Medication Error Reporting Research Articles

Pharmacist intervention on prescribing errors: Use of a standardized approach in the inpatient setting.

PurposeThe objective of this study was to implement a standardized process across health systems to determine the prevalence and clinical relevance of prescribing errors intercepted by pharmacists.MethodsThis prospective, multicenter, observational study was conducted across 11 hospitals. Pharmacist-intercepted prescribing errors were collected during inpatient order verification over 6 consecutive weeks utilizing a standardized documentation process. The potential harm of each error was evaluated using a modified National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) index with physician validation, and errors were stratified into those with potentially low, serious, or life-threatening harm. Endpoints included the median error rate per 1,000 patient days, error type, and potential harm with correlating cost avoidance.ResultsPharmacists intervened on 7,187 errors, resulting in a mean error rate of 39 errors per 1,000 patient days. Among the errors, 46.6% (n = 3,349) were determined to have potentially serious consequences and 2.4% (n = 175) could have been life-threatening if not intercepted. This equates to $874,000 in avoided cost. The top 3 error types occurring with the highest frequency were “wrong dose/rate/frequency” (n = 2,298, 32.0%), “duplicate therapy” (n = 1,431, 19.9%), and “wrong timing” (n = 960, 13.4%). “Wrong dose/rate/frequency” (n = 49, 28%), “duplicate therapy” (n = 26, 14.9%), and “drug-disease interaction” (n = 24, 13.7%) errors occurred with the highest frequency among errors with potential for life-threatening harm. “Wrong dose/rate/frequency” (n = 1,028, 30.7%), “wrong timing” (n = 573, 17.1%), and “duplicate therapy” (n = 482, 14.4%) errors occurred with the highest frequency among errors with potentially serious harm.ConclusionDocumentation of pharmacist intervention on prescribing errors via a standardized process creates a platform for multicenter analysis of prescribing error trends and an opportunity for development of system-wide solutions to reduce potential harm from prescribing errors.

Safety climate, nursing organizational culture and the intention to report medication errors: A cross-sectional study of hospital nurses

Background & Aim: Medication errors are the second most common accident after the fall accident in hospitals. Medication errors are a threat to patient safety. It is important to find the cause of such errors so that we can reduce them. However, the rate of medication error reporting is low. This study aimed to explore the factors associated with the intention to report medication errors among general hospital nurses. Methods & Materials: A cross-sectional study design was used. The participants were 171 registered nurses working in 4 general hospitals in South Korea. Convenient random sampling was used to select participants. Data were collected using mobile self-report structured questionnaires that covered general characteristics, medication errors and the intention to report them, the safety climate, and the nursing organizational culture. The data collection period was from March 14 to April 6, 2018. The data were analyzed by descriptive statistics, the Pearson correlation coefficients, and multiple regression analysis. Results: The mean scores of the intention to report medication errors and safety climate were 5.20±1.40 and 3.04±0.47, respectively. Each mean score of nursing organizational culture types was hierarch-oriented culture 3.63±0.51, relation-oriented culture 3.13±0.69, task-oriented-culture2.99±0.56, and innovation-oriented culture 2.85±0.67. Significant factors associated with the intention to report medication errors were the safety climate (β=.26, p=.001), a task-oriented culture (β=.16, p=.023), educational level (β=-.19, p=.006), the experience of medication errors (β=.19, p=.006), and male (β=-.18, p=.011). They accounted for 25% of the intention to report medication errors. Conclusion: This study found that the safety climate of the hospital, task-oriented culture of the nursing organization, education level, experience of medication errors, and gender associated with the intention to report medication errors. It is necessary to find ways to improve the safety climate of the hospital and the task-oriented culture of the nursing organization and establish a strategy for improving the intention to report medication errors for male nurses and nurses with medication errors.

Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis.

