Causes Of Medication Errors Research Articles

Learning from error: identification and analysis of causative factors leading to medication error in an inpatient hospital setting

Background: Medication errors are preventable causes of medical error. These errors may happen at various steps of medication process. This study tries to find common errors during four stages i.e. prescribing, transcribing, dispensing and administration. Methods: It was a cross sectional study in a tertiary care teaching hospital in north India. Five hundred patients were randomly selected for the study. Medication error was checked at different level by a medication audit tool. Direct observation, chart reviews and personal communication with patients, nurses and pharmacist were done to complete the details of tool. Root cause analysis was done after discussing with concerned professionals. Severity of the medication errors were assessed using national coordinating council for medication error reporting and prevention (NCCMERP) proposed medication error index. Results: Medication error rate was found to be around 50%. i.e. every one of two patients received some form of error. Prescribing error were most common cause of error followed by administration error and transcription error. Dispensing error was least common. Root cause analysis indicated casual attitude, inadequate knowledge and training as the main causes. Conclusions: This study was an initial step in recognising error prone areas of medication management. It can be used to develop standard procedures and formulating guidelines for prevention of such errors.

Investigating the Causes of Medication Errors and Strategies to Prevention of Them from Nurses and Nursing Student Viewpoint.

Introduction and Aim:Medication errors as a serious problem in world and one of the most common medical errors that threaten patient safety and may lead to even death of them. The purpose of this study was to investigate the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint.Materials & Methods:This cross-sectional descriptive study was conducted on 327 nursing staff of khatam-al-anbia hospital and 62 intern nursing students in nursing and midwifery school of Zahedan, Iran, enrolled through the availability sampling in 2015. The data were collected by the valid and reliable questionnaire. To analyze the data, descriptive statistics, T-test and ANOVA were applied by use of SPSS16 software.Findings:The results showed that the most common causes of medications errors in nursing were tiredness due increased workload (97.8%), and in nursing students were drug calculation, (77.4%). The most important way for prevention in nurses and nursing student opinion, was reducing the work pressure by increasing the personnel, proportional to the number and condition of patients and also creating a unit as medication calculation. Also there was a significant relationship between the type of ward and the mean of medication errors in two groups.Conclusion:Based on the results it is recommended that nurse-managers resolve the human resources problem, provide workshops and in-service education about preparing medications, side-effects of drugs and pharmacological knowledge. Using electronic medications cards is a measure which reduces medications errors.

The Importance of Medication Errors Reporting in Improving the Quality of Clinical Care Services.

Introduction:Medication errors have significant implications on patient safety. Error detection through an active management and effective reporting system discloses medication errors and encourages safe practices.Objectives:To improve patient safety through determining and reducing the major causes of medication errors (MEs), after applying tailored preventive strategies.Methodology:A pre-test, post-test study was conducted on all inpatients at a 177 bed hospital where all medication procedures in each ward were monitored by a clinical pharmacist. The patient files were reviewed, as well. Error reports were submitted to a hospital multidisciplinary committee to identify major causes of errors. Accordingly, corrective interventions that consisted of targeted training programs for nurses and physicians were conducted.Results:Medication errors were higher during ordering/prescription stage (38.1%), followed by administration phase (20.9%). About 45% of errors reached the patients: 43.5% were harmless and 1.4% harmful. 7.7% were potential errors and more than 47% could be prevented. After the intervention, error rates decreased from (6.7%) to (3.6%) (P≤0.001).Conclusion:The role of a ward based clinical pharmacist with a hospital multidisciplinary committee was effective in recognizing, designing and implementing tailored interventions for reduction of medication errors. A systematic approach is urgently needed to decrease organizational susceptibility to errors, through providing required resources to monitor, analyze and implement effective interventions.

