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The New England Journal of Medicine May 2010Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has... (Clinical Trial)
Clinical Trial
BACKGROUND
Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR).
METHODS
We conducted a before-and-after, quasi-experimental study in an academic medical center that was implementing the bar-code eMAR. We assessed rates of errors in order transcription and medication administration on units before and after implementation of the bar-code eMAR. Errors that involved early or late administration of medications were classified as timing errors and all others as nontiming errors. Two clinicians reviewed the errors to determine their potential to harm patients and classified those that could be harmful as potential adverse drug events.
RESULTS
We observed 14,041 medication administrations and reviewed 3082 order transcriptions. Observers noted 776 nontiming errors in medication administration on units that did not use the bar-code eMAR (an 11.5% error rate) versus 495 such errors on units that did use it (a 6.8% error rate)--a 41.4% relative reduction in errors (P<0.001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction (P<0.001). The rate of timing errors in medication administration fell by 27.3% (P<0.001), but the rate of potential adverse drug events associated with timing errors did not change significantly. Transcription errors occurred at a rate of 6.1% on units that did not use the bar-code eMAR but were completely eliminated on units that did use it.
CONCLUSIONS
Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors. Our data show that the bar-code eMAR is an important intervention to improve medication safety. (ClinicalTrials.gov number, NCT00243373.)
Topics: Academic Medical Centers; Drug Administration Schedule; Drug-Related Side Effects and Adverse Reactions; Electronic Data Processing; Humans; Medical Order Entry Systems; Medication Errors; Medication Systems, Hospital; Organizational Case Studies; Organizational Innovation; Pharmaceutical Preparations; United States
PubMed: 20445181
DOI: 10.1056/NEJMsa0907115 -
Journal of Patient Safety Aug 2022Medication information is frequently communicated via free-text computerized provider order entry (CPOE) orders in electronic health records. When such information is...
OBJECTIVES
Medication information is frequently communicated via free-text computerized provider order entry (CPOE) orders in electronic health records. When such information is transmitted separately from a structured CPOE medication order, there is a significant risk of medication error. Although prior studies have described the frequency of using free-text CPOE orders for communicating medication information, there is a gap in understanding the nature of the medication information contained in the free-text CPOE orders. The aims of this study are to (1) identify the most common medication names communicated in free-text CPOE orders and their risk levels and (2) identify what actions physicians expect that nurses will complete when they place free-text CPOE orders, and (3) describe differences in these patterns across hospitals.
METHODS
This study was a retrospective analysis of a sample of 26,524 free-text CPOE orders from 6 hospitals in the mid-Atlantic U.S. region.
RESULTS
Free-text CPOE orders contained in the sample mentioned 193 medication names. Free-text CPOE orders were used frequently to communicate information about naloxone, heparin, flumazenil, and dextrose. Twenty-two percent of the free-text CPOE orders related to discontinuing medication(s), whereas 7% of the free-text CPOE orders relate to giving medication(s). There was high variation across hospitals both in the percentage of free-text CPOE orders mentioning medication information and in the proportion of those that referred to high-risk medications.
CONCLUSIONS
The prevalence of medication information in free-text CPOE orders may suggest specific communication challenges in respect to urgency, uncertainty, planning, and other aspects of communication and clinical needs. Understanding and addressing communication challenges around commonly mentioned medication names and actions, especially those that are high risk, can help reduce the risk of medication errors.
Topics: Hospitals; Humans; Medical Order Entry Systems; Medication Errors; Physicians; Retrospective Studies
PubMed: 35948292
DOI: 10.1097/PTS.0000000000000948 -
BMC Health Services Research Apr 2021Nurse managers play a critical role in enhancing nursing and patient outcomes. The work of nurse managers, who can be described as middle-managers at health care...
BACKGROUND
Nurse managers play a critical role in enhancing nursing and patient outcomes. The work of nurse managers, who can be described as middle-managers at health care organizations, is complex and changes on a daily basis. Only a few studies have clarified how nurse managers divide their time across various work activities. This study aimed to describe the relationships between nurse managers' work activities, nurses' job satisfaction, patient satisfaction, and medication errors at the hospital unit level.
METHODS
A cross-sectional and correlational study design was used. The data were collected from nurse managers (n = 29), nursing staff (n = 306), and patients (n = 651) from 28 units across three Finnish acute care hospitals between April and November 2017. In addition, data concerning medication errors (n = 468) over one calendar year (2017) were acquired from the hospitals' incident reporting register. Analysis of covariance (ANCOVA) was used to estimate relationships between data from subareas of Nurse Managers' Work Content Questionnaire, Kuopio University Hospital Job Satisfaction Scale, and Revised Humane Caring Scale, along with medication error reports. A significance level of 95% was applied when estimating the covariances between variables. Unstandardized regression coefficients (B) were used to explain the relationships between variables.
