Consequences Of Medication Errors Research Articles

REGISTRY OF TYPES, FACTORS, AND CONSEQUENCES OF MEDICAL ERRORS IN THE DIAGNOSIS OF DIABETES MELLITUS TYPES

Aim. To identify and systematize the types, factors, and consequences of medical errors in diagnosing types of diabetes mellitus (DM) and to create a registry for them.Materials and Methods. A search, collection, evaluation, and synthesis of scientific data regarding the prevalence of diagnostic errors, their significance, types, causes (including general and diabetes-specific factors), and prevention methods were conducted using Google Scholar, Scopus, Web of Science, PubMed Medline, and Embase databases, as well as publications from open sources. The analysis included guidelines from leading medical societies and expert groups. Based on the systematization of literature data and the authors' clinical observations, a «Registry of Types, Factors, and Consequences of Medical Errors in the Diagnosis of Diabetes Mellitus Types» was created for the first time.Results. General factors contributing to errors in the diagnosis of diabetes mellitus (DM) include limited access to quality healthcare, a shortage of specialists in diabetology, low levels of teamwork, lack of availability of diagnostic tests for determining DM types, ineffective communication, unsatisfactory care coordination, and follow-up, as well as cognitive biases. Diabetes-specific factors include the heterogeneity of DM, atypical disease progression, comorbidities, environmental factors, and technical errors in DM diagnosis. The most typical diagnostic discrepancies involve the misidentification of type 1, type 2, and other specific types of DM. Implementing the created «Registry of Types, Factors, and Consequences of Medical Errors in the Diagnosis of Diabetes Mellitus Types» in endocrinology departments has significantly reduced the number of diagnostic discrepancies for DM types. Additionally, incorporating this registry into the educational process at higher education institutions has improved the competence of students and medical professionals on this issue.Conclusions. The «Registry of Types, Factors, and Consequences of Medical Errors in the Diagnosis of Diabetes Mellitus Types», created based on a synthesis of literature data and the results of clinical observations, contributes to improving the quality and accuracy of diagnosis, enhances the professional level of healthcare workers, and reduces the number of incorrect diagnoses and treatment prescriptions.

Exploring medical and nursing students’ perceptions about a patient safety course: a qualitative study

BackgroundEducating health professionals on patient safety can potentially reduce healthcare-associated harm. Patient safety courses have been incorporated into medical and nursing curricula in many high-income countries and their impact has been demonstrated in the literature through objective assessments. This study aimed to explore student perceptions about a patient safety course to assess its influence on aspiring health professionals at a personal level as well as to explore differences in areas of focus between medical and nursing students.MethodsA dedicated patient safety course was introduced for year III medical and year II and IV nursing students at the Aga Khan University (2021–2022). As part of a post-course assessment, 577 participating students (184 medical and 393 nursing) wrote reflections on the course, detailing its influence on them. These free-text responses were thematically analyzed using NVivo.ResultsThe findings revealed five major themes: acquired skills (clinical, interpersonal), understanding of medical errors (increased awareness, prevention and reduction, responding to errors), personal experiences with patient safety issues, impact of course (changed perceptions, professional integrity, need for similar sessions, importance of the topic) and course feedback (format, preparation for clinical years, suggestions). Students reported a lack of baseline awareness regarding the frequency and consequences of medical errors. After the course, medical students reported a perceptional shift in favor of systems thinking regarding error causality, and nursing students focused on human factors and error prevention. The interactive course format involving scenario-based learning was deemed beneficial in terms of increasing awareness, imparting relevant clinical and interpersonal skills, and changing perspectives on patient safety.ConclusionsStudent perspectives illustrate the benefits of an early introduction of dedicated courses in imparting patient safety education to aspiring health professionals. Students reported a lack of baseline awareness of essential patient safety concepts, highlighting gaps in the existing curricula. This study can help provide an impetus for incorporating patient safety as a core component in medical and nursing curricula nationally and across the region. Additionally, patient safety courses can be tailored to emphasize areas identified as gaps among each professional group, and interprofessional education can be employed for shared learning. The authors further recommend conducting longitudinal studies to assess the long-term impact of such courses.

