scholarly journals Patterns of medication errors involving pediatric population reported to the French Medication Error Guichet

2021 ◽  
Vol 19 (2) ◽  
pp. 2360
Author(s):  
Christine Azar ◽  
Delphine Allué ◽  
Marie B. Valnet-Rabier ◽  
Laurent Chouchana ◽  
Fanny Rocher ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Pediatric Population ◽  
Hospital Setting ◽  
Community Setting ◽  
Blood Substitutes ◽  
Community Settings ◽  
Prevention Measures ◽  
Error Type ◽  
Error Reports

Background: Medication error is a global threat to patient safety, particularly in pediatrics. Yet, this issue remains understudied in this population, in both hospital and community settings. Objectives: To characterize medication errors involving pediatrics reported to the French Medication Error Guichet, and compare them with medication errors in adults, in each of the hospital and community settings. Methods: This was a retrospective secondary data analysis of medication errors reported throughout 2013-2017. Descriptive and multivariate analyses were performed to compare actual and potential medication error reports between pediatrics (aged <18 years) and adults (aged >18 and <60 years). Two subanalyses of actual medication errors with adverse drug reaction (ADR), and serious ADR were conducted. Results:  We analyzed 4,718 medication error reports. In pediatrics, both in hospital (n=791) and community (n=1,541) settings, antibacterials for systemic use (n=121, 15.7%; n=157, 10.4%, respectively) and wrong dose error type (n=391, 49.6%; n=549, 35.7%, respectively) were frequently reported in medication errors. These characteristics were also significantly more likely to be associated with reported errors in pediatrics compared with adults. In the hospital setting, analgesics (adjusted odds ratio (aOR)=1.59; 95% confidence interval (CI) 1.03:2.45), and blood substitutes and perfusion solutions (aOR=3.74; 95%CI 2.24:6.25) were more likely to be associated with reported medication errors in pediatrics; the latter drug class (aOR=3.02; 95%CI 1.59:5.72) along with wrong technique (aOR=2.28; 95%CI 1.01:5.19) and wrong route (aOR=2.74; 95%CI 1.22:6.15) error types related more to reported medication errors with serious ADR in pediatrics. In the community setting, the most frequently reported pediatric medication errors involved vaccines (n=389, 25.7%). Psycholeptics (aOR=2.42; 95%CI 1.36:4.31) were more likely to be associated with reported medication errors with serious ADR in pediatrics. Wrong technique error type (aOR=2.71; 95%CI 1.47:5.00) related more to reported medication errors with ADR in pediatrics. Conclusions: We identified pediatric-specific medication error patterns in the hospital and community settings. Our findings inform focused error prevention measures, and pave the way for interventional research targeting the needs of this population.

scholarly journals P25 Incidents involving paediatric parenteral nutrition

2020 ◽  
Vol 105 (9) ◽  
pp. e19.1-e19
Author(s):  
Kouzhu Zhu ◽  
Andrea Gill
Keyword(s):  
Parenteral Nutrition ◽  
Medication Error ◽  
Total Parenteral Nutrition ◽  
Medication Errors ◽  
Error Reporting ◽  
List Type ◽  
Error Type ◽  
Safe Medication ◽  
Medication Error Reporting ◽  
Coordinating Council

AimParenteral nutrition (PN) is one of the medications most frequently reported to be involved in medication errors in hospital.1 PN is a class of high alert medications listed by The Institute for Safe Medication Practices.2 Medication errors involving PN may have potentially serious consequences especially in infants.3 The purpose of this study was to determine the type of incidents reported, who reported it, severity of incidents and the part of the process involved in the error with the aim of ensuring quality and safety in PN processes.MethodThe incidents involving PN reported on the Ulysses system in a specialist children’s hospital were surveyed between April 2018 and March 2019. Incidents were assigned to different error-type categories. We focused on the whole process of prescribing, transcription, preparation, and administration of PN. Severity classification was based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index.4ResultsThere were 34 incidents involving PN ranging from 1 to 8 per month. Job titles who reported these incidents were nurses (16 incidents), pharmacists (14 incidents), dieticians (2 incidents) and unknown (2 incidents). The most common types of incidents were omitted medicine/dose (7 incidents), labelling error (6 incidents), wrong quantity supplied (4 incidents) and wrong/unclear dose (4 incidents). The processes during which the incident had occurred were administration/supply of a medicine (14 incidents), preparation of medicines/dispensing in a pharmacy (13 incidents) and prescribing (7 incidents). The majority of incidents (82.4%, 28/34) were assigned category C (no harmful consequences), while 14.7% (5/34) and 2.9% (1/34) were assigned to category B (an error occurred but the error did not reach the patient) and category D (an error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm) respectively. The following actions have been taken to try to prevent error with PN: training, providing information, introduction of new labels, changes to the profiles on infusion pumps, reinforcing independent checking and the increased use of standard PN solutions.ConclusionNurses and pharmacists are the main reporters of incidents of PN. Omitted medicine/dose is the most common incident reported. The majority of errors involved administration of PN. The majority of all incidents did not cause harm to patients.ReferencesRinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a systematic review[J]. Pediatrics, 2014, 134(2):338–60.Institute for Safe Medication Practices. ISMP List of High-Alert Medications in Acute Care Settings. Horsham, PA. Available from: http://www.ismp.org/Tools/institutionalhighAlert.asp (accessed January 15, 2017)NHS/PSA/W/2017/005,Risk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. Available from: https://improvement.nhs.uk/news-alerts/infusing-total-parenteral-nutrition-too-rapidly-in-babies/National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP Index for Categorizing Medication Errors. Available from http://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf (accessed March 10, 2017)

