scholarly journals THE NATURAL AND PREVALENCE OF MEDICATION ERRORS IN A TERTIARY HOSPITAL IN INDONESIA

2021 ◽  
pp. 55-58
Author(s):  
ANDIKA DWI MAHENDRA
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Improve Patient Safety ◽  
Medical Center ◽  
Hospital Setting ◽  
Tertiary Hospital ◽  
Prescribing Error ◽  
Electronic Prescription ◽  
Mortality And Morbidity ◽  
Medication Error Reporting

Objective: Medication error is the most common errors in a hospital setting and a serious issue that intimidate the safety of the patient and may cause mortality and morbidity. The aim of this study is to explore the rate of medication errors reporting in an Indonesian hospital. Methods: This study is retrospective and descriptive. This research was conducted at dr. Soeradji Tirtonegoro General Hospital Medical Center from January to June 2020. Medication error reporting, which was reported for six months, was the sample of the study. Results: On the period, 105,171 prescribing sheets were collected. 9.5% of the total prescribing sheets are categorized as Medication Error (ME). The highest incident of ME was prescribing error (88.24%), then followed by transcribing error (7.61%), dispensing error (4.02%), and the last was administration error (0.13%). Conclusion: The most common incident occurred at prescribing stage because the hospital is not supported by electronic prescription. Medication error is an inevitable event during the medication process. But, the incidents can be minimized by implementing some preventive strategies to improve patient safety and safe drug use.

scholarly journals THE IMPACT OF BARCODE MEDICATION ADMINISTRATION ON PATIENT SAFETY: A SYSTEMATIC REVIEW

2021 ◽  
Vol 5 (6) ◽  
Author(s):  
Seham Sahal Aloufi
Keyword(s):  
Systematic Review ◽  
Patient Safety ◽  
Medication Error ◽  
Medication Errors ◽  
Improve Patient Safety ◽  
Hospital Setting ◽  
Medication Administration ◽  
Bar Code ◽  
The Impact ◽  
Improve Patient

Patient safety is considered as an essential feature of healthcare system. Many trials have been conducted in order to find ways to improve patient safety, and many reports indicate that medication errors pose a threat to patient safety. Thus, some studies have investigated the impact of bar code medication administration (BCMA) system on medication error reduction during the medication administration procedure. This systematic review (SR) reports the impact of BCMA system on reducing medication errors to improve patient safety; it also compares traditional medication administration with the BCMA system. The review concentrates on the effectiveness of BCMA technology on medication administration errors, and on the accuracy of medication administration. This review also focused on different designs of quantitative studies, as they are more effective at investigating the impact of the intervention than qualitative studies. The findings from this systematic review show various results depending on the nature of the hospital setting. Most of the studies agree that the BCMA system enhances compliance with the 'five rights’' requirement (right drug, right patient, right dose, right time and right route) of medication administration. In addition, BCMA technology identified medication error types that could not be identified with the traditional approach which is applying the 'five rights' of medication administration. The findings of this systematic review also confirm the impact of BCMA system in reducing medication error, preventing adverse events and increasing the accuracy of the medication administration rate. However, BCMA technology did not consistently reduce the overall errors of medication administration. Keyword: Patient Safety, Impact, BCMA, eMAR

scholarly journals Pharmacist-Initiated Medication Error-Reporting and Monitoring Programme in a Developing Country Scenario

Pharmacy ◽  
2018 ◽  
Vol 6 (4) ◽  
pp. 133 ◽  
Author(s):  
Sri Chalasani ◽  
Madhan Ramesh ◽  
Parthasarathi Gurumurthy
Keyword(s):  
Patient Safety ◽  
Medication Error ◽  
Medication Errors ◽  
Reporting System ◽  
Improve Patient Safety ◽  
Monitoring Programme ◽  
Error Reporting ◽  
Medication Error Reporting ◽  
Hospitalised Patients ◽  
Improve Patient

Medication errors (MEs) often prelude guilt and fear in health care professionals (HCPs), thereby resulting in under-reporting and further compromising patient safety. To improve patient safety, we conducted a study on the implementation of a voluntary medication error-reporting and monitoring programme. The ME reporting system was established using the principles based on prospective, voluntary, open, anonymous, and stand-alone surveillance in a tertiary care teaching hospital located in South India. A prospective observational study was carried out for three years and a voluntary Medication Error-reporting Form was developed to report medication errors MEs that had occurred in patients of either sex were included in the study, and the reporters were given the choice to remain anonymous. The analysis was carried out and discussed with HCPs to minimise the recurrence. A total of 1310 medication errors were reported among 20,256 hospitalised patients and the incidence was 6.4%. Common aetiologies were administration errors [501 (38.2%)], followed by prescribing and transcribing errors [363 (28%)]. Root-cause of these MEs were distractions, workload, and communications. Analgesics/antipyretics (19.4%) and antibiotics (15.7%) were the most commonly implicated classes of medications. A clinical pharmacist initiated non-punitive anonymous ME reporting system could improve patient safety.

