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British Journal of Clinical Pharmacology Jun 2012Medication errors cause substantial harm to patients. We need good methods for counting errors, and we need to know how errors defined in different ways and ascertained...
Medication errors cause substantial harm to patients. We need good methods for counting errors, and we need to know how errors defined in different ways and ascertained by different methods are related to the harm that patients suffer. As errors arise within the complex and poorly designed systems of hospital and primary care, analysis of the factors that lead to error, for example by failure mode and effects analysis, may encourage better designs and reduce harms. There is almost no information on the best ways to train prescribers to be safe or to design effective computerized decision support to help them, although both are important in reducing medication errors and should be investigated. We also need to know how best to provide patients with the data they need to be part of initiatives for safer prescribing.
Topics: Drug Prescriptions; Humans; Medication Errors; Patient Education as Topic; Physician-Patient Relations; Practice Patterns, Physicians'; Risk Management; United Kingdom
PubMed: 22360355
DOI: 10.1111/j.1365-2125.2012.04236.x -
Scientific Reports Oct 2023Patient safety reporting systems give healthcare provider staff the ability to report medication related safety events and errors; however, many of these reports go...
Patient safety reporting systems give healthcare provider staff the ability to report medication related safety events and errors; however, many of these reports go unanalyzed and safety hazards go undetected. The objective of this study is to examine whether natural language processing can be used to better categorize medication related patient safety event reports. 3,861 medication related patient safety event reports that were previously annotated using a consolidated medication error taxonomy were used to develop three models using the following algorithms: (1) logistic regression, (2) elastic net, and (3) XGBoost. After development, models were tested, and model performance was analyzed. We found the XGBoost model performed best across all medication error categories. 'Wrong Drug', 'Wrong Dosage Form or Technique or Route', and 'Improper Dose/Dose Omission' categories performed best across the three models. In addition, we identified five words most closely associated with each medication error category and which medication error categories were most likely to co-occur. Machine learning techniques offer a semi-automated method for identifying specific medication error types from the free text of patient safety event reports. These algorithms have the potential to improve the categorization of medication related patient safety event reports which may lead to better identification of important medication safety patterns and trends.
Topics: Humans; Patient Safety; Medication Errors; Logistic Models; Data Mining; Research Report
PubMed: 37884577
DOI: 10.1038/s41598-023-45152-w -
BMC Pediatrics Oct 2018Medication administration error is a medication error that occurs while administering a medication to a patient. A variety of factors make pediatrics more susceptible to... (Observational Study)
Observational Study
BACKGROUND
Medication administration error is a medication error that occurs while administering a medication to a patient. A variety of factors make pediatrics more susceptible to medication errors and its consequences. In low-income countries, like Ethiopia, there is no sufficient evidence regarding medication administration error among pediatrics. The aim of this study is, therefore, to determine the magnitude and factors associated with medication administration error among pediatric population.
METHODS
A prospective observational based cross sectional study design was conducted from January to April 2017. Data collection was done using pre-tested structured questionnaire and blind observation checklist to health professionals in charge of administering selected medications. A total of 1282 medication administrations were obtained using single population proportion formula from patients in the selected public hospitals and the samples were selected using multistage sampling technique. Multivariable logistic regression using odds ratio and 95% confidence interval was used to determine the relationship between the independent and dependent variables. Variables with p-value < 0.05 were considered as independent factors for medication administration error.
RESULT
A total of 1251 medication administrations were observed from 1251 patients. The occurrence of medication administration error was 62.7% with 95% CI (59.6%, 65.0%), wrong dose being the most common type of medication administration error with an occurrence rate of 53.7%. Medications administered for pediatric patients less than 1 month age, administered by bachelor degree holder health professionals, prepared in facilities without medication preparation room, prepared in facilities without medication administration guide and administer for patients who have two or more prescribed medications were more likely to have medication administration error than their counterparts with AOR (95% CI) of 7.54(2.20-25.86), 1.52 (1.07-2.17), 13.45 (8.59-21.06), 4.11 (2.89-5.85), and 2.42 (1.62-3.61), respectively.
