scholarly journals Medication administration omission errors: Frequency and their causes during medication administration process at Ndola Teaching Hospital in Zambia

2021 ◽  
Vol 15 (9) ◽  
pp. 174-182
Author(s):  
Kampamba Martin ◽  
Demba Fatima ◽  
Mudenda Steward ◽  
Mufwambi Webrod ◽  
Zingani Ellah ◽  
...  
Author(s):  
Serajaddin Gray ◽  
Mohammad Effatpanah ◽  
Sara Salehi ◽  
Siamand Anvari Savojbalaghi ◽  
Leila Momeni ◽  
...  

Background: Given the special importance of preventing from medication, the present study aimed to investigate the determining Causes of Medication Errors (CMEs) and their Priorities for reducing interventions in a hospital.  Methods: The present mixed, sequential and cross-sectional study was conducted in a teaching hospital (2016). For data collection, Fishbone Diagrams, interviews, note taking and checklists were used, and qualitative data were analyzed though the thematic approach. Moreover, the Maxqda Software v.14.0, Excel, Edraw Max v.9.0 were employed for data analysis and reporting. Results: Seventy-five CMEs were classified under two main themes (human and non-human) and four sub-themes (personal, network, organizational, and meta-organizational). Weakness of professionalism and low experience as the personal causes; Actions of pharmacy colleagues, physicians and other nurses as the network causes; Management of nurses and unit specialty as the organizational causes and the quality of academic education, drug features and macro policies of medication as meta-organizational causes were classified. Six causes were given priority for reducing interventions. Conclusion: In the short term, human factors should be considered with the aim of reducing medication errors. It is also recommended that teaching how to deal with nurses’ stress and psychological pressure (especially beginner nurse), resulting from critically ill patients and high workload, be paid special attention. Besides, it is suggested that professionalism be given priority to reduce personal neglects and to create safe environments for reporting personal neglects. In addition, more emphasis should be placed on the right route in the process of medication administration.


Author(s):  
Martin Kampamba ◽  
Steven Mulolo ◽  
Margaret Phiri ◽  
Martha Chibale Chulu ◽  
Webrod Mufwambi ◽  
...  

Background: The first few days of in-patient care are possibly the most significant in a patient’s recovery and any omitted medications during this period may harm the patient or increase their hospital length of stay. Therefore, our study aimed at assessing the frequency of medication administration omission errors and their reasons for the omission in the paediatric wards after admission at University Teaching Children’s Hospital.Methods: This was a descriptive study in which 259 patient files and drug charts were reviewed. Admission prescription charts were studied in detail over a period of four weeks and all drugs prescribed but then not given in the first 48 hours were recorded as omitted medications, along with the reason given for their omission.Results: From the 259 drug charts, a total of 1598 doses of drugs were ordered within 48 hours of admission. However, from this, only a total of 1132 doses were administered with the remaining 466 doses omitted, which accounted for a frequency of 29.2%. When the frequency of medication omission errors was compared, parenteral drugs (70.8% vs. 25.3%, [p=0.0001]), afternoon shift (48.5% vs. 15.8%, [p=0.0001]), and anti-infective medications (69.1% vs. 39.4%, [p=0.0001]) were found to be the most frequently omitted medications. There were also considerably more medication omissions in patients prescribed with more medications (median number: 4, I QR [2, 6] vs. median number: 2, IQR [2, 4], [p=0. 0.001]). The most common reason for the omission was medication unavailability (89.3%), followed by work overload (71.4%), and the patient is off the ward (71.4%).Conclusions: This study revealed that medication omissions are a continuing problem and this may result in increased morbidity and mortality rates. There is a need to put in place specific strategies to reduce this problem. 


2019 ◽  
Vol 10 (04) ◽  
pp. 615-624
Author(s):  
Sarah Berdot ◽  
Abdelali Boussadi ◽  
Aurélie Vilfaillot ◽  
Mathieu Depoisson ◽  
Claudine Guihaire ◽  
...  

