Avoidance of drug errors between hospital and home

IntroductionChildren with cystic fibrosis (CF) take a multitude of therapies at home. Self-Administration of Medicines (SAM) is a scheme whereby the parent/carer and/or older child keep control of their own medicines in hospital. We initiated a scheme and assessed drug errors, cost implications, and parent and nurse satisfaction.MethodsFollowing a pilot stage, the SAM protocol was initiated and amended as necessary. Drug errors were analysed from the Datix hospital electronic reporting system. Cost analysis of use of the patents own drugs was carried out. Questionnaires were given to parents and nursing staff.ResultsIn the initial 10 months, 97 children had 159 admissions, and 60% were deemed suitable for SAM. Drug errors still occurred—33 in 5 years. Cost savings for the hospital over 1 year were £20 022 for 123 admissions. Patient/parent satisfaction was high, and all wished to partake in SAM for further admissions.ConclusionsThe scheme was a success although it took 3 years to bring to fruition. Drug errors still occurred but we were able to amend the protocol appropriately to react to these. Cost savings are an incidental benefit from use of patient’s own medication. The SAM scheme is applicable to all children with chronic disease on long term medications when they are in hospital.

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Fatal drug errors in anaesthesia: Can we override?

Indian Journal of Anaesthesia ◽

10.4103/0019-5049.147189 ◽

2014 ◽

Vol 58 (6) ◽

pp. 785

Author(s):

Amitabh Kumar ◽

Kapil Gupta ◽

Manju Gupta ◽

Shyam Bhandari

Keyword(s):

Drug Errors

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Medication errors with opioids: Results from a national reporting system

Journal of Opioid Management ◽

10.5055/jom.2007.0004 ◽

2007 ◽

Vol 3 (4) ◽

pp. 189 ◽

Cited By ~ 20

Author(s):

Sydney Morss Dy, MD, MSc ◽

Andrew D. Shore, PhD ◽

Rodney W. Hicks, PhD, ARNP ◽

Laura L. Morlock, PhD

Keyword(s):

Error Reporting ◽

Patient Controlled Analgesia ◽

Medication Error Reporting ◽

Wrong Drug ◽

Improvement Programs ◽

National Reporting System ◽

Quality Improvement Programs ◽

Inpatient Units ◽

Omission Errors ◽

Drug Errors

Background: Errors may be more common and more likely to be harmful with opioids than with other medications, but little research has been conducted on these errors.Methods: The authors retrospectively analyzed MEDMARX®, an anonymous national medication error reporting database, and quantitatively described harmful opioid errors on inpatient units that did not involve devices such as patient-controlled analgesia. The authors compared patterns among opioids and qualitatively analyzed error descriptions to help explain the quantitative results.Results: The authors included 644 harmful errors from 222 facilities. Eighty-three percent caused only temporary harm; 60 percent were administration errors and 21 percent prescribing errors; and 23 percent caused underdosing and 52 percent overdosing. Morphine and hydromorphone had a significantly higher proportion of improper dose errors than other opioids (40 percent and 41 percent compared with 22 percent with meperidine). Hydromorphone errors were significantly more likely to be overdoses (78 percent vs 47 percent with other opioids). Omission errors were significantly more common with fentanyl patches (36 percent compared with 12 percent for other opioids). Wrong route errors were significantly more common with meperidine (given intravenously when prescribed as intramuscular, 34 percent vs 3 percent for morphine). Oxycodone errors were significantly more likely to be wrong drug errors (24 percent vs 11 percent for other opioids), often because of confusion between immediate- and sustained-release formulations.Conclusions: Reported opioid errors are usually associated with administration and prescribing and frequently cause uncontrolled pain as well as overdoses. These patterns of errors should be considered when using opioids and incorporated into pain guidelines, education, and quality improvement programs.

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