Classification Of Medication Errors Research Articles

Med rec double check: Inpatient psychiatry medication errors identified on admission using Medicaid Web portals and electronic pharmaceutical claims data.

The role of pharmacists during medication reconciliation (MR) is well established, with a number of reports describing this in the context of psychiatric hospitalizations. However, medication errors (MEs) are common during transitions of care, with no exception during psychiatric hospitalizations. Our institution uses pharmacy-performed MR processes using patient interviews and reviewing objective sources, such as electronic pharmaceutical claims data (EPCD), which includes Medicaid Web portals. The inpatient psychiatric pharmacist reviews EPCD sources against previously pharmacy-completed MRs for new admissions, where if discrepancies are found, the patient is reinterviewed to identify and correct MEs. We performed a prospective quality improvement project during 28 days to evaluate the quantity and classification of MEs upon admission to a 22-bed inpatient psychiatry unit. Of 52 included patients, where a cumulative 426 medications were reviewed, a total of 29 MEs in 16 patients were identified. Eight patients had discrepancies on their home medication lists when compared to EPCD, where 7 of these had at least 1 ME due to inaccurate MR. Of all the MEs identified, the greatest quantity was found secondary to the EPCD "double-check" method. The most common MEs in all patients were the omission of home medications (34%), wrong frequency (28%), and ordering medication the patient is not taking (10%). All patients admitted on long-acting injection antipsychotics had errors in last dose received. No MEs resulted in patient harm, and they were identified and corrected by the psychiatric pharmacist 97% of the time.

A Model for Monitoring Spontaneously Reported Medication Errors Using the Adjuvanted Recombinant Zoster Vaccine as an Example.

A European legislation was put in place for the reporting of medication errors, and guidelines were drafted to help stakeholders in the reporting, evaluation, and, ultimately, minimization of these errors. As part of pharmacovigilance reporting, a proper classification of medication errors is needed. However, this process can be tedious, time-consuming, and resource-intensive. To fulfill this obligation regarding medication errors, we developed an algorithm that classifies the reported errors in an automated way into four categories: potential medication errors, intercepted medication errors, medication errors without harm (i.e., not associated with adverse reaction(s)), and medication errors with harm (i.e., associated with adverse reaction(s)). A fifth category ("conflicting category") was created for reported cases that could not be unambiguously classified as either potential or intercepted medication errors. Our algorithm defines medication error categories based on internationally accepted terminology using the Medical Dictionary for Regulatory Activities (MedDRA®) preferred terms. We present the algorithm and the strengths of this automated way of reporting medication errors. We also give examples of visualizations using spontaneously reported vaccination error data associated with the adjuvanted recombinant zoster vaccine. For this purpose, we used a customized web-based platform that uses visualizations to support safety signal detection. The use of the algorithm facilitates and ensures a consistent way of categorizing medication errors with MedDRA® terms, thereby saving time and resources and avoiding the risk of potential mistakes versus manual classification. This allows further assessment and potential prevention of medication errors. In addition, the algorithm is easy to implement and can be used to categorize medication errors from different databases.

Qualification of medical (medical) errors

In the article the author investigates the qualification signs of actions (inaction) of doctors (medical staff), the consequence of which is a medical error. Their content and influence at the civil law relations that arise between the doctor and the patient are established. The author emphasizes the development of a correct, well-thought-out and unified position about the legal qualification of erroneous actions of doctors (medical staff). Also in the article it is noted that possible defects of medical care are: lack of a positive result, accident, medical error, where medical error is the basis for bringing to civil liability for doctors (medical workers). It is noted that the characteristic signs of such an error are harm to the patient`s health or his death and the presence of both intentional guilt and negligence and wrongful acts (inaction) of doctors (medical workers).
 The analysis and classification of the causes (factors) of occurrence and types of medical error is carried out. The subjective and objective reasons influencing actions (inaction of doctors, medical workers are defined). It is said that the objective reasons the doctor, the medical worker cannot predict and which exclude their responsibility. It is stated that actions under the influence of objective reasons should be considered as types of accident (or incident). Subjective causes (factors) are errors made by doctors (health professionals) that unreasonably deviate from established medical standards, act carelessly, confidently or allow unreasonable risks in the absence of experience or knowledge.
 The article analyses the classification of medical errors by the causes, in particular: diagnostic errors; medical and tactical errors; technical errors; organizational errors and deontological errors. A legal assessment of a medical error as one of the possible grounds for civil liability is provided. It is substantiated that the responsibility of a doctor, medical staff depends on the presence of guilt in his actions and the qualification of the negative result of medical care.
 The article also emphasizes that doctors (medical workers) are not responsible for a medical error, but for the damage caused to the patient as a result of this error.
 Scientifically substantiated proposals and recommendations for improving the civil legislation of Ukraine in the field of medicine are formulated.

