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Mayo Clinic Proceedings Aug 2014Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for... (Review)
Review
Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for practicing physicians that focuses on medication error (1) terminology and definitions, (2) incidence, (3) risk factors, (4) avoidance strategies, and (5) disclosure and legal consequences. A medication error is any error that occurs at any point in the medication use process. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (eg, similar sounding names, low therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition, polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions and other communications, cognitive biases) can precipitate medication errors. Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. Methods to prevent medication errors from occurring (eg, use of information technology, better drug labeling, and medication reconciliation) have been used with varying success. When an error is discovered, patients expect disclosure that is timely, given in person, and accompanied with an apology and communication of efforts to prevent future errors. Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients.
Topics: Disclosure; Drug Labeling; Health Personnel; Humans; Incidence; Inpatients; Liability, Legal; Medication Errors; Medication Reconciliation; Outpatients; Patient Education as Topic; Patient Harm; Pharmacovigilance; Risk Factors; Root Cause Analysis; United States
PubMed: 24981217
DOI: 10.1016/j.mayocp.2014.05.007 -
Studies in Health Technology and... 2017Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third...
Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third leading cause of death. Error rates are significantly higher in the U.S. than in other developed countries such as Canada, Australia, New Zealand, Germany and the United Kingdom (U.K). At the same time less than 10 percent of medical errors are reported. This study describes the results of an investigation of the effectiveness of the implementation of the MEDMARX Medication Error Reporting system in 25 hospitals in Pennsylvania. Data were collected on 17,000 errors reported by participating hospitals over a 12-month period. Latent growth curve analysis revealed that reporting of errors by health care providers increased significantly over the four quarters. At the same time, the proportion of corrective actions taken by the hospitals remained relatively constant over the 12 months. A simulation model was constructed to examine the effect of potential organizational changes resulting from error reporting. Four interventions were simulated. The results suggest that improving patient safety requires more than voluntary reporting. Organizational changes need to be implemented and institutionalized as well.
Topics: Computer Simulation; Health Personnel; Hospital Administration; Hospitals; Humans; Medical Errors; Medication Errors; Organizational Innovation; Patient Safety; Pennsylvania; Risk Management
PubMed: 28186008
DOI: No ID Found -
BMC Health Services Research Oct 2021The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the... (Review)
Review
BACKGROUND
The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the next five years. To achieve this goal, comprehensive identification of barriers to reporting medication errors is imperative.
OBJECTIVE
This review systematically identified and examined the barriers hindering nurses from reporting medication administration errors in the hospital setting.
DESIGN
An integrative review.
REVIEW METHODS
PubMed, Web of Science, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) including Google scholar were searched to identify published studies on barriers to medication administration error reporting from January 2016 to December 2020. Two reviewers (AA, and KDK) independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018.
RESULTS
Of the 10, 929 articles retrieved, 14 studies were included in this study. The main themes and subthemes identified as barriers to reporting medication administration errors after the integration of results from qualitative and quantitative studies were: organisational barriers (inadequate reporting systems, management behaviour, and unclear definition of medication error), and professional and individual barriers (fear of management/colleagues/lawsuit, individual reasons, and inadequate knowledge of errors).
CONCLUSION
Providing an enabling environment void of punitive measures and blame culture is imperious for nurses to report medication administration errors. Policymakers, managers, and nurses should agree on a uniform definition of what constitutes medication error to enhance nurses' ability to report medication administration errors.
Topics: Fear; Hospitals; Humans; Medication Errors; Nurses; Patient Safety
PubMed: 34696788
DOI: 10.1186/s12913-021-07187-5 -
Critical Care Nursing Clinics of North... Jun 2018With an estimated 90% of all hospitalized patients receiving intravenous medications via infusion pumps, intravenous infusion pump systems are among the most frequently... (Review)
Review
With an estimated 90% of all hospitalized patients receiving intravenous medications via infusion pumps, intravenous infusion pump systems are among the most frequently used technologies in health care. This article reviews important issues regarding clinical usability, intravenous medication administration error, and patient safety related to the use of intravenous smart pumps. Although it is possible to address some of the issues with changes in clinical processes, the most fundamental challenges need to be addressed through innovation and the development of new technologies using a human factors approach.
