Identification Of Medication Errors Research Articles

Prevention of Medication Errors in Hospitalized Patients: The Japan Adverse Drug Events Study.

The nature of medication errors (MEs) and the frequency of identified or intercepted MEs are not being scrutinized in daily practice in Japan. The aim of this study was to clarify the epidemiology of MEs and the risk factors for non-intercepted and unidentified MEs. The Japan Adverse Drug Events (JADE) study was a prospective cohort study carried out at three tertiary-care teaching hospitals in Japan. Participants were consecutive patients (N=3459) aged ≥15 years who were admitted to the study wards. MEs were identified by on-site reviews of all medical charts, self-reports, and prescription queries by pharmacists. Two independent physicians reviewed and classified all MEs and adverse drug events and determined the stages at which the MEs occurred and whether there was interception or identification of the MEs. A total of 514 MEs were observed among 433 patients. Sixty-four percent of MEs occurred at the ordering stage. Among these, 60% were due to duplicate drug orders. Overall, 63% and 45% of MEs were not intercepted or identified during hospitalization, respectively. The independent risk factors for non-intercepted MEs were hospitalization in the surgical ward (odds ratio [OR] 2.94) and the intensive care unit (OR 3.57). MEs by resident physicians were more likely to be intercepted (OR 0.52 for non-intercepted MEs). MEs frequently occurred and most at the ordering stage. Almost half of MEs were not intercepted or identified. Many MEs at the later stages were less likely to be intercepted and resulted in actual patient harm. Systems to improve the identification and interception of MEs should be implemented.

Argumentative reasoning and taxonomic analysis for the identification of medical errors

Telemedicine consists of the use of information and communication technologies (ICTs) in the practice of medicine. The massive digitalisation of the society is changing the behaviour of ordinary people even in medical sectors. The impact of digitisation is also having impacts on teleexpertise, where a medical professional can remotely ask some advices through the use of ICTs to provide treatment to a patient in critical conditions in remote environment. However, sometimes the outcome of such advice obtained remotely can lead to medical errors. In these situations, it is important to determine whether the causes of the errors could have been avoidable or not for the purposes of establishing the truth and assuring justice for the victims of medical errors. The proposed work fits this perspective with the objective to formalise elements of argumentation in collaborative medical organisations using telemedicine. In other words, a technique that extends the Dung's argumentation framework in order to bring out the errors committed following a remote medical procedure has been proposed. The proposed technique is underpinned by graphical reasoning. The reasoning is represented through a directed graph in which the extended nodes specify the arguments with their source(s) and the identification of errors is done according to the Makeham's and Tempos taxonomies. To illustrate the functioning of the proposed technique or solution, an example of the practice of teleexpertise (between two French hospitals) that leads to litigation is presented.

A Medical Resident–Pharmacist Collaboration Improves the Rate of Medication Reconciliation Verification at Discharge

At the Hospital of the University of Pennsylvania (Philadelphia), it is standard practice to perform medication reconciliation at patient discharge. Although pharmacists historically were available to assist resident physicians in the discharge medication reconciliation process, the process was never standardized. An internal review showed a 60%-70% rate of pharmacist review of discharge medication lists, potentially enabling medication errors to go unnoticed during transitions of care. In response, a medical resident- and pharmacist-led collaboration was designed, and a pre-post-intervention study was conducted to assess its effectiveness. A new work flow was established in which house staff notified pharmacists when a preliminary discharge medication list was ready for reconciliation and provided access for pharmacists to correct medication errors in the electronic discharge document with physician approval. Length of stay, average time of day of patient discharge, and readmission data were compared in the pre- and post-intervention periods. There were 981 discharges in the preintervention period and 1,207 in the postintervention period. The rate of pharmacist reconciliation increased from 64.0% to 82.4% after the intervention (p<.0001). The average number of errors identified and corrected by pharmacists decreased from 0.979 to 0.862 per discharge (p<.0001). There was no significant change in readmission rates or time of discharge after the intervention. Redesigning the discharge medication reconciliation process in a teaching hospital to include a review of medical resident discharge medication lists by pharmacists provided more opportunities for discharge medication error identification and correction.

