Encountered Medication Errors Research Articles

Medication Error Patients Admitted to Medical Ward in Primary Hospital, Ethiopia: Prospective Observational Study

Medication error (ME) is broadly defined as any error in the prescribing, dispensing, or administration of a drug. ME is the single most preventable cause of patient harm. An infinite number of medication error exist because of the rapidly expanding array of drug products available, the growing number of diseases being recognized & diagnosed, and the growing number of patients entering the health care system. To evaluate the most frequently encountered drug class undergo medication errors, to identify sources of medication error and evaluate predictors of medication errors among patients admitted to medical ward in primary hospital, northwest Ethiopia. Prospective observational study was conducted from April 1/2018-October/2019G.C. All adult patients who met inclusion criteria were included in the study. Patient medication adherence was evaluated using morisky adherence scale. Independent predictors of outcome identified and strength of association between dependent and independent variables determined by using binary logistic regression analysis and statistical significance was considered at p<0.05. Two hundred sixty patients were included in the analysis. Among these, majority of them were encountered medication errors. Anti-infective drugs were mostly prescribed as well as medication error encountered. Unnecessary drug therapy is the most common error. Proportion of patients with medication error is lower among patients who are on 1-3 drugs as compared to those patient who are on more than five drugs (p=0.025). Patients who stayed less than one week less likely encountered medication errors as compared to those stay more than a week (p=0.024). Since medication availability is significant determinant for medication error, hospital should try to avail medication and prevent medication errors. Clinical pharmacists should involve in multidisciplinary team and continuous patient medication reconciliation should be integral part of patient medical management.

The frequency and nature of medication errors in hospitalized patients with acute coronary syndrome.

Background Cardiovascular medications have been commonly associated with medication errors. Objective The objective of this study was to investigate the incidence and predictors of medication errors in patients with acute coronary syndrome. Setting the coronary care unit of a university teaching hospital. Methods This was a prospective observational study on 150 patients admitted to the coronary care unit between August 2014 and July 2015. Main outcome measure The principal outcome was the number (frequency) of encountered medication errors. Results Of total 5790 prescription items reviewed, 547 (9.4%) potential medication errors were identified of which 523 (9.0%) were prescribing errors and 24 were monitoring errors. The most frequent prescribing errors were dosing errors (231, 42.2%) followed by loading dose omission error (91, 16.6%), omission of essential drugs on 1st day (43, 7.9%), and timing error (40, 7.3%). Errors frequently encountered with drugs such as aspirin, enoxaparin, beta-blockers followed by angiotensin-converting enzyme inhibitors and clopidogrel. Multivariate logistic regression analysis revealed that renal impairment (OR 6.02; 95% CI 1.4-35.4; p=0.02) and longer duration of hospital stay (OR 4.01; 95% CI 1.5-10.7; p=0.005) were predictors of the higher incidence of medication errors. Conclusion Prescribing and monitoring errors in coronary care unit are frequent and avoidable, with the majority of errors were ranked to be of mild to moderate severity. Dosing errors, omission of essential drugs and monitoring errors were most common error types encountered. Dosage adjustment based on estimation of the glomerular filtration rate immediately after admission help avoiding dosage-related errors.

Knowledge of healthcare professionals about medication errors in hospitals.

Context:Medication errors are the most common types of medical errors in hospitals and leading cause of morbidity and mortality among patients.Aims:The aim of the present study was to assess the knowledge of healthcare professionals about medication errors in hospitals.Settings and Design:A self-administered questionnaire was distributed to randomly selected healthcare professionals in eight hospitals in Madinah, Saudi Arabia.Subjects and Methods:An 18-item survey was designed and comprised questions on demographic data, knowledge of medication errors, availability of reporting systems in hospitals, attitudes toward error reporting, causes of medication errors.Statistical Analysis Used:Data were analyzed with Statistical Package for the Social Sciences software Version 17.Results:A total of 323 of healthcare professionals completed the questionnaire with 64.6% response rate of 138 (42.72%) physicians, 34 (10.53%) pharmacists, and 151 (46.75%) nurses. A majority of the participants had a good knowledge about medication errors concept and their dangers on patients. Only 68.7% of them were aware of reporting systems in hospitals. Healthcare professionals revealed that there was no clear mechanism available for reporting of errors in most hospitals. Prescribing (46.5%) and administration (29%) errors were the main causes of errors. The most frequently encountered medication errors were anti-hypertensives, antidiabetics, antibiotics, digoxin, and insulin.Conclusions:This study revealed differences in the awareness among healthcare professionals toward medication errors in hospitals. The poor knowledge about medication errors emphasized the urgent necessity to adopt appropriate measures to raise awareness about medication errors in Saudi hospitals.

Risk of Cutting Certain Medication Patches; Warfarin by Generic Name; Why Doctors Must Include Medication Purpose on Prescriptions; Carac-Kuric Mix-Ups

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Misprogramming Patient-Controlled Analgesia Concentration Leads to Dosing Errors; Communicate Alteplase Dose and Indication; Do Not Use Empty Prelabeled Syringes/Bowls

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Controlled Drug Symbol C-IV Mistaken as IV; Fatal Medication Errors in the Home; Ambulatory E-Prescribing Requires Patient's Check; EPINEPHrine-ePHEDrine Mix-Ups

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Epidural-Intravenous Route Mix-Ups: Reducing the Risk for Deadly Errors; Discontinued Drug Leads to Error

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Identify Home Medications Restricted Character Space and Truncated Drug Listings are a Set-Up for Medication Errors “can't Tell a Book by its Cover” Rings True for Medications Child Dies from Misuse of Fentanyl Patch

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Avoid Confusion with Torisel Dose Preparation; Remove Vials from Cartons; Sumatriptan Confused with Sitagliptin; Misdispensing of Purinethol Instead of Propylthiouracil: A Preventable Disaster

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Medication Errors Associated with Cerebyx; Consumer Safety with Creams and Ointments; Caution Regarding Color-Coded Eye Medications; Strength Misread as Total Dose

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Cross Contamination with Insulin Pens; Look-Alike Vials; Kids and Medication Patches; New Look-Alike Name Pair; Preventing Dosing Errors with Methotrexate Injection

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP tollfree, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Keeping Patients Safe from Iatrogenic Methadone Overdoses Final Curtain for IV Colchicine Overdoses

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Persistence Saves Patient's Life; Do Not Use Epidural Tubing for an Intravenous Solution; Topical Antiseptic Given Orally; Refrigerator Monitoring

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

One Tablet or One Bottle? Avoiding Mix-Ups between Sterile Water and Sodium Chloride Bags a Chain is Only as Strong as its Weakest Link

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Errors with Injectable Medications: Unlabeled Syringes are Surprisingly Common; Unintended Consequences of High-Alert Stickers; Easily Misread Abbreviations

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP tollfree, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Preventing Mix-Ups between Various Formulations of Amphotericin B; Cardiac Catheterization Lab Error; Say Again?; Colchicine Deaths

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP tollfree, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Lack of Standard Dosing Methods Contribute to IV Errors Talc Misadministered IV

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Failure to Cap IV Tubing and Disinfect IV Ports Places Patients at Risk for Infections; Unintended Consequences of CPOE; Numerous Problematic Name Pairs Relegated to History

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Reports published by ISMP are anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Ongoing Incidents Involving Fentanyl Patches are Alarming!; Insulin CONCENTRATE U-500; WHO: Dilute Vincristine in a Minibag

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

IV Tubing Misconnected to Tracheostomy Cuff; Unidentifiable Patches; A Risk that should Not be Tolerated

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.