Analisis Faktor Perawat Dalam Pelaksanakan Keselamatan Pasien Terhadap Kejadian Medication Administration Error di Rumah Sakit

2020 ◽  
Author(s):  
Bintang Marsondang Rambe
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Prescribing Error ◽  
Medication Administration Error ◽  
Administration Error

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.

scholarly journals How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

2020 ◽  
Author(s):  
Peter J Gates ◽  
Rae-Anne Hardie ◽  
Magdalena Z Raban ◽  
Ling Li ◽  
Johanna I Westbrook
Keyword(s):  
Systematic Review ◽  
Medication Error ◽  
Medication Errors ◽  
Meta Analysis ◽  
Error Rates ◽  
Prescribing Error ◽  
Before And After ◽  
Actual Harm ◽  
Computer Based ◽  
Wide Scale

Abstract Objective To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS. Materials and Methods We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed. Results There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18–8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72–0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence. Discussion and Conclusion Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.

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)

P33 Health information technology and the changing nature of medication errors in paediatric intensive care – a modified delphi process

2018 ◽  
Vol 103 (2) ◽  
pp. e2.37-e2
Author(s):  
Moninne Howlett ◽  
Brian Cleary ◽  
Cormac Breatnach
Keyword(s):  
Information Technology ◽  
Intensive Care ◽  
Medication Error ◽  
Health Information ◽  
Medication Errors ◽  
Delphi Process ◽  
Paediatric Intensive Care ◽  
Electronic Prescribing ◽  
Prescribing Error ◽  
Smart Pump

AimsThe term ‘medication error’ has numerous definitions, impeding comparison between studies and is susceptible to subjectivity.1 The Delphi Process is widely used in health research to achieve consensus and has been previously used to define and specify medication error scenarios in both paediatric and adult settings.2,3 Novel technology-generated errors are emerging with increasing use of health information technology (HIT).4 Application of earlier Delphi studies to novel errors and those common in the prescribing of infusions in paediatric intensive care is limited. This study aims to achieve consensus on medication error scenarios identified in a paediatric intensive care unit (PICU) that have not been previously defined.MethodsStage 1 identified the scenarios requiring consensus. These were grouped into 3 error categories: electronic prescribing, smart-pump and prescribing of PICU infusions. Stage 2 selected a multidisciplinary expert panel using both purposive and convenience sampling. Stage 3 involved iterative rounds of consensus using paper-based and newer e-Delphi techniques. Participants independently scored on a 9-point scale their extent of agreement on the inclusion of each scenario as an error. Median and inter-quartile ranges were used to assess group consensus and to provide controlled feedback after each round.Results19 scenarios requiring consensus were identified. A panel of 37 participants was selected, comprising of 15 doctors, 13 nurses and 9 pharmacists. 35 participants were from the study site, 1 pharmacist from a local PICU and 1 from a local NICU. Round 1 achieved consensus on 11 scenarios, increasing to 14 in Round 2. Round 3 consisted of 2 scenarios, both electronic prescribing related. Individual opinion on these was diverse, with 1 remaining equivocal after round 3. Some differences between healthcare professionals were found, but were only significant (p<0.05) for two and three scenarios in rounds 2 and 3 respectively.ConclusionThe Delphi Process can successfully be employed to reach consensus on HIT-generated novel errors. The complexity of electronic prescribing systems is evident in the included errors and the difficulty in obtaining consensus. In contrast, the broad consensus reached on all smart-pump scenarios reflects the known risks associated with infusion pumps. The included scenarios highlight the limitation of smart-pump technology as a single intervention. Further similar studies are likely to be required as more novel errors emerge with increased HIT implementation across the entire medication use process. This extended tool should add to the quality of future paediatric medication error studies across a broad range of settings.ReferencesLisby M, Nielsen LP, Brock B, et al. How are medication errors defined? A systematic literature review of definitions and characteristics. Int J Qual Health Care2010;22(6):507–18.Dean B, Barber N, Schachter M. What is a prescribing error?Qual Health Care2000;9(4):232–7.Ghaleb MA, Barber N, Dean Franklin B, et al. What constitutes a prescribing error in paediatrics?Qual Saf Health Care2005;14(5):352–7.Walsh KE, Landrigan CP, Adams WG, et al. Effect of computer order entry on prevention of serious medication errors in hospitalised children. Paediatrics2008;121(3):e421–7.