Medication errors by caregivers in the homes of children discharged from a pediatric department in Ghana.

Medication errors (MEs) by caregivers at home are a cause of morbidity and mortality, shortly after discharge from the hospital. The objective of this study was to determine the rate and types of MEs at the homes of children discharged from a hospital in Ghana and to explore the factors associated with these errors. This was a cross-sectional study of infants and children discharged from the hospital to review medication administration practices. Caregivers of children discharged from the hospital after at least 24 hours of admission were interviewed at their homes about medication administration practices. The study assessed potential harm associated with MEs made by caregivers using the Harm Associated with Medication Error Classification tool. The Least Absolute Shrinkage and Selection Operator regression were used to identify the variables associated with MEs. A total of 95 children (mean age: 28.6 months, 52.6% female) and their caregivers were included. Overall, 65 (68.4%) children experienced one or more MEs. Out of a total of 232 medications reviewed, 102 (44.0%) (95% CI: 37.6-50.4) were associated with a ME. The top two errors, wrong time errors and errors in the frequency of dosing were, 45.1% and 21.6%, respectively. Understanding the information on the disease condition being treated and the medicines dispensed was associated with committing fewer MEs. The number of medicines prescribed was associated with a higher likelihood of MEs. Out of 102 MEs, 48 (47.1%) were assessed as posing potentially no harm, 26 (25.5%) minor harm, 15 (14.7%) moderate harm, and 13 (12.8%) serious harm to the patients. Importantly, none of the MEs were assessed as posing potentially severe or life-threatening harm to the patients. MEs in children following discharge are high, and systems should be developed to prevent these errors.

Incidences and classification of medication errors - a case study

Background. The Medication errors (MEs) affect severely ill health or death and have a substantial financial effect on the patient and health care organization. The present study aims to detect the incidences and classify MEs and increase the patient safety medication of Super Specialty Hospital, Kolkata. Materials and Methods. The prospective observational study of patient prescriptions, transcription, indenting, dispensing, and administration were followed up daily to identify the medication errors in 400+ beds across each admitted inpatient department (IPD) patients file from June 2019 to July 2019 at a Super Specialty Hospital, Kolkata. Results. A total of 395 prescriptions were reviewed in the present study. A total of 29.36% of medication errors have been reported. In June 2019, MEs occurrence rate was 44.85%. The most common MEs were found in Transcription errors (TEs) (77.72%), followed by Administration errors (AEs) (55.44%), Prescription errors (PEs) (55.18%), Dispensing errors (DEs) (31.89%), and Indenting errors (IEs) (4.05%). In comparison, 13.87% of medication errors occurred in July 2019, four times less than in June 2019, with 28.10% in PEs, followed by TEs at 24.05%, AEs at 9.11%, DEs at 8.10% and 0% in IEs. Conclusion. This study revealed that MEs occurred from the common mistake of illegible handwriting, which causes many problems while transcribing and indenting medicine by chemists and nurses while cross-checking the patient file documentation with a medicine card. Further study is needed to determine the factors governing MEs low reporting.

Estimated Costs of Drug-Related Problems Prevented by Pharmacist Prescription Reviews Among Hospitalized Internal Medicine Patients.

