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.

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)

National Program for Medication Error Reporting and Benchmarking: Experience with MedMARx

2001 ◽  
Vol 36 (5) ◽  
pp. 509-513 ◽  
Author(s):  
Marjorie A Shaw Phillips
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Careful Analysis ◽  
Error Reporting ◽  
National Database ◽  
Patient Harm ◽  
Near Misses ◽  
Medication Error Reporting ◽  
Causes Of Errors ◽  
Reporting Rates

This article explains the value of moving to a standardized national reporting program for medication errors. Early benchmarking activities related to medication errors were ineffective due to difficulties in reporting and the stigma associated with higher reporting rates. One institution's participation and experience with MedMARxSM (an Internet-accessible program for tracking and analyzing medication error reports with a link to an anonymous national database) is described, and some useful features of the program are highlighted. Ninety-five percent (95%) of the errors reported in the database did not result in patient harm, yet these records provide information that may guide efforts to reduce errors. Participation in the MedMARx program has helped our institution's medication error reporting program focus on performance improvement through more careful analysis of the causes of errors and “near misses.”

Chemotherapy Related Errors in the Pediatric Oncology Unit At a Tertiary Care Institution,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 4197-4197
Author(s):  
Radha Rohatgi ◽  
Sadhna Shankar
Keyword(s):  
Cancer Patients ◽  
Medication Errors ◽  
Pediatric Oncology ◽  
Reporting System ◽  
Conflicts Of Interest ◽  
Tertiary Care ◽  
Error Reporting ◽  
Prescribing Errors ◽  
Medication Error Reporting ◽  
Dispensing Errors

Abstract Abstract 4197 Medication errors are responsible for 98,000 deaths and over almost a million injuries every year according to the Institute of Medicine report published in 1999. Cancer patients often receive complicated chemotherapy regimens which are at risk for errors. Few studies have evaluated the risk of medication errors related to chemotherapy. Majority of these studies are related to adult cancer patients. Studies regarding chemotherapy errors in pediatric patients are limited. The goal of this study was to evaluate the type and severity of errors related to chemotherapy administration in the pediatric oncology inpatient unit and outpatient clinic at a single institution over a 24 month period using a voluntary error reporting system in the institution. WebEnvision is a voluntary electronic reporting system implemented in 2007, that allows staff to anonymously report patient or staff safety incidents. We evaluated all the chemotherapy related WebEnvision reports from June 1, 2009 to May 31, 2011. All reports related to prescribing, dispensing and administering chemotherapy medications were included. Reports related to a supportive care measures were excluded. The reports were reviewed by both authors and graded according to the National Coordinating Council for Medication Error Reporting and Prevention Index for medication errors. The errors were also classified by type as defined by the American Society of Hospital Pharmacists guidelines for preventing medication errors. A total of 1030 reports related to oncology patients were recorded during the study period. Of these, 246 (23.9%) were related to chemotherapy. Thirty nine thousand preparations were dispensed by the chemotherapy pharmacy during the study period. The median number of chemotherapy drugs on orders associated with an error was 2 with a range of 1 to 6. The median length of chemotherapy treatment per order was 3 days with a range of 1 to 56 days. Approximately half (47%) of the errors occurred in patients undergoing treatment for leukemia or lymphoma, 28% for solid tumors, 17% for brain tumors, and 7% for non-malignant hematology patients. Ninety four (38%) errors were attributed to pharmacy, 83 (34%) to the providers, and 51 (20%) to the nurses. Seventy six (31%) were prescribing errors, 41 (16%) were administration errors, 31 (13%) were dispensing errors, and 26 (11%) were transcription errors. Approximately half (44%) of errors were of category B, an error occurred but did not reach the patient. Seventy six (31%) reports were category A, circumstances for error were present but no error occurred. Fifty nine (24%) were category C, an error reached the patient but caused no harm. Three errors reached the patient and could have contributed to harm (category D, F,G). Approximately one in three dispensing errors (32%), one in six prescribing errors (17%) and one in ten (11%) transcription errors reached the patient. Prescribing errors were the most common chemotherapy related errors in this study. One in four of all errors reached the patients. Errors occurred despite an institutional policy of two independent checks by providers, pharmacists, and nurses. More diligence is necessary on part of the person performing the second check on chemotherapy orders. Computerized provider order entry may help reduce chemotherapy related errors. Table1. Types of chemotherapy related errors Types of Errors N (%) Prescribing 76 (31) Delay 58 (23) Administration 41 (16) Dispensing 31 (13) Transcription 26 (11) Monitoring 7 (3) Compliance 4 (2) Omission 3 (1) Total 246 (100) Disclosures: No relevant conflicts of interest to declare.

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.

