Incidence Of Medication Errors Research Articles

Medical malpractice litigation and daylight saving time.

Daylight saving time (DST) constitutes a natural quasi-experiment to examine the influence of mild sleep loss and circadian misalignment. We investigated the acute effects of spring transition into DST and the chronic effects of DST (compared to standard time) on medical malpractice claims in the United States over 3 decades. We analyzed 288,432 malpractice claims from the National Practitioner Data Bank. To investigate the acute effects of spring DST transition, we compared medical malpractice incidents/decisions 1 week before spring DST transition, 1 week following spring DST transition, and the rest of the year. To investigate the chronic effects of DST months, we compared medical malpractice incidents/decisions averaged across the 7-8 months of DST vs the 4-5 months of standard time. With regard to acute effects, spring DST transitions were significantly associated with higher payment decisions but not associated with the severity of medical incidents. With regard to chronic effects, the 7-8 DST months were associated with higher average payments and worse severity of incidents than the 4-5 standard time months. The mild sleep loss and circadian misalignment associated with DST may influence the incidence of medical errors and decisions on medical malpractice payments both acutely and chronically. Gao C, Lage C, Scullin MK. Medical malpractice litigation and daylight saving time. J Clin Sleep Med. 2024;20(6):933-940.

Patient safety and medication errors

The morbidity and mortality of drug-related problems has most recently been estimated to cost $177.4 billion annually within the United States alone. Empirical investigations have also suggested that almost one-fifth of all medical errors are drug-related within hospital settings, with over half of these being of a preventable nature. As such, minimizing medication errors has emerged as a priority area to ensure patient safety within healthcare systems worldwide, as several nations have implemented broad initiatives to improve the medication use system. Due to the numerous complexities involved, multifaceted and systemwide approaches to redesigning processes are most often advocated. Given the importance of appropriate medication use in achieving optimal patient outcomes, this paper addresses the various nomenclature and taxonomies of error within healthcare as well as the incidence, risk factors, causes, and prevention of medication errors.

Medication reconciliation by pharmacists for pre-admission patients improves patient safety

BackgroundMedication errors related to the pre-admission medication history obtained on admission are a major cause of medication error during hospitalization. Medication reconciliation (MR) improves patient safety through the detection of inadvertent medication discrepancies at transitions of care. The aim of this study was to evaluate the effect of MR by pharmacists for patients prior to hospital admission on the incidence of medication errors in the early post-admission period.Patients and methodsPatients admitted to the orthopedic ward for surgery between April 2012 and March 2020 were included. Pharmacist-led MR for pre-admission patients was started on April 1, 2017. The incidence of medication errors related to pre-admission medications that occurred during hospitalization were compared between the pre- and post-initiation of pharmacist-led MR (pre-initiation: April 1, 2012 to March 31, 2015, post-initiation: April 1, 2017 to March 31, 2020).ResultIn the post-initiation group, 94.2% (1245/1321) of patients who were taking medications on admission had a pharmacist-led MR before admission. The proportion of patients whose physicians ordered the prescription of their pre-admission medications at the time before hospitalization to continue from admission was significantly higher in the post-initiation group than in the pre-initiation group (47.4% vs. 1.0%, p < 0.001). The incidence of medication errors related to pre-admission medications during hospitalization was significantly lower in the post-initiation group than in the pre-initiation group (1.83% vs. 0.85%, p = 0.025). Pharmacist-led MR prior to admission was a significant protective factor against incidents related to pre-admission medication (odds ratio (OR), 0.3810; 95% confidence interval (CI); 0.156–0.9320, p = 0.035).ConclusionPharmacist-led MR for patients prior to hospital admission led to a reduction in medication errors related to pre-admission medications during hospitalization. Patient safety during hospitalization can be improved by accurate medication histories provided early by pharmacists.

Medical errors, affected sites, and adverse consequences among patients in the orthopaedic department: Does age matter?

