scholarly journals Medication Errors among Physician-Assistants Anaesthesia

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
G. Amponsah ◽  
A. Antwi-Kusi ◽  
W. Addison ◽  
B. Abaidoo
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Physician Assistants ◽  
Contributing Factors ◽  
Safety Issues ◽  
Contributory Factors ◽  
Wrong Drug ◽  
Quality Of Patient Care ◽  
Government Hospitals

Background. Safety issues in anaesthesia are currently being discussed widely. Anaesthetists have a unique cross-specialty opportunity to influence the safety and quality of patient care. Anaesthetists administer very potent drugs, in rapid succession, during the course of one anaesthesia event. Methodology. The study was done in April 2013 at the annual refresher course of the Physician-Assistants Anaesthesia using a questionnaire which was completed by the participants on the course. The data was analysed using IBM SPSS Statistics software version 20. Results. There were 164 completed questionnaires, with 92 (62.2%) males and 56 (37.8%) females with a mean age of 32.3 years. The majority of them (66.5%) work in government hospitals. One hundred and seven (65.3%) have had an episode of medication error with 101 (94.4%) experiencing it between 1 and 5 times. The incident occurred in the afternoon or at night in 73 (71.7%) cases. The commonest type of incident was the administration of wrong drug which occurred on 64 (71.9%) occasions resulting in 3 deaths. The contributing factors included distraction, tiredness, and overreliance on vial/ampoule colour. Conclusion. Medication errors among Physician-Assistants Anaesthesia are not uncommon leading to harm and even death of patients. The rate of medication errors can be minimised by addressing some of the contributory factors raised by the respondents.

scholarly journals PENGETAHUAN DAN SIKAP TENAGA KESEHATAN TERHADAP PELAPORAN DAN SISTEM PELAPORAN MEDICATION ERROR DI RSU MONOMPIA GMIBM KOTA KOTAMOBAGU

PHARMACON ◽  
2019 ◽  
Vol 8 (2) ◽  
pp. 360
Author(s):  
Dwi Baluntu ◽  
Weny I. Wiyono ◽  
Marina Mamarimbing
Keyword(s):  
Health Services ◽  
Medication Error ◽  
General Hospital ◽  
Medication Errors ◽  
Health Workers ◽  
Disciplinary Action ◽  
Qualitative Descriptive ◽  
Quality Of Health Services ◽  
Depth Interviews

ABSTRACT This research to determine the knowledge and attitudes of health workers regarding reporting and reporting systems of medication errors has been carried out. Medication errors is any event that can cause or resulted  in improper health services or harm to patients that actually can be avoided. This research is a qualitative descriptive study using in-depth interviews with data analysis conducted using thematic analysis. The results showed that the health workers at Monompia General Hospital GMIBM Kotamobagu did not understand the reporting of medication errors, decision making to report medication errors was determined by the severity of the result of errors and lack of reporting due to fear of disciplinary action and fear of losing their jobs. Monompia General Hospital GMIBM Kotamobagu City continues to strive to improve the quality of health services, but the limitations of facilities and infrastructure as well as human resources were the obsracles. Keywords : Knowledge, Medication Errors, Reporting System ABSTRAK Telah dilakukan penelitian untuk mengetahui pengetahuan dan sikap tenaga kesehatan mengenai pelaporan dan sistem pelaporan medication error. Medication error merupakan setiap kejadian yang dapat menyebabkan atau berakibat pada  pelayanan kesehatan yang tidak tepat atau membahayakan pasien yang sebenarnya dapat dihindari. Penelitian ini merupakan penelitian yang bersifat deskriptif kualitatif menggunakan wawancara mendalam dengan analisis data yang dilakukan menggunakan tematik analisis. Hasil penelitian menunjukan bahwa tenaga kesehatan  di RSU Monompia GMIBM Kota Kotamobagu belum memahami mengenai pelaporan medication error, pengambilan keputusan untuk melaporkan kesalahan pengobatan ditentukan oleh tingkat keparahan hasil dari kesalahan dan minimnya tingkat pelaporan disebabkan karena tenaga kesehatan takut tindakan disiplin serta takut kehilangan pekerjaan. RSU Monompia GMIBM Kota Kotamobagu terus berupaya untuk meningkatkan mutu pelayanan kesehatan, tetapi keterbatasan sarana dan prasarana serta sumber daya manusia menjadi kendala tesendiri. Kata kunci : Pengetahuan, Medication error, sistem pelaporan

scholarly journals Current situation of medication errors in Saudi Arabia: a nationwide observational study

