scholarly journals RISK FACTORS IN MEDICATION ERRORS IN A HIGH-COMPLEXITY CHILEAN PUBLIC HOSPITAL

2020 ◽  
Vol 29 (spe) ◽  
Author(s):  
Ana María Pilquinao Cárcamo ◽  
Francis Solange Vieira Tourinho ◽  
Thaís Fávero Alves
Keyword(s):  
Risk Factors ◽  
Adverse Events ◽  
Medication Errors ◽  
Public Hospital ◽  
Work Organization ◽  
Preventive Measure ◽  
Medication Administration ◽  
High Complexity ◽  
Cross Sectional ◽  
Medication Error Reporting

ABSTRACT Objective: to identify the risk factors in medication errors in a high-complexity chilean public hospital. Method: a research study with a quantitative approach; an exploratory, descriptive and cross-sectional study, with retrospective temporal cuts. The study population consisted of 50 reports of adverse events related with the medication administration process generated between 2014 and 2017 in the Medical and Surgery services of the Magallanes Clinical Hospital, Chile. The classification of the National Coordinating Council for Medication Error Reporting and Prevention was used for data collecting, performed during May and June 2018, and the data were analyzed by means of descriptive statistics. Results: among those involved in the medication errors, the following professions are predominant: nurses, 21 (42%); Medical and Surgery nursing technicians, 18 (36%), and nursing technicians working in the Pharmacy, 7 (14%). The most frequent medication errors were the following: medication transcription, 16 (32%); preparation, 13 (26%); and administration, 11 (22%). The following risk factors stand out in the notified cases: communication and interpretation problems, 13 (26%); incorrect interpretation of the prescription at dispensation, 7 (14%); factors associated with work organization such as insufficient compliance with the priority safety practices, 11 (22%), and individual factors, 9 (18%). Conclusion: more information is required about medication errors to identify the risk factors and to establish strategies for their prevention; consequently, the notification of adverse events must be promoted as a preventive measure.

scholarly journals Medication Discrepancies Involving Hospitalized Children At A High-Complexity Public Hospital

2019 ◽  
Author(s):  
Divaldo Pereira de Lyra ◽  
Thaciana dos Santos Alcântara ◽  
Fernando Castro de Araújo Neto ◽  
Helena Ferreira Lima ◽  
Dyego Carlos S. Anacleto de Araújo ◽  
...  
Keyword(s):  
Medication Errors ◽  
Medication Reconciliation ◽  
Public Hospital ◽  
Hospital Readmissions ◽  
High Complexity ◽  
Dose Frequency ◽  
Cross Sectional ◽  
Medication Discrepancies ◽  
Internal Transfer ◽  
Reconciliation Process

Abstract Background: Children are more susceptible to medication errors and adverse reactions. In addition, variation in body mass and medication discrepancies are the major causes of medication errors, which pose a risk of harm to children. When unresolved, these issues can lead to longer hospital stays, increased hospital readmissions, and emergency room care that burden the healthcare system. Many organizations have struggled to implement medication reconciliation. In this context, studies demonstrated that reliability and improvement science methods can be used to implement a successful and sustained medication reconciliation process. One of the initial steps involved in medication reconciliation process is determining the sector for implementation. Therefore, the aim of this study was to determine the prevalence of medication discrepancies occurring throughout the course of a hospital stay and describe the types of discrepancies and medications most commonly involved in pediatric cases. Methods: A cross-sectional study was carried out from July 2017 to March 2018 in the pediatric department of a high-complexity public hospital in Brazil. Data collection consisted of: collection of sociodemographic data, clinical interview with the patient's caregiver, registration of patient prescriptions, and evaluation of medical records. Discrepancies were classified as intentional or unintentional and included omission of medication, therapeutic duplicity, different dose, frequency, route of administration than prescribed. Study approved by the Research Ethics Committee (CAAE: 36927014.4.0000.5546). Results: During care transitions, 114 children were followed. Patients presented unintentional discrepancies, of which 16 (14.0%) presented discrepancies at hospital admission, 42 (36.8%) during ward transfer, and 52 (45.6%) during discharge. Omission represented 74% (n=20) ofthe errors at admission, 38% (n=26) at ward transfer, and 100% (n=80) at discharge. The most frequent discrepancies in the three transitions were related to antimicrobials, representing 43.3% of discrepancies at admission, 38.8% at internal transfer, and 61.2% during discharge. Conclusion: The results demonstrated that the main transition levels when unintentional discrepancies occurred in children in this hospital were during internal transfer and discharge and indicated difficulties in interprofessional communication and poor documentation. Evaluation of all transition points is essential for determining the most critical point in the quality of care provided at hospitals.

