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British Journal of Anaesthesia Sep 2021The rate of medication errors in anaesthesia is a critical safety indicator but the methods to estimate this metric are imperfect. A number of factors that are difficult...
The rate of medication errors in anaesthesia is a critical safety indicator but the methods to estimate this metric are imperfect. A number of factors that are difficult to control impact their incidence. Newer methods involving computerised records are improving retrospective and real-time monitoring of medication errors.
Topics: Anesthesia; Humans; Medication Errors; Retrospective Studies
PubMed: 34238549
DOI: 10.1016/j.bja.2021.06.008 -
American Journal of Pharmaceutical... Jan 2023Health professions students must develop collaborative skills to disclose errors effectively and improve patient safety. We proposed that an interprofessional...
Health professions students must develop collaborative skills to disclose errors effectively and improve patient safety. We proposed that an interprofessional simulation using telehealth technology would provide medical and pharmacy students the opportunity to practice, develop, and grow in their confidence and skills of working collaboratively and disclosing medication errors. A three-phase interprofessional student simulation was developed. Phase 1 included individual student preparation. An interprofessional telehealth consultation encounter occurred in phase 2 for the error disclosure between the pharmacy and medical students. Phase 3 included faculty-led interprofessional debrief sessions. A pre- and postsimulation survey assessed students' experiences regarding their confidence in error disclosure, use of telehealth technology, and the role of the community pharmacist. Faculty evaluated pharmacy student performance using a 12-point rubric. Presimulation survey responses (n=173) were compared to postsimulation survey responses (n=140). Significant changes were seen for all students' confidence in error disclosure and use of telehealth technology. No significant change was noted in the students' understanding of the community pharmacists' role on the interprofessional team. Pharmacy student performance-based rubric data (n=148) revealed a median score of seven out of 12 for error disclosure and interprofessional communication items. Medical and pharmacy students perceived their confidence improved in interprofessional error disclosure and use of telehealth consultation technology through this interprofessional simulation. Pharmacy students' error disclosure and interprofessional communication skill development were assessed through this simulation.
Topics: Humans; Interprofessional Relations; Education, Pharmacy; Medication Errors; Students, Health Occupations; Truth Disclosure; Students, Pharmacy; Referral and Consultation; Telemedicine
PubMed: 35197254
DOI: 10.5688/ajpe8799 -
PloS One 2016Medications are mostly taken in patients' own homes, increasingly administered by carers, yet studies of medication safety have been largely conducted in the hospital... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Medications are mostly taken in patients' own homes, increasingly administered by carers, yet studies of medication safety have been largely conducted in the hospital setting. We aimed to review studies of how carers cause and/or prevent medication administration errors (MAEs) within the patient's home; to identify types, prevalence and causes of these MAEs and any interventions to prevent them.
METHODS
A narrative systematic review of literature published between 1 Jan 1946 and 23 Sep 2013 was carried out across the databases EMBASE, MEDLINE, PSYCHINFO, COCHRANE and CINAHL. Empirical studies were included where carers were responsible for preventing/causing MAEs in the home and standardised tools used for data extraction and quality assessment.
RESULTS
Thirty-six papers met the criteria for narrative review, 33 of which included parents caring for children, two predominantly comprised adult children and spouses caring for older parents/partners, and one focused on paid carers mostly looking after older adults. The carer administration error rate ranged from 1.9 to 33% of medications administered and from 12 to 92.7% of carers administering medication. These included dosage errors, omitted administration, wrong medication and wrong time or route of administration. Contributory factors included individual carer factors (e.g. carer age), environmental factors (e.g. storage), medication factors (e.g. number of medicines), prescription communication factors (e.g. comprehensibility of instructions), psychosocial factors (e.g. carer-to-carer communication), and care-recipient factors (e.g. recipient age). The few interventions effective in preventing MAEs involved carer training and tailored equipment.
CONCLUSION
This review shows that home medication administration errors made by carers are a potentially serious patient safety issue. Carers made similar errors to those made by professionals in other contexts and a wide variety of contributory factors were identified. The home care setting should be a priority for the development of patient safety interventions.
Topics: Caregivers; Home Care Services; Humans; Medication Errors; Prevalence; Risk Factors
PubMed: 27907072
DOI: 10.1371/journal.pone.0167204 -
Revista Brasileira de Anestesiologia 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; Anesthetics; Humans; Medication Errors; Practice Guidelines as Topic
PubMed: 28038759
DOI: 10.1016/j.bjan.2016.12.006 -
Journal of the American Medical... Jan 2021To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS)... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS.
MATERIALS AND METHODS
We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed.
RESULTS
There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18-8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72-0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence.
DISCUSSION AND CONCLUSION
Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.
Topics: Drug-Related Side Effects and Adverse Reactions; Humans; Inpatients; Length of Stay; Medical Order Entry Systems; Medication Errors; Medication Systems, Hospital
PubMed: 33164058
DOI: 10.1093/jamia/ocaa230 -
The American Journal of Medicine Dec 2011Anticoagulant drugs are among the most common medications that cause adverse drug events (ADEs) in hospitalized patients. We performed a 5-year retrospective study at...
PURPOSE
Anticoagulant drugs are among the most common medications that cause adverse drug events (ADEs) in hospitalized patients. We performed a 5-year retrospective study at Brigham and Women's Hospital to determine clinical characteristics, types, root causes, and outcomes of anticoagulant-associated ADEs.
METHODS
We reviewed all inpatient anticoagulant-associated ADEs, including adverse drug reactions (ADRs) and medication errors, reported at Brigham and Women's Hospital through the Safety Reporting System from May 2004 to May 2009. We also collected data about the cost associated with hospitalizations in which ADRs occurred.