Data are lacking on the estimated costs of pharmacist prescription reviews (PPRs) for hospitalized internal medicine patients. This study investigates the estimated costs of drug-related problems (DRPs) prevented by PPRs among hospitalized internal medicine patients. We reviewed all medication orders for patients at an academic teaching hospital in China for 2 years. DRPs were categorized using the Pharmaceutical Care Network Europe classification. The severity of the potential harm of DRPs was assessed by the Harm Associated with Medication Error Classification (HAMEC) tool. The estimated cost of PPRs was calculated. A total of 162426 medication orders for 4314 patients were reviewed, and 1338 DRPs were identified by pharmacists who spent 2230 hours performing PPRs. Among the 1080 DRPs that were prospectively intervened upon, 703 were resolved. The HAMEC tool showed that 47.1% of DRPs were assessed as level 2, 30.4% as level 3, 20.6% as level 1, and 0.6% carried a life-threatening risk. Pharmacist interventions contributed to the prevention of DRP errors and a reduction of $339 139.44. This resulted in a mean cost saving of $482.42 per patient at an input cost of $21 495.06 over the 2 years. The benefit-cost ratio was 15.8. PPRs are beneficial for detecting potential DRPs and creating potential cost savings among hospitalized internal medicine patients.

Medication use optimization in critical care through a pharmacy morbidity, mortality, and improvement program

AbstractPharmacy‐led morbidity, mortality, and improvement (MMI) programs enhance practitioner education and improve patient‐safety culture. The impact of MMI programs on process improvement (PI) outcomes is lacking, particularly within critical care. The purpose of this retrospective report was to describe PI interventions from critical care medication errors evaluated through a pharmacy MMI program. Medication errors reported between June 2013 and August 2022 that occurred in an intensive care unit, emergency department, or procedural area were included. Error severity and potential were assessed using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index and Harm Associated with Medication Error Classification (HAMEC), respectively. The primary outcome of PI interventions was classified as clinical update, operations change, pharmacy or hospital administration change, and/or informatics and technology (IT) updates. Electronic medical record (EMR) were further classified as best practice advisory, medication order build/change, order set build/change, dose limit/alert, or infusion smart pump change. Institute for Healthcare Improvement (IHI) reliability level was evaluated as a secondary outcome. A total of 54 errors were included. Most errors were classified as NCC MERP category D (13 [24.1%]) and C (12 [22.2%]) with severe harm potential (HAMEC 4, 26 [48.1%]; median score 3 [interquartile range, IQR, 3–4]) error potential. A total of 88 PI interventions were identified (median 1.5 [IQR 1–2] per error); clinical (30 [34.1%]) and IT (26 [29.5%]) updates were the most common. Order set build or change (20 [45.5%]) was the most common EMR enhancement. PI interventions were a median IHI level 1 reliability (IQR, 1–2). EMR enhancements had a median IHI level of reliability of 2 (IQR, 1–2). Critical care medication errors addressed through a formal Pharmacy MMI program have high harm potential and often involve multiple PI interventions. EMR interventions generally had higher levels of empiric reliability.

Application of "Human Factor Analysis and Classification System" (HFACS) Model to the Prevention of Medical Errors and Adverse Events: A Systematic Review.

Hospitals, as one of most important subsectors in human societies, are responsible for providing safe and effective medical services to clients. But sometimes these hospitals are the source of injury and death in patients by creating medical errors. In this systematic review study, the application of human factor analysis and classification system (HFACS) method in the classification of medical errors was investigated. Major electronic databases including Scopus, Web of Science, and MEDLINE were searched. All studies that investigated the application of HFACS method for coding, causation, and classification of medical errors and adverse events conducted from 2001 until February 2021 were included. A total of 108 articles were found. Due to duplication, 18 studies were removed from the review list. After reading the titles and abstracts, 50 of these publications were excluded because they had objectives different from this review. The remaining 40 publications were retrieved for further assessment. Of these, 28 publications were excluded because it did not meet the inclusion criteria. Finally, 12 articles remained for the final systematic review. We found that in 65% of the selected studies, preconditions for unsafe acts have been the major causal level of medical errors and adverse events. In the majority of the studies, communication and coordination, adverse mental states, physical environment, crew resource management, and technological environment have also been recognized as the most important causal categories in this study. As a result, to prevent medical errors and adverse events, the main focus should be on controlling the preconditions for unsafe acts including personnel factors, operator conditions, and environmental factors.

