Drug Errors Research Articles

Implementation of clinical decision support system for anticoagulant prescribing for patients with deep vein thrombosis

Background: Physicians adherence to recommendations for appropriate antithrombotic therapy of venous thromboembolism (VTE) can reduce the risk of recurrent VTE, pulmonary hypertension, bleeding and other adverse events. Clinical decision support systems (CDSS) are shown to increase physicians adherence to clinical guidelines.
 Aims: To assess effectivenes and safety of CDSS for anticoagulant prescribing for inhospital patients with VTE.
 Methods: A prospective cohort study was conducted in a Moscow general hospital from 06.30.2017 to 06.23.2018 to compare physicians compliance with clinical guidelines for DVT anticoagulant therapy, the rate of drug errors and direct costs of anticoagulant therapy before and after CDSS implementation (55 patients in control group and 49 in experimental group).
 Results: The rate of anticoagulant prescribing for patients with DVT did not alter significantly after CDSS implementation (96% compared with 91% before CDSS), but physicians compliance with recommendations on anticoagulant dosage increased from 32.7% to 73.5% (p = 0.0003) with corresponding decrease in the rate of anticoagulant prescribing errors from 1.35 to 0.65 per 1 patient (p = 0.0005). The length of stay and hemorrhagic complication rate did not differ between control and experimental groups. LMWH replacement with new oral anticoagulants has reduced the cost of anticoagulant therapy for 1 patient from 11.800 rubles (IQR = 7000) to 5.430 rubles (IQR = 5700) (p 0.005).
 Conclusions: СDSS can increase physicians adherence to recommended anticoagulant therapy for patients with DVT: to prevent unreasonable under-/overdosing or prolongation of anticoagulant therapy. CDSS for DVT drug therapy can be economically feasible.

Modeling of Computerized Physician Order Entry with Decision Support System for Diabetic Patients

Introduction: Providing care for patients and preventing complications is one of the major subjects in medical sciences. Computerized Physician Order Entry (CPOE) with a decision support system is expected to deliver many benefits. A system with decision support system may help clinicians, patients, and others to suggest patient-appropriate evidence-based treatment options.The present study was conducted to prepare a conceptual model for a CPOE system of diabetic patients (Type 2) using Unified Modeling Language (UML). Then, a software program was designed accordingly.Method: This cross-sectional study was conducted in 2017. A minimum data set of patient records was used as the patient profile in the system, and a list of drugs and functional requirements of the CPOE system for diabetic patients was provided. Following the confirmation of the minimum data set by diabetes specialists, UML figures were drawn and the software was designed.Results: The minimum data set of patient records included demographic and clinical information as well as laboratory tests. Functional requirements of the CPOE system for type 2 diabetic patients consisted of the possibility of recording simple and complicated orders, connecting the system to the pharmacy or other auxiliary information systems, controlling drug side effects, etc.Conclusion: A CPOE system should have minimum errors in documentations and provide information on allergies, drug interactions, and side effects in a timely manner to reduce medical errors, especially drug errors, increase physician efficiency and patient satisfaction, and finally promote the quality of healthcare services.

İntörn Öğrencilerin Hasta Güvenliği Tutum ve Kültürlerinin Tıbbi Hata Durumlarına Etkisi

Objective: This study was conducted to determine the effect of patient safety attitudes and cultures on medical errors in intern students studying health sciences OR: studying in health sciences faculty .Materials and Methods: The sample of this descriptive and cross-sectional study composed of intern students n=624 people; Nursing, Midwifery and Health Management Department, Dentistry, Medicine and Faculty of Pharmacy studying health sciences during the 2017–2018 academic year at Cumhuriyet University. The data were collected by the “Student Description Form”, “Patient Safety Culture Scale PSCS ” and “The Safety Attitudes Questionnaire SAQ ”. Median min-max , percentage distribution and Kruskal-Wallis test were used for statistical evaluation.Results: Of senior students in the study, 24% of them are from medical faculty, 11.1% from dentistry faculty, 35.6% from the department of nursing, 11.4% from the department of midwifery, 15.2% from the department of health management and 2.7% of them are from the faculty of pharmacy. In terms of patient safety, the most common medical errors made by students are drug errors 50.8% and communication errors 24.4% . The most common drug errors made by the students are giving the wrong medication 16.7% and giving the wrong dose of medication 14.8% . The culture 2.88 1.00–3.90 and attitudes 160 81.00–193.00 of students towards patient safety are positively above the average. Those who perform fall-related errors and drug errors have a more negative patient safety culture score. In terms of scale scores, the most negative course was performed by the ones giving the wrong drugs to patients among the error types made with the drug. The attitude towards patient safety between intern pharmacy and medical students is more negative than the other departments p

Out of sight: a lesson in drug errors

A 76-year-old man developed recurrent encephalopathy, visual disturbance, myoclonus, generalised seizures and atonic drop attacks on a background of a gastrectomy for adenocarcinoma and stable chronic lymphocytic leukaemia. He presented...