Drug Related Problems at the Intensive Care Unit of a University Hospital in Saudi Arabia

Background: Medication errors can lead to mild or severe drug related problems. Drug related problems are sometimes unpredictable and can occur without medication errors. Awareness and identification of medication errors and drug related problems aids in adoption of measures to prevent and treat them.&#x0D; Objective: Present study aimed to find out prevalence of drug related problems reporting or occurring at Intensive Care Unit of King Fahd Hospital of the University, Alkhobar, Saudi Arabia.&#x0D; Methods: Scrutinizing written files of all patients reporting to Intensive Care Unit, from January to December 2012.&#x0D; Results: Out of 193 files reviewed, 33 patients (17.1%) had trivial to serious drug related problems, including 8 (4.1%) deaths. Drugs commonly involved in these problems were anticoagulants (Warfarin and heparin, alone or in combination with aspirin or clopidogrel; 8 cases, 24.2%), antiepileptic drugs (Carbamazepine and phenytoin; 6 cases, 18.2%), immune suppressants (Azathioprine and prednisolone; 4 cases, 12.1%), antibiotics (Ciprofloxacin, imipenum, tazocin and vancomycin; 4 cases, 12.1%) and drugs of abuse and dependence (Alcohol, benzodiazepines, cannabis and opioids; 4 cases, 12.1%). Amongst drug related problems detected, 6 cases (18.2%) were linked to drug interactions. Almost 60% of drug related problems found were preventable, including those due to overdose toxicity, non-compliance and drug-drug interactions.&#x0D; Conclusions: Mild to severe drug related problems occurred in intensive care unit of a university hospital and about half of them were preventable. It is hoped that the awareness and insight of drug related problems will help to improve patient care.

СТРАТЕГІЯ ВДОСКОНАЛЕННЯ МЕДИЧНОГО СТРАХУВАННЯ НА ОСНОВІ ПОКАЗНИКІВ ЯКОСТІ НАДАННЯ МЕДИЧНОЇ ДОПОМОГИ

&lt;p class="41"&gt;Issues of improving the health insurance through the creation of quality systems of care are discussed. Particular attention is paid to the identification of medical errors, and that was the aim of this work. Despite the complexity of the process of objectification, examines possible solutions to this problem, and the impact on the risk of the insurance business are analyzed. The prospects of normative-legal and information-mathematical strategies to identify medical errors are considered. In particular, issues of professional liability insurance, which allows a civilized manner to resolve conflicts between doctors and patients, are examined. At the same time, the direct use of this approach meets with incomprehension medical staff a number of provisions, such as the subject of insurance, the allocation of responsibility between the performers of medical appointments, as well as mechanisms of the effect of the law on the reduction of medical errors.&lt;/p&gt;&lt;p class="41"&gt;Today, it seems more practical use of information-based approaches for identifying medical errors. It is emphasized that the starting point of the work to improve the quality of care are the technologies of identifying and addressing its root causes. We consider some&lt;/p&gt;formal algorithms, “Deming wheel,” the organizing principle of the sample survey method, the method of screening sheet, the method of histograms, Pareto charts and others. Note that the process of approach adversely affects its efficiency. Therefore, the most promising should recognize the use of ontological ideas about the dynamics of the pathological process and its standardization.

An evaluation of clinical pharmacist contributions in paediatrics

ObjectiveTo collect clinical pharmacists interventions to profile pharmacy services, evaluate training needs and support business planning for the service; to classify these interventions by severity and stage of medication use...