Orthopaedics have become the focus of research on patient safety due to the high incidence of medical errors. Previous studies were based on all orthopaedic patients and rarely conducted empirical analyses from the perspective of age. This study aimed to fill the academic gap in the age variable by comparing medical errors, affected sites, and adverse consequences in orthopaedic patients. This retrospective study included 329 litigation claims against orthopaedists using data from China Judgments Online. First, we performed computer crawling and screened 5,237 litigation documents using keywords, including medical errors. Second, 2,536 samples were retained through systematic random sampling, and 549 irrelevant cases were deleted after manual reading. Finally, three clinicians from different medical departments selected 329 incidents related to orthopaedics for further analysis, according to the description of the lawsuits. Three other professional orthopaedists evaluated the patients' ages, affected sites of medical errors, and adverse consequences. The greatest number of medical errors was observed in the joints (30.43%) for all orthopaedic patients. However, adult patients (aged 18-60 years) were most susceptible to errors in the extremities (30.42%). A higher rate of complications was associated with a higher rate of morbidity/mortality for the corresponding patients. Medical errors correlated with complications occurred in the following sites: joints (15.38%), extremities (12.50%), spine (16.95%), multiple sites (15.38%), and hands and feet (14.81%). In addition to surgical errors, over 10% of all orthopaedic patients experienced missed diagnoses. The incidence of insufficient adherence to informed consent obligations was 13.5% among adult patients and was much higher in paediatric and older adults patients. When orthopaedic patients suffered from medical technical errors, iatrogenic mortality/morbidity would decrease by 0.3% for one unit increase in age. Dividing patients into different ages demonstrated diverse results in terms of medical errors and affected sites. Negligence in diagnosis and examination can be fatal factors that endanger safety, and complications may cause morbidity/mortality. When patients suffered from technical errors, age is inversely proportional to mortality/morbidity. Special attention needs to be paid to technical errors in the younger older adults population (60-64 years old), which has inspired implications in promoting aging and public health.

Dosage Adjustment as an Efficiency in Treatment Costs for Chronic Kidney Disease Patients

Introduction: Chronic Kidney Disease (CKD) treatment, in all stages, has been shown to impose a big economic burden. To reduce drug costs, dose adjustment can be used in CKD treatment. Apart from saving costs, dose adjustments can also reduce the risk of side effects due to excessive doses. This research aimed to identify the dose suitability of CKD patient treatment and calculate the difference in treatment costs before and after the dose adjustments. Method: This research was a cross-sectional study using descriptive analysis. Data was collected from medical records in UGM Academic Hospital using purposive nonrandom sampling in inpatient CKD patients with decreased creatinine clearance and serum creatinine who underwent hospitalization for at least one year. Result: There were 58.14% male patients and 41.86% female patients. Most of the patients have stage 5 CKD (46.51%) and hypertension comorbidities (59.30%). Around 69.14% of drugs used in treatment required dose adjustment and only 52.33% of them had appropriate doses based on the Lexicomp Drug Information Handbook. The class of drugs that required the most dose adjustments was antibiotics with 14 occurrences. After the dose adjustment, the saved cost from patients with inappropriate doses was IDR 1,766,330. The biggest cost difference after the dose adjustment was IDR 1,090,865, which comes from the antibiotic group. Conclusion: Dosage adjustments can reduce the incidence of medication errors, improve clinical outcomes, and increase the effectiveness of clinical outcomes and cost-effectiveness.

Dabigatran-related serious medication errors: an analysis using data from VigiBase