scholarly journals Scale of adverse events associated to nursing practices: a psychometric study in Portuguese hospital context

2018 ◽  
Vol 26 ◽  
Author(s):  
Teresa Neves ◽  
Vitor Rodrigues ◽  
João Graveto ◽  
Pedro Parreira
Keyword(s):  
Adverse Events ◽  
Public Hospital ◽  
Hospital Setting ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Stable Factor ◽  
Hospital Units ◽  
Northern Regions ◽  
Structural Invariance ◽  
The Stability

Objective to contribute to the validation study of the Scale of Adverse Events associated with Nursing Practices in the hospital context. Method cross-sectional study, in public hospital units, in the central and northern regions of Portugal. The exploratory factor analysis of the Scale of Adverse Events associated to Nursing Practices was conducted with a sample of 165 nurses and the confirmatory factorial analysis was made with a sample of 685 nurses. Reliability, internal consistency and construct validity were estimated. The invariance of the model was evaluated in two subsamples to confirm the stability of the factorial solution. Results the global sample consisted of 850 nurses aged between 22 and 59, mostly licensed professionals. The model had a good overall fit in the subscales (Nursing Practices: χ2/df = 2.88, CFI = 0.90, GFI = 0.86, RMSEA = 0.05, MECVI = 3.30; Adverse Events: χ2/df = 4.62, CFI = 0.93, GFI = 0.95, RMSEA = 0.07, MECVI = 0.39). There was a stable factor structure, indicating strong invariance in the subscale Nursing Practices and structural invariance in the subscale Adverse Events. Conclusion the refined model of the Scale of Adverse Events associated with Nursing Practices revealed good fit and stability of the factorial solution. The instrument was adjusted to evaluate the perception of nurses about adverse events associated with health care, precisely nursing care, in the hospital setting.

scholarly journals Analysis of Reported E-prescribing Medication Administration Errors at King Saud Medical City, Riyadh: A Cross-Sectional, Retrospective Study

2020 ◽  
pp. 34-45
Author(s):  
Dalal Salem Al- Dossari ◽  
Mohammed Ibrahim Alnami ◽  
Naseem Akhtar Qureshi
Keyword(s):  
Saudi Arabia ◽  
Retrospective Study ◽  
Medication Errors ◽  
Drug Administration ◽  
Medication Administration ◽  
Care Hospital ◽  
Cross Sectional ◽  
Common Error ◽  
Clinical Pharmacists ◽  
Medication Administration Errors