Objectives A commercial barcode-assisted medication administration (BCMA) system was integrated to secure the medication process and particularly the dispensing stage by technicians and the administration stage with nurses. We aimed to assess the impact of this system on medication dispensing errors and barriers encountered during integration process. Methods We conducted a controlled randomized study in a teaching hospital, during dispensing process at the pharmacy department. Four wards were randomized in the experimental group and control group, with two wards using the system during 3 days with dedicated pharmacy technicians. The system was a closed loop system without information return to the computerized physician order entry system. The two dedicated technicians had a 1-week training session. Observations were performed by one observer among the four potential observers previously trained. The main outcomes assessed were dispensing error rates and the identification of barriers encountered to expose lessons learned from this study. Results There was no difference between the dispensing error rate of the control and experimental groups (7.9% for both, p = 0.927). We identified 10 barriers to pharmacy barcode-assisted system technology deployment. They concerned technical (problems with semantic interoperability interfaces, bad user interface, false errors generated, lack of barcodes), structural (poor integration with local information technology), work force (short staff training period, insufficient workforce), and strategic issues (system performance problems, insufficient budget). Conclusion This study highlights the difficulties encountered in integrating a commercial system in current hospital information systems. Several issues need to be taken into consideration before the integration of a commercial barcode-assisted system in a teaching hospital. In our experience, interoperability of this system with the electronic health record is the key for the success of this process with an entire closed loop system from prescription to administration. BCMA system at the dispensing process remains essential to purchase securing medication administration process.


Author(s):  
T. Irsath Ahamed ◽  
K. Vaishnavi ◽  
R. R. Harini ◽  
Likhita Yalavarthi ◽  
Jagadeesan M.

Background: Although errors occurring during the process of dispensing may affect the goal of the treatment, they also can be the significant cause of morbidity and mortality. There are only few published evidences which focuses on the errors of dispensing that occurs in the pharmacy.             This study focuses on identifying the dispensing errors, impact of brand substitution on cost and DDIs. Objective: To identify the dispensing errors, impact of brand substitution on cost and DDIs. Methodology: Prospective observational study conducted over a period of eight weeks in outpatient hospital pharmacy of tertiary care multispecialty teaching hospital, Tamil Nadu. Prescriptions and medication bills and dispensed medicines are collected from the hospital pharmacy to obtain data required for the study. Prescription containing only medical devices were excluded from the study. Results: Out of 1010 prescriptions, dispensing errors were present in 419 (41.48%) prescriptions which consist of 557 errors. The errors include dispensing multi-pills to make the required dose is 3.77%,tablet splitting is 0.8%, incorrect strength is 1.07%, omission error due to unavailability is 31.4%,dispensing drugs with brands other than prescribed brands is 63.7%. Prescriptions which had more than three drugs were analyzed for drug-drug interactions (n=389). DDIs were present in 156(40.1%) prescriptions which had a total of 281 interactions. Conclusion: The brand substitution and omission errors are the major causes of dispensing errors. Brand substitution is not always recommended as it may have some adverse effects because of salt and excipients variation. Pharmacists are in the position to identify and reduce DDIs by discussing with the physicians.


1994 ◽  
Vol 15 (11) ◽  
pp. 710-712 ◽  
Author(s):  
Kelley R. Lee ◽  
Robert J. Leggiadro ◽  
Kelly J. Burch

