scholarly journals Assessment of inpatients omission errors made by nurses throughout the medication administration process

2018 ◽  
Vol 4 (4) ◽  
Author(s):  
Tanzeel Ahmed
2021 ◽  
Vol 15 (9) ◽  
pp. 174-182
Author(s):  
Kampamba Martin ◽  
Demba Fatima ◽  
Mudenda Steward ◽  
Mufwambi Webrod ◽  
Zingani Ellah ◽  
...  

Author(s):  
Martin Kampamba ◽  
Steven Mulolo ◽  
Margaret Phiri ◽  
Martha Chibale Chulu ◽  
Webrod Mufwambi ◽  
...  

Background: The first few days of in-patient care are possibly the most significant in a patient’s recovery and any omitted medications during this period may harm the patient or increase their hospital length of stay. Therefore, our study aimed at assessing the frequency of medication administration omission errors and their reasons for the omission in the paediatric wards after admission at University Teaching Children’s Hospital.Methods: This was a descriptive study in which 259 patient files and drug charts were reviewed. Admission prescription charts were studied in detail over a period of four weeks and all drugs prescribed but then not given in the first 48 hours were recorded as omitted medications, along with the reason given for their omission.Results: From the 259 drug charts, a total of 1598 doses of drugs were ordered within 48 hours of admission. However, from this, only a total of 1132 doses were administered with the remaining 466 doses omitted, which accounted for a frequency of 29.2%. When the frequency of medication omission errors was compared, parenteral drugs (70.8% vs. 25.3%, [p=0.0001]), afternoon shift (48.5% vs. 15.8%, [p=0.0001]), and anti-infective medications (69.1% vs. 39.4%, [p=0.0001]) were found to be the most frequently omitted medications. There were also considerably more medication omissions in patients prescribed with more medications (median number: 4, I QR [2, 6] vs. median number: 2, IQR [2, 4], [p=0. 0.001]). The most common reason for the omission was medication unavailability (89.3%), followed by work overload (71.4%), and the patient is off the ward (71.4%).Conclusions: This study revealed that medication omissions are a continuing problem and this may result in increased morbidity and mortality rates. There is a need to put in place specific strategies to reduce this problem. 


2018 ◽  
Vol 49 (2-3) ◽  
pp. 99-107 ◽  
Author(s):  
Thomas G Poder ◽  
Serge Maltais

Objective: Medication administration omission errors (MAOEs) occur frequently in hospitals and can significantly affect patient health. An interdisciplinary committee was formed in summer 2012 to analyse incident/accident reports (AH-223-1 forms) of MAOEs for the 2011–2012 fiscal year in order to identify contributing factors and to propose preventive solutions. Special attention was paid to events with consequences for patients. Method: An aggregate data analysis involving four major steps was conducted: sampling, categorisation, identification of contributing factors, and seeking preventive solutions. One hundred omissions were randomly selected from the 889 reported for this period. All omissions categorised as having had consequences for patients were then added, making a final total of 145 omissions. The omissions were categorised using an Ishikawa diagram developed from an exploratory literature review and process mapping. Subsequent to failure modes, effects and criticality analysis, cause-and-effect diagrams were constructed with the main prioritised categories to differentiate the proximal causes from the root causes. Brainstorming was used to develop solutions, which were then prioritised with an impact/effort matrix. Results: This study identified 27 categories of MAOEs, of which the 7 most frequent and the most critical accounted for 79.3% of the reports. The event categories, in decreasing order of importance, were related to intravenous (IV) therapy (29.0%), failure in using the medication administration record (MAR; 23.4%), failure in creating/updating the MAR (10.3%), medications on the patient’s bedside (7.6%), and three types of MAOEs related to transcribing prescriptions (9.0%). Conclusion: The interdisciplinary committee formulated 10 main recommendations related to these 7 categories, including 3 for IV therapy and 4 for failure in using or creating/updating the MAR.


2020 ◽  
Vol 63 (10) ◽  
pp. 3472-3487
Author(s):  
Natalia V. Rakhlin ◽  
Nan Li ◽  
Abdullah Aljughaiman ◽  
Elena L. Grigorenko

Purpose We examined indices of narrative microstructure as metrics of language development and impairment in Arabic-speaking children. We examined their age sensitivity, correlations with standardized measures, and ability to differentiate children with average language and language impairment. Method We collected story narratives from 177 children (54.2% boys) between 3.08 and 10.92 years old ( M = 6.25, SD = 1.67) divided into six age bands. Each child also received standardized measures of spoken language (Receptive and Expressive Vocabulary, Sentence Imitation, and Pseudoword Repetition). Several narrative indices of microstructure were examined in each age band. Children were divided into (suspected) developmental language disorder and typical language groups using the standardized test scores and compared on the narrative indicators. Sensitivity and specificity of the narrative indicators that showed group differences were calculated. Results The measures that showed age sensitivity included subject omission error rate, number of object clitics, correct use of subject–verb agreement, and mean length of utterance in words. The developmental language disorder group scored higher on subject omission errors (Cohen's d = 0.55) and lower on correct use of subject–verb agreement (Cohen's d = 0.48) than the typical language group. The threshold for impaired performance with the highest combination of specificity and sensitivity was 35th percentile. Conclusions Several indices of narrative microstructure appear to be valid metrics for documenting language development in children acquiring Gulf Arabic. Subject omission errors and correct use of subject–verb agreement differentiate children with typical and atypical levels of language development.


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.


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