Background: Drug prescription error is a medication error that most frequently happens in healthcare organizations and adversely affects the healthcare consumers. Most medication errors (MEs) but not all are captured and corrected before reaching the patient by designed system controls. Medication administration errors (MAEs) mostly are made by nurses but frequently reported by clinical pharmacists in hospitals in Saudi Arabia. Objective: This study aimed to analyze exclusively the voluntarily reported drug administration errors in a tertiary care hospital in Riyadh city. Methods: This cross-sectional, retrospective study evaluated consecutively collected medication administration report forms over a period of one year from January 1, 2015 to December 31, 2015. Results: The number of MAEs occurring during stage of drug administration constituted 7.1% (n=971) of total medication errors (n=13677). The maximum number of MEs (n=6838, 50%) and MAEs (n=455, 46.9%) occurred during the 4th quarter of the year 2015. The most common MAE happened to be category C (n=888, 91.5%) which means error occurred, reached the patient but without causing any harm. Concerning MAE types, the most common error included wrong frequency (40%) followed by wrong drug (17%), wrong time of administration (16%) and wrong rate of infusion (10%). Nurses made the most of the errors (92.2%) while the clinical pharmacists reported the most MAEs (75.5%). High alert medications (HAM) errors constituted 32.3% (n=314) of MAEs (n=971) and most common HAM errors included the wrong route of administration of Lanus Insulin (15%) followed by Insulin Aspart (15%), Enoxaparin (13%) and Insulin Protamine-Nvomix (12%). Look-alike and sound-alike (LASA) errors constituted 55.2% of MAEs (971/536) and most common LASA drugs identified were Gentamycin (13%), Insulin Mixtard (11%), NPH Insulin (8%) Intralipid vial (8%) and Insulin regular (6%). Conclusion: This retrospective study provides some important tentative pharmacovigilance insights into MAEs, which are partially comparable with current international trends in drug administration errors. Further studies on MAEs are warranted not only in the Kingdom of Saudi Arabia but also other Gulf countries.

scholarly journals Assessment of safety culture in a public hospital in the Federal District, Brazil

2019 ◽  
Vol 72 (suppl 1) ◽  
pp. 252-258
Author(s):  
Paloma Aparecida Carvalho ◽  
Carla Albina Soares Laundos ◽  
Juliana Ventura Souza Juliano ◽  
Luiz Augusto Casulari ◽  
Leila Bernarda Donato Gottems
Keyword(s):  
Safety Culture ◽  
Public Hospital ◽  
Federal District ◽  
High Complexity ◽  
Stress Perception ◽  
Cross Sectional ◽  
Safety Attitudes ◽  
Safety Attitudes Questionnaire ◽  
Perception Of Health ◽  
Representative Samples

ABSTRACT Objective: to assess the perception of health professionals regarding safety culture of a high complexity public hospital of the Federal District, Brazil. Method: cross-sectional and descriptive study. The Safety Attitudes Questionnaire was used in electronic format. Descriptive and inferential analyses were carried out. Results: 358 professionals participated, with 242 (67.6%) being female. Of these, 224 (62.6%) worked directly or indirectly with patients in assistance activities; 79 (22.1%) in administrative activities; 14 (3.9%) in management; and 41 (11.5%) in others. The total score was 57.1. Job satisfaction factors and stress perception had the most expressive results, 76.2 and 68.8, respectively. The category "working conditions" presented the lowest result, 40.7. Conclusion: the results are below the score of 75, value recommended as indicative of a positive safety atmosphere. We suggest the implementation of actions for the promotion of safety culture and new studies with representative samples of all segments of workers.

scholarly journals Risk factors for medication errors in the electronic and manual prescription

2016 ◽  
Vol 24 (0) ◽  
Author(s):  
Cris Renata Grou Volpe ◽  
Eveline Maria Magalhães de Melo ◽  
Lucas Barbosa de Aguiar ◽  
Diana Lúcia Moura Pinho ◽  
Marina Morato Stival
Keyword(s):  
Risk Factors ◽  
Retrospective Study ◽  
Medication Errors ◽  
Medical Records ◽  
Public Hospital ◽  
Study Data ◽  
Electronic Records ◽  
Brand Name ◽  
Electronic Prescription ◽  
Medication Process

ABSTRACT Objective: to compare electronic and manual prescriptions of a public hospital of Brasilia, identifying risk factors for the occurrence of medication errors. Method: descriptive-exploratory, comparative and retrospective study. Data collection occurred from July 2012 to January 2013, using an instrument for the review of the information contained in medical records related to the medication process. A total of 190 manual and 199 electronic records composed the sample, with 2027 prescriptions each. Results: compared to the manual prescription, a significant reduction was observed in the risk factors after implantation of the electronic prescription, in items such as "lack of the form of dilution" (71.1% to 22.3%) and "prescription with brand name" (99.5% to 31.5%). Conversely, the risk factors "no check" and "lack of CRM of the prescriber" increased. The lack of the allergy registration and the occurrences related to medication were the same for both groups. Conclusion: generally, the use of the electronic prescription system was associated with a significant reduction in risk factors for medication errors, concerning the following aspects: illegibility, prescription with brand name and presence of essential items that provide a safe and effective prescription.