ObjectiveTo analyze the serious medication errors (MEs) on dabigatran, and their related factors, in order to avoid or reduce the occurrence of adverse events.MethodsSerious MEs related to dabigatran were extracted from the WHO global database of reported potential side effects of medicinal products (VigiBase) by using “Medication errors and other product use errors and issues” High Level Group Term (HLGT) of the international Medical Dictionary for Regulatory Activities (MedDRA). Well-documented reports, vigiGrade completeness score ≥ 0.80, or with an informative narrative were analyzed with a focus on the clinical features of the cases. The PCNE Classification for drug-related problems (DRP) was used to classify medication errors in our analysis of cases.ResultsUntil January 26, 2020, there were 453 cases with serious MEs related to dabigatran in VigiBase, and 113 were well-documented. Among these, 69 patients (61%) were hospitalized or had prolonged hospitalization, 16 (14%) had life-threatening events, and 12 (11%) died. The MEs occurred in the prescription phase in 77 cases, in administration in 35, and at the dispensing stage in one case. The MEs in prescription were related to a drug selection error in 44 cases (24 concerning contraindications and 20 drug interactions) and to dose error in 33 cases (17 with excessive dose; eight with insufficient frequency; four had an incorrect time; in three, the dose was too low; and in one, too frequent). The MEs in administration were medical-staff-related errors in five cases (three with wrong administration route, one administration omission, and one overdose), patient-related errors in 28 (14 insufficient dose or no administration, seven improper drug storage, four wrong administration method, and three over prescribed dose), and other errors in two (without efficacy monitoring). The dispensing error of a wrong drug strength occurred in a pharmacy. The main adverse events in the 113 patients were haemorrhage in 57 cases (50%) and ischemia in 29 cases (26%).ConclusionBased on the analysis of reports in VigiBase, serious MEs related to dabigatran mainly occurred during prescription and administration. Although the incidence of MEs with clinical consequences in the use of dabigatran cannot be determined, attention should be paid to selection of the appropriate dose to a right patient in the prescription, and to patient compliance and storage in drug administration. The patient harm mainly manifested itself as bleeding or ischemia including fatal outcome in rare patients.

Awareness, Practices, and Contributing Factors toward Medication Errors in Children among Pediatric Nurses

ABSTRACT Context: Medication errors are a global issue that poses a significant threat to patient safety and results in serious harm. Inconsistencies in drug formulations make children more susceptible to medication errors. Nurses have the primary responsibility of preventing medication errors in children. Aim: The aim of this study was to assess the awareness, practices, and contributing factors among pediatric nurses at a selected tertiary care hospital, Rishikesh. Setting and Design: This was a cross-sectional study conducted at a tertiary care hospital in Rishikesh (Uttarakhand), India. Methods: One hundred and twenty nurses working in pediatric care units at a tertiary care hospital in Rishikesh were involved in the study. The participants were chosen using the total enumerative sampling technique in accordance with the inclusion criteria. A self-structured questionnaire and Likert scale was used to collect the data. Statistical Analysis: The collected data were analyzed using frequency, mean and standard deviation, Pearson correlation, Fisher’s exact test, and Chi-square test using the SPSS software version 26.0. Results: Majority (70%) of the pediatric nurses were moderately aware and most of them (80%) were practicing safely toward medication errors in children. The most common reason for medication errors in children was a lack of familiarity with look-alike and sound-alike drugs. Conclusion: The study findings revealed that awareness and practices toward reporting of medication errors in children among the pediatric nurses needs to be improved by establishing the guidelines and organizing in-service education programs, the incidence of medication errors in children can be reduced.

Evaluation of Medication Error Incident Reports at a Tertiary Care Hospital

Background: Whether an adverse drug event (ADE) occurred or not, medication errors (MEs) are thought to be a barrier that prevents patients from administering the right dose of treatments at the proper time at any point in the process of taking treatments. It was found that medication errors caused about 7,000 patient deaths, and these errors accounted for 30% of all issues in hospitals. This study aimed at assessing the incidents of medication errors at a tertiary care center of King Fahd Hospital, Jazan, Saudi Arabia. Methods: A retrospective study was conducted from January 2015 to December 2015 of patients\&amp;apos; residents at a bed tertiary care hospital. The hospital\&amp;apos;s medication safety reporting program was used by healthcare professionals to report many types of safety incidents, including MEs. Data were analyzed using SPSS, version 20. A P value &amp;lt; 0.05 was considered significant. Results: The study included 491 patients; their ages ranged between &amp;lt; 20 to &amp;gt;60 years old, and 53.2% were females. The most identified drug-related problems (DRPs) were single (73.1%), and 12.2% of DRPs were multiple. The most common DRP types were improper dosage (38.9%) and wrong frequency (35.3%), followed by wrong drug (9.3%) or omission error (8.8%). The gender of patients was the only significant factor associated with medication error incidence. The type of DRP was the significant factor affecting the multiplicity of DRP. Conclusion: The present study demonstrated a high prevalence of drug-related problems in Jazan, Saudi Arabia. More training and knowledge in prescribing and administering drugs should be provided to healthcare professionals.

