-PCA errors were identified as potential errors (3.9%), nonharmful errors (89.5%), or harmful errors (6.7%) based on the National Coordinating Council for Medication Error Reporting and Prevention taxonomy for categorizing medication errors. Of these, 19.1% required a clinical intervention to address the deleterious effects of the error, indicating an underestimation of the risks associated with IV-PCA errors. The most frequent types of errors were improper dose/quantity (43.2%) and omission errors (19.9%). While human performance deficit was the leading cause of error (50.2%), other common causes included failure to follow procedure and protocol (42.2%) and improper use of the pump (22.7%). Although remedial actions were often taken to prevent error recurrence, actions were taken to rectify the systemic deficits that led to errors in only a minority of cases (11.8%). Conclusion: Preventable errors continue to pose unnecessary risks to patients receiving IV-PCA. Multimodal analgesic regimens and novel PCA systems that reduce human error are needed to prevent errors while preserving the advantages of PCA for the management of acute pain.

scholarly journals P25 Incidents involving paediatric parenteral nutrition

2020 ◽  
Vol 105 (9) ◽  
pp. e19.1-e19
Author(s):  
Kouzhu Zhu ◽  
Andrea Gill
Keyword(s):  
Parenteral Nutrition ◽  
Medication Error ◽  
Total Parenteral Nutrition ◽  
Medication Errors ◽  
Error Reporting ◽  
List Type ◽  
Error Type ◽  
Safe Medication ◽  
Medication Error Reporting ◽  
Coordinating Council

AimParenteral nutrition (PN) is one of the medications most frequently reported to be involved in medication errors in hospital.1 PN is a class of high alert medications listed by The Institute for Safe Medication Practices.2 Medication errors involving PN may have potentially serious consequences especially in infants.3 The purpose of this study was to determine the type of incidents reported, who reported it, severity of incidents and the part of the process involved in the error with the aim of ensuring quality and safety in PN processes.MethodThe incidents involving PN reported on the Ulysses system in a specialist children’s hospital were surveyed between April 2018 and March 2019. Incidents were assigned to different error-type categories. We focused on the whole process of prescribing, transcription, preparation, and administration of PN. Severity classification was based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index.4ResultsThere were 34 incidents involving PN ranging from 1 to 8 per month. Job titles who reported these incidents were nurses (16 incidents), pharmacists (14 incidents), dieticians (2 incidents) and unknown (2 incidents). The most common types of incidents were omitted medicine/dose (7 incidents), labelling error (6 incidents), wrong quantity supplied (4 incidents) and wrong/unclear dose (4 incidents). The processes during which the incident had occurred were administration/supply of a medicine (14 incidents), preparation of medicines/dispensing in a pharmacy (13 incidents) and prescribing (7 incidents). The majority of incidents (82.4%, 28/34) were assigned category C (no harmful consequences), while 14.7% (5/34) and 2.9% (1/34) were assigned to category B (an error occurred but the error did not reach the patient) and category D (an error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm) respectively. The following actions have been taken to try to prevent error with PN: training, providing information, introduction of new labels, changes to the profiles on infusion pumps, reinforcing independent checking and the increased use of standard PN solutions.ConclusionNurses and pharmacists are the main reporters of incidents of PN. Omitted medicine/dose is the most common incident reported. The majority of errors involved administration of PN. The majority of all incidents did not cause harm to patients.ReferencesRinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a systematic review[J]. Pediatrics, 2014, 134(2):338–60.Institute for Safe Medication Practices. ISMP List of High-Alert Medications in Acute Care Settings. Horsham, PA. Available from: http://www.ismp.org/Tools/institutionalhighAlert.asp (accessed January 15, 2017)NHS/PSA/W/2017/005,Risk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. Available from: https://improvement.nhs.uk/news-alerts/infusing-total-parenteral-nutrition-too-rapidly-in-babies/National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP Index for Categorizing Medication Errors. Available from http://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf (accessed March 10, 2017)

scholarly journals Medication Errors among Healthcare Workers in a Major HIV Treatment Centre in Nigeria

2019 ◽  
pp. 1-9
Author(s):  
S. O. Ekama ◽  
A. N. David ◽  
A. Z. Musa ◽  
I. I. Olojo ◽  
E. C. Herbertson ◽  
...  
Keyword(s):  
Medication Errors ◽  
Health Workers ◽  
Well Being ◽  
Error Rates ◽  
Hiv Treatment ◽  
Hiv Care ◽  
Continuous Training ◽  
Error Type ◽  
Care Experience ◽  
Medication Error Reporting