Pengaruh Intervensi Apoteker terhadap Tingkat Bahaya Drug-Related Problems pada Pasien Geriatrik Rawat Inap

Geriatric patients are at high risk of Drug-Related Problems (DRPs) associated with multimorbidity, physiologic changes, and pharmacologic alterations, that caused by the aging process. The pharmacist plays an important role in optimizing the effectiveness and safety of the patient’s drug therapies. This study aims to know the effect of pharmacist intervention in reducing the harmful levels of DRPs and to know the factors associated with the reduction of DRPs harm level in hospitalized geriatric patients. This research uses quasi-experimental study with a one-group pretest and posttest design. This research was conducted in Panti Rapih Hospital between March-April 2021, with patients’ inclusion criteria of ≥ 60 years old, with internal diseases cases, and identified DRPs in the therapy. The exclusion patient criteria are hospitalized in the intensive unit and Covid-19 ward. A pharmacist reviewed patient drug therapy, identified and solved DRPs. The harm level of DRPs was compared before and after pharmacist interventions. The harm level of DRPs was determined through professional adjustment according to The Harm Associated with Medication Error Classification tools, then analyzed using Wilcoxon test with a level of confidence 95%. Factors of age, the number of drugs received by the patient, comorbidities, and acceptance of the intervention were investigated for their effect on reducing the harm level of DRPs using a multivariate logistic regression test. A total of the research subject were 28 inpatients, with 47 DRPs identified. The most frequent DRPs were adverse drug reactions (27,66%). Among all interventions, 77,36% of them were accepted with full implementation. The pharmacist intervention resulted in a significant reduction in the harm level of both potential and actual DRPs (p < 0,05). A factor of the number of drugs received by patients and acceptance of pharmacist intervention was associated with the reduction of the harm level of DRPs (p < 0,05). This study shows that multidisciplinary collaboration is needed in the care of geriatric patients.

ANALYSIS OF SHORTCOMINGS IN MEDICAL CARE PROVIDING TO SERVICEMEN IN THE NATIONAL MILITARY MEDICAL CLINICAL CENTER "MAIN MILITARY CLINICAL HOSPITAL"

Assessing the quality of medical care, identifying defects in its provision, studying the shortcomings of medical activities are extremely important not only for forensic expertise or law enforcement practice, but also for all clinical medicine. For the purpose of clinical and anatomical analysis as well as the creation of classification of medical errors which most often occur in the conditions of military medical and preventive institution, revealing of their reasons in National military medical clinical center "Main military clinical hospital" (Kyiv) research was carried out in the period 2016− In 2018, the defects in the provision of medical care were analyzed using medical records, protocols of pathological examinations, acts of meetings of the commission for the study of lethal consequences, as well as reviews of medical records. It was established that erroneous actions of the medical doctors occurred during diagnosis, treatment, medical records, as well as in the organizational support of medical activities. In 2016, 32 defects were identified, in 2017 this number was 29, and in 2018 that was 37. Inadequate medical care was usually provided in insufficient quantities and late. The largest number of servicemen by category fell on the officer corps, the smallest one did on army conscripts. It has been proven that defects in class XI (digestive diseases), in class X (respiratory diseases), and also in class VI (diseases of the nervous system) occurred much more often. The main shortcomings in the organization of medical care for servicemen were unrecognized underlying diseases and errors in maintaining medical records. The causes of recognized defects are objective difficulties of diagnosis, shortcomings in the organization of the treatment process and the atypical course of the disease. The identified shortcomings in the provision of medical care to servicemen and their internal/external reasons should be taken into account when organizing a more effective treatment process in medical institutions of our country. Key words: National Military Medical Clinical Center "Main Military Clinical Hospital", shortcomings in medical care provision, servicemen.

HOW TO AVOID MEDICAL ERRORS IN SURGERY?