Medication errors are avoidable events that can occur at any stage of the medication use process. They are widespread in healthcare systems and are linked to an increased risk of morbidity and mortality. Several strategies have been studied to reduce their occurrence including different types of pharmacy-based interventions. One of the main pharmacist-led interventions is educational programs, which seem to have promising benefits. To describe and compare various pharmacist-led educational interventions delivered to healthcare providers and to evaluate their impact qualitatively and quantitatively on medication error rates. A systematic review and meta-analysis was conducted through searching Cochrane Library, EBSCO, EMBASE, Medline and Google Scholar from inception to June 2020. Only interventional studies that reported medication error rate change after the intervention were included. Two independent authors worked through the data extraction and quality assessment using Crowe Critical Appraisal Tool (CCAT). Summary odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Research protocol is available in The International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42019116465. Twelve studies involving 115058 participants were included. The two main recipients of the educational interventions were nurses and resident physicians. Educational programs involved lectures, posters, practical teaching sessions, audit and feedback method and flash cards of high-risk abbreviations. All studies included educational sessions as part of their program, either alone or in combination with other approaches, and most studies used errors encountered before implementing the intervention to inform the content of these sessions. Educational programs led by a pharmacist were associated with significant reductions in the overall rate of medication errors occurrence (OR, 0.38; 95% CI, 0.22 to 0.65). Pharmacist-led educational interventions directed to healthcare providers are effective at reducing medication error rates. This review supports the implementation of pharmacist-led educational intervention aimed at reducing medication errors.

Barriers to and facilitators of medication error reporting from the viewpoints of nurses and midwives working in gynecology wards of Tabriz hospitals

Medication error reporting (MER) is an effective way to prevent their repetition in the future. The present study aimed to determine the frequency and factors associated with the causes of MEs and to identify barriers to and facilitators of MER. This descriptive-analytical cross- sectional study was conducted with proportional random sampling on 220 midwives or nurses working in public and private hospitals in Tabriz, Iran. In this study, data were collected using Haddon’s matrix. Data were analyzed using descriptive and inferential statistics. The prevalence of MEs in this study was 36.2%. The most common causes of MEs related to weakness of nurses, wards, management and physicians were nursing staff shortage (30.5%), ward work density (51.8%), low ratio of nurses and midwives per patient (70.7%), and illegible prescriptions (76.4%), respectively. Major barriers to MER reported by nurses and midwives were blaming the individual rather than the system (67.7%). Facilitators of MER were anonymous MRE system and feeling safe about working environment. Staff also reported that if reporting is beneficial (preventing future errors, correcting practice, increasing accountability), the odds of reporting MER will increase (54.5%). Given the underlying cause of MEs from the participants' point of view (staff shortage, fear of reprisal and reprimand), it is suggested that the system and health managers adopt appropriate strategies to reduce these important factors (reducing work density and creating a friendly environment).

Medication Error Concept and Reporting Practices in Saudi Arabia: A Multiregional Study Among Healthcare Professionals.

BackgroundMedication errors pose a risk for individual patients and for public health, with the misuse and overuse of medications being linked to severe patient safety problems. Therefore, the objective of this study was to investigate healthcare professionals’ (HCPs’) knowledge about medication errors, their knowledge about medication error reporting systems, and predictors for HCPs to report medication errors in Saudi Arabia.MethodsAn observational cross-sectional study was conducted among HCPs (physicians, pharmacists, and nurses) between January and March 2020. The study included 6 distinct locations in the Saudi Arabian regions of Hail, Al-Qassim, Al-Jouf, Al-Madinah, the eastern region, and the western region. Descriptive statistical and inferential analyses were computed using Statistical Package for the Social Sciences (SPSS) v.22.ResultsIn total, 980 questionnaires for 348 (35.5%) physicians, 144 (14.7%) pharmacists, and 488 (49.8%) nurses were distributed with a response rate of 100%. Interestingly, only 277 (28.3%) of the HCPs had a good understanding of the stages of medication errors. With regard to reporting practices, a high number of the HCPs, 576 (58.8%), had not reported medication errors in their workplaces, and nearly 369 (37.7%) of respondents said they believe that legal implications are a major barrier to the reporting of medication errors. More than half, 524 (53.5%), of HCPs revealed that no clear electronic system is available for the reporting of medication errors in most hospitals. In addition, 537 (54.8%), of the HCPs had not attended any training programs regarding medication error reporting systems within the past year, which is alarming.ConclusionOur study identified a huge lack of the reporting of medication errors, knowledge about medication error stages, and training on medication errors. Therefore, an urgent need to address these weaknesses exists.