CONCLUSION
This study has revealed that there is high occurrence of medication administration error among pediatric inpatients in public hospitals of Tigray, Northern Ethiopia.. Age of patients, educational level of medication administrators, availability of the medication preparation room and guide, and the number of medications given per single patient were statistically significant factors associated with occurrence of medication administration error.
Topics: Child; Child, Preschool; Clinical Competence; Cross-Sectional Studies; Developing Countries; Ethiopia; Hospitalization; Hospitals, Public; Humans; Infant; Infant, Newborn; Logistic Models; Medication Errors; Personnel, Hospital; Prospective Studies
PubMed: 30305080
DOI: 10.1186/s12887-018-1294-5 -
The Journal of Clinical Pediatric... Nov 2021Parallel to the development of new medications for various diseases run the threat of medication errors. These errors though common, very few are fatal and so goes... (Review)
Review
Parallel to the development of new medications for various diseases run the threat of medication errors. These errors though common, very few are fatal and so goes unnoticed. Such errors occurring with pediatric population can be a major predicament. This review aims to address the various parametric variations and considerations in pediatric population so as to minimize medication errors. A detailing about various causes, types and levels of errors, ways of analysing the amount of error and the essential knowledge about prescription writing which could reduce the incidents have been paid attention to. The article also discusses possible recommendations to the stakeholders and caregivers that could encompass the reason of lack of information for the ever-increasing medication errors.
Topics: Child; Humans; Medication Errors; Pediatric Dentistry
PubMed: 34740267
DOI: 10.17796/1053-4625-45.5.1 -
Journal of Clinical Anesthesia Sep 2018The objective of the study was to: a) characterize the frequency, type, and outcome of anesthetic medication errors spanning an 8.5-year period, b) describe the targeted...
STUDY OBJECTIVE
The objective of the study was to: a) characterize the frequency, type, and outcome of anesthetic medication errors spanning an 8.5-year period, b) describe the targeted error reduction strategies and c) measure the effects, if any, of a focused, continuous, multifaceted Medication Safety Program.
DESIGN
Retrospective analysis.
SETTING
All anesthetizing locations (57).
PATIENTS
All anesthesia patients at all Boston Children's Hospital anesthetizing locations from January 2008 to June 2016 were included.
INTERVENTIONS
Medication libraries, zero-tolerance philosophy, independent verification, trainee education, standardized dosing; retrospective study.
MEASUREMENTS
Number and type of medication errors.
MAIN RESULTS
105 medication errors were identified among the 287,908 cases evaluated during the study period. Incorrect dose (55%) and incorrect medication (28%) were the most frequently observed errors. Beginning within 3 years of the implementation of the 2009 Medication Safety Program, the incidence declined to an average of 3.0 per 10,000 cases in the years from 2010 to 2016 (57% reduction) and declined to an average of only 2.2 per 10,000 cases since 2012 (69% reduction). Logistic regression indicated a 13% reduction per year in the odds of a medication error over the time period (odds ratio = 0.87, 95% CI: 0.79-0.95, P = 0.004).
CONCLUSIONS
Although medication errors persisted, there was a statistically significant reduction in errors during the study period. Formalized Medication Safety Programs should be adopted by other departments and institutions; these Programs could help prevent medication errors and decrease their overall incidence.
Topics: Anesthesia; Anesthesiology; Anesthetics; Child; Hospitals, Pediatric; Humans; Incidence; Medication Errors; Outcome and Process Assessment, Health Care; Patient Safety; Program Evaluation; Retrospective Studies; Safety Management
PubMed: 29913393
DOI: 10.1016/j.jclinane.2018.05.011 -
Jornal de Pediatria 2014to meta-analyze studies that have assessed the medication errors rate in pediatric patients during prescribing, dispensing, and drug administration. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
to meta-analyze studies that have assessed the medication errors rate in pediatric patients during prescribing, dispensing, and drug administration.
SOURCES
searches were performed in the PubMed, Cochrane Library, and Trip databases, selecting articles published in English from 2001 to 2010.