The pharmacists' interventions after a Drug and Therapeutics Committee (DTC) establishment during the COVID-19 pandemic.

Healthcare systems in developing countries faced significant challenges during COVID-19, grappling with limited resources and staffing shortages. Assessment of the impact of pharmaceutical care expertise, particularly in critical care units during the pandemics, in developing countries remains poorly explored. The principal aim of our study was to assess the impact of the Drug and Therapeutics Committee (DTC), comprising clinical pharmacists, on the incidence, types, and severity of medication errors and associated costs in using COVID-19 medications, especially antibiotics. An interventional pre-post study was carried out at a public isolation hospital in Egypt over 6 months. Out of 499 medication orders, 238 (47.7%) had medication errors, averaging 2.38 errors per patient. The most frequent were prescribing errors (44.9%), specifically incorrect drug choice (57.9%), excessive dosage (29.9%), treatment duplication (4.5%), inadequate dosage (4.5%), and overlooked indications (3.6%). Linezolid and Remdesivir were the most common medications associated with prescribing errors. Pharmacists intervened 315 times, primarily discontinuing medications, reducing doses, introducing new medications, and increasing doses. These actions led to statistically significant cost reductions (p < 0.05) and better clinical outcomes; improved oxygen saturation, decreased fever, stabilised respiratory rates, and normalised white blood cell counts. So, clinical pharmacist interventions made a notable clinical and economic difference (66.34% reduction of the expenses) in antibiotics usage specifically and other medications used in COVID-19 management during the pandemic. Crucially, educational initiatives targeting clinical pharmacists can foster judicious prescribing habits.

Strategies for Reporting Medication Errors in Hospitals; An Integrative Review

Background: Despite focused efforts on error prevention, the incidence of medication errors (MEs) occurring in the health care system continues a concern. Patient harm can be diminished or prevented by adequate reporting processes that include identifying, analyzing, and correcting MEs on time. Both medication error prevention and reporting strategies are critical components in advancing patient safety. Methods: To analyze the strategies used by the Health Care Professionals (HCPs) to facilitate reporting medication errors in a health care setting, an integrative review of the literature, guided by Whittemore and Knafl's (2005) five-step process, was applied for the period between 2011-2021. With a comprehensive search conducted using PubMed, DSL, Google Scholar databases, nine articles only met our inclusion criteria which are, in the English language, performed by peers and full-text articles that answered the guiding questions included in this review. Result: The articles were analyzed in terms of objectives, methodological path, main results, and recommendations for improvement. The analysis reveals that MEs reporting strategies are varied either web-based, paper-based, or Technician Enhanced Administration of Medication (TEAM) model. Staff awareness and non-blame culture are influencing HCPs' ability to adopt the proper strategy for reporting MEs, understanding of HCPs' characteristics and organizational factors that influence error reporting can foster the development of effective strategies to report MEs and enable organizations to enhance patient safety.

Blaming Culture Perceptions and Nurses' Attitudes in Reporting Medication Error Incidents in Hospital

Background: Patient safety is an important issue for every country that provides health services, regardless of health services using private or government funding methods. Purpose: This research aims to determine the relationship between perceptions of blaming culture and Nurses' Attitudes in Reporting Medication Error Incidents at Tongas Regional Hospital, Probolinggo. Methods: This research uses a correlational analytical design with a cross-sectional approach. A sample amount 61 respondents obtained using a purposive sampling technique. The instrument used was the blaming culture perception questionnaire adapted from HSOPC, developed by AHRQ 2016. Meanwhile, the nurse attitude questionnaire in reporting medication error incidents had gone through the validity and reliability testing stage with Cronbach's alpha value was 0.876 by previous researchers, and the analytical test used in this research was the Spearman rho test. Results: The Spearman's rho analysis test shows a value of α&lt;0.05, namely (0.000) which means that there is a relationship between the perception of Blaming Culture and the attitude of nurses in reporting medication error incidents at the Tongas Regional Hospital, Probolinggo. Conclusion: Professionalism and strong work culture must be emphasized through standard work behavior, forming solid teamwork, good communication in the work environment, and the involvement of management in taking the initiative to provide ongoing training and motivation to create awareness of the importance of patient safety culture.