Development of a Wearable Camera and AI Algorithm for Medication Behavior Recognition.

As many as 40% to 50% of patients do not adhere to long-term medications for managing chronic conditions, such as diabetes or hypertension. Limited opportunity for medication monitoring is a major problem from the perspective of health professionals. The availability of prompt medication error reports can enable health professionals to provide immediate interventions for patients. Furthermore, it can enable clinical researchers to modify experiments easily and predict health levels based on medication compliance. This study proposes a method in which videos of patients taking medications are recorded using a camera image sensor integrated into a wearable device. The collected data are used as a training dataset based on applying the latest convolutional neural network (CNN) technique. As for an artificial intelligence (AI) algorithm to analyze the medication behavior, we constructed an object detection model (Model 1) using the faster region-based CNN technique and a second model that uses the combined feature values to perform action recognition (Model 2). Moreover, 50,000 image data were collected from 89 participants, and labeling was performed on different data categories to train the algorithm. The experimental combination of the object detection model (Model 1) and action recognition model (Model 2) was newly developed, and the accuracy was 92.7%, which is significantly high for medication behavior recognition. This study is expected to enable rapid intervention for providers seeking to treat patients through rapid reporting of drug errors.

Identifying Health Information Technology Usability Issues Contributing to Medication Errors Across Medication Process Stages.

Different health information technology (health IT) systems are intended to support medication ordering, reviewing, and administration. We sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors. Patient safety event reports from more than 595 healthcare facilities entered between January 2013 and September 2018 were analyzed. We computationally identified reports associated with health IT intended to support the medication process, including computerized provider order entry, electronic medication administration record, and barcode medication administration. From these, 2700 reports were manually reviewed to determine the type of medication error, medication process stage, and health IT usability issue. Of the 2700 manually reviewed reports, 1508 (55.9%) described a medication error that was associated with health IT use and 750 (49.7%) reached the patient. Improper dose errors were frequent (1214 of 1508, 80.5%) with most errors during ordering (673 of 1508, 44.6%) and reviewing medications (639 of 1508, 42.4%). Most health IT-associated medication error reports described usability issues (n = 1468 of 1508, 97.3%) including data entry, workflow support, and alerting. Data entry usability issues impacted few medication process stages, whereas workflow support and alerting impacted several stages. Health IT usability issues are a prevalent contributing factor to medication errors, many of which reach the patient. Data entry, workflow support, and alerting should be prioritized during usability and safety optimization efforts.

Patterns of Medication Errors Involving Older Adults Reported to the French Medication Error Guichet.

