Medication Error Management Research Articles

Managing medical and surgical error: an emotional survival guide

Medical errors are common and often lead to feelings of self-doubt, helplessness, and guilt. Society thinks of physicians as healers, and physicians who see their role as offering a cure will always feel as if they haven’t done enough. This article discusses five steps in the management of medical and surgical error: (1) care for the patient and family, (2) report to appropriate sources, (3) review the incident, (4) manage legal issues, and (5) engage in self-care. There is a focus on managing grief, with tips for coping.

Nurses’ experiences of reporting the medical errors of their colleagues: a qualitative study

BackgroundMedical error is a leading cause of disability and death in healthcare settings and reporting colleagues’ medical errors is one of the main strategies for medical error management and an ethical responsibility of all healthcare providers, including nurses. Most studies into reporting colleagues’ medical errors used quantitative designs while it seems that using qualitative designs can provide better insight in this area.PurposeThis study explored nurses’ experiences of reporting the medical errors of their colleagues.MethodsThis qualitative study was conducted using the conventional content analysis approach. Participants were 22 hospital nurses purposively selected in 2021–2022 from different cities in Iran. Twenty-two in-depth semi-structured interviews were held for data collection. The data were analyzed via Graneheim and Lundman’s conventional content analysis and trustworthiness was maintained using the criteria proposed by Guba and Lincoln.FindingsThe main categories of the study were burnout and intention to leave the profession and growth and development. The two subcategories of the first category were the experience of injury and the experience of violence and the two subcategories of the second category were sense of worthiness and sense of motivation. Moral distress was the most important experience of almost all participants.ConclusionNurses mostly have negative experiences in terms of reporting their colleagues’ medical errors. Negative experiences can act as the barriers to report colleagues’ errors while positive experiences can act as its facilitators. Improvement of the patient safety culture in healthcare settings and interpersonal relationships among healthcare providers can reduce the negative experiences and promote the positive experiences of reporting colleagues’ medical errors.

Synergizing pharmacometrics and pharmacovigilance for medication error management: the case of secukinumab.

To demonstrate the effective integration of pharmacometrics and pharmacovigilance in managing medication errors, highlighted by a case involving secukinumab in a patient with hidradenitis suppurativa. We present the case of a 41-year-old male with progressive hidradenitis suppurativa, unresponsive to multiple antibiotic regimens and infliximab treatment. Due to a medication error, the patient received 300 mg of secukinumab daily for 4 days instead of weekly, totaling 1200 mg. The regional pharmacovigilance center assessed potential toxicity, and a pharmacometric analysis using a population pharmacokinetic model was performed to inform dosing adjustments. Clinical data indicated that the received doses were within a non-toxic range. No adverse effects were observed. Pharmacometric simulations revealed a risk of underexposure due to the dosing error. Based on these simulations, it was recommended to restart monthly secukinumab injections on day 35 after the initial dose. Measured plasma concentrations before re-administration confirmed the model's accuracy. This case highlights the crucial collaboration between clinical services, pharmacovigilance, and pharmacometrics in managing medication errors. Such interdisciplinary efforts ensure therapeutic efficacy and patient safety by maintaining appropriate drug exposure levels.

Communication of medical errors in a simulated clinical scenario. Experience with a pediatric residency group.

To determine the performance of groups of pediatric residents from a Buenos Aires hospital, in terms of correct recognition and communication of a medical error (ME), in a high-fidelity simulation scenario. To describe the reactions and communication attempts following the ME and the self-perception by the trainees before and after a debriefing. Quasi-experimental uncontrolled study conducted in a simulation center. First- and third-year pediatric residents participated. We designed a simulation case in which an ME occurred and the patient deteriorated. During the simulation, participants had to provide information on communicating the ME to the patient's father. We assessed communication performance and, additionally, participants completed a self-perception survey about ME management before and after a debriefing. Eleven groups of residents participated. Ten (90.9%) identified the ME correctly, but only 27.3% (n=3) of them reported that a ME had occurred. None of the groups told the father they were going to give him important news concerning his son's health. All 18 residents who actively participated in this communication completed the self-perception survey, with an average score before and after debriefing of 5.00 and 5.05 (out of 10) (p=0.88). We observed a high number of groups that recognized the presence of a ME, but the communication action was substantially low. Communication skills were insufficient and residents' self-perception of error management was regular and not modified by the debriefing.