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.”

scholarly journals MEDICATION ERROR OVERVIEW AND PREVENTION STRATEGIES

2021 ◽  
pp. 19-24
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Safety ◽  
Improve Patient Safety ◽  
Over The Counter ◽  
Reconciliation Analysis ◽  
Prescribing Medication ◽  
Care Costs ◽  
Improve Patient ◽  
Safety Strategy

This literature review aims to highlight the overview of medication errors and strategies to avoid and decrease medication errors. Availability of various types of over-the-counter and prescribed medication has added to the risk of medication. Also, the medication chain has different steps, and different people are involved in each step, such as prescribing medication, dispensing, and administering medication. Every phase in the medication chain is prone to risks that can lead to medication errors. Medication safety is the responsibility of every healthcare professional involved in the medication chain to deliver effective and safe care to patients with an optimal outcome. A medication error can happen in every health care setting to decrease and prevent medication errors. It is critically important to have complete knowledge of the medication use chain and integrate evidence-based strategies, such as medication reconciliation, analysis of medication error, double-check, and avoiding interruption and distraction into practice. Medication errors can lead to patient harm, prevent on-time discharges, and increase care costs. Medication safety culture can shine in a setting of effectively applying strategy into practice, and everyone's collaboration and commitment to adhere to medication safety strategy can improve patient safety.

Impact of an Antimicrobial Stewardship Team on Reducing Antiretroviral Medication Errors

2020 ◽  
Vol 54 (8) ◽  
pp. 767-774
Author(s):  
Kwabena Nimarko ◽  
Aiman Bandali ◽  
Tiffany E. Bias ◽  
Sharon Mindel
Keyword(s):  
Drug Interactions ◽  
Medication Error ◽  
Medication Errors ◽  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Inpatient Setting ◽  
Error Type ◽  
Significant Difference ◽  
The Impact

Background: Numerous interventions have been used to reduce medication errors related to antiretroviral (ARV) therapy for hospitalized patients with HIV. Objective: This study assessed the impact of an antimicrobial stewardship (ASP) team intervention on reducing the rate of ARV therapy errors in patients admitted to an academic medical center. Methods: This observational, retrospective study included patients who received ARV therapy from June 2016 to December 2017. The primary outcome was evaluation of ASP team performance in detecting ARV medication errors in the inpatient setting. Errors were further categorized by type (interaction, dosing, regimen). The Mann-Whitney U test and χ2 tests were utilized to analyze continuous and categorical data, respectively. Results: Medication errors occurred in 51% of patients in the preintervention group (n = 152) and 48% of patients in the postintervention group (n = 203; P = 0.43). The most frequent medication error type was drug interactions in both groups, involving integrase strand transfer inhibitors and polyvalent cations (64% vs 67%). There was a significant difference between preintervention and postintervention groups regarding number of errors detected (13 vs 106, P < 0.001), corrected (12 vs 86, P < 0.001), and persisting at discharge (106 vs 18, P < 0.001). Conclusion and Relevance: Review of ARV regimens by an ASP team significantly decreased medication errors. Drug interactions are the most common medication error found in HIV-positive patients admitted to our academic center.

Verifying Medication Orders in the Older Population: Are We Using Enough Caution?

2020 ◽  
Vol 35 (4) ◽  
pp. 182-186
Author(s):  
Ali Scrimenti ◽  
Luke A. Probst ◽  
Christopher D. Miller ◽  
Kelly R. Ulen ◽  
John Noviasky ◽  
...  
Keyword(s):  
Older People ◽  
Medication Error ◽  
Drug Information ◽  
Medical Center ◽  
Academic Medical Center ◽  
Age Groups ◽  
Hospital Setting ◽  
Error Prevention ◽  
Attitudinal Differences ◽  
Medication Error Prevention

OBJECTIVE: To test the common hypothesis that pharmacists may use more caution and resources when processing pediatric versus geriatric medication orders in the hospital setting.<br/> DESIGN: A 26-item electronic survey was distributed to a sample of participating academic medical-center pharmacy directors with the request to disseminate it to staff pharmacists. The survey was resent at two-week intervals on two occasions.<br/> MAIN OUTCOME MEASURE(S): To identify if pharmacists take more caution when processing geriatric or pediatric medication orders, to characterize the frequency pharmacists use drug information resources when processing these orders, and to assess the level of importance pharmacists place on guidelines for medication error prevention when processing medication orders.<br/> RESULTS: A total of 173 out of 271 pharmacists completed the survey, resulting in a high final completion rate of 63.8%. Most were clinical, residencytrained pharmacists. A majority of respondents stated that they take more caution when verifying pediatric medication orders than they do for orders for older people (125 out of 172, or 72.7%). Pharmacists report they were 4.2 times more likely to refer to a drug information resource for ≥ 50% of pediatric orders versus geriatric orders (pediatric: 118 out of 171, or 69.0% vs. geriatric: 59 out of 172, or 34.3%; P < 0.001, or 95% confidence interval [CI] 4.156 [2.647-6.524]). Finally, pharmacists familiar with the guidelines for medication error prevention were 2.3 times more likely to state the pediatric guidelines were very important (pediatric: 51/171, or 29.8% vs. geriatric: 27/172, or 15.7%; P = 0.002, or 95% CI 2.28 [1.35-3.86]).<br/> CONCLUSION: This survey reveals evidence for attitudinal differences in work practices for pharmacists working with medication orders relating to different age groups. Given the challenges involved in drug treatment for the older patient population, a similar level of caution, preparedness to refer to drug information, and to use guidelines should apply for both pediatric medication orders and those for older people, in order to provide safe and comprehensive care.

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