Safety in Healthcare: From the Flight Deck to the Operating Room.

The recent health crisis has increased the workload and the stress levels of healthcare professionals around the world. Such stressful working environments are conducive to an increased incidence of medical errors. Implementing education and training specifically focused on human and organizational factors can promote teamwork and decrease the risk of error. Such techniques have been extensively deployed, most notably in commercial aviation. Numerous tools have been developed to reduce the risk of error associated with routine tasks, forgetting a task and handling alarm situations during commercial flights. Many of these tools can be transferred to the healthcare sector. After a brief recap about the importance of the working environment, this narrative review aims to highlight several specific tools used in commercial aviation that can be readily transferred to the operating theatre.

Medication error in geriatric population of an urban area and its relation with different factors influencing medication error

Medication errors have been a matter of concern since the time we started using medicines. The frequency of these errors is influenced by a number of factors few of them were pretty obvious and few surprising. Keeping this in mind this research was designed and carried out in geriatric population of an urban area. We tried to evaluate the role of various factors which influence medication error in geriatric population.1-Primary objective was to estimate the frequency of medication error. 2-Secondary objective was to find out relation of different factors related to medication error. This is a cross sectional study which aims to estimate the frequency of medication error in 250 patients of geriatric age group (Age More Than 65 Years) residing in an urban area and factors related to medication error For this a questionnaire was prepared which had questions related to demographic details and few questions focused on knowing the factors that could have an influence on medication error. These factors were taken into consideration as per the previous studies which were done on medication error.It was found that more than 80% of patients thought that medication errors are only those incidents where they use a medication other than what was prescribed to them hence Patients were properly explained what medication error actually is e.g. they were told that even if they take the correct mediation in wrong dose, frequency or duration it accounts for medication error and after this they started recalling incidents when they have faced these errors. There responses were entered into these questionnaire/case record forms which were later analysed.The data was entered in MS excel and analysed using Epi Info software. The quantitative variables were analysed as frequency. Association between variables was analysed using chi square test. P value &amp;#60;0.05 was considered as significant .The incidence of medication error was found to be 53% and its frequency was higher in patients with greater number of medications, increasing number of chronic health conditions , while it was lower in patients with higher educational status ,those belonging to lower age groups and if doctor or pharmacist explained the medications to them. surprisingly its frequency was low in patients who could just identify their medication with their health condition. It was concluded that medication errors are common health related issue in patients of geriatric age group and a number of factors can influence its incidence. If these factors are properly addressed it will have a considerable impact on the morbidity and mortality associated with this problem.

Evaluation of the Potential for Medication Error in Outpatient Elderly Patients at Siti Fatimah Az-Zahra Regional Hospital

Medication error is an event or situation that can be prevented and avoided, but if drugs cannot be controlled it can lead to inappropriate or harmful use of drugs. Medication error is an error made unintentionally in prescribing (Prescribing), reading prescriptions (transcribing), preparing prescriptions (dispensing) and administration. The purpose of this study was to determine the incidence of medication errors in the prescribing and transcribing phase in elderly patients. This study included descriptive observational research in a retrospective manner with purposive sampling method in the form of prescriptions of elderly patients at Siti Fatimah Az-Zahra Hospital Palembang. The results obtained in this study indicate that the occurrence of medication errors at the Prescribing stage, namely no prescription date 12%, no doctor's SIP 15%, no doctor's signature 10%, no dosage unit 35%, no amount of drug administration 3% and at the Transcribing stage, namely unclear / complete drug names 34%, unclear / complete drug doses 34% and unclear / complete drug amounts 3%.&#x0D; Keywords: medication error, prescribing, transcribing

The Extent of Medication Errors During Hajj in the Kingdom of Saudi Arabia.