Medication Error Identification Rates by Pharmacy, Medical, and Nursing Students

To assess and compare prescribing error-identification rates by health professional students. Medical, pharmacy, and nursing students were asked to complete a questionnaire on which they evaluated the accuracy of 3 prescriptions and indicated the type of error found, if any. The number of correctly identified prescribing errors and the number of correct types of errors identified were compared and error identification rates for each group were calculated. One hundred seventy-five questionnaires were returned (87% response rate). Pharmacy students had a significantly higher error-identification rate than medical and nursing students (p < 0.001). No significant differences were found between medical and nursing students (p = 0.88). Compared to medical students, pharmacy students more often were able to identify correctly the error type for each prescription (p < 0.001; p = 0.023; p = 0.001). Of the 3 student groups, pharmacy students demonstrated a significantly higher error-identification rate, which may be associated with the greater number of pharmacology and pharmacotherapeutics course hours that pharmacy students complete.

Medical errors II, the aftermath: Mea culpa!

Byline: G. Swaminath, R. Raguram Mistakes are a fact of life. It's the response to the error that counts. - Nikki Giovanni (American poet, 1943) Alexander Pope's famous words, To err is human, to forgive divine, apt in most situations do not seem quite appropriate while dealing with medical errors. Forgiveness suggests that there has been the committing of sin, and this is inextricably linked to fault and blame. [sup][1] safety traverses all medical specialties and affects every health-care professional. The attention to medical errors and adverse events and the resultant literature have grown exponentially over the past decade. A number of practicing physicians, however, remain unaware of the extent of the problem, the impact on patients, and the burden on the health-care system. Many are unfamiliar with strategies to reduce the risk of harm. [sup][2] When patients suffer harm, most providers of healthcare are ill prepared to respond. Abandonment of care providers and patients is common. [sup][3] The tendency to shame and blame often perpetuates the wall of silence [sup][4] between providers and patients. [sup][5] It was in response to this unsatisfactory situation that the Patient Safety Movement was founded, guided by the nonjudgmental recognition of the ubiquity of human and system errors. By understanding that error-particularly human error-is inevitable but still largely preventable, patient safety efforts focus on improving systems, creating fail-safe mechanisms that intercept error before it reaches the bedside, and on implementing measures that mitigate harm when an error involves the patient. [sup][1] Explanatory Models of Human Error There are two explanatory models of causation of human error: the person approach and the system approach. The person approach focuses on the errors of individuals, and is apt to accuse them of forgetfulness, inattention or moral failure. Followers of these approaches tend to treat errors as moral issues, assuming that bad things happen to bad people-what psychologists have called the just-world hypothesis. [sup][6] The basic premise in the system approach is that humans are fallible, and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes. These include recurrent error traps in the workplace and the organizational processes that give rise to them. The system approach identifies the conditions and systems under which individuals work, as the source of the error, with the aim of both understanding the origins of error and building defenses to avert errors or to mitigate their effects. [sup][6] The system approach acknowledges that the majority of clinical errors do not result from individual recklessness or the actions of a particular group. [sup][7] The most common systems deficiencies identified as underlying clinical errors are failures in dissemination of drug knowledge or its updating, and inadequate availability of patient information such as test results necessary for safe treatment. [sup][8] Detection of Medical Errors and Adverse Events Difficulty in identifying medical errors and adverse events creates a significant barrier to assessing risk reduction strategies. In the absence of an accurate, reliable methodology to measure errors and events, the ability to assess the impact of patient safety initiatives remains challenging. Historically, identification of medical errors and adverse events relied on incident reports, a methodology that has many pitfalls. If an error or adverse event is identified, staff may assume, mistakenly, that someone else will report it. Personnel who do report events often receive no feedback, which serves as a disincentive for reporting subsequent events. [sup][2] Staff may have valid apprehensions about reporting errors and adverse events. [sup][2] There is a natural hesitancy to point out one's own mistakes for fear of being labeled incompetent and a reluctance to point out others' mistakes for fear of being labeled a whistleblower, [sup][2] a sensationalist or an adversarial professional. …

Malpractice claims associated with infectious causes

Medical errors leading to malpractice claims have had a continuously increasing frequency in the last years in Romania. In this study we try to analyze the characteristics of malpractice claims associated with infectious pathology. Material and method. A study was conducted on 83 cases with malpractice claims, on a four year period. Thirty cases included in the causal chain an infective process (MOSF as a terminal event was excluded). Results. Cases with associated infectious pathology had a lower mean age, a male predominance, an increased severity and mortality. Its presence however wasn’t associated with a significant increase in medical errors frequency. Conclusions. Infectious processes, even if are associated with an increased severity and mortality, don’t have a stronger association with the positive identification of medical errors compared with medical treatments not associated with infectious pathology during their course.