Identifying Effective Factors in the Management of Medication Errors in HIV/AIDS Patients in Iran’s Health System Using Structural Equation Modeling

Background: One center that provides health services and treatment for immunodeficiency virus (HIV)/AIDS patients is a behavioral disease counseling center. Today, patient safety and treatment combined with compliance with ethical and legal standards are among the most important concerns of medical and health centers, including the most important criteria for the credibility of an institution. In the meantime, medication errors in HIV/AIDS patients can lead to treatment disruption, drug poisoning, or even death.
 Objectives: Considering the importance of the subject, the present research was conducted to identify and explain the factors affecting the management of medication errors in HIV/AIDS patients in Iran’s health system.
 Methods: The present study is an applied study performed by descriptive method. First, by reviewing the research literature and interviewing 35 experts in the field of HIV/AIDS treatment, the variables and main components affecting the management of medication errors in HIV/AIDS patients were extracted, and a research questionnaire was designed using them. Data were collected from 400 experts and specialists in infectious diseases, etc. Then, the collected data were analyzed using structural equation modeling, SPSS23 software, and LISREL software. 
 Results: Four factors were identified as effective factors in medication error management in HIV/AIDS patients: Organizational, educational, individual, and communication factors. Organizational and communication factors loading 0.763 and 0.646 had the highest and lowest impact on drug error management in HIV/AIDS patients, respectively.
 Conclusions: To efficiently and effectively manage medication errors in HIV/AIDS patients, while considering all four factors, organizational and educational factors should be given more attention and emphasis by managers.

Evaluation of clinical ethics in Iranian hospitals: Employing a 360° approach-A cross-sectional study.

Clinical ethics is defined as recognizing and resolving value conflicts that arise from providing care in medical centers. This study aimed to evaluate the practice of clinical ethics in Iranian hospitals with a 360° approach. The study was conducted by employing a descriptive-analytical method in 2019. The statistical population included staff, patients, and managers of public, private, and insurance hospitals in Mazandaran province. The sample size for each group was 317, 729, and 36, respectively. The data collection tool was a researcher-made questionnaire. The appearance and content validity of the questionnaire were confirmed by expert opinion and construct validity was confirmed by confirmatory factor analysis. The reliability was confirmed by Cronbach's alpha coefficient. Data were analyzed by one-way analysis of variance and Tukey's post-hoc test. We used SPSS software version 21 to analyse the data. The obtained mean score of clinical ethics from the perspective of service providers (0.56 ± 4.45) was higher than the perspective of service presenters (4.35 ± 0.65) and service recipients (0.79 ± 4.22), which was statistically significant (p < 0.05). Among the eight dimensions of clinical ethics, respect for the patient's right (0.68 ± 4.09) illustrated the highest score and medical error management (0.63 ± 4.33) presented the lowest score. Based on the findings of the study, the level of clinical ethics in the hospitals of Mazandaran province is favorable, and among the dimensions of clinical ethics, respect for patient rights gained the lowest score and communication with other colleagues gained the highest score. Therefore, informing and teaching medical professionals in the field of clinical ethics, formulating binding laws, and paying serious attention to this issue in ranking and accrediting hospitals are recommended.

