scholarly journals Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 2

2020 ◽  
Vol 67 (1) ◽  
pp. 48-59
Author(s):  
Daniel S. Sarasin ◽  
Jason W. Brady ◽  
Roy L. Stevens
Keyword(s):  
General Anesthesia ◽  
Medication Errors ◽  
Medication Safety ◽  
Adverse Drug Events ◽  
Contributing Factors ◽  
Full Spectrum ◽  
Dental Profession ◽  
Novel Method ◽  
Dental Providers ◽  
Preventive Methods

For decades, the dental profession has provided the full spectrum of anesthesia services ranging from local anesthesia to general anesthesia in the office-based ambulatory environment to alleviate pain and anxiety. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article illuminated the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medical anesthesia has implemented to manage such problems that may have utility in dentistry, and introduce a novel method for addressing these issues within dentistry known as the Dental Anesthesia Medication Safety Paradigm (DAMSP).

scholarly journals Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 1

2019 ◽  
Vol 66 (3) ◽  
pp. 162-172
Author(s):  
Daniel S. Sarasin ◽  
Jason W. Brady ◽  
Roy L. Stevens
Keyword(s):  
General Anesthesia ◽  
Medication Errors ◽  
Medication Safety ◽  
Adverse Drug Events ◽  
Medical Literature ◽  
Contributing Factors ◽  
Prevention And Early Detection ◽  
Dental Profession ◽  
Dental Providers ◽  
Preventive Methods

For decades, the dental profession has provided anesthesia services in office-based, ambulatory settings to alleviate pain and anxiety, ranging from local anesthesia to general anesthesia. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a substantial lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article will illuminate the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medicine has implemented to manage such problems, and introduce a method for addressing these issues with the dental anesthesia medication safety paradigm.

Improving Medication Safety Through the Use of Metrics

2013 ◽  
Vol 27 (1) ◽  
pp. 61-64
Author(s):  
Robert D. Beckett ◽  
Marina Yazdi ◽  
Laura J. Hanson ◽  
Ross W. Thompson
Keyword(s):  
Medication Errors ◽  
Medication Safety ◽  
Adverse Drug Events ◽  
Safety Information ◽  
Medication Use ◽  
Cross Sectional Study ◽  
Survey Instrument ◽  
Sectional Study ◽  
Cross Sectional ◽  
Safety Metrics

Purpose: Describe medication safety metrics used at University HealthSystem Consortium (UHC) institutions and recommend a meaningful way to report and communicate medication safety information across an organization. Methods: A cross-sectional study was conducted using an electronically distributed, open-ended survey instrument. Results: Twenty percent of the UHC institutions responded to our survey. Seventy-seven percent of those institutions responding to our survey reported their organization has defined metrics to measure medication safety; an additional 21% of the institutions were still in the process of defining metrics. Of metrics that were reported, 33% were true medication safety metrics. Results are distributed to a wide variety of institutional venues. Conclusion: Institutions should take several actions related to medication safety including defining local metrics; building metrics addressing preventable adverse drug events, medication errors, and technology; and reporting results to a variety of venues in order to design specific interventions to improve local medication use.

scholarly journals Contributing factors that influence medication errors in the prehospital paramedic environment: a mixed-method systematic review protocol

BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e034094
Author(s):  
Dennis Walker ◽  
Clint Moloney ◽  
Brendan SueSee ◽  
Renee Sharples
Keyword(s):  
Systematic Review ◽  
Medication Errors ◽  
Medication Safety ◽  
Data Extraction ◽  
Prehospital Care ◽  
Integrated Approach ◽  
Care Providers ◽  
Contributing Factors ◽  
Multiple Sources ◽  
Qualitative Synthesis