Anticoagulant medication errors in hospitals and primary care: a cross-sectional study

2018 ◽  
Vol 31 (5) ◽  
pp. 346-352 ◽  
Author(s):  
Albert R Dreijer ◽  
Jeroen Diepstraten ◽  
Vera E Bukkems ◽  
Peter G M Mol ◽  
Frank W G Leebeek ◽  
...  
Keyword(s):  
Human Factors ◽  
Medication Error ◽  
Medication Errors ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Cross Sectional ◽  
Medication Process ◽  
Before And After ◽  
Anticoagulant Medication ◽  
Error Reports

Abstract Objective To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase). Design A cross-sectional study. Setting Medication errors reported to the Central Medication incidents Registration reporting system. Participants Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR. Intervention N/A. Main outcome measure Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline. Results Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline. Conclusions Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.

scholarly journals THE IMPACT OF BARCODE MEDICATION ADMINISTRATION ON PATIENT SAFETY: A SYSTEMATIC REVIEW

2021 ◽  
Vol 5 (6) ◽  
Author(s):  
Seham Sahal Aloufi
Keyword(s):  
Systematic Review ◽  
Patient Safety ◽  
Medication Error ◽  
Medication Errors ◽  
Improve Patient Safety ◽  
Hospital Setting ◽  
Medication Administration ◽  
Bar Code ◽  
The Impact ◽  
Improve Patient

Patient safety is considered as an essential feature of healthcare system. Many trials have been conducted in order to find ways to improve patient safety, and many reports indicate that medication errors pose a threat to patient safety. Thus, some studies have investigated the impact of bar code medication administration (BCMA) system on medication error reduction during the medication administration procedure. This systematic review (SR) reports the impact of BCMA system on reducing medication errors to improve patient safety; it also compares traditional medication administration with the BCMA system. The review concentrates on the effectiveness of BCMA technology on medication administration errors, and on the accuracy of medication administration. This review also focused on different designs of quantitative studies, as they are more effective at investigating the impact of the intervention than qualitative studies. The findings from this systematic review show various results depending on the nature of the hospital setting. Most of the studies agree that the BCMA system enhances compliance with the 'five rights’' requirement (right drug, right patient, right dose, right time and right route) of medication administration. In addition, BCMA technology identified medication error types that could not be identified with the traditional approach which is applying the 'five rights' of medication administration. The findings of this systematic review also confirm the impact of BCMA system in reducing medication error, preventing adverse events and increasing the accuracy of the medication administration rate. However, BCMA technology did not consistently reduce the overall errors of medication administration. Keyword: Patient Safety, Impact, BCMA, eMAR

Impact of an Antimicrobial Stewardship Team on Reducing Antiretroviral Medication Errors

2020 ◽  
Vol 54 (8) ◽  
pp. 767-774
Author(s):  
Kwabena Nimarko ◽  
Aiman Bandali ◽  
Tiffany E. Bias ◽  
Sharon Mindel
Keyword(s):  
Drug Interactions ◽  
Medication Error ◽  
Medication Errors ◽  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Inpatient Setting ◽  
Error Type ◽  
Significant Difference ◽  
The Impact

