Medication error with artesunate-amodiaquine: Case report and root cause analysis

2014 ◽  
Vol 13 (1) ◽  
pp. 62
Author(s):  
ObehiAituaje Akoria ◽  
FranklinChisom Anamefuna
Keyword(s):  
Case Report ◽  
Medication Error ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

scholarly journals To err is human: medication patient safety in aged care, a case study

2018 ◽  
Vol 19 (2) ◽  
pp. 126-134
Author(s):  
Julia Gilbert ◽  
Jeong-ah Kim
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Management ◽  
Care Facility ◽  
Root Cause Analysis ◽  
Aged Care ◽  
Cause Analysis ◽  
Content Type ◽  
Root Cause

Purpose The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study. Design/methodology/approach In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility. Findings Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013). Originality/value Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

scholarly journals Applying MAC-F Method for Causes Analysis of the Proven Medication Error in a Moroccan Hospital

2020 ◽  
Vol 5 (2) ◽  
pp. 255-277
Author(s):  
Souad FILALI EL GHORFI ◽  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
High Reliability ◽  
Decision Support Tool ◽  
Root Cause Analysis ◽  
Organizational System ◽  
Cause Analysis ◽  
Support Tool ◽  
Root Cause ◽  
Overall Reliability

Medication error (ME) is a serious problem of public health. Difficulties related to the management of this error are numerous. Each stage of this process suffers from several flaws: identification, root causes analysis and improvement. This paper focuses on root cause analysis of medication error. We developed an original semi-quantitative method named “MAC-F (Méthode d’Analyse des Causes basée sur la Fiabilité globale, in French). It’s specific to the hospital context and constitutes a decision-making tool for professional of care. It based on a rigorous theoretical and conceptual framework (human reliability theory and high reliability organization theory). We used our method MAC F to analyze serious proven medication errors. They have been collected over the past six months (from January to June 2020) in Moroccan hospital. The reliability matrix shows that the overall reliability index is very low (Ω= 0,07). Moroccan hospital is therefore unreliable. The failure of the organizational system (Ω CF= 0,03) and the absence of preventive strategies (ΩIF= 0) don’t help practitioners to recover the medication errors (ΩSF= 0,23). Root cause analysis is the most critical step in managing medication errors. Our aim is to provide healthcare professionals with a decision support tool “MAC-F” that we believe will help them to prevent Medication Errors and to achieve overall reliability (reliable organization and practitioner). Our method was tested in a Belgian hospital before and Moroccan hospital recently.

scholarly journals Delay in diagnosis of cancer as a patient safety issue - a root cause analysis based on a representative case report

2011 ◽  
Vol 5 (1) ◽  
pp. 19 ◽  
Author(s):  
Subramanian Vaidyanathan ◽  
Bakul M Soni ◽  
Gurpreet Singh ◽  
Peter L Hughes ◽  
Paul Mansour ◽  
...  
Keyword(s):  
Patient Safety ◽  
Case Report ◽  
Safety Issue ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Representative Case ◽  
Delay In Diagnosis ◽  
Root Cause ◽  
Diagnosis Of Cancer ◽  
Patient Safety Issue

Root Cause analysis of SG tube ODSCC indications within the tube sheets of NPP biblis unit A

2011 ◽  
pp. 78-86
Author(s):  
R. Kilian ◽  
J. Beck ◽  
H. Lang ◽  
V. Schneider ◽  
T. Schönherr ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Rule Construction and its Execution for Root Cause Analysis

2012 ◽  
Vol 132 (10) ◽  
pp. 1689-1697
Author(s):  
Yutaka Kudo ◽  
Tomohiro Morimura ◽  
Kiminori Sugauchi ◽  
Tetsuya Masuishi ◽  
Norihisa Komoda
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause
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