Prevalence and risk factors of workplace violence against healthcare workers in Bangladesh and its consequences: A nationwide cross-sectional study

BackgroundWorkplace violence (WPV) is a global concern that poses major threats to healthcare professionals. Understanding the prevalence, risk factors, and consequences of WPV is key to developing effective preventive measures to ensure the safety of healthcare workers. ObjectivesThis study aimed to assess the weighted prevalence, risk factors, and consequences of WPV among healthcare professionals in Bangladesh. MethodsA cross-sectional study was conducted from May 9, 2022, to April 3, 2023. A total of 3977 healthcare professionals from various healthcare settings participated through a convenience sampling technique. A structured questionnaire was used to collect data in three phases. Statistical analyses included descriptive statistics, Fisher's exact tests, and multinomial logistic regression. ResultsThe study revealed that 77.29% of healthcare professionals (n = 3074) reported experiencing WPV. Verbal abuse/threat (28.74%), emotional violence (20.9%), physical violence (17.53%), and sexual harassment (17.85%) were the most prevalent types of violence reported. WPV incidents primarily occurred at patients' bedside (27.31%) and in nursing/doctor stations (24.84%). The night shift had the highest prevalence of violence (35.66%). Patient relatives/friends (43.55%) and visitors (31.38%) were the primary perpetrators. The major factors associated with WPV included lack of organizational policy (11.32%), long waiting (11.16%), medical error (9.71%), and poor patient management systems (9.53%). Consequences of physical WPV included head injuries (23.69%), ocular injuries (27.21%), fractures (14.99%), and unconsciousness (17.05%). ConclusionsThis study highlights the alarming prevalence of workplace violence among healthcare professionals in Bangladesh and identified major risk factors to the occurrence of violence. Urgent attention from policymakers and healthcare organizations is required to develop and implement preventive measures targeting these risk factors. Strengthening security systems, establishing workplace violence policies, and providing training programs are essential to ensure a safer environment for healthcare workers. It is imperative to increase awareness of workplace violence laws and their enforcement to effectively address this pressing issue and safeguard the well-being of healthcare professionals in Bangladesh.

Use of Web-Based Medication Error Reporting and Management Systems in Improving Medication Safety in Assisted Living Facilities: A Systematic Review

Use of Web-Based Medication Error Reporting and Management Systems in Improving Medication Safety in Assisted Living Facilities: A Systematic Review

Human Factors and Ergonomics in Healthcare: Industry Demands and a Path Forward

This article reviews three industry demands that will impact the future of Human Factors and Ergonomics in Healthcare settings. These demands include the growing population of older adults, the increasing use of telemedicine, and a focus on patient-centered care. Following, we discuss a path forward through improved medical teams, error management, and safety testing of medical devices and tools. Future challenges are discussed.

Error Disclosure Algorithms: How to Disclose Colleague's Medical Error at Individual and Organizational Levels.

Background: Medical error is one of the most important causes of mortality and morbidity in the health care system. Considering the significance of medical error management in the healthcare system, error disclosure is an imperative moral responsibility of medical and healthcare professionals from medical ethics experts’ perspective. In literature, no or inadequate protocols were suggested for disclosing colleague’s medical error; and hence, this study was conducted to provide two algorithms for colleague’s medical error disclosure at individual and organizational levels. Methods: This study conducted a narrative review on several valid Internet databases, including PubMed, Science Direct, and Scopus. First, the literature on the colleague’s error was reviewed using articles of the last 20 years focusing on medical errors and error disclosure keywords. Next, two algorithms were developed for the colleague’s error disclosure for individuals and with the assistance of organizations, respectively. Results: If we personally notice a colleague's error at an individual level, we should plan for a conversation to encourage the colleague to inform the patient or the related organization about the error. If we notice a medical error from a colleague relating to an organization, we should decide based on circumstances considering the organization’s responsible parties for handling error disclosure. Conclusion: This study proposes a simple protocol for detecting peer error at the individual level and at the organizational level, using the existing literature. However, the improvement of these types of methods requires analysis of the specific conditions of each health system.

