Narrative review of neuraxial potassium chloride administration errors: clinical features, human factors, and prevention measures

BackgroundAdministration of the wrong drug via the epidural or intrathecal route can cause devastating consequences. Because of the commonality of potassium replacement therapy coupled to its potential neurotoxic profile, we suspected that injuries related to this drug error would be present in the literature.ObjectivesWe aimed to identify clinical characteristics associated with the inadvertent administration of potassium chloride (KCl) during neuraxial anesthesia. Our secondary objective was to identify human factors that may have been associated.Evidence reviewPublished reports of neuraxial administration of KCl in humans were searched using Medline and Google Scholar. Error reports in any language were included.Findings25 case reports/series reported administration of KCl via epidural (25 patients) or intrathecal routes (three patients). There were six cases during interventional pain procedures, five cases in operating rooms and 17 in wards or intensive care units. Neuraxial KCl caused paraplegia in 22 patients. Mechanical ventilation was instituted in 11 of 28 patients. Three patients died. Epidural (eight patients) and spinal (two patients) lavage were performed to minimize consequences. A correctly prepared KCl infusion was connected to the epidural catheter for nine patients on wards (32%; 95% upper confidence limit: 48%) due to epidural–intravenous line confusion. Among the other 19 errors, KCl was confused with normal saline for 13 patients or local anesthetic in three patients. A wide range of concentrations and doses of KCl were administered. Variable use of intravenous steroid (13 patients) and epidural saline (eight patients) was found among patients who received epidural KCl. Human factors identified included incorrect visual perception, inadequate monitoring of infusions and substandard practice related to neuraxial anesthesia or analgesia.ConclusionsKCl administration via epidural or intrathecal route has been reported to cause catastrophic consequences.

Prevalence and factors contributing to medication errors in a referral hospital in Iran: A retrospective study

Background: A medication error is defined as any inappropriate drug administration that can harm the patient while being preventable and equally occurring under the supervision of a medical team. Objectives: The current study was conducted to clarify the error status, evaluate the regularity of medical mistakes in a referral hospital in the South West of Iran. Methods: Data were gathered from multiple wards at various shift works based on an optional error reporting form, either self-reporting or colleague-reporting, and then it has been made available to the "Quality Improvement Office" experts. Since the current study was retrospective, the samples were calculated from 2017 to 2019. The average and standard deviations were implemented to describe qualitative variables, and ANOVA to determine any statistically significant differences between groups. Results: Of 305 medication errors reported to the Quality Improvement Office, the "Administering the wrong drug" rate was 32.5%, and it has dedicated the most significant percentage of mistake types. The most-reported medication errors occurred in the general ward, and there was no significant difference in the number of mistakes in other shifts. Conclusion: Results suggest there is an association between the incidence of medication errors and the therapeutic ward. Although the most prevalent medication error in this study was "Administering the wrong drug. Keywords: medical error, error reporting, drug administration, mistakes, hospital

Medication incidents and pharmacist interventions in relation to directly acting oral anticoagulants in hospital settings: evaluation using Reason’s Accident Causation Theory

BackgroundDirect oral anticoagulants (DOACs) have revolutionised anticoagulant pharmacotherapy. However DOACs medication incidents are known to be common.ObjectiveTo assess medication incidents associated with DOACs using an error theory and to analyse pharmacists’ contributions in minimising medication incidents in secondary care settings.SettingA large University tertiary academic hospital in the West Midlands of England.MethodsMedication incident data from the incident reporting system (48-months period) and pharmacist interventions data from the prescribing system (26-month period) were extracted. Reason’s Accident Causation Model was used to identify potential causality of the incidents. Pharmacists’ intervention data was thematically analysed.Main outcome measure(a) Frequency, type and potential causality of DOACs incidents, (b) Nature of pharmacists’ interventions.ResultsA total of 812 DOACs reports were included in the study (124 medication incidents and 688 intervention reports). Missing drug/omission was the most common incident type (26.6%,n = 33) followed by wrong drug (16.1%,n = 20) and wrong dose/strength (11.3%,n = 14). A high majority (89.5%,n = 111) of medication incidents were caused by active failures. Patient discharge without anticoagulation supply and failure to restart DOACs post procedure/scan were commonly recurring themes. The majority of (38.1%,n = 262) the pharmacist interventions were related to pharmacological strategy (i.e., drug or dose changes or discontinuation). Impaired renal function was the most common reason for dose adjustments.ConclusionPrescribers’ active failure rather than system errors (i.e. latent failures) are contributing to DOACs incidents. Rreinforcement of guideline adherence, prescriber education, harnessing pharmacists’ roles and mandating renal function information in prescriptions are likely to improve patient safety.

Dispensing errors in hospital pharmacies: A prospective study in Yemen

AimsThe aim of this study was to describe the dispensing errors that occurred during the dispensing process in selected hospital pharmacies in Sana’a, Yemen; and to describe their types and causes.MethodologyA prospective study was carried out in selected hospital pharmacies in Yemen over 40 days using a validated tool. ResultsA total of 9000 dispensed prescriptions were evaluated for the dispensing errors and 2.13 % dispensing errors were identified. Wrong dosage form (134/192); wrong strength (24/192); wrong drug (18/192); wrong quantity, wrong instructions written and drug available in the pharmacy but not given were (6/192) and dispense the expired drugs (3/192) were the reported dispensing errors in this study. Poor handwriting, similar drug names, similar drug packaging, fatigue, heavy work, workforce issues, and poor communication were the most common reported causes of dispensing errors. ConclusionThe prevalence of dispensing errors in this study was 2.13%. Pharmacists can play an important role in the improving the safety of medicines. Study of the dispensing errors incidence in national wide, it's types and causes of dispensing errors are very important and highly recommended. Study the impact of different interventions to improve dispensing quality, reducing and preventing dispensing errors are strongly recommended.

