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The American Journal of Medicine Sep 2023Anticoagulants often cause adverse drug events (ADEs), comprised of medication errors and adverse drug reactions, in patients. Our study objective was to determine the... (Review)
Review
PURPOSE
Anticoagulants often cause adverse drug events (ADEs), comprised of medication errors and adverse drug reactions, in patients. Our study objective was to determine the clinical characteristics, types, severity, cause, and outcomes of anticoagulation-associated ADEs from 2015-2020 (a contemporary period following implementation of an electronic health record, infusion device technology, and anticoagulant dosing nomograms) and to compare them with those of a historical period (2004-2009).
METHODS
We reviewed all anticoagulant-associated ADEs reported as part of our hospital-wide safety system. Reviewers classified type, severity, root cause, and outcomes for each ADE according to standard definitions. Reviewers also assessed events for patient harm. Patients were followed up to 30 days after the event.
RESULTS
Despite implementation of enhanced patient safety technology and procedure, ADEs increased in the contemporary period. In the contemporary period, we found 925 patients who had 984 anticoagulation-associated ADEs, including 811 isolated medication errors (82.4%); 13 isolated adverse drug reactions (1.4%); and 160 combined medication errors, adverse drug reactions, or both (16.2%). Unfractionated heparin was the most frequent ADE-related anticoagulant (77.7%, contemporary period vs 58.3%, historical period). The most frequent anticoagulation-associated medication error in the contemporary period was wrong rate or frequency of administration (26.1%, n = 253), with the most frequent root cause being prescribing errors (21.3%, n = 207). The type, root cause, and harm from ADEs were similar between periods.
CONCLUSIONS
We found that anticoagulation-associated ADEs occurred despite advances in patient safety technologies and practices. Events were common, suggesting marginal improvements in anticoagulant safety over time and ample opportunities for improvement.
Topics: Humans; Heparin; Drug-Related Side Effects and Adverse Reactions; Medication Errors; Patients; Anticoagulants
PubMed: 37247752
DOI: 10.1016/j.amjmed.2023.05.013 -
Journal of Medical Systems Nov 2022Medication errors are common. Electronic Health Records (EHR) reduce some of the roots with some while they create others. EHR need to evolve. A suggestion is made to...
Medication errors are common. Electronic Health Records (EHR) reduce some of the roots with some while they create others. EHR need to evolve. A suggestion is made to deal with prescriptions that are new. being titrated, to support the process of prescribing and hopefully correcting errors linked to it.
Topics: Humans; Electronic Prescribing; Medication Errors; Electronic Health Records
PubMed: 36344640
DOI: 10.1007/s10916-022-01884-2 -
Current Drug Safety 2022Medication errors are amongst the most frequently occurring healthcare-related incidents and have the potential to lead to life-threatening harm to patients. An incident...
Medication errors are amongst the most frequently occurring healthcare-related incidents and have the potential to lead to life-threatening harm to patients. An incident reporting system is a traditional approach to the improvement of patient safety and entails the retrieval of information from incident reports. This not only provides a better understanding of causes and contributing factors but also enables the collection of data on the severity of incidents, system deficiencies and the role of human factors in safety incidents. Medication error reporting systems are often developed as a part of larger incident reporting systems that deal with other types of incidents. Although a rise in the prevalence of medication errors has led to an increased demand for medication error reporting, little is known about the characteristics and limitations of medication error reporting systems. The authors broach the subject of medication error reporting systems and propose a more robust and standardized approach.
Topics: Humans; Medication Errors; Patient Safety; Risk Management
PubMed: 33902416
DOI: 10.2174/1574886316666210423115029 -
British Journal of Anaesthesia Apr 2022The definitions of terms related to iatrogenic harm and the potential for iatrogenic harm (e.g. error, medication error, near miss) in the anaesthesia literature are...
The definitions of terms related to iatrogenic harm and the potential for iatrogenic harm (e.g. error, medication error, near miss) in the anaesthesia literature are imprecise and variable, resulting in wide discrepancy in conclusions about their rates and potential solutions. Clarification of these terms is both critical and difficult: a concerted effort to achieve expert consensus is warranted.
Topics: Anesthesia; Anesthesiology; Consensus; Humans; Medication Errors; Patient Safety
PubMed: 35190175
DOI: 10.1016/j.bja.2022.01.028 -
Journal of Patient Safety Dec 2021High-alert medications may cause significant patient harm when used in error. Hospital-specific safety data should be used to customize high-alert medication lists to...
OBJECTIVES
High-alert medications may cause significant patient harm when used in error. Hospital-specific safety data should be used to customize high-alert medication lists to fit the local context. The aim of this study was to identify organizational high-alert medications by evaluating university hospital's data on adverse drug reaction (ADR) and medication error (ME).
METHODS
The Anatomical Therapeutic Chemical (ATC) codes and top active substances in ADR (n = 401) and ME (n = 11,668) reports of Helsinki University Hospital from 2015-2016 were analyzed and compared with hospitals' drug consumption and the Institute for Safe Medication Practices' (ISMP) list of high-alert medications.