SUMMARY OF THE FINDINGS
a total of 25 original studies that met inclusion criteria were selected, which referred to pediatric inpatients or pediatric patients in emergency departments aged 0-16 years, and assessed the frequency of medication errors in the stages of prescribing, dispensing, and drug administration.
CONCLUSIONS
the combined medication error rate for prescribing errors to medication orders was 0.175 (95% Confidence Interval: [CI] 0.108-0.270), the rate of prescribing errors to total medication errors was 0.342 (95% CI: 0.146-0.611), that of dispensing errors to total medication errors was 0.065 (95% CI: 0.026-0.154), and that ofadministration errors to total medication errors was 0.316 (95% CI: 0.148-0.550). Furthermore, the combined medication error rate for administration errors to drug administrations was 0.209 (95% CI: 0.152-0.281). Medication errors constitute a reality in healthcare services. The medication process is significantly prone to errors, especially during prescription and drug administration. Implementation of medication error reduction strategies is required in order to increase the safety and quality of pediatric healthcare.
Topics: Adolescent; Attitude of Health Personnel; Child; Child, Preschool; Confidence Intervals; Drug Prescriptions; Hospitalization; Humans; Infant; Infant, Newborn; Medical Records; Medication Errors; Medication Systems, Hospital
PubMed: 24726455
DOI: 10.1016/j.jped.2014.01.008 -
International Journal of Environmental... May 2021Reporting medication errors is crucial for improving quality of care and patient safety in acute care settings. To date, little is known about how reporting varies...
Reporting medication errors is crucial for improving quality of care and patient safety in acute care settings. To date, little is known about how reporting varies between early and mid-career nurses. Thus, this study used a cross-sectional, secondary data analysis design to investigate the differences between early (under the age of 35) and mid-career (ages 35-54) female nurses by examining their perceptions of patient safety culture using the Korean Hospital Survey on Patient Safety Culture (HSPSC) and single-item self-report measure of medication error reporting. A total of 311 hospital nurses (260 early-career and 51 mid-career nurses) completed questionnaires on perceived patient safety culture and medication error reporting. Early-career nurses had lower levels of perception regarding patient safety culture ( = 0.034) compared to mid-career nurses. A multiple logistic regression analysis showed that relatively short clinical experience (<3 years) and a higher level of perceived patient safety culture increased the rate of appropriate medication error reporting among early-career nurses. However, there was no significant association between perception of patient safety culture and medication error reporting among mid-career nurses. Future studies should investigate the role of positive perception of patient safety culture on reporting errors considering multidimensional aspects, and include hospital contextual factors among early-, mid-, and late-career nurses.
Topics: Adult; Cross-Sectional Studies; Female; Humans; Medication Errors; Middle Aged; Nurses; Nursing Staff, Hospital; Organizational Culture; Patient Safety; Perception; Republic of Korea; Safety Management; Surveys and Questionnaires
PubMed: 34062845
DOI: 10.3390/ijerph18094853 -
Arquivos de Neuro-psiquiatria Mar 2022With the continuous increase of Alzheimer's disease (AD), it is also imminent to treat patients with AD for medication reconciliation. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
With the continuous increase of Alzheimer's disease (AD), it is also imminent to treat patients with AD for medication reconciliation.
OBJECTIVE
To explore the role and value of medication reconciliation in AD treatment.
METHODS
100 patients over 65 years of age diagnosed with AD were randomly separated into two groups: conventional treatment and medication reforming. The list of medical orders of all subjects was obtained within 24 hours after admission with Beers criteria, STOPP/START criteria, and Chinese Pharmacopoeia used as the MED intervention criteria. Medication reconciliation was performed at 2 weeks, 1 month, and 2 months after hospital admission. The number of medications prescribed, the quantity of the medication, medication error rate, therapeutic effect, adverse drug reactions, and satisfaction levels of family members and main caregivers were compared between the two groups.