Background: Medication errors are major challenging clinical incidents in health care settings that could jeopardize a patient’s life and well being. These errors could occur at any step of the medication use process from prescribing, prescription verification, dispensing, drug administration to monitoring. This study aims to assess and classify medication errors among doctors and pharmacists. Methods: A prospective observational study from July to September 2018. Randomly selected prescriptions were screened for errors before and after dispensing of drugs. Errors were assessed and classified according to the National Coordination Council for Medication Error Reporting and Prevention (NCCMERP) index to determine the level of harm it posed to the patient. Results: Out of 1529 prescriptions analyzed, 182(11.9%) medication errors were observed; 104(57.1%) and 78 (42.9%) among doctors and pharmacists respectively. Majority of the errors were for female patients, those on first line antiretroviral drug regimen, in the age group 41-50 years and according to the NCCMERP index of the error type D. The most common medication errors among the doctors were omission errors (36.5%) and errors in patient data (21.1%) while unsigned prescriptions (33.3%) and omitting prescribed drugs from dispensed drugs (28.2%) ranked highest among pharmacists’ errors. Doctors and pharmacists (53.3% and 75% respectively) with < 5years HIV care experience had higher error rates. Conclusion: Medication errors associated with cotrimoxazole therapy were most common for both categories of health workers and this has a potential for poor treatment outcome. There is need for continuous training of health workers in HIV management.

Voluntary Medication Error Reporting Program in a Japanese National University Hospital

2003 ◽  
Vol 37 (11) ◽  
pp. 1716-1722 ◽  
Author(s):  
Hiroyuki Furukawa ◽  
Hisashi Bunko ◽  
Fumito Tsuchiya ◽  
Ken-ichi Miyamoto
Keyword(s):  
Medication Errors ◽  
Human Error ◽  
Safety Management ◽  
University Hospital ◽  
Error Reporting ◽  
Public Confidence ◽  
Medication Error Reporting ◽  
National University ◽  
Computer Based ◽  
Investigation Period

BACKGROUND: In Japan, as in other countries, medical accidents arising from human error can seriously damage public confidence in medical services, as well as being intrinsically undesirable. OBJECTIVE: Errors voluntarily reported by the healthcare practitioners in our institution (Kanazawa University Hospital) were considered to assess the contributory factors by using the accumulated error database in the hospital information system. METHODS: Medical errors in our institution during the period from July 1, 2000, to June 30, 2002, were counted using the error reporting system database and were classified. RESULTS: The number of errors reported during the investigation period was 1378, of which 78% were reported by nursing staff. Medication errors involving administration of injectable or oral drugs to inpatients, dispensing, and prescription accounted for about 50% of that number. Among dispensing errors, 53% were detected by patients or their families and 36% by nurses. CONCLUSIONS: The best method of error prevention is to learn from previous errors. For this purpose, the error reporting program is effective. In patient safety management, it is important to take into account the potential risks of future errors, as well as to capture information about errors that have already happened. For safety management, adoption of appropriate information technology (e.g., implementation of a prescription order entry system) is effective in reducing medication errors. However, it is important to note that serious errors can also arise in computer-based systems.

Air Traffic Control: Human Error Type Interactions

2006 ◽  
Author(s):  
Larry Bailey ◽  
Julia Pounds ◽  
Carol Manning ◽  
David Schroeder
Keyword(s):  
Traffic Control ◽  
Air Traffic Control ◽  
Human Error ◽  
Air Traffic ◽  
Error Type

Safety Issues with Patient-Controlled Analgesia; Wake-Up Call: Unlabeled Containers Lead to Patient's Death

2005 ◽  
Vol 40 (2) ◽  
pp. 117-126
Author(s):  
Michael R. Cohen
Keyword(s):  
Medication Errors ◽  
Web Sites ◽  
Health Care Facilities ◽  
Inservice Training ◽  
Patient Controlled Analgesia ◽  
Safe Medication ◽  
Safety Issues ◽  
Care Facilities ◽  
Fail Safe ◽  
E Mail

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 (MERP), 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. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 1-800-FAIL SAFE or via e-mail at [email protected] . ISMP guarantees the confidentiality and security of the information received and respects reporters’ wishes as to the level of detail included in publications.