A retrospective review of medical errors adjudicated in court between 2002 and 2012 in Spain

This paper describes verdicts in court involving injury-producing medical errors in Spain. A descriptive analysis of 1041 closed court verdicts from Spain between January 2002 and December 2012. It was determined whether a medical error had occurred, and among those with medical error (n = 270), characteristics and results of litigation were analyzed. Data on litigation were obtained from the Thomson Reuters Aranzadi Westlaw databases. All verdicts involving health system were reviewed and classified according to the presence of medical error. Among those, contributory factors, medical specialty involved, health impact (death, disability and severity) and results of litigation (resolution, time to verdict and economic compensations) were described. Medical errors were involved in 25.9% of court verdicts. The cause of medical error was a diagnosis-related problem in 25.1% and surgical treatment in 22.2%, and Obstetrics-Gynecology was the most frequent involved specialty (21%). Most of them were of high severity (59.4%), one-third (32%) caused death. The average time interval between the occurrence of the error and the verdict was 7.8 years. The average indemnity payment was €239 505.24; the highest was psychiatry (€7 585 075.86) and the lowest was Emergency Medicine (€69 871.19). This study indicates that in Spain medical errors are common among verdicts involving the health system, most of them causing high-severity adverse outcomes. The interval between the medical error and the verdict is excessive, and there is a wide range of economic compensation.

Incorporating metacognition into morbidity and mortality rounds: The next frontier in quality improvement.

This Perspective proposes the introduction of metacognition (thinking about thinking) into the existing format of hospital-based morbidity and mortality rounds. It is placed in the context of historical movements to advance quality improvement by expanding the spectrum of the causes of medical error from systems-based issues to flawed human decision-making capabilities. We suggest that the current approach that focuses on systems-based issues can be improved by exploiting the opportunities to educate physicians about predictable errors committed by reliance on cognitive heuristics. In addition, because the field of educating clinicians about cognitive heuristics has shown mixed results, this proposal represents fertile ground for further research. Educating clinicians about cognitive heuristics may improve metacognition and perhaps be the next frontier in quality improvement.

An integrative review of drug errors in critical care.

Medication error is the commonest cause of medical error and the consequences can be grave. This integrative review was undertaken to critically appraise recent literature to further define prevalence, most frequently-implicated drugs and effects on patient morbidity and mortality in the critical care environment. Forty studies were compared revealing a markedly heterogeneous data set with significant variability in reported incidence. There is an important differentiation to be made between medication error (incidence 5.1-967 per 1000 patient days) and adverse drug event (incidence 1-96.5 per 1000 patient days) with significant ramifications for patient outcome and cost. The most commonly implicated drugs were cardiovascular, gastrointestinal, antimicrobial and hypoglycaemic agents. Beneficial interventions to reduce such errors include computerised prescribing, education and pharmacist input. The studies described provide insight into suboptimal management in the critical care environment and have implications for the development of specific improvement strategies and future training.

Care Transitions in Long-term Care and Acute Care: Health Information Exchange and Readmission Rates

Care transitions between settings are a well-known cause of medical errors. A key component of transition is information exchange, especially in long-term care (LTC). However, LTC is behind other settings in adoption of health information technologies (HIT). In this article, we provide some brief background information about care transitions in LTC and concerns related to technology. We describe a pilot project using HIT and secure messaging in LTC to facilitate electronic information exchange during care transitions. Five LTC facilities were included, all located within Oklahoma and serviced by the same regional health system. The study duration was 20 months. Both inpatient readmission and return emergency department (ED) visit rates were lower than baseline following implementation. We provide discussion of positive outcomes, lessons learned, and limitations. Finally, we offer implications for practice and research for implementation of HIT and information exchange across care settings that may contribute to reduction in readmission rates in acute care and ED settings.

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

The purpose of this review was to explore what is known about interruptions and distractions on medication administration in the context of undergraduate nurse education. Incidents and errors during the process of medication administration continue to be a substantial patient safety issue in health care settings internationally. Interruptions to the medication administration process have been identified as a leading cause of medication error. Literature recognises that some interruptions are unavoidable; therefore in an effort to reduce errors, it is essential understand how undergraduate nurses learn to manage interruptions to the medication administration process. Systematic, critical literature review. Utilising the electronic databases, of Medline, Scopus, PubMed and CINAHL, and recognised quality assessment guidelines, 19 articles met the inclusion criteria. Search terms included: nurses, medication incidents or errors, interruptions, disruption, distractions and multitasking. Researchers have responded to the impact of interruptions and distractions on the medication administration by attempting to eliminate them. Despite the introduction of quality improvements, little is known about how nurses manage interruptions and distractions during medication administration or how they learn to do so. A significant gap in the literature exists in relation to innovative sustainable strategies that assist undergraduate nurses to learn how to safely and confidently manage interruptions in the clinical environment. Study findings highlight the need for further exploration into the way nurses learn to manage interruptions and distractions during medication administration. This is essential given the critical relationship between interruptions and medication error rates. Better preparing nurses to safely fulfil the task of medication administration in the clinical environment, with increased confidence in the face of interruptions, could lead to a reduction in errors and concomitant improvements to patient safety.