RESULTS
Multiple relationships between nurse managers' work activities, nurses' job satisfaction, patient satisfaction, and medication errors were identified. Nurse managers' work activities had both positive and negative relationships on the other studied variables. The Requiring factors of work (p < .001) subarea of nurses' job satisfaction, total patient satisfaction (p < .001), and medication errors (p < .001) were identified as the variables most significantly affected by other factors.
CONCLUSIONS
The findings suggest that nurse managers should focus on improving nursing practices by managing and organizing nurses' work in a way that makes their employees feel supported, motivated and secure. Furthermore, nurse managers should adopt a leadership style that emphasizes safe and patient-centered care. The results also suggest that the administration of today's health care organizations should actively evaluate nurse managers' share of work activities to ensure that their daily work is in line with the organizational goals.
Topics: Cross-Sectional Studies; Humans; Job Satisfaction; Leadership; Medication Errors; Nurse Administrators; Nursing Staff, Hospital; Patient Satisfaction; Personal Satisfaction; Surveys and Questionnaires
PubMed: 33794875
DOI: 10.1186/s12913-021-06288-5 -
European Journal of Hospital Pharmacy :... Mar 2023Assessing the cost-effectiveness of complex pharmaceutical care interventions and medication error outcomes is hindered by lack of available data on actual outcomes... (Observational Study)
Observational Study
OBJECTIVES
Assessing the cost-effectiveness of complex pharmaceutical care interventions and medication error outcomes is hindered by lack of available data on actual outcomes consequent to errors that were intercepted for patient safety reasons. Expert judgement is an approach to acquire data regarding unknown parameters in an economic model which are otherwise insufficient or not possible to obtain. The aim of this paper is to describe a method to approach this problem using findings from a single intervention study and to calculate the potential costs and consequences associated with discharge medication error.
METHODS
Using data from a previous intervention study, the hypothetical consequences of medication error(s) at hospital discharge, in terms of diagnosis, healthcare resource utilisation and impact on health-related quality of life, were identified by expert judgement of anonymised cases. Primary healthcare utilisation costs were derived from published tariffs, inpatient costs were derived by simulation in the hospital discharge activity database test environment and the difference between adjudicated baseline and posterror health state was expressed as quality-adjusted life year (QALY) decrement.
RESULTS
Four experts provided judgement on 81 cases. Of these, 75 were judged to have potential clinical consequences. Between 56 and 69 of the 81 cases were variably judged to require remedial healthcare utilisation. The mean calculated cost per case (representing an individual patient), based on all 81 cases, was €1009.58, 95% CI 726.64 to 1585.67. The mean QALY loss was 0.03 (95% CI 0.01 to 0.05).
CONCLUSION
An expert judgement process proved feasible and useful to estimate financial cost and QALY loss associated with hospital discharge medication error. These estimates will be employed in model-based economic evaluation. This method could be transferred to other prospective observational patient safety research which seeks to assess value for money of complex interventions.
Topics: Humans; Patient Discharge; Quality of Life; Judgment; Hospitals; Medication Errors
PubMed: 35145001
DOI: 10.1136/ejhpharm-2021-002697 -
Andes Pediatrica : Revista Chilena de... Apr 2021Medication errors (ME) are preventable incidents of inappropriate use of medications by health per sonnel or by the patient. These events can occur at any stage of drug... (Review)
Review
INTRODUCTION
Medication errors (ME) are preventable incidents of inappropriate use of medications by health per sonnel or by the patient. These events can occur at any stage of drug use generating significant costs to the health system and, in some cases, these can even lead to death. The pediatric population is con sidered susceptible to ME with a prevalence 3 times higher than adult patients.
OBJECTIVE
To identify the prevalence of medication errors in hospitalized pediatric patients, as well as their classification according to the stage of use of the medication when they occurred.
METHOD
A literature review of ME in pediatrics was carried out through a Pubmed / Medline search using Mesh terms ("Medication Errors" and "Pediatrics") in the last 10 years. Three investigators reviewed independently the identi fied articles considering the STROBE checklist for observational studies.
RESULTS
192 bibliographic references were identified, 22 of them were eligible for review and data collection. Studies reported an error rate between 1% and 58% of the evaluated medication indications, with errors reported in different processes of drug use. 9 articles (41%) described errors related only to prescription, mainly associated with incorrect dosage, 6 (27%) errors related to prescription, administration, and other processes, 3 (14%) related to prescription and administration, 2 (9%) related only to administra tion, 1 (4%) article reported errors related to conciliation, and 1 (4%) described errors related to preparation and administration.