Prevalence and characteristics of medication errors at an emergency department of a teaching hospital in Malaysia

BackgroundMedication use process in the emergency department (ED) can be challenging and the risk for medication error (ME) to occur is high. In Malaysia, several studies on ME have been conducted in various hospital settings. However, little is known about the prevalence of ME in emergency department (ED) in these hospitals.The objective of this study was to determine the prevalence and characteristics of ME at an ED of a teaching hospital in Malaysia.MethodsA cross-sectional study was conducted over the period of 9 weeks in patients who visited the ED of Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia. Data on patient medication orders and demographic information was collected from the doctor’s clerking sheet. Observations were made on nursing activities and these were documented in the data collection form. Other information related to the administration of medications were obtained from the nursing care records.ResultsObservations and data collections were made for 547 patients who fulfilled the study criteria. From these, 311 patient data were randomly selected for analysis. Ninety-five patients had at least one ME. The prevalence of ME was calculated to be 30.5%. The most common types of ME were wrong time error (46.9%), unauthorized drug error (25.4%), omission error (18.5%) and dose error (9.2%). The most frequently drug associated with ME was analgesics. No adverse event was observed.ConclusionsThe prevalence of ME in our ED setting was moderately high. However, the majority of them did not result in any adverse event. Intervention measures are needed to prevent further occurrence.

A segurança do doente é influenciada pelo ambiente da prática de cuidados dos enfermeiros que trabalham em serviço de urgência? Uma revisão integrativa

Introduction: The identification of factors that may influence patient safety makes it possible to implement improvements in the care provided, reducing the occurrence of possible damage to patients. The aim of this study is related to the need to identify errors that occurred in the provision of care to patients in an emergency department. Aim: Identify the factors that influence patient safety in emergency services. Materials and Methods: Integrative review carried out on the Ebsco database from 2017 to 2019, using MeSH descriptors combined by a boolean operator AND: “medication errors or drug errors or medication administration errors or drug administration errors”, “emergency room or emergency department” and “nurse or nurses or nursing”. As inclusion criteria were defined the articles that fit the objective of this study and all duplicate articles, articles referring to intensive care units and pediatrics and articles that did not fit the study objective were excluded. Results: The 17 articles analyzed revealed that the factors related to the high influx of patients to the emergency department, the work overload, the shortage of human resources and the constant interruptions lead to the occurrence of errors and the consequent risk to patient safety. Conclusion: Physical and human conditions must be created for the safe practice of care, reducing the occurrence of errors and ensuring the safety of the patient in emergency services.

Drug Error beyond the Hospital and Role of Pharmacists in drug Safety Process

Medication related error is one of the most common error prevailing in this time. Medication error can be defined as a ‘failure in the treatment process that leads to or has potential to lead to harm to the patient. Medication error can occur from the process of ordering to the administration to the patient. Among the healthcare professionals; a pharmacist can be responsible in identification of contributing factors and reducing its occurrence. Great efforts are needed in this area, due to diversity in the types of errors, the relationship between the provider and the patient, information transfer, optimization of e-prescribing systems, the lack of adequate training in analyzing the collected data and poor practical strategies for maintaining accurate drug lists in electronic medical records. Recently healthcare professionals have started becoming aware about the risks of patients’ medication exposure. After all, still the area of medication safety beyond the hospital setting needs community pharmacy intervention to avoid malpractice claims and misled decisions in solving medication safety-related problems in the outpatient setting. Approaches like medication reviews and reconciliation, monitoring drug therapy, reporting error will help in identify and prompt the detection of errors, open productive discussions, quality control checks, and effective system-based decisions like performing risk assessment subsequently reduces the harm and risks before patient is exposed to any form of drug error.