Background Medication errors are frequently identified in healthcare institutions and pose a risk to patients. The mass gathering during Hajj may expose the pilgrims to numerous health risks. No study has reported the extent of medication errors during Hajj in Saudi Arabia.Weinvestigated the rate, nature, reporting, severity, and causes of medication errors in Hajj pilgrims. Methodology A retrospective analysis of medication errors reported by healthcare professionals was conducted from July 5, 2022, to July 15, 2022, at Mina Al Wadi Hospital, Saudi Arabia. This study included all medication error report forms collected during the Hajj season. The National Coordinating Council for Medication Error Reporting and Prevention Index was used to classify the severity of medication errors. Results There were reports of 43 medication errors in 3,210 prescriptions. The medication error incidence rate was 1.5% (43/3,210). The highest proportion of medication errors (83.72%, 95% confidence interval (CI) = 72.69-94.75) occurred during the prescribing phase, and 97% (95% CI = 93.16-100.0) of medication errors were classified as near misses. Wrong drugs (23.25%) and frequency (18.60%) were responsible for nearly half of the medication errors. Lack of drug information was the leading cause of reported medication errors (58.14%), followed by environmental, personnel, and workload issues (23.25%), and look-alike/sound-alike medication issues (18.60%). Conclusions This study found that the incidence of medication errors was consistent with the global standard, and many of them did not reach pilgrims and were preventable. This highlights the importance of targeted interventions. Incorrect medication was the common type of medication error, highlighting a crucial area for intervention and improvement. Lack of drug information was the primary underlying factor in the occurrence of medication errors. Pharmacists were more likely than other healthcare professionals to report medication errors, highlighting the importance of their involvement in improving medication safety among pilgrims. Future research needs to focus on examining the effectiveness of interventions (e.g., provision of education regarding medicines and medication review) in reducing medicine-related events during Hajj.

Incidence and root causes of medication errors by anesthetists: a multicenter web-based survey from 8 teaching hospitals in Ethiopia

BakgroundThe operating room is a demanding and time-constrained setting, in comparison to primary care settings, where perioperative medication administration is more complicated and there is a high risk that the patient will experience a medication error. Without consulting the pharmacist or seeking assistance from other staff members, anesthesia clinicians prepare, deliver, and monitor strong anesthetic drugs. The purpose of this study was to determine the Incidence and root causes of medication errors by anesthetists in Amhara region, Ethiopia.MethodsA multi-center cross sectional web-based survey study was conducted from October 1 to November 30, 2022, across eight referral and teaching hospitals of Amhara region. A self-administered semi structured questionnaire was distributed using survey planet. Data analysis was conducted using SPSS version 20. Descriptive statistics were computed and binary logistic regression was used for data analysis. A p-value < 0.05 was considered statistically significant.ResultsThe study included 108 anesthetists in total, yielding a response rate of 42.35%. Out of 104 anesthetists, Majority of participants (82.7%) were male. During their clinical practice, more than half (64.4%) of participants experienced atleast one drug administration error. 39 (37.50%) of the respondents revealed that they experienced more medication errors while on night shifts. Anesthetists who did not always double-check their anesthetic drugs before administration had a 3.51 higher risk of developing MAEs compared to those who always double-check anesthetic drugs before administration (AOR = 3.51; 95% CI: 1.34, 9.19). Additionally, participants who administer medications that have been prepared by someone else are about five times more likely to experience MAEs than participants who prepare their own anesthetic medications prior to administration (AOR = 4.95; 95% CI: 1.54, 15.95).ConclusionThe study found a considerable rate of errors in the administration of anaesthetic drugs. The failure to always double-check medications before administration and the use of drugs prepared by another anaesthetist were identified to be underlying root causes for drug administration errors.

Implementation of medication reconciliation at admission and discharge in Ministry of Defense Health Services hospitals: a multicentre study

There is potential for many medication errors to occur due to the complex medication use process. The medication reconciliation process can significantly lower the incidence of medication errors that may...

