scholarly journals The Prevalence, Barriers to Medication Error Reports, and Perceptions of Nurses toward the Causes of Medication Errors in the Hospitals Affiliated to North Khorasan University of Medical Sciences, Iran

2019 ◽  
Vol 32 (117) ◽  
pp. 58-68
Author(s):  
M Ghorbanzadeh ◽  
S Gholami ◽  
A Sarani ◽  
F Badeli ◽  
F Nasimi ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medical Sciences ◽  
Error Reports

Anticoagulant medication errors in hospitals and primary care: a cross-sectional study

2018 ◽  
Vol 31 (5) ◽  
pp. 346-352 ◽  
Author(s):  
Albert R Dreijer ◽  
Jeroen Diepstraten ◽  
Vera E Bukkems ◽  
Peter G M Mol ◽  
Frank W G Leebeek ◽  
...  
Keyword(s):  
Human Factors ◽  
Medication Error ◽  
Medication Errors ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Cross Sectional ◽  
Medication Process ◽  
Before And After ◽  
Anticoagulant Medication ◽  
Error Reports

Abstract Objective To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase). Design A cross-sectional study. Setting Medication errors reported to the Central Medication incidents Registration reporting system. Participants Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR. Intervention N/A. Main outcome measure Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline. Results Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline. Conclusions Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.

Analysis of Medication Error Reports

2004 ◽  
Author(s):  
Paul Whitney ◽  
Jonathan Young ◽  
John Santell ◽  
Rodney Hicks ◽  
Christian Posse ◽  
...  
Keyword(s):  
Data Analysis ◽  
Medication Error ◽  
Medication Errors ◽  
Free Text ◽  
Area Of Interest ◽  
Analysis Tools ◽  
Depth Analysis ◽  
Reporting Programs ◽  
Types Of Information ◽  
Error Reports

In medicine, as in many areas of research and society, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been a corresponding lag in our abilities to analyze this mass of data, and traditional forms and expressions of statistical analysis do not allow researchers and practitioners to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports are approached as data comparisons, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Additionally, the “types” of information objects that can be the objects of data analysis have been extended to include text [8][9]. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. USP conducts an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.

scholarly journals Patterns of medication errors involving pediatric population reported to the French Medication Error Guichet

2021 ◽  
Vol 19 (2) ◽  
pp. 2360
Author(s):  
Christine Azar ◽  
Delphine Allué ◽  
Marie B. Valnet-Rabier ◽  
Laurent Chouchana ◽  
Fanny Rocher ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Pediatric Population ◽  
Hospital Setting ◽  
Community Setting ◽  
Blood Substitutes ◽  
Community Settings ◽  
Prevention Measures ◽  
Error Type ◽  
Error Reports

Background: Medication error is a global threat to patient safety, particularly in pediatrics. Yet, this issue remains understudied in this population, in both hospital and community settings. Objectives: To characterize medication errors involving pediatrics reported to the French Medication Error Guichet, and compare them with medication errors in adults, in each of the hospital and community settings. Methods: This was a retrospective secondary data analysis of medication errors reported throughout 2013-2017. Descriptive and multivariate analyses were performed to compare actual and potential medication error reports between pediatrics (aged <18 years) and adults (aged >18 and <60 years). Two subanalyses of actual medication errors with adverse drug reaction (ADR), and serious ADR were conducted. Results:  We analyzed 4,718 medication error reports. In pediatrics, both in hospital (n=791) and community (n=1,541) settings, antibacterials for systemic use (n=121, 15.7%; n=157, 10.4%, respectively) and wrong dose error type (n=391, 49.6%; n=549, 35.7%, respectively) were frequently reported in medication errors. These characteristics were also significantly more likely to be associated with reported errors in pediatrics compared with adults. In the hospital setting, analgesics (adjusted odds ratio (aOR)=1.59; 95% confidence interval (CI) 1.03:2.45), and blood substitutes and perfusion solutions (aOR=3.74; 95%CI 2.24:6.25) were more likely to be associated with reported medication errors in pediatrics; the latter drug class (aOR=3.02; 95%CI 1.59:5.72) along with wrong technique (aOR=2.28; 95%CI 1.01:5.19) and wrong route (aOR=2.74; 95%CI 1.22:6.15) error types related more to reported medication errors with serious ADR in pediatrics. In the community setting, the most frequently reported pediatric medication errors involved vaccines (n=389, 25.7%). Psycholeptics (aOR=2.42; 95%CI 1.36:4.31) were more likely to be associated with reported medication errors with serious ADR in pediatrics. Wrong technique error type (aOR=2.71; 95%CI 1.47:5.00) related more to reported medication errors with ADR in pediatrics. Conclusions: We identified pediatric-specific medication error patterns in the hospital and community settings. Our findings inform focused error prevention measures, and pave the way for interventional research targeting the needs of this population.

