Evaluation of Medical Practice Allegation Cases Within the Scope of Pharmacy Services and Applications

Medication errors and adverse drug events in a UK hospital during the optimisation of electronic prescriptions: a prospective observational study

Analysis of Medical Errors: A Case Study

Patient Safety: Grantmakers Join The Effort To Reduce Medical Errors

Risk and safety management in infertility and assisted reproductive technology (ART): from the doctor's office to the ART procedure

ObjectivesThe study analysed medical malpractice claims to assess patient safety in hospitals. The information derived from malpractice claims reflects potential risks and could help lead to reducing medical errors and...

BackgroundAlthough the various advantages of clinical information systems in intensive care units (ICUs), such as intensive care information systems (ICISs), have been reported, their role in preventing medical errors remains unclear.ObjectiveThis study aimed to investigate the changes in the incidence and type of errors in the ICU before and after ICIS implementation in a setting where a hospital electronic medical record system is already in use.MethodsAn ICIS was introduced to the general ICU of a university hospital. After a step-by-step implementation lasting 3 months, the ICIS was used for all patients starting from April 2019. We performed a retrospective analysis of the errors in the ICU during the 6-month period before and after ICIS implementation by using data from an incident reporting system, and the number, incidence rate, type, and patient outcome level of errors were determined.ResultsFrom April 2018 to September 2018, 755 patients were admitted to the ICU, and 719 patients were admitted from April 2019 to September 2019. The number of errors was 153 in the 2018 study period and 71 in the 2019 study period. The error incidence rates in 2018 and 2019 were 54.1 (95% CI 45.9-63.4) and 27.3 (95% CI 21.3-34.4) events per 1000 patient-days, respectively (P<.001). During both periods, there were no significant changes in the composition of the types of errors (P=.16), and the most common type of error was medication error.ConclusionsICIS implementation was temporally associated with a 50% reduction in the number and incidence rate of errors in the ICU. Although the most common type of error was medication error in both study periods, ICIS implementation significantly reduced the number and incidence rate of medication errors.Trial RegistrationUniversity Hospital Medical Information Network Clinical Trials Registry UMIN000041471; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047345

Mastering the Patient Handoff

Medication errors in the operating room have high potential for patient harm. While electronic clinical decision support (CDS) software has been effective in preventing medication errors in many nonoperating room patient care areas, it is not yet widely used in operating rooms. The purpose of this study was to determine the percentage of self-reported intraoperative medication errors that could be prevented by CDS algorithms. In this retrospective cross-sectional study, we obtained safety reports involving medication errors documented by anesthesia clinicians between August 2020 and August 2022 at a 1046-bed tertiary care academic medical center. Reviewers classified each medication error by its stage in the medication use process, error type, presence of an adverse medication event, and its associated severity and preventability by CDS. Informational gaps were corroborated by retrospective chart review and disagreements between reviewers were resolved by consensus. The primary outcome was the percentage of errors that were preventable by CDS. Secondary outcomes were preventability by CDS stratified by medication error type and severity. We received 127 safety reports involving 80 medication errors, and 76/80 (95%) of the errors were classified as preventable by CDS. Certain error types were more likely to be preventable by CDS than others ( P < .001). The most likely error types to be preventable by CDS were wrong medication (N = 36, 100% rated as preventable), wrong dose (N = 30, 100% rated as preventable), and documentation errors (N = 3, 100% rated as preventable). The least likely error type to be preventable by CDS was inadvertent bolus (N = 3, none rated as preventable). Ninety-five percent of self-reported medication errors in the operating room were classified as preventable by CDS. Future research should include a randomized controlled trial to assess medication error rates and types with and without the use of CDS.

In Reply.