Use of clinical simulation to train healthcare teams in conflict management: A scoping review

ObjectiveTo assess and analyze the impact of clinical simulation as a training tool in healthcare teams ability to resolve and manage conflicts, through an exploratory systematic review. MethodsA structured literature review was performed with the terms [Clinical Simulation OR Patient Simulation OR Simulation Training OR High Fidelity simulation Training] AND [Conflict OR Conflict Resolution] in the following databases: MEDLINE, LILACS, Cochrane, Scielo, PubMed, CINHAL, ScienceDirect, MEDES, IBECS y DOCUMED. Articles were considered if they involved clinical simulation oriented to training of healthcare professionals or trainees in conflict management, using clinical scenarios, and excluding those studies older than 20 years. Absence of debriefing was not considered an exclusion criterion, neither the use of simulation along with other methodologies. A quantitative analysis was performed. Results10 articles were retrieved, mostly with quasi-experimental designs, in which clinical simulation was designed as an interprofessional training and was used with multiple other methodologies like roleplay, reflexive practice and audiovisual aids, strategy that suggest an increase its effectivity. Different scenarios have been recreated, like decision-making divergences and management of medical errors, in order to apply the competences of mediation, communication, emotional skills among others, and followed by debriefing. The use of validated scales and conventional assessment methods reveal a positive impact on satisfaction, perception and learning of students, as well as transfer to clinical practice and decrease in errors. ConclusionMultiple studies describe and support the use of clinical simulation for training in management and resolution of conflicts among healthcare professionals. Simulation is accepted by participants, developing transfer of skills and competences and impact at the organizational level. Nonetheless, studies are recent and limited in number, making this area a developing field that promotes future research.

A Causal Model to Design more Effective Policies and Practices in Error Management in the Healthcare Industry

Background: Identification of the factors contributing to the errors of medical staff and examining the causal relationships among those factors can help better manage and design more effective policies and practices. Objectives: This study aimed to identify the causes and factors affecting medical error management and determine a model for better management of such errors. Methods: This descriptive-analytical study was conducted in two qualitative and quantitative phases. In the quantitative part of the study, the factors related to medical error management were identified and validated through reviewing previous studies and interviewing some specialists. Following that, the fuzzy decision-making trial and evaluation method was used for structural modeling of the factors and investigating the causal relationships among them in the quantitative part. Results: In this study, the results showed that the "education and learning from error" subfactor had the most significant impact on the system. The second highly effective subfactors in the management of medical errors were "organizational communication and improved information access", "safety culture and climate", and "policies, procedures, and guidelines". In addition, the "safety culture and climate" was the most important factor that had the most critical impact on the system. Moreover, the "handoff conversations and communication" subfactor was mostly influenced by the other factors, followed by the "incident reporting system", "error prevention and corrective measures", "safety culture and climate", and "individuals' participation". Conclusions: According to the results of this study, the health care industry should take into consideration both organizational and individual factors in error management. In order to achieve better planning and higher performance in error management, increase patient safety, and ultimately improve the quality of hospital services, it is suggested to consider the causes and factors affecting the system.

Knowledge, attitudes, and Expectations of Medical Staff Toward Medical Error Management Policies in Humanitarian Medicine: A Qualitative Study.

Patient safety, a major component of quality of care, is now an attribute of health care systems in developed countries at least. Although there is ever more research on this subject in developed countries, humanitarian medicine, mainly implemented in resource-poor countries, has yet to structure its own set of policies and strategies on patient safety and the management of medical errors. We assessed the knowledge, attitudes, and expectations of medical humanitarian staff regarding the development of policies and strategies related to patient safety and medical error management in medical humanitarian action. We conducted 36 semistructured interviews with international medical and paramedical staff active in 6 medical humanitarian organizations after having interviewed the medical directors or the person in charge of quality of care and the legal advisors. Interviews were transcribed verbatim and subjected to a thematic analysis. The interviews confirmed the current absence of clear investments in dealing with safety risks in the selected medical humanitarian organizations. The difficulties experienced by medical staff in reporting medical errors such as blame culture, lack of training, and absence of leadership committed on patient safety are nonspecific. Other arguments are related to the specific conditions of humanitarian settings: coexistence of different medical culture, absence of international or local regulations or external pressures, and great diversity of activities and contexts. Interviewed staff expressed high expectations of receiving guidance from their organizations and support to adopt clear patient safety and medical error management policies adapted to their complex operational and clinical realities.