The aims of the study were to describe medication errors (MEs) involving older adults reported to the French Medication Error Guichet and to compare them with MEs in younger adults, in each of the hospital and community settings. Retrospective secondary data analysis of MEs reported throughout 2013 to 2017 was performed. Descriptive and multivariate analyses were performed to compare actual and potential ME reports between older adults (aged ≥60 y) and younger adults (aged ≥18, <60 y). We analyzed 4979 reports. In older adults, both in hospital (n = 1329) and community (n = 1264) settings, antithrombotic agents were frequently reported in MEs and were significantly more likely to be associated with reported MEs in older adults compared with younger adults. In hospital setting, antibacterials for systemic use (adjusted odds ratio [aOR] = 1.87, 95% confidence interval [CI] = 1.19-2.93) and antineoplastic agents (aOR = 2.22, 95% CI = 1.34-3.69), whereas in community setting, psycholeptics (aOR = 1.43, 95% CI = 1.04-1.98) and drugs used in diabetes (aOR = 6.01, 95% CI = 3.21-11.2) were more likely to be associated with reported MEs in older adults. In both settings, wrong dose and wrong drug were the most frequently reported error types in older adults; however, wrong technique error type (aOR = 2.06, 95% CI = 1.30-3.28) in hospital setting and wrong patient (aOR = 2.17, 95% CI = 1.30-3.60) in community setting were more likely to be associated with reported MEs in older adults. We identified specific ME patterns for older adults, including antithrombotic agents in both settings; antibacterials for systemic use, antineoplastic agents, and wrong technique in hospital setting; and psycholeptics, drugs used in diabetes, and wrong patient in community setting. These findings inform future studies investigating population-specific medication safety strategies.

Perceptions of Patient Safety Culture and Medication Error Reporting among Early- and Mid-Career Female Nurses in South Korea.

Reporting medication errors is crucial for improving quality of care and patient safety in acute care settings. To date, little is known about how reporting varies between early and mid-career nurses. Thus, this study used a cross-sectional, secondary data analysis design to investigate the differences between early (under the age of 35) and mid-career (ages 35–54) female nurses by examining their perceptions of patient safety culture using the Korean Hospital Survey on Patient Safety Culture (HSPSC) and single-item self-report measure of medication error reporting. A total of 311 hospital nurses (260 early-career and 51 mid-career nurses) completed questionnaires on perceived patient safety culture and medication error reporting. Early-career nurses had lower levels of perception regarding patient safety culture (p = 0.034) compared to mid-career nurses. A multiple logistic regression analysis showed that relatively short clinical experience (<3 years) and a higher level of perceived patient safety culture increased the rate of appropriate medication error reporting among early-career nurses. However, there was no significant association between perception of patient safety culture and medication error reporting among mid-career nurses. Future studies should investigate the role of positive perception of patient safety culture on reporting errors considering multidimensional aspects, and include hospital contextual factors among early-, mid-, and late-career nurses.

Relationships between nurse managers\u2019 work activities, nurses\u2019 job satisfaction, patient satisfaction, and medication errors at the unit level: a correlational study

BackgroundNurse managers play a critical role in enhancing nursing and patient outcomes. The work of nurse managers, who can be described as middle-managers at health care organizations, is complex and changes on a daily basis. Only a few studies have clarified how nurse managers divide their time across various work activities. This study aimed to describe the relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the hospital unit level.MethodsA cross-sectional and correlational study design was used. The data were collected from nurse managers (n = 29), nursing staff (n = 306), and patients (n = 651) from 28 units across three Finnish acute care hospitals between April and November 2017. In addition, data concerning medication errors (n = 468) over one calendar year (2017) were acquired from the hospitals’ incident reporting register. Analysis of covariance (ANCOVA) was used to estimate relationships between data from subareas of Nurse Managers’ Work Content Questionnaire, Kuopio University Hospital Job Satisfaction Scale, and Revised Humane Caring Scale, along with medication error reports. A significance level of 95% was applied when estimating the covariances between variables. Unstandardized regression coefficients (B) were used to explain the relationships between variables.ResultsMultiple relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors were identified. Nurse managers’ work activities had both positive and negative relationships on the other studied variables. The Requiring factors of work (p < .001) subarea of nurses’ job satisfaction, total patient satisfaction (p < .001), and medication errors (p < .001) were identified as the variables most significantly affected by other factors.ConclusionsThe findings suggest that nurse managers should focus on improving nursing practices by managing and organizing nurses’ work in a way that makes their employees feel supported, motivated and secure. Furthermore, nurse managers should adopt a leadership style that emphasizes safe and patient-centered care. The results also suggest that the administration of today’s health care organizations should actively evaluate nurse managers’ share of work activities to ensure that their daily work is in line with the organizational goals.