Background: Numerous interventions have been used to reduce medication errors related to antiretroviral (ARV) therapy for hospitalized patients with HIV. Objective: This study assessed the impact of an antimicrobial stewardship (ASP) team intervention on reducing the rate of ARV therapy errors in patients admitted to an academic medical center. Methods: This observational, retrospective study included patients who received ARV therapy from June 2016 to December 2017. The primary outcome was evaluation of ASP team performance in detecting ARV medication errors in the inpatient setting. Errors were further categorized by type (interaction, dosing, regimen). The Mann-Whitney U test and χ2 tests were utilized to analyze continuous and categorical data, respectively. Results: Medication errors occurred in 51% of patients in the preintervention group (n = 152) and 48% of patients in the postintervention group (n = 203; P = 0.43). The most frequent medication error type was drug interactions in both groups, involving integrase strand transfer inhibitors and polyvalent cations (64% vs 67%). There was a significant difference between preintervention and postintervention groups regarding number of errors detected (13 vs 106, P < 0.001), corrected (12 vs 86, P < 0.001), and persisting at discharge (106 vs 18, P < 0.001). Conclusion and Relevance: Review of ARV regimens by an ASP team significantly decreased medication errors. Drug interactions are the most common medication error found in HIV-positive patients admitted to our academic center.

Analysis of Medication Error Reports

2004 ◽  
Author(s):  
Paul Whitney ◽  
Jonathan Young ◽  
John Santell ◽  
Rodney Hicks ◽  
Christian Posse ◽  
...  
Keyword(s):  
Data Analysis ◽  
Medication Error ◽  
Medication Errors ◽  
Free Text ◽  
Area Of Interest ◽  
Analysis Tools ◽  
Depth Analysis ◽  
Reporting Programs ◽  
Types Of Information ◽  
Error Reports

In medicine, as in many areas of research and society, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been a corresponding lag in our abilities to analyze this mass of data, and traditional forms and expressions of statistical analysis do not allow researchers and practitioners to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports are approached as data comparisons, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Additionally, the “types” of information objects that can be the objects of data analysis have been extended to include text [8][9]. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. USP conducts an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.

scholarly journals THE NATURAL AND PREVALENCE OF MEDICATION ERRORS IN A TERTIARY HOSPITAL IN INDONESIA

2021 ◽  
pp. 55-58
Author(s):  
ANDIKA DWI MAHENDRA
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Improve Patient Safety ◽  
Medical Center ◽  
Hospital Setting ◽  
Tertiary Hospital ◽  
Prescribing Error ◽  
Electronic Prescription ◽  
Mortality And Morbidity ◽  
Medication Error Reporting

Objective: Medication error is the most common errors in a hospital setting and a serious issue that intimidate the safety of the patient and may cause mortality and morbidity. The aim of this study is to explore the rate of medication errors reporting in an Indonesian hospital. Methods: This study is retrospective and descriptive. This research was conducted at dr. Soeradji Tirtonegoro General Hospital Medical Center from January to June 2020. Medication error reporting, which was reported for six months, was the sample of the study. Results: On the period, 105,171 prescribing sheets were collected. 9.5% of the total prescribing sheets are categorized as Medication Error (ME). The highest incident of ME was prescribing error (88.24%), then followed by transcribing error (7.61%), dispensing error (4.02%), and the last was administration error (0.13%). Conclusion: The most common incident occurred at prescribing stage because the hospital is not supported by electronic prescription. Medication error is an inevitable event during the medication process. But, the incidents can be minimized by implementing some preventive strategies to improve patient safety and safe drug use.

scholarly journals Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study

Healthcare ◽  
2021 ◽  
Vol 9 (12) ◽  
pp. 1673
Author(s):  
Noemi Giannetta ◽  
Rebecca Sergi ◽  
Giulia Villa ◽  
Federico Pennestrì ◽  
Roberta Sala ◽  
...  
Keyword(s):  
Health Care Professionals ◽  
Healthcare Professionals ◽  
Moral Distress ◽  
Hospital Setting ◽  
Community Setting ◽  
Cross Sectional Study ◽  
Community Settings ◽  
Sectional Study ◽  
Cross Sectional ◽  
Ethical Approval