The public’s views on responsibility for medical errors in Kazakhstan

ABSTRACT Introduction Patients’ attitudes toward medical errors (MEs) have been studied relatively extensively in developed countries around the world, but little is known about Central Asian countries, especially post-Soviet states. The growing importance of patient safety has raised concerns about who should be held accountable for MEs. Due to a lack of research, this issue is poorly understood in Kazakhstan. Materials and Methods This study examines respondents’ attitudes toward MEs based on whether they had this experience in Kazakhstan between 2019 and 2021. The statistical analysis of data on MEs was carried out for the whole country. Respondents were asked about the causes of and solutions to the problem of preventable medical errors, as well as what the consequences of MEs should be. Results In total, 40.8% of the respondents confirmed that they had experienced problems with MEs. Nearly one-third of Kazakhstani adults agree that the lack of professional qualifications of health professionals is the root cause of MEs. Conclusions Differences existed among the regions in the opinion of the public and indicators of the degree of responsibility for and response to MEs. Further study of the causes and attitudes of the public is warranted, which will help better understand the problem of MEs in Kazakhstan.

Factors associated with pharmacists’ knowledge regarding high-alert medications: a convenience sample survey in China

The consequences of medication errors are more severe for high-alert medications than general drugs. Improving pharmacists’ knowledge regarding high-alert medications is important to increase drug safety and maintain patient health. This study was aimed at understanding Chinese hospital pharmacists’ knowledge regarding high-alert medications and exploring associated factors, to provide suggestions for management of high-alert medications. A total of 380 pharmacists from four hospitals in southern, northern and central China were selected through a convenience sampling method. Through a questionnaire survey, the pharmacists’ demographic sociology characteristics and knowledge regarding high-alert medications were investigated. Chi-square tests and binary logistic regression were used to analyze the factors associated with pharmacists’ knowledge regarding high-alert medications. A total of 336 valid questionnaires were returned, with an effective recovery rate of 88.4%. Among the respondents, 79.2% had high knowledge regarding high-alert medications. The analysis results show that the main factors significantly associated with pharmacists’ knowledge levels of high-alert medication were work experience and professional title, whether high alert-medication knowledge was obtained through the network channel, whether high-alert-medication knowledge was obtained through daily work practice and whether high-alert medications were double independent checked before use. Increase the sharing of work cases and knowledge cooperation among different pharmacists and departments in high-alert medications, rationally adjust and arrange the responsibilities of pharmacists, and improve the internal circulation of hospital high-alert medications are helpful to improve pharmacists’ cognitive level of high-alert medication and improve the hospital’s ability to control the risk of high-alert medication.

Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study.

PurposeThis study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting.Patients and MethodsWe performed a 10-year retrospective study (January 2011–December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome.ResultsIn total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour–14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs.ConclusionSmall children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.

The public’s views on responsibility for medical errors in the Republic of Kazakhstan

Abstract Background Healthcare professionals, public committees and leaders, as well as and people in positions of responsibility, deeply apprehensive with improving patient safety in Kazakhstan. Patient attitude towards of medical error is relatively well studied in developed countries of the world, but little is known about Central Asian countries, especially post-soviet space. This study aimed to analyze the attitude towards medical errors, depending on whether the respondents themselves or their relatives had this experience in the Republic of Kazakhstan from 2019 to 2021. Methods The study included two hundred sixty-seven participants. The statistical analysis of data on medical error was performed for the whole country. Data on medical error from public were retrieved for the period 2019-2020. Respondents were asked about the causes of and solutions to the challenge of preventable medical errors and what the consequences of medical error should be. Results A total of 40.8% (109/267) of respondents confirmed that they had experienced problems regarding medical errors while 59.2% (158/267) had not encountered any medical errors in their life experience. Nearly one in three Kazakhstan's adults agree that cause of medical errors is lack of professional qualifications of health professionals 36.3% (97/267). The respondents noted that hospital administration 47.6% (127/267) should be held accountable for medical errors, followed by the health professionals 25.5% (68/267). Conclusions There were significant differences between the regions of the country in the causes of medical errors in the opinion of public, as well as in indicators of the degree of responsibility for and response to medical errors. There is a need for further study of the causes and attitudes of public, which may have helped to better understand the challenge of medical errors in Kazakhstan. Key messages There is a need to performing regular analysis and evaluation to find out the cause of the problem and taken into account in deciding regarding the medical error. We recommend raising awareness about medical errors and the need for incident reporting, introducing training and learning workshops, and improving medical error reporting.

