scholarly journals Medication Error Reporting: Underreporting and Acceptability of Smartphone Application for Reporting among Health Care Professionals in Perak, Malaysia

Cureus ◽  
2018 ◽  
Author(s):  
Doris George ◽  
Amar-Singh HSS ◽  
Azmi Hassali
Keyword(s):  
Health Care ◽  
Medication Error ◽  
Health Care Professionals ◽  
Smartphone Application ◽  
Error Reporting ◽  
Medication Error Reporting

scholarly journals Usability Testing of a Mobile App to Report Medication Errors Anonymously: Mixed-Methods Approach (Preprint)

2018 ◽  
Author(s):  
Doris George ◽  
Mohamed Azmi Hassali ◽  
Amar-Singh HSS
Keyword(s):  
Health Care ◽  
Medication Error ◽  
Medication Errors ◽  
Usability Testing ◽  
Mobile App ◽  
Error Reporting ◽  
Medication Error Reporting ◽  
System Usability Scale ◽  
Mean Time ◽  
Doctors And Nurses

BACKGROUND Reporting of medication errors is one of the essential mechanisms to identify risky health care systems and practices that lead to medication errors. Unreported medication errors are a real issue; one of the identified causes is a burdensome medication error reporting system. An anonymous and user-friendly mobile app for reporting medication errors could be an alternative method of reporting medication error in busy health care settings. OBJECTIVE The objective of this paper is to report usability testing of the Medication Error Reporting App (MERA), a mobile app for reporting medication errors anonymously. METHODS Quantitative and qualitative methods were employed involving 45 different testers (pharmacists, doctors, and nurses) from a large tertiary hospital in Malaysia. Quantitative data was retrieved using task performance and rating of MERA and qualitative data were retrieved through focus group discussions. Three sessions, with 15 testers each session, were conducted from January to March 2018. RESULTS The majority of testers were pharmacists (23/45, 51%), female (35/45, 78%), and the mean age was 36 (SD 9) years. A total of 135 complete reports were successfully submitted by the testers (three reports per tester) and 79.2% (107/135) of the reports were correct. There was significant improvement in mean System Usability Scale scores in each session of the development process (P<.001) and mean time to report medication errors using the app was not significantly different between each session (P=.70) with an overall mean time of 6.7 (SD 2.4) minutes. Testers found the app easy to use, but doctors and nurses were unfamiliar with terms used especially medication process at which error occurred and type of error. Although, testers agreed the app can be used in the future for reporting, they were apprehensive about security, validation, and abuse of feedback featured in the app. CONCLUSIONS MERA can be used to report medication errors easily by various health care personnel and it has the capacity to provide feedback on reporting. However, education on medication error reporting should be provided to doctors and nurses in Malaysia and the security of the app needs to be established to boost reporting by this method.

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy

2021 ◽  
pp. 107815522199431
Author(s):  
Jennifer P Booth ◽  
Julie M Kennerly-Shah ◽  
Amber D Hartman
Keyword(s):  
Cancer Therapy ◽  
Medication Error ◽  
Retrospective Analysis ◽  
Error Reporting ◽  
Single Center ◽  
Medication Error Reporting ◽  
Anti Cancer ◽  
Secondary Endpoints ◽  
Type Frequency

Introduction To describe pharmacist interventions as a result of an independent double check during cognitive order verification of outpatient parenteral anti-cancer therapy. Methods A single-center, retrospective analysis of all individual orders for outpatient, parenteral anti-cancer agents within a hematology/oncology infusion center during a 30 day period was conducted. The primary endpoint was error identification rates during first and second verification. Secondary endpoints included the type, frequency, and severity of errors identified during second verification using a modified National Coordinating Council for Medication Error Reporting and Prevention Index. Results A total of 1970 anti-cancer parenteral orders were screened, from which 1645 received an independent double check and were included. The number of errors identified during first and second verification were 30 (1.8%) and 10 (0.6%) respectively; second verification resulted in a 33.3% increase in corrected errors. The 10 errors identified during second verification included: four rate transcriptions to optimize pump interoperability, three rate and/or volume modifications, two dosage adjustments, and one treatment deferral due to toxicity. The severity was classified as Category A for four (40%), Category C for three (30%), and Category D for three (30%) errors. This correlated to a low capacity for harm for seven (70%) and a serious capacity for three (30%) errors. Conclusions Second verification of outpatient, parenteral anti-cancer medication orders resulted in a 33.3% increase in corrected errors. Three errors detected during second verification were determined to have a serious capacity for harm, supporting the value of independent double checks during pharmacist cognitive order verification.

Medication Error Reduction: The Pharmacy Technician's Role

1998 ◽  
Vol 14 (2) ◽  
pp. 70-77 ◽  
Author(s):  
Eddie B Dunn ◽  
Jonathan J Wolfe
Keyword(s):  
Public Health ◽  
Medication Error ◽  
Error Reduction ◽  
Error Reporting ◽  
Health Issue ◽  
Public Health Issue ◽  
Pharmacy Technician ◽  
Medication Error Reporting ◽  
The Us ◽  
Coordinating Council

This article presents medication error reduction as a public health issue relevant to the pharmacy technician. The chief types of errors are presented, and opportunities for technicians to identify errors and factors that promote errors are described. The article then discusses the importance of medication error reporting by technicians. Emphasis is placed on the necessity of examining the reason why errors occur rather than assigning blame. The US Pharmacopeia Practitioners' Reporting Network is described in detail, along with the newer National Coordinating Council for Medication Error Reporting and Prevention.

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)

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