Estudio APRICOT sobre la seguridad de los más pequeños

El manejo anestésico del paciente pediátrico requiere de una formación y unas estructuras específicas, debido a las situaciones adversas que se pueden producir. El estudio APRICOT (Anaesthesia PRactice In Children Obervational Trial) con una muestra de más de 30.000 pacientes de 33 países europeos y a través de un minucioso análisis observacional de cohortes prospectivo, recoge la naturaleza, la incidencia y los factores de riesgo de los evento críticos más comprometedores; desde los más comunes como el laringoespasmo o el broncoespasmo, la bradicardia hasta la parada cardiaca, pasando por fenómenos neurológicos, anafilaxia o errores de medicación. Obtiene unos resultados que distan en algunos aspectos de lo estudiado hasta ahora. La diversidad de los datos analizados permite identificar aquellos factores de riesgo relacionados con los eventos críticos, entre ellos el anestesista y el centro hospitalario. Pero sobre todo da pie a la necesidad de crear guías de manejo anestésico pediátrico encaminadas hacia una Anestesia más segura. ABSTRACT APRICOT report about our yougest´s safety The perioperative care of infants and children demands special training and facilities due to possible critical events. The APRICOT study (Anaesthesia PRactice In Children Obervational Trial) analyses more than 30.000 anaesthetic procedures from 33 different European countries. Through a detailed prospective observational cohort study, this trial identifies the incidence, the nature and the outcomes of severe critical events in children, including laryngospasm, bronchospasm, cardiovascular instability and cardiac arrest, neurological damage, anaphylaxis or drug errors. Some reported results differ from what was previously published in the literature. Large variation of the collected data allows to identify those risk factors contributing to the severe critical events, among them, the anaesthetist and the centre. This study especially motivates to create clinical practice guidelines of paediatric anaesthesia management for a safer Anaesthesia.

Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error

The National Committee on Confidential Enquiries into Maternal Deaths recently received notification of a death in South Africa caused by inadvertent intrathecal administration of tranexamic acid (TXA). TXA is increasingly used during caesarean delivery following updated recommendations from the World Health Organization in 2017. However, its greater availability has led to an international rise in drug errors during obstetric spinal anaesthesia. This case highlights a growing clinical risk, of which all operating theatre staff should be aware. Review of existing operating theatre drug handling practices is required in order to decrease this risk. Recommendations are made that aim to minimise drug errors associated with the use of this potentially life-saving intervention.

Incidence of medication administration errors in Ethiopia: A systematic review and meta-analysis of observational studies

Abstract Introduction: In Ethiopia, the overall incidence of medication administration errors (MAEs) has been variously estimated within the range of 16% to 99%; a wide range and difficult to conclude. Thus, this study aimed to assess the pooled incidence of MAEs in Ethiopia. Materials and methods: A systematic literature search in the databases of Pub-Med, Cochrane, and Google Scholar were performed. The quality of study was assessed using criteria adopted from similar studies. Heterogeneity test and evidence of publication bias were assessed. Sensitivity test and trim and fill analysis was also performed. Pooled incidence of MAE was calculated using random effects model. Results: A total of nine studies, including a total of 46,426 medication administrations interventions, were included in this systematic review and meta-analysis. The frequently reported MAEs were wrong dose, wrong time, and wrong route. The reported error was ranged from 0.1% for wrong medication to 95.8% for omitted drug error. Overall the pooled incidence of MAE was found to be 37.9% (95% CI, 34%-41.9%). It has no evidence of significant heterogeneity (I2 = 0%, p <0.820) and publication bias from the visual inspection of funnel plot and Egger’s test (P =0.481). Conclusion: The incidence of MAE was high. Wrong dose, wrong time, and wrong route were the frequently reported errors. Omission error was the most incident errors. Authors suggested to give more attentions to the rights of medication administration guide, particularly to prevent omission error.

Evaluation of prevalence, distribution and types of drug errors reported in Besat Medical Center of Hamadan during 2014-2015

Evaluation of prevalence, distribution and types of drug errors reported in Besat Medical Center of Hamadan during 2014-2015

Accidental injection of lignocaine with adrenaline in subarachnoid space: a case report

Drug errors are very common in medical field especially in anaesthesia where it’s the game of drugs. Here, we are presenting a case in which accidentally we injected lignocaine with adrenaline in place of heavy bupivacaine. Patient was of geriatric age group and posted for lower limb surgery under combined spinal epidural anaesthesia after placement of epidural catheter lumber puncture was done and 3ml of lignocaine with adrenaline was injected. After this patient develop complete sensory, motor blockade with hypotension. Level of block was up to T12 level patient was monitored for signs and symptoms of ransient neurologic syndrome (TNS) and anterior spinal artery syndrome for 24 hours. After 24 hours patient develop no complications and posted for surgery under general anaesthesia.so we have to be very careful about the labelling of drugs.