2020 ◽  
Author(s):  
Thamir M Alshammari ◽  
Khalidah A. Alenzi ◽  
Yasser M Alatawi ◽  
Afnan S. Almordi ◽  
Ali F. Altebainawi
Keyword(s):  
Observational Study ◽  
Medication Error ◽  
Medication Errors ◽  
Healthcare Professionals ◽  
Medication Use ◽  
Medication Information ◽  
Government Hospitals ◽  
Patient Work ◽  
Nationwide Observational Study ◽  
Process Complexity

Abstract BackgroundMedication process complexity could cause confusion among healthcare professionals (HCPs) and patients and lead to medication errors. This nationwide study aimed to characterize the types of medication errors and determine the error occurs in different stages of the medication process.MethodsThis was a retrospective observational study of medication errors reported by 265 government hospitals and primary care centers during the period of March 2018 to June 2019. The reported information include several aspects of medication errors, including patient information, medication information, error information, and the level of staff reporting and causing the error. The medication use process was categorized into ordering/prescribing, transcribing, dispensing, administering, and monitoring. ResultsA total of 71,332 medication error reports were reported between March 2018 and June 2019. The reported errors involved patients aged <10 (12,1312; 17.3%) and >60 (8,857; 12.4%) years, and the medication error rate was estimated to be 0.15%. Errors were frequently made by physicians 63120 (88.5%) and frequently detected by pharmacists (75.9%). The majority of errors were detected at the prescribing stage (84.8%), followed by the transcribing (5.8%) and dispensing (5.7%) stages. A total of 4,182 (5.8%) errors reached the patient. Work overload of staff was associated with one-third of the reported errors (31.6%), and 22.7% of the errors were due to a lack of experience among HCPs.ConclusionsThe study highlights the concern regarding medication errors occurrence during different medication use process. Despite all efforts, prescribing stage is still a big concern as source of harm to the patients.

Prevalence and factors contributing to medication errors in a referral hospital in Iran: A retrospective study

2021 ◽  
Vol 15 (6) ◽  
pp. 1785-1789
Author(s):  
Meisam Moezzi ◽  
Golshan Afshari ◽  
Fakher Rahim
Keyword(s):  
Quality Improvement ◽  
Medication Error ◽  
Medication Errors ◽  
Drug Administration ◽  
Referral Hospital ◽  
Error Reporting ◽  
Inappropriate Drug ◽  
Wrong Drug ◽  
Significant Difference ◽  
Qualitative Variables

Background: A medication error is defined as any inappropriate drug administration that can harm the patient while being preventable and equally occurring under the supervision of a medical team. Objectives: The current study was conducted to clarify the error status, evaluate the regularity of medical mistakes in a referral hospital in the South West of Iran. Methods: Data were gathered from multiple wards at various shift works based on an optional error reporting form, either self-reporting or colleague-reporting, and then it has been made available to the "Quality Improvement Office" experts. Since the current study was retrospective, the samples were calculated from 2017 to 2019. The average and standard deviations were implemented to describe qualitative variables, and ANOVA to determine any statistically significant differences between groups. Results: Of 305 medication errors reported to the Quality Improvement Office, the "Administering the wrong drug" rate was 32.5%, and it has dedicated the most significant percentage of mistake types. The most-reported medication errors occurred in the general ward, and there was no significant difference in the number of mistakes in other shifts. Conclusion: Results suggest there is an association between the incidence of medication errors and the therapeutic ward. Although the most prevalent medication error in this study was "Administering the wrong drug. Keywords: medical error, error reporting, drug administration, mistakes, hospital

scholarly journals Neonatal Heparin Overdose—A Multidisciplinary Team Approach to Medication Error Prevention

2008 ◽  
Vol 13 (2) ◽  
pp. 96-98
Author(s):  
Jason Arimura ◽  
Robert L. Poole ◽  
Michael Jeng ◽  
William Rhine ◽  
Paul Sharek
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Multidisciplinary Team ◽  
Team Approach ◽  
Contributing Factors ◽  
Error Prevention ◽  
System Failures ◽  
Multidisciplinary Team Approach ◽  
Life Threatening ◽  
Medication Error Prevention

Despite the efforts of many hospitals, system failures can result in medication errors that may be life threatening. During 2006 and 2007, nine neonates received potentially fatal doses of heparin. This paper will review contributing factors to the heparin medication errors and ways to minimize the risk of heparin overdose.

Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS

2021 ◽  
pp. 0310057X2110275
Author(s):  
Jee Young Kim ◽  
Matthew R Moore ◽  
Martin D Culwick ◽  
Jacqueline A Hannam ◽  
Craig S Webster ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Safety Culture ◽  
Medication Safety ◽  
Reporting System ◽  
Current Evidence ◽  
Contributing Factors ◽  
Incident Reporting System ◽  
Wrong Side ◽  
Inappropriate Choice

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.

Necrotising fasciitis following accidental injection of intraoral xylene: a preventable medication error

2020 ◽  
Vol 13 (11) ◽  
pp. e236018
Author(s):  
Sudhagar Eswaran ◽  
Anupriya Ayyaswamy ◽  
Prasanna Kumar Saravanam
Keyword(s):  
Medication Error ◽  
Healthcare System ◽  
Medication Errors ◽  
Anaesthetic Agent ◽  
Drug Prescription ◽  
Physician Education ◽  
Mortality And Morbidity ◽  
Delivery Problem ◽  
Wrong Drug ◽  
Patient Health

The most common cause of preventable mortality and morbidity to the patient in a healthcare system is medication error. Medication errors have got a significant impact on the patient health and healthcare system. These errors are multidisciplinary and can occur at various stages of drug therapy. Physicians, nursing staff, pharmacists, hospital administration all have an important role in preventing medication errors from recurring. The most common causes include wrong patient, wrong drug prescription, look-alike sound-alike drugs, faulty drug administration, wrong dosage, drug storage, delivery problem, lack of staff, patient and physician education and failure to monitor closely. This case illustrates the importance of incorporating protocol and cross-checking before administering a drug during the procedure. Here, we discuss a case of accidental intraoral injection of xylene instead of xylocaine (local anaesthetic agent), which was a sound-alike drug that resulted in significant morbidity to the patient.

scholarly journals CONTRIBUTING FACTORS TO MEDICATION ERRORS AS PERCEIVED BY NURSING STUDENTS IN ILIGAN CITY, PHILIPPINES

2018 ◽  
Vol 4 (6) ◽  
pp. 537-544 ◽  
Author(s):  
Khandy Lorraine Guerrero Apsay ◽  
Gianille Geselle Alvarado ◽  
Marlon Charles Paguntalan ◽  
Sittie Hannah Tumog
Keyword(s):  
Nursing Students ◽  
Environmental Factors ◽  
Medication Error ◽  
Medication Errors ◽  
Clinical Supervision ◽  
Student Nurses ◽  
Medication Administration ◽  
Contributing Factors ◽  
Correlational Design ◽  
Medication Administration Errors

Background: Nursing students are allowed to give medication with clinical supervision to give medications with clinical supervision to enhance skills in medication administration. However, studies suggest that some students commit medication errors due to knowledge, personal, administrative and environmental factors.Objective: This study will identify factors that cause student nurses to commit medication errors and correlate it to the number of perceived medication errors committed.Methods: A correlational design was used to correlate the factors contributing to medication administration and the number of medication errors committed by the students. 388 randomly selected nursing students were asked to answer a Modified Medication Error Questionnaire which measures the knowledge, administrative, personal and environmental factors which may contribute to medication administration errors. Medication administration errors are measured according to the number of times a student commits as perceived by them.Results: Lack of knowledge of the drug and equipment to be used for administration, decrease in confidence, poor clinical assessment of patients; conditions, and poor follow ups from clinical instructor are identified concerns under knowledge factor. Poor positive feedback, inadequate supervision and belittling ways of clinical instructors are identified under the administrative factor. Fear of administering an injection or giving medications is a common problem under personal factor. Inappropriate labelling of medications, unfavorable room temperature, lack of space, inadequate lighting, disorganized medication administration schedule and noise are problems found under environmental factor. A minority of 17.3% claimed that they have encountered a medication error in any of their clinical duties.Conclusion: Knowledge, administrative, personal and environmental factors have no effect towards medication errors. However, the relationship between age and the number of perceived medications errors is established. More in-depth investigation is recommended to determine the type of medication errors committed and its detrimental effects towards patient safety.

scholarly journals A Systematized Review of Nurses’ Perceptions of Medication Errors Contributing Factors in Developing Countries

2021 ◽  
Vol 3 (1) ◽  
pp. 186-193
Author(s):  
Abaid Mutlaq H. Al Sahli ◽  
Mohammed Ibrahim Osman Ahmed ◽  
Abdulrahman Ibrahim M. Alshammer ◽  
Mohammed Nasser S. Hakami ◽  
Ismail Ahmed Hazazi ◽  
...  
Keyword(s):  
Developing Countries ◽  
Medication Error ◽  
Medication Errors ◽  
Research Question ◽  
Contributing Factors ◽  
Communication Breakdown ◽  
Systematized Review ◽  
Nurses Perceptions ◽  
Main Component ◽  
Error Risk