The enchantment of numbers of surgical interventions and the widespread adoption of modern technologies, lead to a parallel increase in technological errors and morbidity in recent years. This article analyzes such section of surgery as «medical errors», provides a modern classification of medical errors and complications according to foreign and Russian authors. The article contains information about definition, legal foundations and principles for the prevention of unexpected consequences of surgical interventions.

ABOUT MEDICAL ERRORS

The article gives a general classification of medical errors. There are given arguments in favor the replacement of a «medical error» for an «innocent mistake». It is proved expedient to replace “negligence, frivolity” to “a mistake due to negligence and frivolity”. Common features and criteria for distinguishing both types of mistakes are written. There is given an example of thinking errors due to stereotype and its analysis.

Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC).

Classifying harm associated with a medication error can be time consuming and labour intensive and limited studies undertake this step. There is no standardised process, and few studies that report harm assessment provide adequate methods to allow for study replication. Studies typically mention that a clinical review panel classified patient harm and provide a reference to a classification tool. Moreover, in many studies it is unclear whether potential or actual harm was classified as studies refer only to ‘error severity’. The tools used to categorise the severity of patient harm vary widely across studies and few have been assessed for inter-rater reliability and criterion validity. In this paper, we describe the systematic process we undertook to synthesise the defining elements and strengths, while mitigating the limitations, of existing harm classification tools to derive the Harm Associated with Medication Error Classification (HAMEC). This new tool provides a harm classification for use across clinical and research settings. The provision of an explicit process for its application and guiding category descriptors are designed to reduce the risk of misclassification and produce results that are comparable across studies. As the World Health Organisation embarks on its international safety challenge of reducing medication-related harm by 50%, accompanying methodological advances are required to measure progress.Electronic supplementary materialThe online version of this article (10.1007/s40264-019-00823-4) contains supplementary material, which is available to authorized users.

Inter-rater reliability of medication error classification in a voluntary patient safety incident reporting system HaiPro in Finland.

Medication errors are common in healthcare. Medication error reporting systems can be established for learning from medication errors and risk prone processes, and their data can be analysed and used for improving medication processes in healthcare organisations. However, data reliability testing is crucial to avoid biases in data interpretation and misleading findings informing patient safety improvement. To assess the inter-rater reliability of medication error classifications in a voluntary patient safety incident reporting system (HaiPro) widely used in Finland, and to explore reported medication errors and their contributing factors. The data consisted of medication errors (n = 32 592), including near misses, reported by 36 Finnish healthcare organisations in 2007-2009. The reliability of the original classifications was tested by an independent researcher reclassifying a random sample of errors (1%, n = 288) based on narratives. The inter-rater reliability of agreement (κ) of the classifications was calculated to describe the degree of conformity between the researcher and the original data classifiers. Descriptive statistics were used to describe the medication errors. The inter-rater reliability between the researcher and the original data classifiers was acceptable (κ ≥ 0.41) in 11 of 42 (26%) medication error classes. Thus, these errors could be pooled from different healthcare units for the exploration of medication errors at the level of all reporting organisations. Contributing factors were identified in 48% (n = 137) of the medication error narratives in the random sample (n = 288). The most commonly reported errors were dispensing errors (34%, n = 10 906), administration errors 25% (n = 7972), and documentation errors 17% (n = 5641). The data classified by different classifiers can be pooled for some of the medication error classes. Consistency of the classification and the quality of narratives need improvement, as well as reporting and classification of contributing factors to provide high quality information on medication errors.

Medication errors resulting in harm: Using chargemaster data to determine association with cost of hospitalization and length of stay.