OVERVIEW OF MEDICATION ERROR INCIDENCE IN HOSPITALS IN VARIOUS COUNTRIES: LITERATURE REVIEW

Background: Medication error is one of the most common types of errors contributing to patient safety incidents in hospitals. In addition to their numerous cases and high costs, medication errors also contribute to deaths in various countries. Aims: This study describes the incidence of medication errors in hospitals in various countries, determines the phase of errors that occurred the most, and describes preventive strategies for medication errors in hospitals. Methods: This study was conducted between April 2021-July 2021 using the literature review method. Data were retrieved from ProQuest, ScienceDirect, PubMed, Google Scholar, and Garuda RistekBRIN. The data are generalized and extracted in a table based on the incidence of medication errors and preventive strategies. Results: Of the eleven included studies, the incidence of medication errors in one study conducted in Nigeria was the highest (80%). Four of the eleven studies were conducted in India with varying incidence rates. Most errors occurred during the prescribing stage. The number of reports and the number of events actually have no relevance. It can be said that countries with a high number of reporting have good reporting indicators. Strategies for preventing medication errors include the implementation of an information system in the CPOE (Computerized Physician Order Entry) form and providing training for staff. Conclusion: The difference in the incidence of medication errors in developing and developed economies can be attributed to factors in the healthcare system and the lower prescribing ratio and nurse ratio in developing countries. Keywords: literature review, medication errors, patient safety

OVERVIEW OF MEDICATION ERROR INCIDENCE IN HOSPITALS IN VARIOUS COUNTRIES: LITERATURE REVIEW

Background: Medication error is one of the most common types of errors contributing to patient safety incidents in hospitals. In addition to their numerous cases and high costs, medication errors also contribute to deaths in various countries. Aims: This study describes the incidence of medication errors in hospitals in various countries, determines the phase of errors that occurred the most, and describes preventive strategies for medication errors in hospitals. Methods: This study was conducted between April 2021-July 2021 using the literature review method. Data were retrieved from ProQuest, ScienceDirect, PubMed, Google Scholar, and Garuda RistekBRIN. The data are generalized and extracted in a table based on the incidence of medication errors and preventive strategies. Results: Of the eleven included studies, the incidence of medication errors in one study conducted in Nigeria was the highest (80%). Four of the eleven studies were conducted in India with varying incidence rates. Most errors occurred during the prescribing stage. The number of reports and the number of events actually have no relevance. It can be said that countries with a high number of reporting have good reporting indicators. Strategies for preventing medication errors include the implementation of an information system in the CPOE (Computerized Physician Order Entry) form and providing training for staff. Conclusion: The difference in the incidence of medication errors in developing and developed economies can be attributed to factors in the healthcare system and the lower prescribing ratio and nurse ratio in developing countries. Keywords: literature review, medication errors, patient safety

Evaluating the role of clinical pharmacist in the detection and reduction of medication errors in a specialized burn unit.

This study evaluated the frequency and types of medication errors and the role of clinical pharmacist in the reduction of medication errors in a burn unit. The clinical pharmacist monitored medication use process in all patients admitted to the burn unit in the 4-month interventional study. Direct observation and chart review methods were used to detect medication errors. Medication errors were classified according to the classification of American Society of Health-system Pharmacists. The seriousness of medication errors was categorized based on the National Coordinating Council for Medication Error Reporting and Prevention index. During the study, 1653 drugs were prescribed to 94 patients. Totally, 259 medication errors were identified. The rates of medication errors were 2.75 errors/patient, 0.16 errors/ordered medication, and 0.98 errors/prescription. The most common type of errors was prescribing error (61.8%) followed by dispensing error (14.7%). Regarding the seriousness of medication errors, 1.9%, 21.6%, 45.9%, 30.1%, and 0.4% of errors were in the categories B, C, D, E, and F, respectively. Antibiotics had the highest rate of errors. Of all detected medication errors, 64.5% were intercepted or corrected by the clinical pharmacist interventions. Medication errors were not rare in the burn unit. Providing clinical pharmacy services to burn patients to reduce the incidence of medication errors is highly recommended.