Introduction: Nurses are a main factor in maintaining the safety of a patient. Nurses are the main component and are indeed at the front of dispensing medicines to patients; they also have a responsibility to maintain the patient’s safety. Objective: This systematized review intends to review studies that assess and explore nurses’ attitudes and perceptions of medication errors in developing countries within the Middle East region, thereby contributing to knowledge regarding medication error risk. Methodology: a database search has been conducted for studies related to the research question that has been formulated using PEO framework, the database includes: MEDLINE and CINAHL EBSCO and OVID, NICE, Science Direct and ERIC. The reference lists and bibliographies were also analyzed, all the studies founded during the search process were assessed according to predefine inclusion and exclusion criteria. 10 studies (6 quantitative studies, 3 qualitative and 1 which used mixed methods) were chosen and were included in this review. Result: The studies assessed in this review were noted to have moderate to strong quality. The review found a range of factors that contribute to medication error, including both human and environmental factors. Among the contributing factors that most frequently mentioned inthis review were insufficient pharmacological knowledge, fatigue and overwork, communication breakdown, inadequate staff training, and high patient-to-nurse ratio. Conclusion and Recommendation: It would behave Saudi Arabia and neighboring countries to invest attention in this topic. Particularly advised would be additional theoretically focused research to determine the causes of medication errors.

Medication Without Harm: Developing optimal medication error reporting systems

2021 ◽  
Vol 16 ◽  
Author(s):  
Yuko Shiima ◽  
Muzaffar Malik ◽  
Michael Okorie
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Traditional Approach ◽  
Incident Reporting ◽  
Error Reporting ◽  
Contributing Factors ◽  
Medication Error Reporting ◽  
Incident Reporting Systems ◽  
Reporting Systems ◽  
Life Threatening

: Medication errors are amongst the most frequently occurring health care related incidents and have the potential to lead to life-threatening harm to patients. An incident reporting system is a traditional approach to 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 which 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 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.

scholarly journals P08 Ten-fold medication errors in a tertiary paediatric hospital

2020 ◽  
Vol 105 (9) ◽  
pp. e10.1-e10
Author(s):  
Caitlin Cubbin
Keyword(s):  
Critical Care ◽  
Data Collection ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
List Type ◽  
Contributing Factors ◽  
Paediatric Hospital ◽  
Medication Process ◽  
Data Collection Sheet

AimTo perform a retrospective analysis of tenfold medication errors between the 1st January 2017 and the 31st December 2018 and identify contributing factors.MethodInformation from all tenfold medication errors reported to the Ulysses system between 1st January 2017 and 31st December 2018 which met the criteria was inputted into a data collection sheet. Information gathered included the age of the patient, the time the error occurred, the location within the hospital, the point in the medication process the error occurred, the drug involved and the NCC-MERP category of harm assigned to the error. Reports were excluded if they were repeated entries or if they did not meet the criteria for a tenfold medication error. The total number of medication errors reported per month and the total number of admissions per month was also identified. Once data collection was complete, these errors were qualitatively analysed and compared with those of a previous audit using errors reported from 1st January 2013 to 31st December 2014.ResultsTenfold errors were most likely to be reported in the Critical Care areas (34.4% of tenfold errors being reported over the two-year period). Prescribing was the most common origin of error accounting for 54.3% of tenfold errors in 2017 and 51.7% in 2018. The most common category of harm assigned was category B (no harm – error did not reach patient) with a total of 40.6% of the errors reported. The age group with the highest number of errors reported was 29–364 days with 39.3% tenfold medication errors reported over the two-year period. Morphine was the most common drug involved accounting for 13.8% of errors reported.ConclusionThe findings from this report mirror the results from the previous audit performed in 2014 in respect to error origin and patient age. Tenfold prescribing errors have more chance of being intercepted before reaching the patient due to there being more steps in the process before administration, therefore it is less likely that errors that originate at prescribing will reach the patient. Tenfold administration errors were more likely to reach the patient and therefore to cause harm. Morphine was the most reported drug in both 2017/18 and the 2013/14 audit suggesting that more work needs to be done on the safe use of opioids. Critical Care was the location with the highest number of errors reported, patients in this area often require complex medication regimes increasing the likelihood of being involved in a medication error.1ReferenceBower R, Coad J, Manning J, et al. A qualitative, exploratory study of nurses’ decision-making when interrupted during medication administration within the paediatric intensive care unit. Intensive Crit Care Nurs 2018;44:11–17.

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