Introduction Healthcare services should eliminate errors, but any human-involved tasks are prone to error and healthcare is no exception.1 Medication errors are possible in hospitals though they should be eliminated with utmost care. Such medication errors would lead to an increased fatality rate, the emergence of new diseases, increased mediation costs and extended hospital stays.2,3 Aim This cross-sectional study aimed to classify and to identify the reasons for medication error as reported by the nurses and the impact of the collaborative work of Nurses, Pharmacists and Doctors in reducing medication errors and improving patient safety. Methods An exploratory (cross-sectional) study was conducted to classify and to identify the reasons for medication error among 474 nurses working in private multispecialty hospitals in Madurai between January to May 2023. The data for the study was collected using a questionnaire which included demographic variables and questions on medication errors. The questionnaire was filled through a one-to-one interview method and the data collected were analysed using SPSS 21.0. Results The results of analyses done using SPSS revealed that 58.2% of nurses reported having made medication errors and 88.4% of them said they had reported these immediately on the occurrence of such errors to their nursing superintendents. The most common type of medication errors reported were wrong infusion rates and wrong medicines, especially for medicines with similar sounding names (sound-alike drugs). Lack of awareness of the causes of medication errors was found to be the major reason for the occurrence of such errors in hospitals. The analyses showed that there was a significant relationship between age, years of experience and medication errors. One-way ANOVA analysis revealed that the greater the age and experience, the lesser the occurrence of medication errors. However, there was no significant relationship between working shifts and medication errors. The findings also highlighted that the greater the number of patients in the ward, the higher the error in oral administration of drugs. The finding reveals that teamwork between nurses, pharmacists and doctors was reported to help to drastically reduce the number of errors. Discussion/Conclusion Whilst a small-scale study only and reliant on accurate self-reporting, the findings suggest that not all nurses report medication errors, which could result in adverse outcomes for patients. Hence the nursing managers or nursing superintendents should encourage nurses to report medication errors to ensure patient safety. The findings also suggest that collaborative work between nurses, pharmacists, and doctors can reduce medication errors, hence collaborative work and appointing clinical Pharmacists is important to reducing medication errors.

Incidence and nature of dosing errors in paediatric medications: a systematic review.

Medication errors in nursing negatively affect the quality of the provided health-treatment services and society's mentality about the health system, threatening the patient's life. Therefore, this study evaluates medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals. All the nurses working at teaching hospitals affiliated with Ahvaz Jundishapur University of Medical Sciences (southwest of Iran) comprised the statistical population of this research (260 participants). Data were collected using three questionnaires: a demographic characteristics questionnaire, a medication error questionnaire, and the standard Circadian Type Inventory (CTI) for a normal physiological cycle. At least one medication error was observed in 83.1% of nurses during their work span. A medication error was found in 36.2% of nurses during the COVID-19 pandemic (over the past year). Most medication errors (65.8%) occurred during the night shift. A significant relationship was detected between medication errors and shift work. Medicating one patient's drug to another (28.84%) and giving the wrong dose of drugs (27.69) were the most common types of medication errors. The utmost medication error was reported in emergency wards. The fear of reporting (with an average of 33.06) was the most important reason for not reporting medication errors (p < 0.01). Most nurses experienced a history of medication errors, which were increased by shift work and the COVID-19 pandemic. Necessary plans are recommended to reduce the fatigue and anxiety of nurses and prevent their burnout, particularly in critical situations. Efforts to identify risky areas, setting up reporting systems and error reduction strategies can help to develop preventive medicine. On the other hand, since the quality of people's lives is considered the standard of countries' superiority, by clarifying medical errors, a higher level of health, satisfaction and safety of patients will be provided.

The U.S. Institute of Medicine (IOM) much publicized report in “To Err is Human” (2000, National Academy Press) stated that as many as 98 000 hospitalized patients in the U.S. die each year due to preventable medical errors. This revelation about medical error and patient safety focused the public and the medical community's attention on errors in healthcare delivery including laboratory and point-of-care-testing (POCT). Errors introduced anywhere in the POCT process clearly can impact quality and place patient's safety at risk. While POCT performed by or near the patient reduces the potential of some errors, the process presents many challenges to quality with its multiple tests sites, test menus, testing devices and non-laboratory analysts, who often have little understanding of quality testing. Incoherent or no regulations and the rapid availability of test results for immediate clinical intervention can further amplify errors. System planning and management of the entire POCT process are essential to reduce errors and improve quality and patient safety.

Assessment and categorization of medication errors in a veterinary teaching hospital.

Patient safety and medical error prevention remain critical issues in general practice, where medical errors can lead to adverse patient outcomes and increased healthcare costs. This systematic review synthesizes recent evidence on prevalent types of medical errors, effective prevention strategies, and outcomes of patient safety interventions within general practice settings. Following a comprehensive search across multiple databases, 52 studies published from 2014 to 2024 were included. Findings highlight medication errors, diagnostic inaccuracies, and communication lapses as the most common types of errors. Effective prevention strategies include the adoption of electronic health records (EHR), structured team communication protocols, checklist systems, and staff training programs on safety practices. These interventions have shown significant reductions in error rates and improvements in patient outcomes, though implementation is often hindered by barriers such as limited resources, resistance to change, and lack of training. This review underscores the importance of a multifaceted approach that combines technological, organizational, and educational interventions to enhance patient safety in general practice. Future research should explore long-term impacts of these interventions and address context-specific challenges to foster a culture of safety in healthcare settings.