RESULTS
The top ATC groups and active substances in ADR and ME reports were not similar. The most numerous ATC groups were L, antineoplastic and immunomodulating agents (30%) in ADRs and N, nervous system (26%) in MEs. According to ADR and ME reports, several high-alert medications from Institute for Safe Medication Practices' lists, such as antineoplastic agents, antithrombotics, opioids, and insulins, should be considered high-alert medications also in Helsinki University Hospital. Although no ADR reports of amphotericin B existed, it had the highest number of MEs causing severe/moderate harm or unexpected reactions relative to its consumption.
CONCLUSIONS
To identify organizational high-alert medications, both drug safety information and medication safety information should be used. Adverse drug reaction and ME data are needed to recognize high-alert medications, but these should also be combined with a literature search and local expert opinions.
Topics: Adverse Drug Reaction Reporting Systems; Drug-Related Side Effects and Adverse Reactions; Hospitals; Humans; Insulin; Medication Errors; Pharmaceutical Preparations
PubMed: 29994819
DOI: 10.1097/PTS.0000000000000512 -
Journal of Nepal Health Research Council Mar 2024Patient safety is the major concern in providing quality care. Medication errors have been identified as the most common type of preventable errors. This study aimed to...
BACKGROUND
Patient safety is the major concern in providing quality care. Medication errors have been identified as the most common type of preventable errors. This study aimed to assess the knowledge and perception regarding medication error among nurses.
METHODS
A quantitative cross-sectional research design was used. The study was conducted in four different private hospitals in Lalitpur. A total enumerative sampling technique was used to select 302 nurses from these hospitals. Descriptive statistical methods were used to assess socio-demographic variables and inferential statistics methods such as the chi-squared test was used to analyse the association between knowledge, perception, and its socio-demographic characteristics.
RESULTS
Most of the respondents 244 (80.8%) agreed the cause of medication error occurs due to unclear handwriting and 217 (71.9%) agreed prescribing the wrong route or dose and time. Mostly respondents 126 (41.7%) had inadequate knowledge, 101 (33.4%) had adequate knowledge and 75 (24.8%) had moderate knowledge on medication error. Mostly respondents 273 (90.4%) had positive perception and 26 (8.6 %) had negative perception.
CONCLUSIONS
Most of the nurses had inadequate knowledge but has positive perception on medication error. Appropriate strategies for reducing nurses' workload, barriers to reporting, and sensitization workshops in a regular basis by the administrator should be developed to address medication errors and enhance patient safety in hospital settings.
Topics: Humans; Cross-Sectional Studies; Nepal; Medication Errors; Patient Safety; Perception
PubMed: 38616594
DOI: 10.33314/jnhrc.v21i4.4883 -
Journal of Dentistry Apr 2022Prescribing errors are a common type of medication error, even in dental practice. However, prescribing is a skill to which little attention is paid, as the profession... (Review)
Review
INTRODUCTION
Prescribing errors are a common type of medication error, even in dental practice. However, prescribing is a skill to which little attention is paid, as the profession is mostly focussed on performing dental procedures, eschewing the use of drugs, to treat dental conditions. Most dentists in Australia report learning little about prescribing during their university training, gaining these skills informally on the job after they graduate. Despite this, dentists are the second largest prescriber group in Australia and prescribe a wide variety of drugs including antibiotics, non-steroidal anti-inflammatory drugs, opioid analgesics, muscle relaxants and anxiolytics.
OBJECTIVES
To summarise medication safety, medication and prescribing errors in the context of dental practice.
DATA
The sources of medication and prescribing errors are reviewed.
SOURCES
For this narrative review, pivotal concepts regarding sources of medication error and types of prescribing error are highlighted. The Swiss Cheese model of prescribing errors is also discussed, highlighting possible interventions when errors can be detected and averted.
STUDY SELECTION
Case reports of prescribing error in dentistry in Australia are presented, highlighting examples of how dental prescribing is prone to error.
CONCLUSIONS
Solutions lie in addressing the systems and processes in which dentists work. Examples include implementing forced functions such as checklists and electronic prescribing tools.
CLINICAL SIGNIFICANCE
Dentists are the second largest prescriber group in Australia and prescribe a wide variety of drugs. As such, prescribing errors are common in dental practice. Solutions to reduce medication and prescribing errors lie in addressing the systems which govern dentistry, as well as implementing forced functions such as prescribing tools.
Topics: Australia; Humans; Medication Errors
PubMed: 35257844
DOI: 10.1016/j.jdent.2022.104086 -
Research in Social & Administrative... Jul 2020The impact of medication reconciliation (MR) in low-middle-income countries, including Thailand, may differ from other developed countries. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The impact of medication reconciliation (MR) in low-middle-income countries, including Thailand, may differ from other developed countries.
OBJECTIVE
To evaluate the effect of medication reconciliation (MR) on the reduction of medication error in Thailand.