Medication Errors Associated with Look-alike/Sound-alike Drugs: A Brief Review

The existence of confusing drug names is one of the most common causes of medication errors. There are many types of medication errors: wrong drug, wrong dose, wrong route of administration, wrong patient etc. Misreading medication names that look similar is a common mistake. These look-alike medication names may also sound alike and can lead to errors associated with verbal prescriptions. Similar sounding drugs may produce confusion and may lead to unintended interchange of drugs causing harm to patients or even patient death. The main aim of the study was to evaluate medication errors related to look alikesound alike drug names and to find out the strategies to prevent these medication errors.J Enam Med Col 2015; 5(2): 110-117

Medical Errors In U.S. Healthcare Organizations: Have We Made Any Progress?

Since the Institute of Medicine’s landmark 1999 report on medical errors, mandates, legislation, and recommendations have been forced on the U.S. healthcare industry. However, only limited progress has been made. Part of the difficulty is identifying the scope of the problem, which has been far larger than thought since the advent of new reporting tools. The major causes of medical errors lie in the lack of a (a) pervasive safety culture, (b) commitment by top healthcare organization management to reduce medical errors, and (c) integrated IT systems, including electronic health records. Compared to other “high reliability” organizations that have achieved excellent results in regard to safety, healthcare is perceived as lagging far behind. Healthcare is not the sole industry needing a safety culture. However, many healthcare leaders perceive existing industry tools that high reliability organizations routinely use as irrelevant. Positive change will come when attitudes change and healthcare organizations embrace the solutions that other industrial organizations have utilized to produce satisfactory safety outcomes.

Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment.

Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking. To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. Pediatric hospitalist services at 9 institutions in the United States and Canada. Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices. Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended. Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

Identifying effective computerized strategies to prevent drug–drug interactions in hospital: A user-centered approach

BackgroundDrug–drug interactions (DDIs) are an important and preventable cause of medication errors in hospitals. Recent developments in technology have seen new strategies emerge for preventing DDIs but these computerized strategies are rarely evaluated and are typically implemented with little input from the individuals using them. AimTo determine the opinions of both experts and users (prescribers) on computerized strategies available to assist in the identification and prevention of DDIs in hospitals. MethodEight drug safety experts and 18 prescribers took part in semi-structured interviews. Participants were asked about their confidence in identifying DDIs and their views on potential computerized strategies to prevent DDIs. ResultsNo prescribers reported complete confidence in identifying dangerous DDIs, with junior prescribers appearing less confident than senior prescribers. Most prescribers believed that computerized alerts would be the most effective strategy for preventing DDIs, while experts were more critical of alerts. ConclusionThe lack of confidence displayed by prescribers in their ability to identify DDIs suggests that an appropriate strategy would be one that does not rely on individuals seeking out the information themselves. While a large number of problems related to DDI alert implementation have been reported in the literature (e.g. alert overload), prescribers appeared to be receptive to the idea of being alerted. By ensuring users are aware of the limitations of the system and involving them in DDI strategy design we expect greater use and satisfaction with the adopted strategy.

Should a Pharmacy Dean be a Pharmacist?

Should a Pharmacy Dean be a Pharmacist?