Results of an analysis of the economic impact of adverse drug events (ADEs) resulting in patient harm on hospitalization costs and length of stay (LOS) are reported. In a retrospective single-site study, medication errors among patients admitted to an academic medical center during the period April 2014-May 2015 were identified using voluntary event reporting system data and diagnosis codes. Hospitalization cases involving documented ADEs resulting in harm, as defined on a widely used medication error classification index, were matched with control cases by admission period, diagnosis-related group, and patient age and sex. Total hospitalization costs and LOS in the study groups were analyzed using an independent 2-sample Mann-Whitney U test. Among 416 hospitalization cases evaluated for inclusion in the study, 242 were matched with 3,279 control cases for analysis. The primary drug classes implicated in the evaluated medication errors included chemotherapy agents (38%), corticosteroids (14%), and opioids (11%). Total hospitalization costs differed significantly (p = 0.044) between patients who experienced ADEs resulting in harm (median, $19,444; interquartile range [IQR], $13,481-$40,580) and those who did not (median, $17,173; IQR, $12,500-$27,125); the former group also had a significantly (p = 0.005) longer median LOS. Chargemaster data for an academic medical center revealed that the median total hospitalization cost and LOS were significantly greater for hospitalizations during which a harm-causing medication error was recorded versus hospitalizations during which harm-causing medication errors were not recorded.

The use of a contextual, modal and psychological classification of medication errors in the emergency department: a retrospective descriptive study.

To describe the contextual, modal and psychological classification of medication errors in the emergency department to know the factors associated with the reported medication errors. The causes of medication errors are unique in every clinical setting; hence, error minimisation strategies are not always effective. For this reason, it is fundamental to understand the causes specific to the emergency department so that targeted strategies can be implemented. Retrospective analysis of reported medication errors in the emergency department. All voluntarily staff-reported medication-related incidents from 2010-2015 from the hospital's electronic incident management system were retrieved for analysis. Contextual classification involved the time, place and the type of medications involved. Modal classification pertained to the stage and issue (e.g. wrong medication, wrong patient). Psychological classification categorised the errors in planning (knowledge-based and rule-based errors) and skill (slips and lapses). There were 405 errors reported. Most errors occurred in the acute care area, short-stay unit and resuscitation area, during the busiest shifts (0800-1559, 1600-2259). Half of the errors involved high-alert medications. Many of the errors occurred during administration (62·7%), prescribing (28·6%) and commonly during both stages (18·5%). Wrong dose, wrong medication and omission were the issues that dominated. Knowledge-based errors characterised the errors that occurred in prescribing and administration. The highest proportion of slips (79·5%) and lapses (76·1%) occurred during medication administration. It is likely that some of the errors occurred due to the lack of adherence to safety protocols. Technology such as computerised prescribing, barcode medication administration and reminder systems could potentially decrease the medication errors in the emergency department. There was a possibility that some of the errors could be prevented if safety protocols were adhered to, which highlights the need to also address clinicians' attitudes towards safety. Technology can be implemented to help minimise errors in the ED, but this must be coupled with efforts to enhance the culture of safety.

Correlation between psychophysiological response and hospital management model for nurses involved in medication errors

Because hospitals in Taiwan now place a lot of emphasis on hospital accreditation, leading to a heavy workload for nurses, nurses are unintentional involved in patient medication errors (MEs). In this research, we explore the possible correlation between psychophysiological responses of nursing staff and a hospital management model regarding MEs. We conducted a cross-sectional study design in one hospital in central Taiwan. A total of 345 nurses at Tali Jen-Ai Hospital l were selected. A questionnaire was chosen as the study instrument. The questionnaire asked the following information: basic data, classification of MEs, frequency and severity of psychophysiological responses, and information about the hospital’s management model and support system. We found that the hospital management model had a significant negative correlation with the frequency of physiological symptoms (r = -0.14, p < .01). Likewise, the support system also had a substantial negative correlation with the scores of the physiological symptom, behavioral responses, and psychophysiological responses. Using multiple regression analysis adjusted for work duration, job title, and degree of injury, we found that the support system was significantly correlated with the nurses’ psychophysiological responses. Both the hospital management and the support system decreased the psychophysiological responses of the nurses. Therefore, we recommend that supervisors implement a management strategy to deal specifically with MEs. When nurse managers have frequently empathy and no-blame attitude to replace disrespectful or skeptical ways to nurse with ME, they will empower their enthusiasm and responsibility to improve the reduction of ME.