CONCLUSION
The studies reported different medication errors in the pediatric population. Most of them reported ME related to prescription followed by ME in the administration. Knowing the proportion of ME allows focusing interventions aimed at reducing their prevalence.
Topics: Child; Child, Hospitalized; Humans; Medication Errors; Pediatrics
PubMed: 34106170
DOI: 10.32641/andespediatr.v92i2.1357 -
BMC Health Services Research Nov 2022Medication errors are categorized among the most common medical errors that may lead to irreparable damages to patients and impose huge costs on the health system. A...
BACKGROUND
Medication errors are categorized among the most common medical errors that may lead to irreparable damages to patients and impose huge costs on the health system. A correct understanding of the prevalence of medication errors and the factors affecting their occurrence is indispensable to prevent such errors. The purpose of this study was to investigate the prevalence and types of medication errors among nurses in a hospital in northeastern Iran.
METHODS
The present descriptive-analytical research was conducted on 147 medical records of patients admitted to the Department of Internal Medicine at a hospital in northeastern Iran in 2019, selected by systematic sampling. The data were collected through a researcher-made checklist containing the demographic profiles of the nurses, the number of doctor's orders, the number of medication errors and the type of medication error, and were finally analyzed using STATA version 11 software at a significance level of 0.05.
RESULTS
Based on the findings of this study, the mean prevalence of medication error per each medical case was 2.42. Giving non-prescription medicine (47.8%) was the highest and using the wrong form of the drug (3.9%) was the lowest medication error. In addition, there was no statistically significant relationship between medication error and the age, gender and marital status of nurses (p > 0.05), while the prevalence of medication error in corporate nurses was 1.76 times higher than that of nurses with permanent employment status (IRR = 1.76, p = 0.009). The prevalence of medication error in the morning shift (IRR = 0.65, p = 0.001) and evening shift (IRR = 0.69, p = 0.011) was significantly lower than that in the night shift.
CONCLUSION
Estimating the prevalence and types of medication errors and identified risk factors allows for more targeted interventions. According to the findings of the study, training nurses, adopting an evidence-based care approach and creating interaction and coordination between nurses and pharmacists in the hospital can play an effective role in reducing the medication error of nurses. However, further research is needed to evaluate the effectiveness of interventions to reduce the prevalence of medication errors.
Topics: Humans; Hospitals, Teaching; Iran; Medical Records; Medication Errors; Retrospective Studies; Nurses; Nursing Staff, Hospital; Nurse's Role
PubMed: 36443775
DOI: 10.1186/s12913-022-08864-9 -
Clinical Therapeutics Nov 2008
Topics: Complementary Therapies; Data Collection; Humans; Medication Errors; Medication Therapy Management; National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division; Nonprescription Drugs; United States
PubMed: 19108803
DOI: 10.1016/j.clinthera.2008.11.010 -
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 -
Brazilian Journal of Anesthesiology... 2017Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to... (Review)
Review
Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.
Topics: Anesthesia; Anesthesiology; Anesthetics; Drug-Related Side Effects and Adverse Reactions; Humans; Intensive Care Units; Medication Errors; Quality Improvement
PubMed: 28236867
DOI: 10.1016/j.bjane.2015.09.006 -
BMJ Open May 2022Medication errors (MEs) are associated with patient harm and high economic costs. Healthcare authorities and pharmacovigilance organisations in many countries routinely...
INTRODUCTION
Medication errors (MEs) are associated with patient harm and high economic costs. Healthcare authorities and pharmacovigilance organisations in many countries routinely collect data on MEs via reporting systems to improve patient safety and for learning purposes. Different approaches have been developed and used for the ME analysis, but an overview of the scope of available methods currently is lacking. This scoping review aimed to identify, explore and map available literature on methods used to analyse MEs in reporting systems.
METHODS AND ANALYSES
This protocol describes a scoping review, based on the Joanna Briggs Institute methodological framework. A systematic search will be performed in MEDLINE (Ovid), Embase (Ovid), Cinahl (EBSCOhost), Cochrane Central, Google Scholar, websites of the major pharmacovigilance centres and national healthcare safety agencies, and citation search in Scopus in August 2022. All retrieved records are to be independently screened by two researchers on title, abstract and full text, involving a third researcher in case of disagreement. Data will be extracted and presented in descriptive and tabular form. The extraction will be based on information about methods of ME analyses, type of reporting system and information on MEs (medication name, ATC codes, ME type, medication-event categories and harm categories).
ETHICS AND DISSEMINATION
Ethical approval is not required. The results will be disseminated via publication in peer-reviewed journals, scientific networks and relevant conferences.
Topics: Delivery of Health Care; Humans; Medication Errors; Patient Safety; Pharmacovigilance; Research Design; Systematic Reviews as Topic
PubMed: 35613756
DOI: 10.1136/bmjopen-2021-057764