Text Formatting Based on Keyword Detection

Adverse drug effects are a major cause of death across the world each year because of prescription errors. Many of such errors involve the administration of the wrong drug or dosage by care givers to patients due to indecipherable handwritings, drug interactions, confusing drug names etc. The adoption of voice-based prescription project could eliminate some of these errors because they allow prescription information to be captured and heard through voice response rather than in the physician’s handwriting. Our project will generate an electronic prescription using a “Speech to Text converter” (Perceptual Linear Prediction (PLP)) and capture the data from the keywords spoken by doctor(s). There won’t be any need to carry paper prescriptions on revisiting doctors. A patient will be able to share his historic medical records to a new doctor. This project also provide facility to sign the prescription and send to the patient directly on his phone and email id. The System enables the patient to manage the privacy of their personal health record. This project is proposed to target those doctors and clinics that are still using paper-based handwritten prescriptions

Assessing automated product selection success rates in transmissions between electronic prescribing and community pharmacy platforms

Objective Wrong drug product errors occurring in community pharmacies often originate at the transcription stage. Electronic prescribing and automated product selection are strategies to reduce product selection errors. However, it is unclear how often automated product selection succeeds in outpatient pharmacy platforms. Materials and Methods The intake of over 800 e-prescriptions was observed at baseline and after intervention to assess the rate of automated product selection success. A dispensing accuracy audit was performed at baseline and postintervention to determine whether enhanced automated product selection would result in greater accuracy; data for both analyses were compared by 2x2 Chi square tests. In addition, an anonymous survey was sent to a convenience sample of 60 area community pharmacy managers. Results At baseline, 79.8% of 888 e-prescriptions achieved automated product selection. After the intervention period, 84.5% of 903 e-prescriptions achieved automated product selection (P = .008). Analysis of dispensing accuracy audits detected a slight but not statistically significant improvement in accuracy rate (99.3% versus 98.9%, P = .359). Fourteen surveys were returned, revealing that other community pharmacies experience similar automated product selection failure rates. Discussion Our results suggest that manual product selection by pharmacy personnel is required for a higher than anticipated proportion of e-prescriptions received and filled by community pharmacies, which may pose risks to both medication safety and efficiency. Conclusion The question of how to increase automated product selection rates and enhance interoperability between prescriber and community pharmacy platforms warrants further investigation.

Necrotising fasciitis following accidental injection of intraoral xylene: a preventable medication error

The most common cause of preventable mortality and morbidity to the patient in a healthcare system is medication error. Medication errors have got a significant impact on the patient health and healthcare system. These errors are multidisciplinary and can occur at various stages of drug therapy. Physicians, nursing staff, pharmacists, hospital administration all have an important role in preventing medication errors from recurring. The most common causes include wrong patient, wrong drug prescription, look-alike sound-alike drugs, faulty drug administration, wrong dosage, drug storage, delivery problem, lack of staff, patient and physician education and failure to monitor closely. This case illustrates the importance of incorporating protocol and cross-checking before administering a drug during the procedure. Here, we discuss a case of accidental intraoral injection of xylene instead of xylocaine (local anaesthetic agent), which was a sound-alike drug that resulted in significant morbidity to the patient.

Dispensing errors in community pharmacies in the United Arab Emirates: investigating incidence, types, severity, and causes

Background: Medication dispensing is a fundamental function of community pharmacies, and errors that occur during the dispensing process are a major threat to patient safety. However, to date there has been no national study of medication dispensing errors in the United Arab Emirates (UAE). Objective: The study aimed to investigate the incidence, types, clinical significance, causes and predictors of medication dispensing errors. Methods: The study was conducted in randomly selected community pharmacies (n=350) across all regions of UAE over six months using a mixed-method approach, incorporating prospective disguised observation of dispensing errors and interviews with pharmacists regarding the causes of errors. A multidisciplinary committee, which included an otolaryngologist, a general practitioner and a clinical pharmacist, evaluated the severity of errors. SPSS (Version 26) was used for data analysis. Results: The overall rate of medication dispensing errors was 6.7% (n=30912/ 464222), of which 2.6% (n=12274/464222) were prescription-related errors and 4.1% (n= 18638/464222) pharmacist counselling errors. The most common type of prescription-related errors was wrong quantity (30.0%), whereas the most common pharmacist counselling error was wrong drug (32.1%). The majority of errors were caused by medicine replaced with near expire one (24.7%) followed by look-alike/sound-alike drugs (22.3%). The majority of errors were moderate (46.8%) and minor (44.5%); 8.7% were serious errors. Predictors of medication dispensing errors were: grade A pharmacies (dispensing  60 prescriptions a day (OR 2.1; 95%CI 1.4-3.6; p=0.03) and prescriptions containing ≥4 medication orders (OR 2.5; 95%CI 1.7-4.3; p=0.01). Conclusions: Medication dispensing errors are common in the UAE and our findings can be generalised and considered as a reference to launch training programmes on safe medication dispensing practice.