METHODS
A systematic search was conducted in the following databases: PubMed, CENTRAL, CINAHL, Scopus, Thai Journals Online, Thai index Medicus, Thai Medical Index, and Health Science Journal in Thailand from inception to January 2018. Studies that evaluated the effect of MR compared to usual care within hospitals in Thailand and reported the occurrence of medication error were included. Meta-analyses were performed using random-effects model.
RESULTS
Of the 107 articles retrieved, 7 articles involving 1581 patients were included in quantitative synthesis. Three of the included studies were randomized controlled trials (RCT). Overall, the risk of medication error in patients who received MR in all transitions of care was 75% lower than those receiving usual care (RR 0.25; 95%CI 0.15-0.43). The effect on the reduction of medication error appeared higher when MR was provided to ambulatory patients (RR 0.17 [95%CI 0.04-0.80] compared with hospitalized patients during admission (RR 0.37 [95%CI 0.20-0.65]) and discharge (RR 0.27 [95%CI 0.17-0.43]). Effects on reducing medication error was greater when MR was provided in secondary care hospitals compared with primary care hospitals both during admission (RR 0.49 [95%CI, 0.34-0.69] vs RR 0.25 [95%CI, 0.05-1.26]), and discharge transition (RR 0.19 [95%CI, 0.09-0.39] vs RR 0.30 [95%CI, 0.12-0.79]).
CONCLUSION
Overall, current evidence indicates that the provision of MR in Thailand is effective in reducing medication errors in all transitions of care. However, to promote patient safety, appropriate strategies should be developed to support MR in specific transition of care and hospital setting so patients can benefit most from this service.
Topics: Hospitalization; Humans; Medication Errors; Medication Reconciliation; Patient Discharge; Thailand
PubMed: 31607507
DOI: 10.1016/j.sapharm.2019.10.004 -
AANA Journal Aug 2021Anesthesia providers are regularly responsible for assessing, diagnosing, and determining pharmacologic treatment of a problem. This critical workflow often includes... (Review)
Review
Anesthesia providers are regularly responsible for assessing, diagnosing, and determining pharmacologic treatment of a problem. This critical workflow often includes medication preparation. Decision making in anesthesia frequently requires rapid intervention, and caring for the pediatric population poses additional challenges, such as needing to quickly calculate the weight-based dosing of medications. The objective of this review article was to identify and describe themes related to pediatric medication errors associated with anesthesia. Additional goals of the review consisted of identifying and comparing various error reduction strategies with a primary goal of communicating the most effective methods to reduce medication errors in the pediatric population. Screening criteria were set, and 17 published scholarly articles meeting inclusion criteria were evaluated using a systematic process. Common themes found leading to medication errors were incorrect dosing, incorrect medication, syringe swap, wrong patient, and wrong dosing interval. The most valuable and sustainable error reduction strategies found were standardized labeling, prefilled syringes, and 2-person medication checks. It is believed that this review will expound on the factors that can be controlled or minimized to decrease the incidence of anesthesia-related pediatric medication errors and facilitate implementation of risk mitigation strategies immediately into clinical practice.
Topics: Adolescent; Anesthesia; Child; Child, Preschool; Dose-Response Relationship, Drug; Female; Humans; Infant; Infant, Newborn; Male; Medication Errors; Pediatrics; Perioperative Period; Practice Guidelines as Topic; United States
PubMed: 34342569
DOI: No ID Found -
The American Journal of Nursing Jul 2023Reported medication errors in an ICU at an academic teaching hospital raised concerns about adherence to safety protocols, including barcode scanning before medication...
Reported medication errors in an ICU at an academic teaching hospital raised concerns about adherence to safety protocols, including barcode scanning before medication administration. A group of nurse leaders, bedside nurses, and pharmacists formed a medication safety task force to increase compliance with barcode scanning and reduce reported medication errors in which failure to scan was a contributing factor.Three task force members observed nurses' workflow in ICU medication administration. The members observed three nurses administer medications before scanning the barcode and three other nurses scan medications in a location where they were unable to see alerts on the computer. After the observations, the task force implemented three interventions: medication tables to provide a surface in front of the computer where medications could be placed when scanning; standardized workflow; and nursing staff education. Task force members then conducted postimplementation observations to evaluate improvement in barcode scanning compliance.In the postintervention observations, all medications were scanned in front of the computer before administration, an increase of 27.3 percentage points (from 72.7% preintervention) in the barcode scanning compliance rate. The ICU also went 17 months in the postintervention period without a reported medication administration error in which failure to scan was a contributing factor.The task force's observation of medication administration led to interventions that made it easier for nurses to adhere to best practice. Medication tables were a simple, sustainable intervention that used human factors principles to increase barcode scanning compliance.
Topics: Humans; Medication Errors; Advisory Committees; Hospitals; Nursing Staff; Intensive Care Units
PubMed: 37345780
DOI: 10.1097/01.NAJ.0000944924.15137.c8