scholarly journals Medication Errors and Reducing Interventions: A Mixed Study in a Teaching Hospital

2021 ◽  
Author(s):  
Serajaddin Gray ◽  
Mohammad Effatpanah ◽  
Sara Salehi ◽  
Siamand Anvari Savojbalaghi ◽  
Leila Momeni ◽  
...  
Keyword(s):  
Medication Errors ◽  
Teaching Hospital ◽  
Medication Administration ◽  
Cross Sectional Study ◽  
Special Importance ◽  
Academic Education ◽  
Personal Network ◽  
Cross Sectional ◽  
Psychological Pressure ◽  
The Right

Background: Given the special importance of preventing from medication, the present study aimed to investigate the determining Causes of Medication Errors (CMEs) and their Priorities for reducing interventions in a hospital.  Methods: The present mixed, sequential and cross-sectional study was conducted in a teaching hospital (2016). For data collection, Fishbone Diagrams, interviews, note taking and checklists were used, and qualitative data were analyzed though the thematic approach. Moreover, the Maxqda Software v.14.0, Excel, Edraw Max v.9.0 were employed for data analysis and reporting. Results: Seventy-five CMEs were classified under two main themes (human and non-human) and four sub-themes (personal, network, organizational, and meta-organizational). Weakness of professionalism and low experience as the personal causes; Actions of pharmacy colleagues, physicians and other nurses as the network causes; Management of nurses and unit specialty as the organizational causes and the quality of academic education, drug features and macro policies of medication as meta-organizational causes were classified. Six causes were given priority for reducing interventions. Conclusion: In the short term, human factors should be considered with the aim of reducing medication errors. It is also recommended that teaching how to deal with nurses’ stress and psychological pressure (especially beginner nurse), resulting from critically ill patients and high workload, be paid special attention. Besides, it is suggested that professionalism be given priority to reduce personal neglects and to create safe environments for reporting personal neglects. In addition, more emphasis should be placed on the right route in the process of medication administration.

scholarly journals THE DESCRIPTION OF MODIFIABLE RISK FACTORS IN CORONARY HEART DISEASE AT DR. SOETOMO REGIONAL PUBLIC HOSPITAL

2019 ◽  
Vol 7 (2) ◽  
pp. 85
Author(s):  
Mayla Renata Sandi ◽  
Santi Martini ◽  
Kurnia Dwi Artanti ◽  
Sri Widati
Keyword(s):  
Risk Factors ◽  
Coronary Heart Disease ◽  
Heart Disease ◽  
Public Hospital ◽  
Communicable Disease ◽  
Univariate Analysis ◽  
Sampling Technique ◽  
Primary Data ◽  
Modifiable Risk Factors ◽  
Cross Sectional

Background: Coronary heart disease (CHD) is a non-communicable disease that causes the highest mortality in the world, including in Indonesia. Risk factors for CHD are divided into modifiable and non- modifiable risk factors. Purpose: This study aims to discover the description of risk factors that are modifiable in coronary heart disease patients at Dr Soetomo Regional Public Hospital. Methods: It was a descriptive observational study with cross sectional study design. The study population was coronary heart disease patients who were doing outpatient treatment at the Integrated Heart Service Center (PPJT) of Dr. Soetomo Regional Public Hospital. The number of study sample was 72 respondents using accidental sampling technique. Data sources used are primary data using questionnaires and secondary data using medical record. Data were collected during November 2018. The location of this study was Dr. Soetomo Regional Public Hospital. The data analysis technique chosen was univariate analysis and presented in the form of a frequency distribution table. Results: The results of the study showed that the characteristics of respondents were mostly between 56-65 years old (43,05%) and male (70,84%). Risk factors found on the respondents were smoking (84,72%), hypertension (72,22%), hyperlipidemia (68,05%), diabetes mellitus (81,94%) and poor physical activity (77,77%). Conclusion: Modifiable risk factor that was mostly found on coronary heart patients was smoking, while least one was hiperlipidemia.