Physicians' attitudes regarding the disclosure of medical errors: A qualitative study.

The experiences of physicians’ errors could affect their professional practice. The aim of study was to explore physicians’ experiences of medical errors and its consequences. This was a qualitative study in which ten Brazilian physicians were selected through purposive sampling. The data were collected via semistructured interviews and analyzed through principles derived of the phenomenological method. The interview topics were around how the error occurred in their practice, its process of disclosure and consequences of medical errors. Excessive workload and difficulty communicating among physicians are some of the factors that may increase the likelihood of medical error. Not looking for help after the error was a common attitude. This may be related to the difficulty for some physicians to acquire new practices after the error, even though physicians have shown that experiencing a medical error situation has a negative impact in their lives. To disclose training and institutional practices which contribute to the dissemination of conduct favorable to the improvement of medical practice.

Impact of round‐the‐clock pharmacist inpatient medication chart review on medication errors

AbstractIntroductionMedication errors are common causes of preventable adverse drug events and increase the risk of morbidity and mortality. Beginning in July 2014, Tan Tock Seng Hospital Pharmacy Department (Singapore) implemented the round‐the‐clock inpatient medication chart review service by pharmacists. We evaluated the impact of this service on medication errors and the consequences of these errors.MethodsPharmacy intervention data from 2013 to 2015 were accessed. Severity of medication errors was defined according to the National Coordination Council for Medication Error Reporting and Prevention (NCCMERP) categories. Interrupted time series analysis was used to assess the impact of the service on monthly error rates. Consequences of medication errors were investigated in a matched case‐control analysis comparing outcomes and costs between cases with “errors” (Category D to I) and controls who had “near‐misses” (Category B). A cost analysis was done in Singapore dollars (S$).ResultsThe mean number of “near‐misses” was 32.04 per 1000 patient‐days/month prior to the service. When the service was implemented, the interrupted time series analysis showed a level increase of 21.43 per 1000 patient‐days/month (95% confidence interval [CI], 14.21, 28.65, P &lt; .01) with a positive trend change of 1.04 per 1000 patient‐days/month. Patients with “near misses” had lower median hospitalization costs (S$2673.60 interquartile range [IQR] [S$1365.70‐5336.20], vs S$6326.60 IQR [S$1926.20‐13 609.00], P = .002) and length of stay (10 days [4‐21] vs 17 days [5‐42], P = .025). No significant differences were observed for all other outcomes studied.ConclusionRound‐the‐clock pharmacist inpatient medication review service increased detection of “near misses” and prevented these errors from reaching patients, which may otherwise have resulted in increased hospitalization costs and length of stay.

Detection and Management of Common Medication Errors in Internal Medicine Wards: Impact on Medication Costs and Patient Care.

Purpose: Medication errors (MEs) are a leading cause of morbidity and mortality, yet they have remained as confusing and underappreciated concept. The complex pharmacotherapy in hospitalized patients necessitates continued report and surveillance of MEs as well as persistent pharmaceutical care. This study evaluated the frequency, types, clinical significance, and costs of MEs in internal medicine wards. Methods: In this 8-month prospective and cross-sectional study, an attending clinical pharmacist visited the patients during each physician’s ward round at the morning. All MEs including prescription, transcription, and administration errors were detected, recorded, and subsequently appropriate corrective interventions were proposed during these rounds. The changes in the medications’ cost after implementing clinical pharmacist’s interventions were compared to the calculated medications’ cost, assuming that the MEs would not have been detected by clinical pharmacist and continued up to discharge time of the patients. Results: 89% of the patients experienced at least one ME during their hospitalization. A mean of 2.6 errors per patient or 0.2 errors per ordered medication occurred in this study. More than 70% of MEs happened at the prescription stage by treating physicians. The most prevalent prescription errors were inappropriate drug selection, unauthorized drugs and untreated indication. The highest MEs occurred on cardiovascular agents followed by antibiotics, and vitamins, minerals, and electrolytes. The net effect of clinical pharmacist’s contributions in medication therapy management was to decline medications’ costs by 33.9%. Conclusion: The role of clinical pharmacy services in detection, prevention and reducing the cost of MEs is of paramount importance to internal medicine wards.