AbstractObjective:To determine the incidence and type of antibiotic use variances at our institution.Design:Inpatient bacterial culture and susceptibility results were reviewed for 1 week per month. Medication administration records were evaluated to determine whether antibiotic selection was appropriate, given the susceptibility of the organism. Process indicators included use of the least costly antibiotic. as well as appropriate dose, interval, and route of administration. The complete medical record was reviewed for all patients if management did not appear to meet criteria.Setting:A 225-bed. tertiary-care children’s teaching hospital.Results:Thirty-five (8.2%) of 428 patients reviewed over 12 months had a total of 49 variances: failure to treat (3), treatment of contaminant/colonizer (2), use of more costly agent (10), failure to revise therapy (8), inappropriate route (2), inappropriate empiric antibiotic (4), incorrect dose (3), unnecessary multiple antibiotics (6), inappropriate drug (8), and prolonged prophylaxis (3).Conclusions:Thirty-five patients with 10 types of variances were identified during the study. Follow-up monitoring will assess the impact of educational efforts on the incidence of variances. Specific problem antibiotics have been identified for further audits.


2018 ◽  
Vol 49 (2-3) ◽  
pp. 99-107 ◽  
Author(s):  
Thomas G Poder ◽  
Serge Maltais

Objective: Medication administration omission errors (MAOEs) occur frequently in hospitals and can significantly affect patient health. An interdisciplinary committee was formed in summer 2012 to analyse incident/accident reports (AH-223-1 forms) of MAOEs for the 2011–2012 fiscal year in order to identify contributing factors and to propose preventive solutions. Special attention was paid to events with consequences for patients. Method: An aggregate data analysis involving four major steps was conducted: sampling, categorisation, identification of contributing factors, and seeking preventive solutions. One hundred omissions were randomly selected from the 889 reported for this period. All omissions categorised as having had consequences for patients were then added, making a final total of 145 omissions. The omissions were categorised using an Ishikawa diagram developed from an exploratory literature review and process mapping. Subsequent to failure modes, effects and criticality analysis, cause-and-effect diagrams were constructed with the main prioritised categories to differentiate the proximal causes from the root causes. Brainstorming was used to develop solutions, which were then prioritised with an impact/effort matrix. Results: This study identified 27 categories of MAOEs, of which the 7 most frequent and the most critical accounted for 79.3% of the reports. The event categories, in decreasing order of importance, were related to intravenous (IV) therapy (29.0%), failure in using the medication administration record (MAR; 23.4%), failure in creating/updating the MAR (10.3%), medications on the patient’s bedside (7.6%), and three types of MAOEs related to transcribing prescriptions (9.0%). Conclusion: The interdisciplinary committee formulated 10 main recommendations related to these 7 categories, including 3 for IV therapy and 4 for failure in using or creating/updating the MAR.


2020 ◽  
Vol 63 (10) ◽  
pp. 3472-3487
Author(s):  
Natalia V. Rakhlin ◽  
Nan Li ◽  
Abdullah Aljughaiman ◽  
Elena L. Grigorenko

Purpose We examined indices of narrative microstructure as metrics of language development and impairment in Arabic-speaking children. We examined their age sensitivity, correlations with standardized measures, and ability to differentiate children with average language and language impairment. Method We collected story narratives from 177 children (54.2% boys) between 3.08 and 10.92 years old ( M = 6.25, SD = 1.67) divided into six age bands. Each child also received standardized measures of spoken language (Receptive and Expressive Vocabulary, Sentence Imitation, and Pseudoword Repetition). Several narrative indices of microstructure were examined in each age band. Children were divided into (suspected) developmental language disorder and typical language groups using the standardized test scores and compared on the narrative indicators. Sensitivity and specificity of the narrative indicators that showed group differences were calculated. Results The measures that showed age sensitivity included subject omission error rate, number of object clitics, correct use of subject–verb agreement, and mean length of utterance in words. The developmental language disorder group scored higher on subject omission errors (Cohen's d = 0.55) and lower on correct use of subject–verb agreement (Cohen's d = 0.48) than the typical language group. The threshold for impaired performance with the highest combination of specificity and sensitivity was 35th percentile. Conclusions Several indices of narrative microstructure appear to be valid metrics for documenting language development in children acquiring Gulf Arabic. Subject omission errors and correct use of subject–verb agreement differentiate children with typical and atypical levels of language development.


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