scholarly journals Theory-Based Failure Modes and Effect Analysis for Medication Errors

2021 ◽  
Vol 2021 ◽  
pp. 1-14
Author(s):  
Saeid Jafarzadeh Ghoushchi ◽  
Shadi Dorosti ◽  
Mohd Nizam Ab Rahman ◽  
Marzieh Khakifirooz ◽  
Mahdi Fathi
Keyword(s):  
Risk Factors ◽  
Decision Making ◽  
Medication Errors ◽  
Failure Modes ◽  
Multiple Criteria Decision Making ◽  
Medication Administration ◽  
Healthcare Management ◽  
Accurate Information ◽  
Effect Analysis ◽  
Product Assessment

Medication Errors (MEs) are still significant challenges, especially in nonautomated health systems. Qualitative studies are mostly used to identify the parameters involved in MEs. Failing to provide accurate information in expert-based decisions can provoke unrealistic results and inappropriate corrective actions eventually. However, mostly, some levels of uncertainty accompany the decisions in real practice. This study tries to present a hybrid decision-making approach to assigning different weights to risk factors and considering the uncertainty in the ranking process in the Failure Modes and Effect Analysis (FMEA) technique. Initially, significant MEs are identified by three groups of qualified experts (doctors, nurses, and pharmacists). Afterward, for assigning weights to the risk factors, Z-number couples with the Stepwise Weight Assessment Ratio Analysis (SWARA) method, named Z-SWARA, to add reliability concept in the decision-making process. Finally, the identified MEs are ranked through the developed Weighted Aggregated Sum Product Assessment (WASPAS) method, namely, Z-WASPAS. To demonstrate the applicability of the proposed approach, the ranking results compare with typical methods, such as fuzzy-WASPAS and FMEA. The findings of the present study highlight improper medication administration as the main failure mode, which can result in a fatality or patient injury. Moreover, the utilization of multiple-criteria decision-making methods in combination with Z-number can be a useful tool in the healthcare management field since it can address the problems by considering reliability and uncertainty simultaneously.

Family Perceptions of Medication Administration at School: Errors, Risk Factors, and Consequences

2008 ◽  
Vol 24 (2) ◽  
pp. 95-102 ◽  
Author(s):  
Daniel Clay ◽  
Karen Farris ◽  
Ann Marie McCarthy ◽  
Michael W. Kelly ◽  
Robyn Howarth
Keyword(s):  
Risk Factors ◽  
Medication Errors ◽  
Medication Management ◽  
Medication Administration ◽  
Health Condition ◽  
School Nurses ◽  
Family Perceptions ◽  
Students With Adhd ◽  
Physical Consequences ◽  
The Impact

Medications are administered every day in schools across the country. Researchers and clinicians have studied school nurses’ and educators’ experiences with medication administration, but not the experiences of children or their parents. This study examined medication administration from the child and parent perspectives to (a) determine problems children experience with medicines at school, (b) clarify risk factors for medication errors, and (c) examine the perceived impact of medication errors on school performance and social relationships. Participants included children ages 8 to 18 years ( n = 157) being treated at a large Midwestern Children’s Hospital in diabetes, asthma, and Attention Deficit Hyperactivity Disorder (ADHD) clinics. Findings suggest that forgetting a dose and running out of medication were the most common problems. Missing a dose was more frequent in students with ADHD than in students with diabetes or asthma. Medication nonadherence at school, which includes medication administration errors such as missing a dose, may potentially lead to a variety of educational, social/emotional, and physical consequences. These results indicate that the impact of missing medication on children with ADHD appeared to have a greater effect on schoolwork and friendships, while the physical consequences appeared to vary widely based on health condition. Interestingly, children with more self-responsibility for medications were less likely to report medication errors. School nurses will want to include students when planning for medication management at school.

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