Healthcare Delivery System Security: the orchestration of automated and organizational solutions

Many studies from around the world enhance awareness of medication errors in hospitals. A French national study on Adverse Events (AE) revealed that 60 000 to 130 000 AE per year appear to be consequences of medication errors, and 15 000 to 60 000 AE are preventable. Furthermore, hospital spending represents 37% of the French healthcare costs. Enhancing medication system quality and efficiency by reducing medication errors and costs are then considered as important public health issues. Medication management is a complex socio-technical system involving multiple people and numerous steps. Automated dispensing systems have been reported to be key components of strategies to prevent medication errors and create a better workflow. Few hospital pharmacies are implementing automated nominative dispensing robot that increase secure treatment preparation as well as dispensing safety and performance. Automated storage systems and medication delivery devices also reduce hidden costs related to pharmaceutical products stock control and remove professional agent time from non-value-added tasks for a more efficient redeployment tasks.Nevertheless, our results from auditing hospital pharmacies that are investing in automated systems revealed risks and hidden costs related to reception station, dispensing and care unit orders that should be settled by computerization and organizational actions. Our study shows that hospital pharmacy organizations require the implementation of specific actions settling software interface problems and enhancing coordination skills among health care actors in order to secure medication delivery system and prevent from hidden costs related to organizational factors. Then, automation does not seem a self-sustaining option to handle pharmacy’s activity dysfunctions. Many other parameters intervene.This paper presents a pharmacy’s automation project. It takes example at a French Hospital Center in Lens in the north of France (CHL). We present a human centered automation approach that includes an identification of tasks eligible for automation and tasks that need to be supervised, controlled or operated by a human agent.

Challenges faced by the visually disabled in use of medication, consequences of medication errors and their self-adopted coping strategies at a tertiary care hospital in Goa, India

Background: Visual impairment (VI) does limit individual’s ability to complete everyday tasks and impact their quality of life and ability to interact with their environment. The objectives of this study are to determine challenges faced by people with Visually Disability, medicine administration errors and self-adopted coping strategies.Methods: An observational case series study design was used for the data collection. The data was collected from January-June 2014. The study participants were included all patients more than 18 years who were certified as visually handicap.Results: The major challenges faced by total 146 visually disabled patients studied were, 51.36% couldn’t locate the place of medication and 45.89% couldn’t identify the separate containers of medications. The major Medications errors included of 30.13% study participants had missed doses and spilled medications. The most commonly used coping measures were keeping medications at specific places, identifying separate drugs by feeling the shape of the container.Conclusions: The challenges included, inability to locate the place of medication, inability to identify the separate containers of medications, unaware of correct dose, inability to maintain dose schedule and difficulty in using liquid medications. Medication errors included, missing doses, spillage of medications, consumption of wrong medication, wrong dosage, inability to complete course of prescribed medications. The coping strategies adopted included, keeping medications at specific places, identifying separate drugs by feeling the shape of the container, tracking the time of routine medications with the timings of the TV serials/shows.

Quantitative exploration of medication errors among older people: a systematic review