Medication errors: the role of the patient

1. Patients and their carers will usually be the first to notice any observable problems resulting from medication errors. They will probably be unable to distinguish between medication errors, adverse drug reactions, or 'side effects'. 2. Little is known about how patients understand drug related problems or how they make attributions of adverse effects. Some research suggests that patients' cognitive models of adverse drug reactions bear a close relationship to models of illness perception. 3. Attributions of adverse drug reactions are related to people's previous experiences and to their level of education. The evidence suggests that on the whole patients' reports of adverse drug reactions are accurate. However, patients do not report all the problems they perceive and are more likely to report those that they do perceive as severe. Patients may not report problems attributed to their medications if they are fearful of doctors' reactions. Doctors may respond inappropriately to patients' concerns, for example by ignoring them. Some authors have proposed the use of a symptom checklist to elicit patients' reports of suspected adverse drug reactions. 4. Many patients want information about adverse drug effects, and the challenge for the professional is to judge how much information to provide and the best way of doing so. Professionals' inappropriate emphasis on adherence may be dangerous when a medication error has occurred. 5. Recent NICE guidelines recommend that professionals should ask patients if they have any concerns about their medicines, and this approach is likely to yield information conducive to the identification of medication errors.

Patients Identify Undocumented Adverse Events

Recent emphasis on identification of medical errors, including a shift to anonymous reporting, is intended to improve patient safety, but are we still

Medication Errors Related to Computerized Order Entry for Children

The objective of this study was to determine the frequency and types of pediatric medication errors attributable to design features of a computerized order entry system. A total of 352 randomly selected, inpatient, pediatric admissions were reviewed retrospectively for identification of medication errors, 3 to 12 months after implementation of computerized order entry. Errors were identified and classified by using an established, comprehensive, active surveillance method. Errors attributable to the computer system were classified according to type. Among 6916 medication orders in 1930 patient-days, there were 104 pediatric medication errors, of which 71 were serious (37 serious medication errors per 1000 patient-days). Of all pediatric medication errors detected, 19% (7 serious and 13 with little potential for harm) were computer related. The rate of computer-related pediatric errors was 10 errors per 1000 patient-days, and the rate of serious computer-related pediatric errors was 3.6 errors per 1000 patient-days. The following 4 types of computer-related errors were identified: duplicate medication orders (same medication ordered twice in different concentrations of syrup, to work around computer constraints; 2 errors), drop-down menu selection errors (wrong selection from a drop-down box; 9 errors), keypad entry error (5 typed instead of 50; 1 error), and order set errors (orders selected from a pediatric order set that were not appropriate for the patient; 8 errors). In addition, 4 preventable adverse drug events in drug ordering occurred that were not considered computer-related but were not prevented by the computerized physician order entry system. Serious pediatric computer-related errors are uncommon (3.6 errors per 1000 patient-days), but computer systems can introduce some new pediatric medication errors that are not typically seen in a paper ordering system.

