scholarly journals Literature Review: Cause Factor Analysis and an Effort to prevent Medication Administration Error (MAE) at Hospital

2020 ◽  
Vol 9 (2) ◽  
pp. 98-107
Author(s):  
Innes Rizma Brigitta ◽  
Inge Dhamanti

The high number of medical errors, especially in medication administration errors (MAE) in the last few decades that have occurred in hospitals in developed and developing countries makes patient safety an important issue. This requires the hospital to take steps that prioritize patient safety by focusing on preventive measures, so as to reduce the risk of an MAE. The writing of this article of literature review aims to explain the determinants of MAE in hospitals and their prevention efforts through preventive measures, so that patient safety standards in hospitals (zero defects) can be achieved. The design of the article search in this literature study was carried out through Google scholar, JAKI, and PSNet with the keywords of patient safety incident, medication administration error, contributing factor of MAEs, and determinant factor of MAEs. Based on 13 articles that have been obtained in accordance with the criteria, there are 38 determinant factors in MAE which are grouped into three categories, namely ineffective communication factors, work environment factors, and human factors. Various preventive efforts that can be done to prevent MAEs include: implementing crew resource management, clarifying the chain of command, using the communication form of SBAR, designing an ergonomic workplace, implementing Patient Advocacy Reporting System (PARS), providing training and education for health workers, and setting work schedules that do not exceed workload. Implementation of effective MAE preventive measures can reduce the number of MAEs in the hospital directly.

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.


2013 ◽  
Vol 845 ◽  
pp. 604-608 ◽  
Author(s):  
Ali Anjomshoae ◽  
Adnan Hassan ◽  
Mat Rebi Abdul Rani

This paper is an overview of recent issues in determining healthcare delivery systems and aims to explain how Human Factor and Ergonomics (HFE) and simulation modeling can contribute to the quality of patient safety and healthcare delivery. It has been found that the layout of the patient unit and resources are significant factors that influence the amount of medication errors and therefore should be included in any description of the research context. Therefore current trends and applications of HFE as well as simulation modeling and how they can contribute to provide safe, efficient, and effective service to the patients are discussed. This review provides previous work of researchers to identify relationships between these two areas of research, particularly in patient safety. The review suggests that, high rate of medication administration error is due to inefficient healthcare delivery system and highlights the efficiency of simulation modeling versus ergonomics in analyzing the root cause of problems in clinical performance.


2020 ◽  
Vol 27 (3) ◽  
pp. e100170
Author(s):  
Johanna I Westbrook ◽  
Neroli S Sunderland ◽  
Amanda Woods ◽  
Magda Z Raban ◽  
Peter Gates ◽  
...  

BackgroundElectronic medication systems (EMS) have been highly effective in reducing prescribing errors, but little research has investigated their effects on medication administration errors (MAEs).ObjectiveTo assess changes in MAE rates and types associated with EMS implementation.MethodsThis was a controlled before and after study (three intervention and three control wards) at two adult teaching hospitals. Intervention wards used an EMS with no bar-coding. Independent, trained observers shadowed nurses and recorded medications administered and compliance with 10 safety procedures. Observational data were compared against medication charts to identify errors (eg, wrong dose). Potential error severity was classified on a 5-point scale, with those scoring ≥3 identified as serious. Changes in MAE rates preintervention and postintervention by study group, accounting for differences at baseline, were calculated.Results7451 administrations were observed (4176 pre-EMS and 3275 post-EMS). At baseline, 30.2% of administrations contained ≥1 MAE, with wrong intravenous rate, timing, volume and dose the most frequent. Post-EMS, MAEs decreased on intervention wards relative to control wards by 4.2 errors per 100 administrations (95% CI 0.2 to 8.3; p=0.04). Wrong timing errors alone decreased by 3.4 per 100 administrations (95% CI 0.01 to 6.7; p<0.05). EMS use was associated with an absolute decline in potentially serious MAEs by 2.4% (95% CI 0.8 to 3.9; p=0.003), a 56% reduction in the proportion of potentially serious MAEs. At baseline, 74.1% of administrations were non-compliant with ≥1 of 10 procedures and this rate did not significantly improve post-EMS.ConclusionsImplementation of EMS was associated with a modest, but significant, reduction in overall MAE rate, but halved the proportion of MAEs rated as potentially serious.


2001 ◽  
Vol 16 (4) ◽  
pp. 128-134 ◽  
Author(s):  
Bonnie J. Wakefield ◽  
Mary A. Blegen ◽  
Tanya Uden-Holman ◽  
Thomas Vaughn ◽  
Elizabeth Chrischilles ◽  
...  

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