scholarly journals Descriptive Study on Reported Medication Error among Nurses in Queen Elizabeth II Hospital, Kota Kinabalu, Sabah

2020 ◽  
pp. 7
Author(s):  
Jenet Guan Chin ◽  
Mary Tan ◽  
Stephanie Yvonnesky Francis ◽  
Siti Rahmah Idris ◽  
Mary Padtong ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Continuous Monitoring ◽  
Descriptive Study ◽  
Precise Information ◽  
Root Cause ◽  
Preventative Measures ◽  
Global Issue ◽  
Reduce Medication Error

Introduction: Medication error is a global issue. Despite, the various impacts on health and non-health, continuous monitoring, assessment and intervention are required to reduce the number of medication error. Precise information on the root cause of medication error in Hospital Queen Elizabeth II, Kota Kinabalu will aid in the preventative measures to reduce medication error among nurses. Thus, this study aims to describe the incident of medication errors among nurses.

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.

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 Medication Management System: An Approach to Reduce Medication Error In Apollo Hospitals Dhaka

Pulse ◽  
2014 ◽  
Vol 5 (2) ◽  
pp. 41-47
Author(s):  
A Mahmud ◽  
F Noor ◽  
M Nasrullah
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Reconciliation ◽  
Medication Management ◽  
Drug Reactions ◽  
Acceptable Range ◽  
Rational Drug ◽  
Reduce Medication Error ◽  
Proper Training ◽  
Dispensing Errors

Apollo Hospitals Dhaka surely stepped ahead than any other hospital of Bangladesh for reducing medication errors significantly. From the very beginning of its establishment, reducing medication errors was taken as a major challenge and effective and approved strategies were developed when no other hospital took efforts in this regard. Strategies included tracking incidents of medication errors, analyzing, reporting & arranging proper training sessions for hospital staffs etc. All four types of errors like Prescription errors, Transcription errors, Dispensing errors and Administration errors are rectified and officially reported by hospital pharmacists. Along with these, Prescription Reviewing, Medication Reconciliation, incidents of Adverse Drug Reactions (ADR) are also monitored to ensure rational drug use for patients. With all its efforts, Apollo Hospitals Dhaka was able to reduce the rate of medication errors within the internationally acceptable range. DOI: http://dx.doi.org/10.3329/pulse.v5i2.20265 Pulse Vol.5 July 2011 p.41-47

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.

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 A Matrix FMEA Analysis of Variable Delivery Vane Pumps

Energies ◽  
2021 ◽  
Vol 14 (6) ◽  
pp. 1741
Author(s):  
Joanna Fabis-Domagala ◽  
Mariusz Domagala ◽  
Hassan Momeni
Keyword(s):  
Risk Analysis ◽  
Failure Modes ◽  
High Reliability ◽  
Matrix Analysis ◽  
Hydraulic Systems ◽  
Vane Pump ◽  
End Effects ◽  
Root Cause ◽  
Preventative Measures ◽  
Fmea Analysis

Hydraulic systems are widely used in the aeronautic, machinery, and energy industries. The functions that these systems perform require high reliability, which can be achieved by examining the causes of possible defects and failures and by taking appropriate preventative measures. One of the most popular methods used to achieve this goal is FMEA (Failure Modes and Effects Analysis), the foundations of which were developed and implemented in the early 1950s. It was systematized in the following years and practically implemented. It has also been standardized and implemented as one of the methods of the International Organization for Standardization (ISO) 9000 series standards on quality assurance and management. Apart from wide application, FMEA has a number of weaknesses, which undoubtedly include risk analysis based on the RPN (Risk Priority Number), which is evaluated as a product of severity, occurrence, and detection. In recent years, the risk analysis has been very often replaced by fuzzy logic. This study proposes the use of matrix analysis and statistical methods for performing simplified RCA (Root Cause Analysis) and for classification potential failures for a variable delivery vane pump. The presented methodology is an extension of matrix FMEA and allows for prioritizing potential failures and their causes in relation to functions performed by pump components, the end effects, and the defined symptoms of failure of the vane pump.

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 GAMBARAN KEJADIAN MEDICATION ERROR DI INSTALASI GAWAT DARURAT RSU ELIM RANTEPAO

PHARMACON ◽  
2019 ◽  
Vol 8 (1) ◽  
pp. 152
Author(s):  
Priskha Widiastuti ◽  
Gayatri Citraningtyas ◽  
Jainer P Siampa
Keyword(s):  
Data Collection ◽  
Medication Error ◽  
Medication Errors ◽  
Health Personnel ◽  
Dosage Form ◽  
Emergency Services ◽  
Descriptive Analysis ◽  
Medical Record Number ◽  
Prospective Data ◽  
Prescription Date

ABSTRACT Medication Error is an event that is detrimental to the patient due to errors in the administration of drugs during the handling of health personnel, which can actually be prevented. Data on incidents of medication errors at Elim Hospital, Rantepao in 2017 were 85 cases (0.085% of the total 98,892 prescription sheets served). This study aims to determine the incidence and the percentage of medication errors during the prescribing and dispensing phase in the Emergency Installation of Elim Hospital ,Rantepao. This research is a descriptive analysis with prospective data collection. The results showed that medication errors which occurred at prescribing stage included no prescription doctor's name was 9.19%, no medical record number was 6.13%, no doctor's initial was 99.61%, patient's name was not clear was 0.57% , there was no patient age, was 6.89%, no concentration / dosage was 2.68%, no dosage form was 52.10%, and no prescription date was  1.72%. While medication errors at the dispensing stage include taking the drug was 0.38% and the lack of drug prepared was 0.19%. Based on the results of the study, it can be concluded that the biggest occurrence of medication errors in Emergency Services at Elim Hospital, Rantepao was occurred in the prescribing phase.Keywords: medication error, prescribing, dispensing, Emergency Installation ABSTRAKMedication Error adalah kejadian yang merugikan pasien akibat kesalahan dalam pemberian obat selama penanganan tenaga kesehatan, yang sebetulnya dapat dicegah.  Data insiden kejadian medication error RSU Elim Rantepao pada tahun 2017 yaitu sebanyak 85 kasus (0,085 % dari total 98.892 lembar resep yang dilayani). Penelitian ini bertujuan menentukan kejadian dan persentase medication error pada fase prescribing dan dispensing di Instalasi Gawat Darurat RSU Elim Rantepao. Penelitian ini merupakan penelitian yang bersifat analisis deskriptif dengan pengumpulan data secara prospektif. Hasil penelitian menunjukkan bahwa medication error yang terjadi pada tahap prescribing meliputi tidak ada nama dokter penulis resep 9,19%, tidak ada nomor rekam medik 6,13%, tidak ada paraf dokter 99,61%, nama pasien tidak jelas 0,57%, tidak ada usia pasien 6,89%, tidak ada konsentrasi/dosis sediaan 2,68%, tidak ada bentuk sediaan 52,10 %, dan tidak ada tanggal pembuatan resep 1,72%. Sedangkan medication error pada tahap dispensing meliputi salah pengambilan obat 0,38% dan obat ada yang kurang 0,19%. Berdasarkan hasil penelitian maka dapat disimpulkan bahwa kejadian medication error di Instalasi Gawat Darurat RSU Elim Rantepao terbesar yaitu terjadi pada fase prescribing.Kata-kata kunci : medication error , prescribing, dispensing, Instalasi Gawat Darurat

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