Cognitive Bias Impact on Management of Postoperative Complications, Medical Error, and Standard of Care

BackgroundCognitive bias (CB) is increasingly recognized as an important source of medical error and up to 75% of errors in internal medicine are thought to be cognitive in origin (O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicans Edinb. 2018;48;225-232). However, primary data regarding the true incidence of bias is lacking. A prospective evaluation of CB in the management of surgical cases with complications has not been reported. This study reports the incidence and distribution of various types of CBs, and evaluates their impact on management errors and standard of care (SOC). MethodsA prospectively collected series of 736 general surgical cases with complications from three university hospitals was analyzed. Surgical residents evaluated cases for 22 types of CBs (Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-780). Supervising quality officers validated all quality assessments. Data were assessed for the incidence of CBs, error assessments (diagnostic, technical, judgment, system, communication, therapeutic, and professionalism), and SOC. ResultsCB was attributed in 32.7% (241/736) of all cases with complications. The most common CBs identified, both singly and in groups, were anchoring, confirmation, omission, commission, overconfidence, premature closure, hindsight, diagnosis momentum, outcome, and ascertainment bias. The attribution of CB was correlated to a statistically significant increase in the incidence of management errors by the surgical team and lower SOC assessments. ConclusionsCBs are identified in the management of cases with complications and are associated with an increase in management errors and a degradation in SOC. Insight into the types of CBs and their association with the type and severity of management errors may prove useful in improving quality care.

Medical error: concept, characterization and management

Abstract The objective of this study is to better understand the tensions involved in the fear of making an error due to the harm and risk this would pose to those involved. This is a qualitative study based on the narratives of the experiences lived by ten acting physicians in the state of São Paulo, Brazil. The concept and characterization of errors were discussed, as well as the fear of making an error, the near misses or error in itself, how to deal with errors and what to do to avoid them. The analysis indicates an excessive pressure in the medical profession for error-free practices, with a well-established physician-patient relationship to facilitate the management of medical errors. The error occurs but the lack of information and discussion often leads to its concealment due to fear of possible judgment by society or peers. The establishment of programs that encourage appropriate medical conduct in the event of an error requires coherent answers for humanization in Brazilian medical science.

The Practices of Disclosure and Management of Medical Errors by Surgical Trainees-Better Preparing A Future Surgeon

Abstract not available&#x0D; Journal of Surgical Sciences (2014) Vol. 18 (2) : 43-44

Deployment of Critical Incident Reporting System (CIRS) in public Styrian hospitals: a five year perspective

BackgroundTo increase patient safety, so-called Critical Incident Reporting Systems (CIRS) were implemented. For Austria, no data are available on how CIRS is used within a healthcare facility. Therefore, the aim of this study was to present the development of CIRS within one of the biggest hospital providers in Austria.MethodsIn the province of Styria, CIRS was introduced in 2012 within KAGes (holder of public hospitals) in 22 regional hospitals and one tertiary university hospital. CIRS is available in all of these hospitals using the same software solution. For reporting a CIRS case an overall guideline exists.ResultsAs of 2013, 2.504 CIRS cases were reported. Predominantly, CIRS-cases derived from surgical and associated disciplines (ranging from 35 to 45%). According to the list of hazards (also called “risk atlas”), errors in patient identification (ranging from 7 to 12%), errors in management of medicinal products (ranging from < 5 to 9%), errors in management of medical devices (ranging from < 5 to 10%) and errors in communication (ranging from < 5 to 6%) occurred most frequently. Most often, a CIRS case was reported due to individual error-related reasons (48%), followed by errors caused by organization, team factors, communication or documentation failures (34%).ConclusionsIn summary, CIRS has been used for 5 years and 2.504 CIRS-cases were reported. There is a steady increase of reported CIRS cases per year. It became also obvious that disregarding guidelines or standards are a very common reason for reporting a CIRS case. CIRS can be regarded as a helpful supportive tool in clinical risk management and supports organizational learning and thereby collective knowledge management.