The causes of medical errors in medical practice today

The causes of medical errors in medical practice today

Study and Evaluation of Medication Errors in Medicine and Orthopedic Wards of a Tertiary Care Hospital

Aims: The main aim of the present study was to detect and evaluate the incidence, types, factors and severity of medication errors in the medicine and orthopedic wards of a tertiary care hospital. Study Design: This was a prospective and observational study. Place and Duration of Study: Department of Medicine and Orthopedic wards of Sri Adichunchanagiri Hospital and Research Centre, B.G.Nagara-571448, Karnataka, India, between June 2014 to February 2015. Methodology: The patients who satisfied inclusion and exclusion criteria were enrolled after obtaining their consent. The required data was collected in the Case Record Form and reviewed daily from the day of admission to discharge in the posted department. Different types of medication errors was identified, documented and the severity of medication error was identified by using NCC MERP guidelines. Results: A total of 200 inpatient cases from orthopedic ward and medicine ward were collected, 100 cases from each ward. In orthopedic ward, 40% patients were of 20-39 years age and in medicine ward, 48% patients were of 60-79 years age. A total of 136 and 103 medication errors were observed in orthopedic and medicine ward, among them 65% and 62% were prescription errors, 25% and 18% were administration errors, 6% and 12% were transcription errors and 4% and 8% were dispensing errors. The cause of medication errors were 64.7% and 62.1% were due to physicians, 31.6% and 30.1% were due to nurses and 3.7% and 7.8% were due to pharmacists in orthopedic and medicine ward. Majority of medication errors 68.4% and 62.1% were belonged to category-B severity in orthopedic and medicine ward respectively. Conclusion: Clinical pharmacist can play a major role in preventing medication errors by early detection. Since our system lacks a well-organize detection and reporting mechanism, Hence, as the first step we must implement a system where errors are routinely detected and reported.

A Study of Patient-Physician Communication and Barriers in Communication

ABSTRACT Context Effective doctor-patient communication is the basic requirement in building a good doctor-patient relationship. Safe practices and effective, patient-centered communication is key to quality care. Good doctor-patient communication has the potential to help regulate patients’ emotions, facilitate comprehension of medical information and allow for better identification of patients’ needs, perceptions and expectations. Doctors with better communication and interpersonal skills are able to detect problems earlier, can prevent medical crisis and expensive intervention, and provide better support to their patients. Current research indicates that ineffective communication among healthcare professionals is one of the leading causes of medical errors and patient harm. There are many barriers to good communication in the doctor-patient relationship, including patients’ anxiety and fear, doctors’ burden of work, fear of litigation, fear of physical or verbal abuse, and unrealistic patient expectations. National accreditation board for hospitals and healthcare providers (NABH) standards and international patient safety goals focus on the importance of effective communication in healthcare settings and how it leads to patient safety. This study is an attempt to identify gaps in patient physician communication in the current healthcare settings, find the barriers in communication and give recommendation to enhance good practices in the future. Aims The aim of the study is to analyze the current levels of effective patient communication in a tertiary care hospital in Delhi-NCR with help of a self-administered questionnaire. The study will assess the level of information shared with the patient. Settings and design The design of our proposed study is a descriptive study where we will use a self-administered questionnaire to assess the level of patient-physician communication in the selected study setting. Materials and methods The NABH standard were used as a guideline for preparing the self-administered questionnaire. All admitted vulnerable patients of the selected study area will consist of the population for the study. Simple random sampling technique will be used to derive the sample out of the population. Statistical analysis used Correlation and analysis of variance (ANOVA) were used to establish associations between the independent and dependent variables. Results The study shows that 48% of the respondents were of opinion that they were given partial information, while 20% of the respondents alleged that they were not given any information about the explanation of their disease, its prognosis and the treatment option that were available, i.e. a total of 62% of the patients said that they had partial information to complete lack of information that would have made them aware of their diseases, its prognosis and the treatments options available to cure it, while only 32% of the patients agreed that they were supplied with thorough information during their interaction with the physicians. Conclusion The majority of the patients were not wellinformed about their disease, its prognosis, treatment plan and continuity of care. There was a significant positive correlation between the communication made at initial stages of hospital stay and during the end stages of stay of patient. The main barrier to patient physician communication was time. Key message To ensure patient safety, it is imperative to inform patients about all the important aspects starting from admission till discharge. How to cite this article Sabherwal N, Mittal A, Pandey NK, Kaushal G, Kaustav P. A Study of Patient-Physician Communication and Barriers in Communication. Int J Res Foundation Hosp Healthc Adm 2015;3(2):71-78.