RESULTS
Of 463 anticoagulant-associated ADEs, 226 were medication errors (48.8%), 141 were ADRs (30.5%), and 96 (20.7%) involved both a medication error and ADR. Seventy percent of anticoagulant-associated ADEs were potentially preventable. Transcription errors (48%) were the most frequent root cause of anticoagulant-associated medication errors, while medication errors (40%) were a common root cause of anticoagulant-associated ADRs. Death within 30 days of anticoagulant-associated ADEs occurred in 11% of patients. After an anticoagulant-associated ADR, most hospitalization expenditures were attributable to nursing costs (mean $33,189 per ADR), followed by pharmacy costs (mean $7451 per ADR).
CONCLUSION
Most anticoagulant-associated ADEs among inpatients result from medication errors and are, therefore, potentially preventable. We observed an elevated 30-day mortality rate among patients who suffered an anticoagulant-associated ADE and high hospitalization costs following ADRs. Further quality improvement efforts to reduce anticoagulant-associated medication errors are warranted to improve patient safety and decrease health care expenditures.
Topics: Adverse Drug Reaction Reporting Systems; Aged; Anticoagulants; Drug-Related Side Effects and Adverse Reactions; Female; Humans; Inpatients; Male; Medication Errors; Middle Aged; Risk Factors
PubMed: 22114827
DOI: 10.1016/j.amjmed.2011.06.009 -
Nursing Open Nov 2021To analyse medication error data from a hospital's electronic reporting system and identify the factors affecting error types and harmfulness.
AIM
To analyse medication error data from a hospital's electronic reporting system and identify the factors affecting error types and harmfulness.
DESIGN
A retrospective study.
METHODS
The 805 near misses and adverse events reported to the hospital's electronic reporting system between January 2014 and December 2018 were analysed using descriptive statistics, chi-square tests and logistic regression analyses.
RESULTS
A total of 632 near misses and 173 adverse events were reported. Near misses and adverse events were the most common error type during the dispensing stage and medication administration, respectively. The odds of medication errors reported by nurses with 1-9 years of clinical experience were relatively low. After adjusting for confounders, the odds of medication errors directly observed by nurses were 65% lower than the odds of medication errors not directly detected. In clinical practice, nurses must be educated about errors in reporting depending on their degree of clinical experience.
Topics: Electronics; Humans; Medication Errors; Retrospective Studies
PubMed: 34392612
DOI: 10.1002/nop2.1038 -
Hong Kong Medical Journal = Xianggang... Oct 2006
Topics: Aged; Humans; Medication Errors; Poisoning
PubMed: 17028350
DOI: No ID Found -
Boletin Medico Del Hospital Infantil de... 2022Due to many antineoplastic drugs' toxicity and narrow therapeutic window, medication errors are a health concern in pediatric oncology patients. This study aimed to... (Observational Study)
Observational Study
BACKGROUND
Due to many antineoplastic drugs' toxicity and narrow therapeutic window, medication errors are a health concern in pediatric oncology patients. This study aimed to identify and classify medication errors in a pediatric inpatient chemotherapy facility and evaluate the outcomes of these medication errors.
METHODS
We conducted an observational retrospective study over 5 months in a chemotherapy facility for pediatric patients. The evaluation consisted of the review of the available medical records. The medication errors detected were manually recorded in a medical logbook. The International Classification for Patient Safety was adjusted to our clinical setting for the analysis, the terminology, and the classification system. A descriptive analysis was performed.
RESULTS
A total of 286 medical records were reviewed; one type of medication error was noted in at least 97.6%, and 962 errors were identified totally, with an overall rate of 3.36 errors per visit. Most errors occurred in the documentation stage (643; 66.8%), followed by the administration stage (227; 23.6%). Of all medication errors, 37.2% had the potential to cause injury, but only five reached the patient (0.5%), and only two (0.2%) resulted in a severe harmful incident.
CONCLUSIONS
Medication errors were common, especially at the documentation stage. Better documentation strategies need to be implemented to reduce the rate of near misses and prevent potential adverse events.
Topics: Antineoplastic Agents; Child; Drug-Related Side Effects and Adverse Reactions; Humans; Inpatients; Medication Errors; Retrospective Studies
PubMed: 35882027
DOI: 10.24875/BMHIM.21000175 -
British Journal of Anaesthesia Mar 2022Literature focused on quantifying or reducing patient harm in anaesthesia uses a variety of labels and definitions to represent patient safety-related events, such as... (Review)
Review
Literature focused on quantifying or reducing patient harm in anaesthesia uses a variety of labels and definitions to represent patient safety-related events, such as 'medication errors', 'adverse events', and 'critical incidents'. This review extracts and compares definitions of patient safety-related terminology in anaesthesia to examine the scope of this variability and inconsistencies. A structured review was performed in which 36 of the 769 articles reviewed met the inclusion criteria. Similar terms were grouped into six categories by similarities in keyword choice (Adverse Event, Critical Incident, Medication Error, Error, Near Miss, and Harm) and their definitions were broken down into three base components to allow for comparison. Our analysis found that the Medication Error category, which encompasses the greatest number of terms, had widely variant definitions which represent fundamentally different concepts. Definitions of terms within the other categories consistently represented relatively similar concepts, though key variations in wording remain. This inconsistency in terminology can lead to problems with synthesising, interpreting, and overall sensemaking in relation to anaesthesia medication safety. Guidance towards how 'medication errors' should be defined is provided, yet a definition will have little impact on the future of patient safety without organisations and journals taking the lead to promote, publish, and standardise definitions.
Topics: Anesthesia; Anesthesiology; Animals; Drug-Related Side Effects and Adverse Reactions; Humans; Medication Errors; Patient Safety; Risk Management
PubMed: 35086685
DOI: 10.1016/j.bja.2021.11.038