The Prevention of Laparoscopic Bile Duct Injuries: An Analysis of 300 Cases of from a Human Factors and Cognitive Psychology Perspective

2007 ◽  
Vol 51 (11) ◽  
pp. 617-620 ◽  
Author(s):  
Lygia Stewart ◽  
Lawrence W. Way
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Bile Duct ◽  
Human Factors ◽  
Bile Duct Injury ◽  
Human Error ◽  
Perceptual Illusion ◽  
Bile Duct Injuries ◽  
Psychology Perspective ◽  
Cause Of Error ◽  
Key Steps

Application of human factors concepts to high-risk activities has facilitated reduction in human error. With introduction of laparoscopic cholecystectomy, the incidence of bile duct injury increased. Seeking ideas for prevention, we analyzed 300 laparoscopic bile duct injuries within the framework of human error analysis. The primary cause of error (97%) was a visual perceptual illusion. The laparoscopic environment contributed to 75% of injuries, poor visibility 22%. Most injuries involved deliberate major bile duct transection due to misperception of the anatomy. This illusion was so compelling that the surgeon usually did not recognize it. Even when irregular cues were detected, improper rules were employed, eliminating feedback. Since the complication-causing error occurred at few key steps during laparoscopic cholecystectomy; we instituted focused training to heighten vigilance, and have formulated specific rules to decrease the incidence of bile duct injury. In addition, factors in the laparoscopic environment contributing to this illusion are discussed.

HUMAN FACTOR ANALYSIS OF CONTAINER VESSEL’S GROUNDING ACCIDENTS

2021 ◽  
Vol 159 (A1) ◽  
Author(s):  
U Yildirim ◽  
O Ugurlu ◽  
E Basar ◽  
E Yuksekyildiz
Keyword(s):  
Monte Carlo Simulation ◽  
Monte Carlo ◽  
Human Error ◽  
Human Performance ◽  
Human Factor ◽  
Study Data ◽  
Team Management ◽  
Contribution Rate ◽  
Physical Problems ◽  
Mental Problems

Investigation on maritime accidents is a very important tool in identifying human factor-related problems. This study examines the causes of accidents, in particular the reasons for the grounding of container ships. These are analysed and evaluation according to the contribution rate using the Monte Carlo simulation. The OpenFTA program is used to run the simulation. The study data are obtained from 46 accident reports from 1993 to 2011. The data were prepared by the International Maritime Organization (IMO) Global Integrated Shipping Information System (GISIS). The GISIS is one of the organizations that investigate reported accidents in an international framework and in national shipping companies. The Monte Carlo simulation determined a total of 23.96% human error mental problems, 26.04% physical problems, 38.58% voyage management errors, and 11.42% team management error causes. Consequently, 50% of the human error is attributable to human performance disorders, while 50% team failure has been found.

scholarly journals Comparing continual task learning in minds and machines

2018 ◽  
Vol 115 (44) ◽  
pp. E10313-E10322 ◽  
Author(s):  
Timo Flesch ◽  
Jan Balaguer ◽  
Ronald Dekker ◽  
Hamed Nili ◽  
Christopher Summerfield
Keyword(s):  
Human Error ◽  
Human Performance ◽  
Deep Neural Networks ◽  
Artificial Agents ◽  
Trial And Error ◽  
Stimulus Space ◽  
Cognitive Mechanisms ◽  
Error Training ◽  
Multiple Tasks ◽  
Continual Learning

Humans can learn to perform multiple tasks in succession over the lifespan (“continual” learning), whereas current machine learning systems fail. Here, we investigated the cognitive mechanisms that permit successful continual learning in humans and harnessed our behavioral findings for neural network design. Humans categorized naturalistic images of trees according to one of two orthogonal task rules that were learned by trial and error. Training regimes that focused on individual rules for prolonged periods (blocked training) improved human performance on a later test involving randomly interleaved rules, compared with control regimes that trained in an interleaved fashion. Analysis of human error patterns suggested that blocked training encouraged humans to form “factorized” representation that optimally segregated the tasks, especially for those individuals with a strong prior bias to represent the stimulus space in a well-structured way. By contrast, standard supervised deep neural networks trained on the same tasks suffered catastrophic forgetting under blocked training, due to representational interference in the deeper layers. However, augmenting deep networks with an unsupervised generative model that allowed it to first learn a good embedding of the stimulus space (similar to that observed in humans) reduced catastrophic forgetting under blocked training. Building artificial agents that first learn a model of the world may be one promising route to solving continual task performance in artificial intelligence research.

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

Sign in / Sign up

Export Citation Format

Share Document