Gestion des erreurs médicamenteuses en médecine générale : étude en maison de santé pluridisciplinaire

Medication errors are the most frequent medical care adverse events in France. Their management process used in hospital remains poorly applied in primary ambulatory care. The main objective of our study was to assess medication error management in general ambulatory practice. The secondary objectives were the characterization of the errors and the analysis of their root causes in order to implement corrective measures. The study was performed in a pluriprofessionnal health care house, applying the stages and tools validated by the French high health authority, that we previously adapted to ambulatory medical cares. During the 3months study 4712medical consultations were performed and we collected 64medication errors. Most of affected patients were at the extreme ages of life (9,4% before 9years and 64% after 70years). Medication errors occurred at home in 39,1% of cases, at pluriprofessionnal health care house (25,0%) or at drugstore (17,2%). They led to serious clinical consequences (classified as major, critical or catastrophic) in 17,2% of cases. Drug induced adverse effects occurred in 5patients, 3of them needing hospitalization (1patient recovered, 1displayed sequelae and 1died). In more than half of cases, the errors occurred at prescribing stage. The most frequent type of errors was the use of a wrong drug, different from that indicated for the patient (37,5%) and poor treatment adherence (18,75%). The systemic reported causes were a care process dysfunction (in coordination or procedure), the health care action context (patient home, not planned act, professional overwork), human factors such as patient and professional condition. The professional team adherence to the study was excellent. Our study demonstrates, for the first time in France, that medication errors management in ambulatory general medical care can be implemented in a pluriprofessionnal health care house with two conditions: the presence of a trained team coordinator, and the use of validated adapted and simple processes and tools. This study also shows that medications errors in general practice are specific of the care process organization. We identified vulnerable points, as transferring and communication between home and care facilities or conversely, medical coordination and involvement of the patient himself in his care.

Forecasting, uncertainty and risk; perspectives on clinical decision-making in preventive and curative medicine

Should we screen the population routinely for the presence of breast or prostatic cancer? This simple proposition masks a landscape of complexities, including the economics of screening, the prevalence and probability of the disease, desired frequencies of intervention and a willingness to adopt preventive screening. These ‘risk factors’ form part of a broader landscape of uncertainty that characterises the intricacies of clinical decision-making. Deepening our understanding of the way in which clinicians evaluate risk and uncertainty requires a framing of insights into language, communication, psychology and epistemology. This paper explores perspectives in forecasting and uncertainty as a basis for understanding individuals’ perceptions of risk when assessing their options in both preventative and curative medicine. At the heart of the issue is the prevalence of diagnostic error; this paper argues for the use of systematised approaches to medical error management and inclusive approaches to research in the field. The advantages of augmenting the management of unforeseen consequences through an improved understanding of the issues that are of concern to patients, carers, and medical practitioners alike forms a key construct in this paper. We conclude with an exploration of potential opportunities for improvements in medical practice: changes that may reduce the disbenefits of uncertainty and enhance the management of the general risks associated with clinical decision-making.

Research progress of medication error management in anesthesia

Medication error in anesthesia is a serious problem, which may endanger to patients′ life. The aim of this article is to review the study on medication errors in anaesthesia, so as to provide references for building the prevention strategies against medication errors in anaesthesia, and ensure the safety of patients. Key words: Review; Anesthesia; Medication error; Management