IntroductionThere is limited reliable research available on medication errors in relation to paramedic practice, with most evidence-based medication safety guidelines based on research in nursing, operating theatre and pharmacy settings. While similarities exist, evidence suggests that the prehospital environment is distinctly different in many aspects. The prevention of errors requires attention to factors from the organisational and regulatory level down to specific tasks and patient characteristics. The evidence available suggests errors may occur in up to 12.76% of medication administrations in some prehospital settings. With multiple sources stating that the errors are under-reported, this represents significant potential for patient harm. This review will seek to identify the factors influencing the occurrence of medication errors by paramedics in the prehospital environment.Methods and analysisThe review will include qualitative and quantitative studies involving interventions or phenomena regarding medication errors or medication safety relating to paramedics (including emergency medical technicians and other prehospital care providers) within the prehospital environment. A search will be conducted using MEDLINE (Ovid), EBSCOhost Megafile Search, the International Committee of Medical Journal Editors trial registry, Google Scholar and the OpenGrey database to identify studies meeting this inclusion criteria, with initial searches commencing 30 September 2019. Studies selected will undergo assessment of methodological quality, with data to be extracted from all studies irrespective of quality. Each stage of study selection, appraisal and data extraction will be conducted by two reviewers, with a third reviewer deciding any unresolved conflicts. The review will follow a convergent integrated approach, conducting a single qualitative synthesis of qualitative and ‘qualitised’ quantitative data.Ethics and disseminationNo ethical approval was required for this review. Findings from this systematic review will be disseminated via publications, reports and conference presentations.

Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS

2021 ◽  
pp. 0310057X2110275
Author(s):  
Jee Young Kim ◽  
Matthew R Moore ◽  
Martin D Culwick ◽  
Jacqueline A Hannam ◽  
Craig S Webster ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Safety Culture ◽  
Medication Safety ◽  
Reporting System ◽  
Current Evidence ◽  
Contributing Factors ◽  
Incident Reporting System ◽  
Wrong Side ◽  
Inappropriate Choice

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.

scholarly journals Understanding Health Information Technology Induced Medication Safety Events by Two Conceptual Frameworks

2019 ◽  
Vol 10 (01) ◽  
pp. 158-167 ◽  
Author(s):  
Ju Wang ◽  
Hongyuan Liang ◽  
Hong Kang ◽  
Yang Gong
Keyword(s):  
Information Technology ◽  
Health Information ◽  
Medication Errors ◽  
Value Chain ◽  
Medication Safety ◽  
Information Value ◽  
Health It ◽  
Missing Information ◽  
Contributing Factors ◽  
The Impact

Background While health information technology (health IT) is able to prevent medication errors in many ways, it may also potentially introduce new paths to errors. To understand the impact of health IT induced medication errors, this study aims to conduct a retrospective analysis of medication safety reports. Methods From the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience database, we identified reports in which health IT is a contributing factor to medication errors. We applied two conceptual frameworks, Sittig and Singh's sociotechnical model and Coiera's information value chain, to examine the identified reports. Results We identified 152 unique reports on health IT induced medication errors as the final report set for review. The majority (65.13%) of the reports involved multiple contributing factors according to the sociotechnical model. Three dimensions, that is, clinical content, human–computer interface, and people, were involved in more reports than the others. The transition of the effects of health IT on medication practice was summarized using information value chain. Health IT related contributing factors may lead to receiving wrong information, missing information, receiving partial information and delayed information, and receiving wrong information and missing information tend to cause the commission errors in decision-making. Conclusion The two frameworks provide an opportunity to understand a comprehensive context of safety event and the impact of health IT induced errors on medication safety. The sociotechnical model helps identify the aspects causing medication safety issues. The information value chain helps uncover the effect of the health IT induced medication errors on health care process and patient outcomes.

scholarly journals Medication Safety in Patients under 18 Years Old; a Retrospective Study based on Iraqi Pharmacovigilance Center Database

2020 ◽  
Vol 29 (2) ◽  
pp. 152-160
Author(s):  
Hani Gh. Jawad ◽  
Eman S. Saleh ◽  
Manal M. Younus
Keyword(s):  
Adverse Drug Reaction ◽  
Drug Reaction ◽  
Medication Errors ◽  
Medication Safety ◽  
Treatment Process ◽  
Adverse Drug Events ◽  
Risk Groups ◽  
World Health ◽  
Global Challenge ◽  
Pharmacovigilance Center