Moral distress is a concern for all healthcare professionals working in all care settings. Based on our knowledge, no studies explore the differences in levels of moral distress in hospital and community settings. This study aims to examine the level of moral distress among healthcare professional working in community or hospital settings and compare it by demographic and workplace characteristics. This is a cross-sectional study. All the professionals working in the hospitals or community settings involved received personal e-mail invitations to participate in the study. The Moral Distress Thermometer was used to measure moral distress among healthcare professionals. Before data collection, ethical approval was obtained from each setting where the participants were enrolled. The sample of this study is made up of 397 healthcare professionals: 53.65% of the sample works in hospital setting while 46.35% of the sample works in community setting. Moral distress was present in all professional groups. Findings have shown that nurses experienced level of moral distress higher than other healthcare professionals (mean: 4.91). There was a significant differences between moral distress among different professional categories (H(6) = 14.407; p < 0.05). The ETA Coefficient test showed significant variation between healthcare professionals working in community and in hospital settings. Specifically, healthcare professionals who work in hospital experienced a higher level of moral distress than those who work in community settings (means 4.92 vs. means 3.80). The results of this study confirm that it is imperative to develop educational programs to reduce moral distress even in those settings where the level perceived is low, in order to mitigate the moral residue and the crescendo effect.

Technology and medication errors: impact in nursing homes

2014 ◽  
Vol 27 (3) ◽  
pp. 244-258 ◽  
Author(s):  
Chantal Baril ◽  
Viviane Gascon ◽  
Liette St-Pierre ◽  
Denis Lagacé
Keyword(s):  
Nursing Homes ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Error Type ◽  
Content Type ◽  
Bar Code ◽  
Significant Difference ◽  
Before And After ◽  
Healthcare Administrators

Purpose – The purpose of this paper is to study a medication distribution technology's (MDT) impact on medication errors reported in public nursing homes in Québec Province. Design/methodology/approach – The work was carried out in six nursing homes (800 patients). Medication error data were collected from nursing staff through a voluntary reporting process before and after MDT was implemented. The errors were analysed using: totals errors; medication error type; severity and patient consequences. A statistical analysis verified whether there was a significant difference between the variables before and after introducing MDT. Findings – The results show that the MDT detected medication errors. The authors' analysis also indicates that errors are detected more rapidly resulting in less severe consequences for patients. Practical implications – MDT is a step towards safer and more efficient medication processes. Our findings should convince healthcare administrators to implement technology such as electronic prescriber or bar code medication administration systems to improve medication processes and to provide better healthcare to patients. Originality/value – Few studies have been carried out in long-term healthcare facilities such as nursing homes. The authors' study extends what is known about MDT's impact on medication errors in nursing homes.

scholarly journals A COmfortably Vented, Indigenously Designed (COVID) Fabric Helmet to curb infection spread in Education, Healthcare and other community settings

2020 ◽  
Author(s):  
Ashish Karn ◽  
Shashank Singh Deo ◽  
Raman Kumar Singh ◽  
Abhay Kumar
Keyword(s):  
Pediatric Population ◽  
Low Cost ◽  
Community Setting ◽  
Educational Institutions ◽  
Community Settings ◽  
Innovative Design ◽  
Protective Gear ◽  
Healthcare Settings ◽  
Current Scenario ◽  
Infection Spread

Considering the current scenario of Coronavirus outbreak and the post-pandemic situation, the need of protective gear such as facemasks assumes utmost importance, for the common populace, as well as in areas of concern such as community and healthcare settings. Prior reported research shows that although the usage of masks may be helpful in curbing the infection spread, a major issue stems from the lack of adherence of proper steps in wearing/taking off masks. The users touch their face, ears, eyes, nose etc. after taking off the masks, ultimately making themselves more susceptible to infection, and thus reducing the efficacy of the suggested measure of using masks. The current masks are quite inadequate. It covers only the nose and mouth, leaving room for the users to touch their face, ears, nose and eyes, which are all the vulnerable gates for the infection transmission. The masks are uncomfortable and require regular adjustment, there are problems of humidity build-up inside masks, high chances of leakage, problems with breathing, and one even needs to take off the mask for ingesting liquids, food, medicine etc. even if one is in a community setting or in a crowded region. Further, since these masks provide insufficient protection, there is an additional burden on the supply chain requirements for other personal protective gear. To address these limitations of the commercially available masks, we propose the design of a low-cost COmfortably Vented, Indigenously Designed (COVID) fabric helmet. It is designed in such a way that usage of this cheap helmet along with the usually worn cloth is enough to provide complete protection to an individual. The fabric helmet is integrated with many innovative design features that will not only address the concerns of the users, but will be comfortable, cheap and also ease pressure on the requirement for expensive, and already scarce personal protective equipment and thus greatly curtail COVID-19 infection spread in the country. Most importantly, the prosed design will serve as a very effective device in the protection of the pediatric population in the educational institutions as well as in residential and healthcare settings, as situations spring back to normalcy in communities around the globe.

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