How Useful Are Voluntary Medication Error Reports? The Case of Warfarin-Related Medication Errors

2008 ◽  
Vol 34 (1) ◽  
pp. 36-45 ◽  
Author(s):  
Chunliu Zhan ◽  
Scott R. Smith ◽  
Margaret A. Keyes ◽  
Rodney W. Hicks ◽  
Diane D. Cousins ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Error Reports

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 Medication Error in Anaesthesia – A Review

2016 ◽  
Vol 27 (1) ◽  
pp. 31-35
Author(s):  
Montosh Kumar Mondal ◽  
Beauty Rani Roy ◽  
Shibani Banik ◽  
Debabrata Banik
Keyword(s):  
Public Health ◽  
Risk Factors ◽  
Medication Error ◽  
Medication Errors ◽  
Health Problem ◽  
Preventive Measures ◽  
Medical Profession ◽  
Public Health Problem ◽  
Global Public Health ◽  
Global Public Health Problem

Medication error is a major cause of morbidity and mortality in medical profession . There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers.Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 31-35

scholarly journals Medication Errors: Scope and prevention strategies

2012 ◽  
Vol 1 (2) ◽  
pp. 54 ◽  
Author(s):  
Luigi Brunetti ◽  
Dong-Churl Suh
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Health Concern ◽  
Prevention Strategies ◽  
Error Prevention ◽  
Integration Of Technology ◽  
Significant Public Health Concern ◽  
Significant Public Health ◽  
Safety Systems ◽  
Improve Patient

Background: Medication errors are a significant public health concern.  Although significant advances have been made, errors are still relatively common and represent an opportunity for healthcare improvement.Methodology/Principal Findings: Since the publication of To Err is Human, medication errors have been under tremendous scrutiny.  Organizations have moved towards a non-punitive approach to evaluating errors.  This approach to medication errors has aided in identifying common pathways to medication errors and improving understanding regarding the anatomy of a medication error.  As a result, prevention strategies have been developed to target common themes contributing to errors.  Error prevention strategies may target common contributors of medication errors, broadly grouped as performance lapses, lack of knowledge, and lack or failure of safety systems.  Strategies to thwart medication errors range from process improvement to integration of technology in the health care environment.Conclusions/Significance:  Organizations should devote resources to address medication error prevention strategies in an effort to improve patient outcomes and decrease morbidity and mortality associated with medication errors.

scholarly journals Observational Study of Medication Error in Outpatient Pharmacy RSUP Dr. Hasan Sadikin Bandung

2017 ◽  
Vol 15 (2) ◽  
pp. 210
Author(s):  
Viki Hestiarini ◽  
Lia Amalia ◽  
Eni Margayani
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Drug Information ◽  
Data Entry ◽  
Care Process ◽  
Analysis Method ◽  
Risk Priority Number ◽  
Effect Analysis ◽  
Root Cause ◽  
Cause Of Failure

Medication error can occur at all stages, starting from prescribing, dispensing and administration of drugs. This study aims to assess the medication errors that occur in the pharmaceutical care process and analyze the cause of failure using the root cause analysis method, to improvement action and decrease the incidence of medication errors. The data were completeness prescription, frequency of dispensing error and completeness of drug information. The number of sample was 1100 prescriptions Prescribing errors were found the potential injury 15.69±11.51% and near missed error 0.5±0.55%. At dispensing stage, occur 427 incidences (9.71%), consist of two incidences (0.04%) for validation assessment regulations, 224 incidences (5.09%) of data entry, 113 incidences (2.57%) of retrieval of drugs, 19 incidences (0.43%) of fi ll in drugs, 69 incidences (1.57%) of fi nal check. At dispensing stage, near missed 330 incidences (7.51%) of near missed and 97 incidences (2.21%) of potential injury. Failure mode and effect analysis calculate of risk priority number, the drug retrieval (RPN 210) and data entry (RPN 126) were analyzed root cause of the analysis for man, material, method, facility and environment.

Sign in / Sign up

Export Citation Format

Share Document