Medication safety is an important part of the comprehensive patient safety term. Medication safety is gaining more attention as the World Health Organization set the goal of decreasing medication harm by (50%) for the next 5 years when launching the third global challenge. Studying medication safety in the risk groups such as young ages, children are crucial to learn more about the effect of medicines in this risk group since they are not included in the clinical trials. Adverse drug reaction is defined as any harm resulted from the drug itself during medical process journey, while medication errors are any harm resulted from the treatment process rather than the drug or it is the result of the failure in a step of the treatment process and by that it came clear that adverse drug reaction in non-preventable event while medication error is preventable one. The objectives of this study are to find the preventable medication errors from the Iraqi database of Adverse drug events in ages from neonatal to adolescent age. This study is a retrospective descriptive study conducted using the Iraqi pharmacovigilance center database. The study included reports that were received by the Iraqi pharmacovigilance center from 1st of January 2014 until the 1st of January 2020. In this study, the total number of reports included was 2344. The type of medication involved, type of adverse event, type of error and

scholarly journals Engaging hospital patients in the medication reconciliation process using tablet computers

2018 ◽  
Vol 25 (11) ◽  
pp. 1460-1469 ◽  
Author(s):  
Jennifer E Prey ◽  
Fernanda Polubriaginof ◽  
Lisa V Grossman ◽  
Ruth Masterson Creber ◽  
Demetra Tsapepas ◽  
...  
Keyword(s):  
Medication Review ◽  
Medication Safety ◽  
Medication Reconciliation ◽  
Adverse Drug Events ◽  
Medication List ◽  
Medication Discrepancies ◽  
Home Medication ◽  
Verbal Participation ◽  
Hospital Patients ◽  
Home Medication Review

Abstract Objective Unintentional medication discrepancies contribute to preventable adverse drug events in patients. Patient engagement in medication safety beyond verbal participation in medication reconciliation is limited. We conducted a pilot study to determine whether patients’ use of an electronic home medication review tool could improve medication safety during hospitalization. Materials and Methods Patients were randomized to use a toolbefore orafter hospital admission medication reconciliation to review and modify their home medication list. We assessed the quantity, potential severity, and potential harm of patients’ and clinicians’ medication changes. We also surveyed clinicians to assess the tool’s usefulness. Results Of 76 patients approached, 65 (86%) participated. Forty-eight (74%) made changes to their home medication list [before: 29 (81%),after: 19 (66%),p = .170].Before group participants identified 57 changes that clinicians subsequently missed on admission medication reconciliation. Thirty-nine (74%) had a significant or greater potential severity, and 19 (36%) had a greater than 50-50 chance of harm.After group patients identified 68 additional changes to their reconciled medication lists. Fifty-one (75%) had a significant or greater potential severity, and 33 (49%) had a greater than 50-50 chance of harm. Clinicians reported believing that the tool would save time, and patients would supply useful information. Discussion The results demonstrate a high willingness of patients to engage in medication reconciliation, and show that patients were able to identify important medication discrepancies and often changes that clinicians missed. Conclusion Engaging patients in admission medication reconciliation using an electronic home medication review tool may improve medication safety during hospitalization.

scholarly journals Reducing the Risk of Harm from Medication Errors in Children

2013 ◽  
Vol 6 ◽  
pp. HSI.S10454 ◽  
Author(s):  
Daniel R. Neuspiel ◽  
Melissa M. Taylor
Keyword(s):  
Medication Errors ◽  
Health Care Providers ◽  
Adverse Drug Events ◽  
Chronic Illnesses ◽  
Future Research ◽  
Care Providers ◽  
Pediatric Age Group ◽  
Improvement Interventions ◽  
Communication Ability ◽  
Quality Improvement Interventions

Medication errors affect the pediatric age group in all settings: outpatient, inpatient, emergency department, and at home. Children may be at special risk due to size and physiologic variability, limited communication ability, and treatment by nonpediatric health care providers. Those with chronic illnesses and on multiple medications may be at higher risk of experiencing adverse drug events. Some strategies that have been employed to reduce harm from pediatric medication errors include e-prescribing and computerized provider order entry with decision support, medication reconciliation, barcode systems, clinical pharmacists in medical settings, medical staff training, package changes to reduce look-alike/sound-alike confusion, standardization of labeling and measurement devices for home administration, and quality improvement interventions to promote nonpunitive reporting of medication errors coupled with changes in systems and cultures. Future research is needed to measure the effectiveness of these preventive strategies.

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