Medication errors (MEs) in older people are of importance due to global aging patterns. Following on from aging-related changes in pharmacokinetics, pharmacodynamics, and the potential presence of multiple co-morbidities treated with polypharmacy, older people are highly vulnerable to the effects and consequences of MEs. The primary outcome of this study was to systematically review studies on the incidence and categories of MEs in older people. Secondary outcomes included economic and clinical consequences of MEs in older people, risk factors for MEs in older people, and medications involved. A comprehensive, electronic search was conducted using PubMed, EBSCOhost, OvidMedline and Proquest central databases for studies evaluating MEs in older people published in peer-reviewed journals before November 2017. A secondary manual search was also conducted by checking the bibliographies of included studies to identify other relevant studies. There was no limitation imposed on the language, time of publication, or the setting in which the study was carried out. The quality of identified studies was assessed based on 17 criteria adopted from Alsulami et al. and Metsala et al. The results were categorized using the phases of medication use when the error was detected or occurred. Eighteen studies met the inclusion criteria with a total of 467,193 participants from 11 countries. Identified MEs were administration errors [number of times ME subcategory was reported (n = 7); error frequency rate 1.2–59.0%], prescribing errors (n = 7; 1.6–49.7%), transcribing errors (n = 5; 15.0–70.2%), reconciliation errors (n = 4; 5.0–53.6%), and dispensing errors (n = 2; 2.0–14.0%). People with polypharmacy had the highest tendency of MEs. Three studies reported severe clinical consequences from MEs ranging from 2.9% to 13.0%. The main category of medications involved in MEs were cardiovascular medications (n = 15); nervous system medications (n = 11); and medications for the alimentary tract and metabolism (n = 8). Administration and prescribing errors were the most frequently reported MEs in older people. Medication classes that were most commonly reported in the context of MEs in older people were cardiovascular medications and nervous system medications. We identified polypharmacy as a risk factor for MEs, which was found to correlate with the number of MEs in many stages of medication use. A lack of studies from Asia, Latin America, and Africa highlights the need for future research in these regions. CRD42016042975.

Analysis of medication errors at a large tertiary care hospital in Saudi Arabia: a retrospective analysis.

Background Medication errors (MEs) are common in health care settings and pose a threat for the hospitalized population. Therefore, aspects of MEs were explored in a tertiary setting serving a diverse population. Objective To examine the occurrence, severity and reporting of MEs in hospitalized patients. Methods This retrospective analysis included 10,683 ME report forms that were received by the Medication Safety Unit of King Saud Medical City (KSMC) in 2015. ME outcomes were determined according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for categorizing MEs algorithm. Results A total of 13,677 MEs in 912,500 prescriptions were reported. The incidence rate of MEs was 1.5% (13,677/912,500). The highest percentage (42.2%) of MEs occurred during the transcription stage, and 70.0% of MEs were reported as near misses. Wrong frequency and wrong concentration accounted for nearly half of the MEs. Conclusion We found 1.5 MEs per 100 prescriptions; more than two-thirds of the MEs were preventable and were intercepted before reaching the patients. Most MEs reported by pharmacists occurred at the transcription stage while wrong frequency was the most common error type encountered. Further studies should explore the clinical consequences of MEs at a healthcare institution.

170 Risk-Management and Medical Malpractice Curriculum for Emergency Medicine Residency

Lawsuits frequently name resident physicians as co-defendants along with attending physicians and the hospital. Many residents are not aware of the full extent of their exposure to medical malpractice liability nor do they understand the medical liability coverage they are provided by their training programs. Our efforts as a medical profession to prepare resident physicians to navigate the current legal system are either lacking or deficient. According to one large Northeast malpractice insurer, from 1994 to 2003, in the graduate medical education setting, residents were named in 22% of medical malpractice lawsuits. Between 1990 and 2004, the National Practitioner Database reported 1530 claims awarded in suits involving residents, a number regarded as low due to underreporting. The purpose of this study is to review the current literature regarding emergency medicine (EM) resident physician medical malpractice education and to make recommendations based on this literature to develop a model medical malpractice program for EM residents. A PubMed search was performed using the combined keywords “resident liability,” “resident lawsuits,” and “resident medical malpractice.” The search yielded 24 citations. These were reviewed along with the bibliographies of relevant articles. A search was also performed of the Cochrane Database of Systemic Reviews using the same strategy, which yielded only 1 relevant review. Seven articles were selected for review that directly addressed medical malpractice education in residency programs. Two of the articles specifically described elements of an EM resident medical malpractice education program. All selected articles discussed how residency programs recognize the need for more in-depth medicolegal education but lack a curriculum for such. The article review revealed that some programs invite hospital attorneys to discuss such topics as pitfalls inherent to charting, and explain the format of a medical malpractice trial and the pre-trial litigation process. The timing of such training appears to be an obstacle. The most relevant article discussed how a mock trial involving emergency medicine residents improved their communication skills and expanded their knowledge of documentation pitfalls, problems with staff interaction, and consequences of medical errors. Medicolegal curriculum allowed residents to learn how the lay public and patients view the care that they deliver. It taught residents how they are perceived, both positively and negatively, while they are administering medical care. Malpractice risk is serious concern for residents and a financial liability for hospitals but there is a paucity of organized education programs during residency. Physician-defendants have been forced to become educated on the subject of medical malpractice first hand instead of having a dedicated education program in residency. Although there is consensus on the importance of medicolegal education during residency there is limited information in the literature on residency programs having a dedicated educational program for such.