Paediatric postoperative analgesia prescribing report card: “could do better”

Background: A key element of paediatric pain management is prescribing and dispensing analgesia. This process differs in children, putting them at greater risk of drug error. Methods: This study was a retrospective postoperative analgesia prescription chart review of children who had orthopaedic surgery in a tertiary hospital in Durban, South Africa. Patient records of 202 children, aged 6 months to 12 years, with 232 theatre visits were reviewed. Prescription charts were inspected for patient characteristics, evidence of good prescribing practice and data regarding the prescribing and administration of analgesia. Results: Of the 257 analysed charts 254 (99%) had paracetamol, 208 (81%) had an opioid and 49 (19%) had a nonsteroidal antiinflammatory drug (NSAID) prescribed. Underdosing was evident in all groups of analgesics prescribed. Opioids were more often prescribed with a pro-re-nata caveat and were the least correctly dispensed. There were no prescription charts in which all the requirements for good prescribing practice were complete. Conclusions: This study demonstrates a high rate of paediatric drug error in both the prescribing and dispensing of analgesia. Potential under-utilisation of NSAIDs in this orthopaedic population is also noted. Lack of knowledge or confidence needed by clinicians to adhere to principles of paediatric dosing and multimodal analgesia may be contributing factors. Issues pertaining to paediatric analgesia prescribing and dispensing are highlighted and should be targeted by institution and population specific interventions.

Assessment of the degree of awareness among post-graduate medical physicians and Pharmacists about look-alike, sound-alike drug and potential medication errors

Background: With thousands of drugs currently in the market, the potential for medication errors due to confusing drug names amongst practising physicians, pharmacists and patients is significant. The existence of confusing drug names is one of the most common causes of medication error. There are many look-alikes, sound-alike (LASA) combinations that could potentially result in medication errors. There is insufficient data about medication errors due to LASA. Hence, we conducted the present study to determine the degree of awareness regarding LASA drugs among post graduate medical physicians and Pharmacists.Methods: This study was a cross-sectional, questionnaire-based survey, conducted among 137 year post graduate medical residents of a tertiary care teaching hospital and 121 local pharmacists in an urban metropolitan Indian city.Results: There were 34% resident doctors and 17% pharmacists were aware of concept of LASA drugs. Only 46% resident doctors and 22% pharmacists had knowledge about the full form of LASA. Among resident doctors, 39% came across prescription errors due to LASA drugs. Only 69% of the pharmacists agreed that they consulted their doctors when they faced problems due to prescription errors due to similar looking and similar sounding drugs.Conclusions: Look-Alike, Sound-Alike (LASA) drugs are common source of medication errors. Our study suggests that there is lack of awareness about LASA drugs amongst resident doctors and pharmacists, which may contribute to occurrence of medication errors. Therefore, combined efforts by prescribers, pharmacists, organizations, manufacturers and patients is required to overcome medication errors due to LASA drugs.

Reducing drug errors by engaging student nurses in medication management simulation

The occurrence of drug errors in the NHS has been much discussed in the media. Nurses are in a position to prevent drug errors, as they are often involved in administering medication or advising patients. To enable nurses to do this they need to be able to begin safe medication practice early in their education. This can be achieved through performing safe medication management simulations in undergraduate nursing courses. By setting up a number of patient scenarios in a skills laboratory, student nurses can practise medication management skills that are realistic in an environment where it is safe to make mistakes in order to ensure patient safety at all times.

Description of practices and complications in the French centres that participated to APRICOT: A secondary analysis

IntroductionAnalysing national patients’ profile and organisation of human resources are important for improving the perioperative quality of care. The aim of the current study was to achieve these goals using the French data from the APRICOT study. Material and methodsData from the French centres that participated to the APRICOT study were extracted and analysed. The primary goal of the study was to describe patients’ characteristics, procedures and perioperative anaesthetic management in France, and compare them to the results of the European APRICOT trial. Secondary outcomes were the description of major perioperative complications and the determination of human resources organisation possibly associated with these perioperative complications. ResultsOverall 3535 procedures collected in 20 facilities (17 teaching hospitals, one community hospital and two private institutions) were analysed. Comparison between the French and European APRICOT cohorts found differences related to the more specialised French centres participating to the study. Overall complications (respiratory complications, haemodynamic instability, cardiac arrest, drug errors, and anaphylactic reactions) were observed in 6.4% [95% CI: 5.6; 6.3] of cases. Multivariate analysis identified the anaesthesiologist's experience of<15 years and the absence of an anaesthetic nurse as human factors independently associated with an increased risk for perioperative complications. DiscussionThe current study identified some important differences between the French and the whole APRICOT cohort in terms of preoperative evaluation, surgical specialties involved, and monitoring of neuromuscular blockade. It confirms that, in France, the presence of an anaesthetic nurse and an experienced anaesthesiologist prevents anaesthetic complications.

Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors.

Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty. With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution. A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P < .001). The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty. Error rates varied among institutions ranged from 12% to 22% (P = .021). Anesthesiology residents and faculty erred frequently on a computational test, with junior residents and faculty with more experience committing errors more frequently. Residents committed more serious errors twice as frequently as faculty.

Simulation-Based Event Analysis Improves Error Discovery and Generates Improved Strategies for Error Prevention.

An adverse event (AE) is a negative consequence of health care that results in unintended injury or illness. The study investigates whether simulation-based event analysis is different from traditional event analysis in uncovering root causes and generating recommendations when analyzing AEs in hospitalized children. Two simulation scenarios were created based on real-life AEs identified through the hospital's Safety Reporting System. Scenario A involved an error of commission (inpatient drug error) and scenario B involved detecting an error that already occurred (drug infusion error). Each scenario was repeated 5 times with different, voluntary clinicians. Content analysis, using deductive and inductive approaches to coding, was used to analyze debriefing data. Causes and recommendations were compiled and compared with the traditional event analysis. Errors were reproduced in 60% (3/5) of scenario A. In scenario B, participants identified the error in 100% (5/5) of simulations (average time to error detection = 15 minutes). Debriefings identified reasons for errors including product labeling, memory aid interpretation, and lack of standard work for patient handover. To prevent error, participants suggested improved drug labeling, specialized drug kits, alert signs, and handoff checklists. Compared with traditional event analysis, simulation-based event analysis revealed unique causes for error and new recommendations. Using simulation to analyze AEs increased unique error discovery and generated new recommendations. This method is different from traditional event analysis because of the immediate clinician debriefings in the clinical environment. Hospitals should consider simulation-based event analysis as an important addition to the traditional process.

The impacts of medication shortages on patient outcomes: A scoping review.

BackgroundIn recent years, medication shortages have become a growing worldwide issue. This scoping review aimed to systematically synthesise the literature to report on the economic, clinical, and humanistic impacts of medication shortages on patient outcomes.MethodsMedline, Embase, Global Health, PsycINFO and International Pharmaceutical s were searched using the two key concepts of medicine shortage and patient outcomes. Articles were limited to the English language, human studies and there were no limits to the year of publication. Manuscripts included contained information regarding the shortage of a scheduled medication and had gathered data regarding the economic, clinical, and/or humanistic outcomes of drug shortages on human patients.FindingsWe found that drug shortages were predominantly reported to have adverse economic, clinical and humanistic outcomes to patients. Patients were more commonly reported to have increased out of pocket costs, rates of drug errors, adverse events, mortality, and complaints during times of shortage. There were also reports of equivalent and improved patient outcomes in some cases.ConclusionsThe results of this review provide valuable insights into the impact drug shortages have on patient outcomes. The majority of studies reported medication shortages resulted in negative patient clinical, economic and humanistic outcomes.

Special Considerations for Proprietary Name Review: Focus on Products That May Be Prescribed "As Directed".

Look-alike and sound-alike (LASA) drug name similarity is often cited as a major factor contributing to wrong drug errors. When present on a prescription, differing product characteristics or directions for use may help health care professionals differentiate between 2 LASA drug names. However, evidence suggests that 1% to 5% of prescriptions include only the signa "use as directed" rather than explicit directions for use. Using nationally projected US outpatient physician survey data, we analyzed drug classes and their associated signa to identify products commonly prescribed with the signa "as directed." The following categories of products are commonly associated with the signa "as directed": (1) inhalers; (2) oral contraceptives; (3) one-time treatments, such as those for lice or scabies; (4) prepackaged items with specific directions for use on the package; (5) migraine medications; (6) erectile dysfunction medications; (7) bowel evacuation/colonoscopy preparations; (8) topical medications; (9) medications with regimens that may change frequently (eg, warfarin, insulin); (10) otic products; (11) transdermal products; (12) products administered vaginally; (13) products administered rectally; and (14) products that may be titrated upon initiation. Prescriptions for these products with the signa "as directed" may not include product characteristics or other directions for use. The potential for products to be prescribed with the signa "as directed" should be taken into consideration when evaluating the safety of proposed proprietary names. Sponsors and the FDA can use the results of our research to aid in the selection and review of proposed proprietary names, respectively.