RESULTS
After the intervention, the types and amount of medication in the MED group were less compared to the CON group along with a reduced medication deviation rate. The Mini-mental state examination (MMSE) score and the proportion of well-nourished patients in the MED group were higher than those in the CON group. It was also observed that the physical self-care ability score and the proportion of patients with abnormal swallowing were lower when in comparison with the CON group. The incidence of adverse drug reactions in the MED group was lower than that in the CON group. However, the satisfaction rate was higher than that in the CON group.
CONCLUSION
Medication reconciliation can reduce the medication deviation in AD patients.
Topics: Alzheimer Disease; Drug-Related Side Effects and Adverse Reactions; Hospitalization; Humans; Medication Errors; Medication Reconciliation
PubMed: 35239819
DOI: 10.1590/0004-282X-ANP-2021-0147 -
British Journal of Clinical Pharmacology Sep 2016Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to... (Review)
Review
AIMS
Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has been conducted and how medication discrepancies have been classified.
METHODS
We searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstracts (IPA), and Web of Science (WOS), in accordance with the PRISMA statement up to April 2016. Studies were eligible for inclusion if they evaluated the types of medication discrepancy found through the medication reconciliation process and contained a classification system for discrepancies. Data were extracted by one author based on a predefined table, and 10% of included studies were verified by two authors.
RESULTS
Ninety-five studies met the inclusion criteria. Approximately one-third of included studies (n = 35, 36.8%) utilized a 'gold' standard medication list. The majority of studies (n = 57, 60%) used an empirical classification system and the number of classification terms ranged from 2 to 50 terms. Whilst we identified three taxonomies, only eight studies utilized these tools to categorize discrepancies, and 11.6% of included studies used different patient safety related terms rather than discrepancy to describe the disagreement between the medication lists.
CONCLUSIONS
We suggest that clear and consistent information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well-designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice.
Topics: Humans; Medication Errors; Medication Reconciliation; Patient Safety
PubMed: 27198753
DOI: 10.1111/bcp.13017 -
British Journal of Clinical Pharmacology Aug 2022Anticoagulants represent a main source of medication errors (MEs) and complications that have catastrophic implications, posing an obligation on health care providers to...
AIMS
Anticoagulants represent a main source of medication errors (MEs) and complications that have catastrophic implications, posing an obligation on health care providers to assess anticoagulant-related MEs and factors affecting their occurrence. This study investigates the occurrence and severity of prescribing MEs in patients on anticoagulants and explores their potential predictors.
METHODS
This study was a prospective cohort study in a tertiary hospital on 116 patients with a total of 2166 anticoagulant doses.
RESULTS
Forty-four percent of prescribed anticoagulant doses resulted in MEs with low molecular weight heparin (LMWH) and unfractionated heparin (UFH) causing 61% and 34%, respectively, of the total MEs. More than 50% of all MEs were incorrect doses (high and low) shared between heparin and tinzaparin. The highest severity of error was Category D followed by Category F and Category C. A Poisson regression analysis model revealed that female (incidence rate ratio [IRR] 1.32, 95% confidence interval [CI] 1.13-1.54, P < .001), bridging (IRR 1.52; 95% CI 1.10-2.09; P = .011), venous thromboembolism (VTE) prophylaxis (IRR 7.65; 95% CI 4.88-12.02; P < .001), physician non-adherence (IRR 2.71; 95% CI 2.22-3.29; P < .001), and polypharmacy (IRR 1.68; 95% CI 1.26-2.23; P = .036) were predictors of the higher incidence of MEs. Ordinal logistic regression analysis demonstrated that physician non-adherence (OR 24.67; 95% CI 5.54-207; P < .001) was the main predictor of increased error severity.
CONCLUSION
The major predictor in increasing both the incidence and severity of MEs is physician adherence to evidence-based guidelines (EBG). Strict regulations for anticoagulant prescribing through an anticoagulant stewardship program are a necessity.
Topics: Anticoagulants; Female; Heparin; Heparin, Low-Molecular-Weight; Humans; Incidence; Medication Errors; Physicians; Prospective Studies; Venous Thromboembolism
PubMed: 35293625
DOI: 10.1111/bcp.15314