Medical Errors in Greece: An Economic Analysis of Compensations Awarded by Civil Courts (2000-2009)

Medical errors are reported with increased frequency both in Europe and in the United States of America and measures are put in place to deal with the problem. In Greece, more and more patients think that it is likely to experience a medical error during health care delivery and the organizations they can turn to if this happens are hardly enough and with meagre response. The consequences of medical errors are multiple and complex with significant financial implications. Nowadays there is an urgent need to resolve problems that refer to cost containment in the Greek Health System. Some research findings from the review of 128 compensations awarded by civil courts for the years 2000 to 2009 for medical errors in Greece are quite interesting. The mean compensation amounted to €292,613 representing 35.41% of claimed compensation. Only a small proportion of medical errors gain publicity as the majority of claims get settled out of court, covered by the insurance policy or the hospitals. The burden of the obvious and hidden cost affects not only the patient, his family and the hospital but also the whole of the society. This comes from our estimation that the level of compensation awarded by the civil courts for medical errors is remarkable high. Unfortunately only some estimates of the cost are possible due to the lack of statistical data. The creation of an independent oversight body for the review of medical errors and complaints nationwide as well as the modernization of the hospitals’ monitoring systems is necessary in order to handle the medical error phenomenon. Above all, cooperation and trust between patients, health care professionals, hospital managers, medical boards and the government are essential to get to the root of the problem.

Preparing Emergency Physicians for Malpractice Litigation: A Joint Emergency Medicine Residency-law School Mock Trial Competition

BackgroundFear of malpractice affects the daily life of many emergency physicians. Educational programs to prepare for litigation are lacking. ObjectivesAn educational collaboration between an emergency medicine residency and a law school, whereby a medical malpractice mock trial competition is used to teach residents basic skills for testifying in legal proceedings. MethodsTen residents in an academic emergency medicine program volunteered as witnesses in a malpractice mock trial competition at a law school. Residents testified two or three times and, after each appearance, were provided feedback to prepare them for subsequent rounds of testimony. They were also given access to videotaped testimony. Judges rated each resident using a nine-question survey scored on a 10-point Likert scale. Scores were compared as a group between rounds of testimony. ResultsParticipants demonstrated significant improvement in seven of nine measured categories. p-Values reached significance in: Worked Well on Direct Examination (p < 0.001), Demeanor/Body Language (p < 0.001), Was Not Arrogant/Did Not Lose Poise on Cross-Examination (p = 0.001), Convincing Witness (p = 0.001), Appeared Knowledgeable (p = 0.012), Courtroom Attire (p = 0.012), and Expressed Themselves Clearly (p = 0.017). In addition, residents anonymously reported broad educational benefit. ConclusionThis novel educational collaboration taught residents about the process of litigation. It improved their communication skills and expanded their knowledge of documentation pitfalls, problems with staff interaction, and consequences of medical errors. This mutually beneficial partnership between a medical residency and a law school solidified it as a permanent feature of the residency program.

GRP-053 Drug Distribution Systems: Effect on Medication Error Rates and Cost of Safety in a Geriatric Short Stay Unit

BackgroundMedication management of older peoples is of special importance regarding to their sensitivity to adverse drugs effects.Purpose This study compared the medication error rates and the operating costs before and...