Identification of Medication Errors by Nurses During a Simulated Ward, Medication Safety Orientation Program

ABSTRACTAimTo assess the ability of nurses to identify medication errors and apply strategies to prevent adverse drug events.MethodThis was a prospective study of the incidence of error detection in simulated medication scenarios at a teaching hospital. All newly employed registered nurses (n = 591) were asked to administer medications in six scenarios containing errors with potential for patient harm. Feedback was provided to participants at the end of each scenario. The main outcome measures were: self‐reported incidence of detection of errors and modification of practice in accordance with knowledge, knowledge of concept but error not detected, or the error being a new concept.Results63 to 85% of nurses reported that they would have detected the error and taken appropriate action; 11 to 30% had some concept of the error but would not have detected it; and for 2 to 7% the error was a new concept. 32% could identify the errors in all six scenarios and initiate appropriate action.ConclusionIn this study, nurses frequently failed to detect medication errors. Practical medication risk awareness training, improvements in the safety of medication systems and pharmacist review of medication are of paramount importance.

The identification of medical errors by family physicians during outpatient visits.

We wanted to describe errors and preventable adverse events identified by family physicians during the office-based clinical encounter and to determine the physicians' perception of patient harm resulting from these events. We sampled Cincinnati area family physicians representing different practice locations and demographics. After each clinical encounter, physicians completed a form identifying process errors and preventable adverse events. Brief interviews were held with physicians to ascertain their perceptions of harm or potential harm to the patient. Fifteen physicians in 7 practices completed forms for 351 outpatient visits. Errors and preventable adverse events were identified in 24% of these visits. There was wide variation in how often individual physicians identified errors (3% to 60% of visits). Office administration errors were most frequently noted. Harm was believe to have occurred as a result of 24% of the errors, and was a potential in another 70%. Although most harm was believed to be minor, there was disagreement as to whether to include emotional discomfort and wasted time as patient harm. Family physicians identify errors and preventable adverse events frequently during patient visits, but there is variation in how some error categories are interpreted and how harm is defined.

Assessing medication prescribing errors in pediatric intensive care units.

To evaluate a matrix for determining the predominant type, cause category, and rate of medication prescribing errors, and to explore the effectiveness of hospital-based improvement initiatives among pediatric intensive care units (PICUs). This study involved the prospective identification of medication errors for categorization and evaluation by using a matrix methodology. A pretest-posttest design without a control group was used to explore the impact of initiatives employed to reduce medication error rates and severity. PICUs in nine freestanding, collaborating tertiary care children's hospitals that participated in both baseline and postintervention analyses. We evaluated 12,026 PICU medication orders at baseline and 9,187 orders postintervention for prescribing errors, excluding resuscitation orders. A standardized tool and process captured error type, cause category, and severity for 2 wks before and after intervention. Three levels of error detection were used and included pharmacy order entry, PICU nurse order transcription, and team-based overview. Site-specific interventions were implemented, which included predominantly provider education as well as informational (47%) and dosing "assists" via preprinted orders, forcing functions, or prompts (39%). Of baseline orders, 11.1% had at least one prescribing error. The interception of prescribing errors improved 30.9% (1.6% of all orders at baseline, 2.0% post intervention). Preventable adverse drug events were uncommon (0.6% of all medication errors) and of low severity at baseline; most were wrong dose errors. The implementation of improvement initiatives, specific for each facility, resulted in a 31.6% reduction in prescribing errors from 11.1% to 7.6%. However, site results varied considerably. A benchmark for medication prescribing errors in the PICU was identified among nine children's hospitals. The methodology was successful in accounting for site-specific differences with regard to identifying and documenting errors as well as reporting results of improvement initiatives. Furthermore, the methodology employed was generalizable in the identification of predominant prescribing error types, which helped to track individual hospital improvement initiative development and implementation. Overall improvement in prescribing error rates was noted; however, considerable variation in the success of improvement initiatives was noted and bears further attention.

Medication error identification is a key to prevention: a performance improvement approach.

The leadership of Memorial Hospital of Carbondale sponsored an interdisciplinary continuous quality improvement team effort to address medication errors. The need for increased awareness, documentation, and reporting of medication errors throughout the organization was identified as a priority through risk assessment. Ineffective reporting of medication errors occurred in all medication distribution categories: prescribing, transcribing, dispensing, and administration. Improvement interventions focused on building an awareness of the occurrence of medication errors through identification and on the reporting of those errors to the risk management department.