Topics: Critical Care Nursing; Drug Therapy, Computer-Assisted; Humans; Infusion Pumps; Infusions, Intravenous; Medication Errors; Patient Safety
PubMed: 29724440
DOI: 10.1016/j.cnc.2018.02.004 -
BMC Health Services Research Sep 2019Medication errors are a serious and complex problem in clinical practice, especially in intensive care units whose patients can suffer potentially very serious...
BACKGROUND
Medication errors are a serious and complex problem in clinical practice, especially in intensive care units whose patients can suffer potentially very serious consequences because of the critical nature of their diseases and the pharmacotherapy programs implemented in these patients. The origins of these errors discussed in the literature are wide-ranging, although far-reaching variables are of particular special interest to those involved in training nurses. The main objective of this research was to study if the level of knowledge that critical-care nurses have about the use and administration of medications is related to the most common medication errors.
METHODS
This was a mixed (multi-method) study with three phases that combined quantitative and qualitative techniques. In phase 1 patient medical records were reviewed; phase 2 consisted of an interview with a focus group; and an ad hoc questionnaire was carried out in phase 3.
RESULTS
The global medication error index was 1.93%. The main risk areas were errors in the interval of administration of antibiotics (8.15% error rate); high-risk medication dilution, concentration, and infusion-rate errors (2.94% error rate); and errors in the administration of medications via nasogastric tubes (11.16% error rate).
CONCLUSIONS
Nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU.
Topics: Critical Care Nursing; Critical Illness; Female; Focus Groups; Health Knowledge, Attitudes, Practice; Humans; Intensive Care Units; Intubation, Gastrointestinal; Male; Medication Errors; Middle Aged; Pharmaceutical Preparations; Surveys and Questionnaires
PubMed: 31492188
DOI: 10.1186/s12913-019-4481-7 -
British Journal of Clinical Pharmacology Feb 2021Look-alike or sound-alike (LASA) medication names may be mistaken for each other, e.g. mercaptamine and mercaptopurine. If an error of this sort is not intercepted, it... (Review)
Review
Look-alike or sound-alike (LASA) medication names may be mistaken for each other, e.g. mercaptamine and mercaptopurine. If an error of this sort is not intercepted, it can reach the patient and may result in harm. LASA errors occur because of shared linguistic properties between names (phonetic or orthographic), and potential for error is compounded by similar packaging, tablet appearance, tablet strength, route of administration or therapeutic indication. Estimates of prevalence range from 0.00003 to 0.0022% of all prescriptions, 7% of near misses, and between 6.2 and 14.7% of all medication error events. Solutions to LASA errors can target people or systems, and include reducing interruptions or distractions during medication administration, typographic tweaks, such as selective capitalization (Tall Man letters) or boldface, barcoding, and computerized physician order entry.
Topics: Humans; Male; Medical Order Entry Systems; Medication Errors; Pharmaceutical Preparations
PubMed: 32198938
DOI: 10.1111/bcp.14285 -
Nurse Education Today Jan 2020Medication errors are the most common clinical errors in healthcare practice and can lead to serious consequences. Medication error encouragement training (MEET) brings... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Medication errors are the most common clinical errors in healthcare practice and can lead to serious consequences. Medication error encouragement training (MEET) brings students face-to-face with potential errors in the medication process, in a safe environment where they are encouraged to understand both the error and the context in which it occurred.
OBJECTIVES
The study aimed to examine the effects of a MEET intervention on medication safety confidence among nursing undergraduates.
DESIGN
This was a quasi-experimental study with a nonequivalent control group design.
PARTICIPANTS
Our sample was recruited from the nursing education department of a university, with 47 participants randomly assigned to the experimental group, and 50 to the control group.