National Study on the Distribution, Causes, and Consequences of Voluntarily Reported Medication Errors Between the ICU and Non-ICU Settings*

To compare the distribution, causes, and consequences of medication errors in the ICU with those in non-ICU settings. : A cross-sectional study of all hospital ICU and non-ICU medication errors reported to the MEDMARX system between 1999 and 2005. Adjusted odds ratios are presented. Hospitals participating in the MEDMARX reporting system. None. MEDMARX is an anonymous, self-reported, confidential, deidentified, internet-accessible medication error reporting program that allows hospitals to report, track, and share medication error data. There were 839,553 errors reported from 537 hospitals. ICUs accounted for 55,767 (6.6%) errors, of which 2,045 (3.7%) were considered harmful. Non-ICUs accounted for 783,800 (93.4%) errors, of which 14,471 (1.9%) were harmful. Errors most often originated in the administration phase (ICU 44% vs. non-ICU 33%; odds ratio 1.63 [1.43-1.86]). The most common error type was omission (ICU 26% vs. non-ICU 28%; odds ratio 1.00 [0.91-1.10]). Among harmful errors, dispensing devices (ICU 14% vs. non-ICU 7.1%; odds ratio 2.09 [1.69-2.59]) and calculation mistakes (ICU 9.8% vs. non-ICU 5.3%; odds ratio 1.82 [1.48-2.24]) were more commonly identified to be the cause in the ICU compared to the non-ICU setting. ICU errors were more likely to be associated with any harm (odds ratio 1.89 [1.62-2.17]), permanent harm (odds ratio 2.45 [1.17-5.13]), harm requiring life-sustaining intervention (odds ratio 2.91 [1.86-4.56]), or death (odds ratio 2.48 [1.18-5.19]). When an error did occur, patients and their caregivers were rarely informed (ICU 1.5% vs. non-ICU 2.1%; odds ratio 0.63 [0.48-0.84]) by the time of reporting. More harmful errors are reported in ICU than non-ICU settings. Medication errors occur frequently in the administration phase in the ICU. When errors occur, patients and their caregivers are rarely informed. Consideration should be given to developing additional safeguards against ICU errors, particularly during drug administration, and eliminating barriers to error disclosures.

Medication Errors in a Swiss Cardiovascular Surgery Department: A Cross-Sectional Study Based on a Novel Medication Error Report Method

The purpose of this study was (1) to determine frequency and type of medication errors (MEs), (2) to assess the number of MEs prevented by registered nurses, (3) to assess the consequences of ME for patients, and (4) to compare the number of MEs reported by a newly developed medication error self-reporting tool to the number reported by the traditional incident reporting system. We conducted a cross-sectional study on ME in the Cardiovascular Surgery Department of Bern University Hospital in Switzerland. Eligible registered nurses (n = 119) involving in the medication process were included. Data on ME were collected using an investigator-developed medication error self reporting tool (MESRT) that asked about the occurrence and characteristics of ME. Registered nurses were instructed to complete a MESRT at the end of each shift even if there was no ME. All MESRTs were completed anonymously. During the one-month study period, a total of 987 MESRTs were returned. Of the 987 completed MESRTs, 288 (29%) indicated that there had been an ME. Registered nurses reported preventing 49 (5%) MEs. Overall, eight (2.8%) MEs had patient consequences. The high response rate suggests that this new method may be a very effective approach to detect, report, and describe ME in hospitals.

Knowledge Assessment and Information Needs of Oncology Nurses Regarding Inpatient Medication

Although several studies have evaluated the frequency and consequences of medication errors, few have explored their causes. In particular, nurses' knowledge regarding medications has been evaluated minimally. This survey was conducted to determine how nurses master medications prescribed to their patients to determine problems nurses may have with prescribed drugs and identify possible support tools. A questionnaire was created and presented to nurses in a French cancer center. A majority of the respondents correctly identified pharmaceutical classes and medications, as well as administration and storage conditions. However, side effects, contraindications, and drug-drug interactions were not adequately identified. Nurses reported facing problems mainly related to drug administration, drug storage, and generic drugs and their therapeutic equivalence. Multiple tools are in development to help nurses in these areas. This collaborative study between pharmacy and care wards identifies some difficulties nurses have regarding drugs and will help to establish improvement measures within the hospital.