Emergency Department Nurses' Perceptions toward Factors Influencing the Occurrence of Medication Administration Errors

Background: Significant efforts have been directed to understand medication errors causes in recent years because it contributes directly to patient morbidity and mortality. This study was conducted to determine the factors influencing the occurrence of medication administration errors, as perceived by nurses in emergency department (ED). Aim: The current study aimed to assess emergency department nurses’ perceptions toward factors influencing the occurrence of medication administration errors. Design: The study followed a cross-sectional descriptive design. Setting: The present study was carried out at ED in teaching Main University Hospital in Alexandria governorate, Egypt. Subjects: 84 nursing staff worked in the previous mentioned setting. Tool: The data gathering tool was Medication Administration Errors (MAEs) Reporting Questionnaire which was developed by Wakefield in 1998 [1]. It contains 16 items regarding reasons why medication errors occur. Results: This study suggested four categories for reasons of why MAEs occur in emergency department and the leading cause of medication errors was due to nurses- physicians' communication. Conclusion: Medication errors are common in emergency department. A wide range of factors perceived as contributing factors of the occurrence of medication administration errors were identified such as nurses- physicians communication, medication packaging, pharmacy processes and nurse staffing. This information could be used to improve the medication system in emergency department in Egypt. Recommendations: This study recommended for provision of safe work environment that encourage good physicians-nurses team work relationship, dissemination of safety guidelines in all hospital department specially nursing and pharmacy, on-going education and training on safe medication administration and supervision of newly hired nursing staff during medication administration process and provision of adequate staffing and fair scheduling for nursing staff working in a highly urgent care departments.

Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system

BackgroundThe acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of medication error jeopardizing patient safety are LASA as well as high workload.Case presentationA critical incident report of medication errors of opioids for postoperative analgesia by look-alike packaging highlights the LASA aspects in everyday scenarios. A change to a generic brand of medication saved costs of up to 16% per annum. Consequently, confusion of medication incidents occurred due to the similar appearance of the newly introduced generic opioid. Due to consecutive underdosing no life-threatening situation arose out of this LASA based medication error.ConclusionsCurrent recommendations for the prevention of LASA are quite extensive; still, in a system with a lump sum payment per case not all of these security measures may be feasible. This issue remains to be approached on an individual basis, taking into consideration local set ups as well as financial issues.Electronic supplementary materialThe online version of this article (doi:10.1186/s13037-014-0047-0) contains supplementary material, which is available to authorized users.

A Focus on Medication Error

A medication error is any avoidable adverse incident that happens due to negligence or incorrect administration of the medication to the patients that lead to an erroneous or imperfect diagnosis of a disease, injury, syndrome, behaviour, infection or other illness. The cause of medication error can be associated to healthcare professionals’ careless practice, outdated health care products, improper follow-ups of the procedures and systems. There are various factors involved that promote such events to happen, for example, an error in dosage or route of administration, incorrect prescription, problem in reading handwritten prescription, failure to administer the correct formulation for a particular disease, use of expired drugs, incorrect timing for administration of the drug, lack of awareness of adverse effects of certain drug combinations, shortage of information about a patient's drug allergies or sensitivities, problem with product labelling, packaging, compounding, dispensing, distribution, monitoring, administration and nomenclature, that is, confusion about different drugs with similar names.

Sepsis in Poland: Why Do We Die?

Objective: To investigate the adverse events and potential risk factors in patients who develop sepsis. Subjects and Methods: Fifty-five medico-legal opinion forms relating to sepsis cases issued by the Department of Forensic Medicine, Wroclaw, Poland, between 2004 and 2013 were analyzed for medical errors and risk factors for adverse events. Results: The most common causes of medical errors were a lack of knowledge in recognition, diagnosis and therapy as well as ignorance of risk. The common risk factors for adverse events were deferral of a diagnostic or therapeutic decision, high-level anxiety of patients or their families about the patient's health and actively seeking for help. The most significant risk factors were communication errors, not enough medical staff, stereotype-based thinking about diseases and providing easy explanations for serious symptoms. Conclusion: The most common cause of adverse events related to sepsis in the Polish health-care system was a lack of knowledge about the symptoms, diagnosis and treatment as well as the ignoring of danger. A possible means of improving safety might be through spreading knowledge and creating medical management algorithms for all health-care workers, especially physicians.