Improving medication safety in primary care. A review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care

ABSTRACTBackground: Drug treatment is an important clinical process in primary care that is associated with risk of error and adverse events.Objective: To review currently available research evidence on the topic and to develop a framework, which can help to guide improvement of medication safety.Methods: Systematic reviews were performed on adverse drug events (ADE), their preventability, and on available tools and methods to improve medication safety with a particular focus on information technology. Consensus methods were used to develop a framework to guide the improvement of medication safety based on the findings of our literature review.Results: The median prevalence rate of ADEs in primary care patients was 12.8%. Only a median of 16.5% of ADEs were preventable and thus could be classified as medication errors. Our review of information technology interventions found that only about half of the studies found a reduction of medication errors. In both reviews, the wide range between studies emphasizes the necessity of a validated medication error classification system. Another important aspect of medication safety appears to be a general lack of safety culture in primary care, which led us to the development of the Salzburg medication safety framework (SaMSaF), based on the MaPSaF tool to improve patient safety. The tool proved to be feasible and useful in a pilot study with several GP practices.Conclusion: A number of tools and interventions to investigate and enhance medication safety have been identified. Further research is necessary to implement and evaluate current concepts.

PS-032 Pharmaceutical validation as safety assurance for the management of cytostatics

Background The addition of a pharmacist during the validation, preparation and administration of cytostatics ensures the detection and resolution of drug-related problems. Purpose To quantify and analyse the pharmacist’s contribution during the validation process, to ensure safety during all the stages of use of cytostatic drugs. Material and methods A prospective observational study of 4 months. All pharmacist interventions (PIs) related to medication errors (MEs) were recorded, from the prescription to the administration of chemotherapy. All prescriptions associated with chemotherapy, biological treatments and supportive care drugs were considered. The MEs and their severity were classified according to the Updated Classification of Medication Errors, by the Ruiz-Jarabo group 2000. The variables recorded were: potential gravity, if it reached the patient, drugs involved and medical policy. Results During the study period 38 PIs were recorded (24 drugs involved). PIs were made more often during the prescription process (86.8%), followed by administration (7.9%) and preparation (5.3%). Of these, in 81.6% of cases a cytostatic and/or biological agent was involved, and 18.4% involved a supportive care drug. The severity of PIs was: 18.4% minor, 31.6% moderate, 42.1% severe and 7.9% very severe. They reached the patient in 10.5% of cases. The drugs involved more often were carboplatin (33.3%), aprepitant (20.8%), paclitaxel (16.67%), azacitidine (12.5%), irinotecan, oxaliplatin and vincristine (5.3% each). The main MEs were: omission of medicine needed (26.3%), dose higher than needed (15.8%), omission in transcription (13.2%), dose lower than needed (10.5%), administration error (7.9%) and preparation error (5.3%). Conclusion The pharmacist’s contribution prevented 89.5% of MEs from reaching the patient. These results reveal the importance of incorporating the pharmacist as an essential part of a multidisciplinary team to contribute to the safety of patients. The pharmacist should have a more active role in the areas of medicines preparation and administration; an appropriate ratio of pharmacists vs. number of validated patients is needed. References and/or acknowledgements Ruiz-Jarabo 2000. No conflict of interest.

Establishment and application of medication error classification standards in nursing care based on the International Classification of Patient Safety

ObjectiveTo standardize the classification, reporting and analysis of medication errors in nursing in order to improve patient safety management by achieving real-time monitoring and systemic analysis. MethodsA system of classifying nurse-related adverse drug effects into four category grades was developed based on the framework provided by the International Classification of Patient Safety. Three investigators used the system to classify 1343 nursing-related drug adverse events reported between January 2006 and December 2010 at 15 tertiary medical institutions in Shanghai. ResultsThe classification standard incorporated all relevant information provided in the reporting system and revealed that the greatest frequency of drug adverse events resulted from staff-related factors. In particular, the largest number of events resulted from routine violations, followed by technology type errors of negligence and fault. ConclusionApplication of this classification system will help nursing administrators to accurately detect system- and process-related defects leading to medication errors, and enable the factors to be targeted to improve the level of patient safety management.