ARV Medication Errors: Experience of a Community-Based HIV Specialty Clinic and Review of the Literature

2007 ◽  
Vol 42 (8) ◽  
pp. 720-728 ◽  
Author(s):  
Jennifer Cocohoba ◽  
Betty J. Dong
Keyword(s):  
Medication Errors ◽  
Systems Of Care ◽  
Drug Distribution ◽  
Urban Setting ◽  
Error Reporting ◽  
Review Of The Literature ◽  
Community Based ◽  
Medication Error Reporting ◽  
Immunodeficiency Virus ◽  
Distribution Process

Objective To describe antiretroviral (ARV) medication errors reported within a community Human Immunodeficiency Virus (HIV) clinic, identify potential strategies to prevent errors, and review the literature pertaining to ARV medication errors. Design Review of voluntarily reported ARV errors. Errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) Index. The clinic's medication distribution process was also analyzed. Setting Community-based clinic with HIV-experienced clinicians in an urban setting. Results Thirty-seven errors were reported over 3 years; 81.1% of these were classified as NCC-MERP category C. Most errors resulted from lapses in clinic and pharmacy systems of care (n = 21). Pharmacy and clinic prescribing errors were less (n = 11). Conclusion ARV medication errors were notable. Changes in drug distribution and prescribing processes may reduce future ARV medication errors.

scholarly journals The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems

Medicines ◽  
2021 ◽  
Vol 8 (9) ◽  
pp. 46
Author(s):  
Abbas Al Mutair ◽  
Saad Alhumaid ◽  
Abbas Shamsan ◽  
Abdul Rehman Zia Zaidi ◽  
Mohammed Al Mohaini ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
The United States ◽  
Population Based ◽  
Error Reporting ◽  
Effective Strategies ◽  
Medication Error Reporting ◽  
Background Population ◽  
Safety Improvement ◽  
Reporting Systems

Background: Population-based studies from several countries have constantly shown excessively high rates of medication errors and avoidable deaths. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Improvement efforts and system changes of medication error reporting systems should be targeted towards reductions in the likelihood of injury to future patients. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems. Methods: Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles were found and 60 papers were ultimately included in the review. Data were mined by two reviewers and verified by two other reviewers. The search yielded 684 articles, which were then reduced to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers. Results: Studies were principally from the United States of America and the United Kingdom. Limited studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt. Detection, measurement, and analysis of medication errors require an active rather than a passive approach. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). The National Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification system to describe and analyze the details around individual medication error events. Conclusion: A successful medication error reporting program should be safe for the reporter, result in constructive and useful recommendations and effective changes while being inclusive of everyone and supported with required resources. Health organizations need to adopt an effectual reporting environment for the medication use process in order to advance into a sounder practice.

scholarly journals Potential Medication Errors in Electronic Prescribing in A Primary Health Care

2019 ◽  
Vol 2 (1) ◽  
pp. 45-54
Author(s):  
Rizki Siti Nurfitria ◽  
Rima Nur Adillah Effendi ◽  
Deni Iskandar
Keyword(s):  
Health Care ◽  
Medication Errors ◽  
Electronic Prescribing ◽  
Error Reporting ◽  
Prescription Data ◽  
Electronic Prescription ◽  
Prescribing Indicators ◽  
Outpatient Prescription ◽  
Medication Error Reporting ◽  
A Company

An effort to reduce medication errors is to use drugs prescription electronically[1,2,4]. However, there needs to be an evaluation of this system, because this system is not free from errors in medication. This study aimed to find out the description of prescribing flow, to examine electronic prescription completeness, and find out the potential medication errors that occur in the prescribing phase of electronic prescription using prescribing indicators[1,5,9,10]. This study used observational method by taking general practice outpatient prescription data of March 2018 in a company health service located in Bandung and analyzed descriptively[6,7,8]. Electronic prescription of medicines at this health care was made and inputted by doctors. When an error occured on a computer system, the doctor would prescribe it manually so that the patient can still be served. Incompleteness of the most common recipe was on administrative requirements where all prescriptions did not listed the doctor's practice permit, patient's gender, patient's weight, telephone number of the place of practice, and patient's contact number. Medication errors had the most potential for the occurrence of prescription writing with two or more drugs interacting and this error was classified as category D according to The National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP).  

Identifying High-alert Medications in a University Hospital by Applying Data From the Medication Error Reporting System

2017 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Lotta Tyynismaa ◽  
Anni Honkala ◽  
Marja Airaksinen ◽  
Kenneth Shermock ◽  
Lasse Lehtonen
Keyword(s):  
Medication Error ◽  
Reporting System ◽  
University Hospital ◽  
Error Reporting ◽  
Medication Error Reporting ◽  
Error Reporting System
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