METHODS
Both groups received theoretical training, followed by applied training. The experimental group received the MEET intervention developed specifically for this study, while the control group received traditional error avoidance training. Participants' medication administration confidence was measured pre- and post-intervention.
RESULTS
Following training, the experimental group's confidence was significantly higher than that of the control group. With regard to individual medication administration procedures, the experimental groups' medication safety confidence increased significantly after training compared to the control group in patient identification, drug information confirmation, and drug preparation.
CONCLUSIONS
Introducing MEET into nursing curricula could reduce medication errors and related complications in healthcare institutions. Further studies are needed to investigate the long-term effects of MEET interventions, as well as the generalizability of our findings.
Topics: Clinical Competence; Curriculum; Education, Nursing, Baccalaureate; Female; Humans; Male; Medication Errors; Patient Safety; Students, Nursing; Young Adult
PubMed: 31698293
DOI: 10.1016/j.nedt.2019.104250 -
Journal of Paediatrics and Child Health Mar 2019This study aimed to examine reported medication error trends in an Australian paediatric hospital over a 5-year period and to determine the effects of person-related,...
AIM
This study aimed to examine reported medication error trends in an Australian paediatric hospital over a 5-year period and to determine the effects of person-related, environment-related and communication-related factors on the severity of medication outcomes. In particular, the focus was on the influence of changes to a hospital site and structure on the severity of medication errors.
METHODS
A retrospective clinical audit was undertaken over a 5-year period of paediatric medication errors submitted to an online voluntary reporting system of an Australian, tertiary, public teaching paediatric hospital. All medication errors submitted to the online system between 1 July 2010 and 30 June 2015 were included.
RESULTS
A total of 3340 medication errors was reported, which corresponded to 0.56% medication errors per combined admissions and presentations or 5.73 medication errors per 1000 bed days. The most common patient outcomes related to errors requiring monitoring or an intervention to ensure no harm occurred (n = 1631, 48.8%). A new hospital site and structure had 0.354 reduced odds of producing medication errors causing possible or probable harm (95% confidence interval 0.298-0.421, P < 0.0001). Patient and family involvement had 1.270 increased odds of identifying medication errors associated with possible or probable harm compared with those causing no harm (95% confidence interval 1.028-1.568, P = 0.027). Interrupted time series analyses showed that moving to a new hospital site and structure was associated with a reduction in reported medication errors.
CONCLUSION
Encouraging child and family involvement, facilitating hospital redesign and improving communication could help to reduce the harm associated with medication errors.
Topics: Australia; Causality; Child; Health Care Surveys; Hospitalization; Hospitals, Pediatric; Humans; Interdisciplinary Communication; Medication Errors; Retrospective Studies
PubMed: 30168236
DOI: 10.1111/jpc.14193 -
Journal of General Internal Medicine Oct 2019Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients.
METHODS
MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation.
RESULTS
Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62-1.70), I 28%, n = 7), length of stay (MD - 0.18 (95% - 1.42, 1.05), I 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I 74%, n = 9). The quality of evidence was rated very low.
DISCUSSION
Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies.
Topics: Decision Support Systems, Clinical; Drug-Related Side Effects and Adverse Reactions; Electronic Prescribing; Humans; Medication Errors; Outcome Assessment, Health Care; Randomized Controlled Trials as Topic
PubMed: 31396810
DOI: 10.1007/s11606-019-05236-8 -
Nursing Forum Nov 2022This paper addresses the ethics of the prosecution of nurse RaDonda Vaught for a medication error that led to the death of her patient. It is argued that the prosecution...
This paper addresses the ethics of the prosecution of nurse RaDonda Vaught for a medication error that led to the death of her patient. It is argued that the prosecution of Ms. Vaught was wrong; however, in contrast to some commentators, it is argued that the wrongness of Ms. Vaught's prosecution did not stem from its effects on patient safety, but from the fact that the charges, in this case, were legally and ethically unjustified in themselves.
Topics: Female; Humans; Medication Errors
PubMed: 36352526
DOI: 10.1111/nuf.12838