Current Situation of Medication Errors in Saudi Arabia: A Nationwide Observational Study.

Medication errors are common and highly preventable events that significantly affect patients' health. This nationwide study primarily aims to quantify the rate and level of harm from the reported medication errors and to determine the medication process stages in which the reported errors occurred. This retrospective observational study concerns medication errors reported to the General Department of Pharmaceutical Care database from March 2018 to June 2019. The database stores all aspects of medication error information, including patient, medication, and error information, along with the job position of the staff involved and contributing factors. The medication use process was categorized into these stages: ordering/prescribing, transcribing, dispensing, administering, and monitoring. We recorded each medication error based on categories from the U.S. National Coordinating Council for Medication Error Reporting and Prevention. A total of 71,332 medication error events were reported to the database. Physicians made 63,120 (88.5%) reported errors, and pharmacists most frequently detected the errors (75.9%). The majority of reported errors appeared at the prescribing phase (84.8%), followed by the transcribing (5.8%) and dispensing (5.7%) phases. A total of 4182 (5.8%) errors reached the patient. Health care professionals' work overload and lack of experience were associated with 31.6% and 22.7% of the reported errors, respectively. Our study highlights the concern regarding medication errors and their low reporting by indicating that pharmacists reported and detected the majority of errors. Promoting a no-blame culture and education for health professionals is vital for improving the error-reporting rate.

Nurses’ Perception about Medication Errors Types, Causes and Barriers to Report it

Background: Since there is a continuous rise in the number of patients requiring quantity of prescribedmedications and medical care, there is always an increasing requirement for a complete system that cancarefully evaluate all the medication errors that may occur.Objective: Determine types, causes, and barriers of medication errors reportSetting: The current study was conducted in Imam Sadiq Hospital - Babel City during 2019 yearSubjects: The study comprised of 100 nurses with at least two years of clinical experienceTools: The Medication Administration Errors (MAEs) method was used to gather the data by reportingruestionnaire that was formulated by Wakefield et al.(1996) and revised by the researchers. The questionnairehas 65 questions; 15 items are related to the reasons of medication errors occurrence, 7 items concerningthe reasons of not reporting medication errors and 5 items related to the percentage of each medicationerror type reported on units which classified into 9 items for non- intravenous and 11 items for intravenousmedication administration errors.Results: most of nurses reported no mistakes related to wrong route, wrong dose, wrong method;Whilewrong time, allergic reaction and infusion rate mistakes were more repetitive errors accordingto their perception. Fears about punishmentand from patient relatives was most common barriers to reportmedicationerrors.Conclusion: Medication errors is highly priority health system problem; more than half of nurses reportedno mistakes related to wrong dose, wrong method, and wrong patient, most of them indicated that no clearlydefinition of medication error was identified, unclear reporting system wasexisted.Recommendations Assessment and surveillance system should be followed to minimize medication errorspotentiality. Nurses have to always remember that they are responsible and accountable to the results of theirdecisions andactions whatever they are.

The Mindful Path to Nursing Accuracy: A Quasi-Experimental Study on Minimizing Medication Administration Errors.

Achieving error-free health care is critically vital and includes freedom from the occurrence of medication errors, which, as yet, is an unrealized goal in the United States. The purpose of this study was to minimize or potentially eliminate medication errors by adding training in mindfulness thinking to the current system protocol. The goal of this quantitative, quasi-experimental study was to determine whether training nurses in mindfulness thinking founded on the Dossey Integral Theory changed the frequency and severity of medication administration errors. Data analysis included the following steps: recording of data using the NCC MERP (National Coordinating Council for Medication Error Reporting) instrument, statistical analysis using paired t test, and a logistical interpretation of descriptive statistics. An error reduction of 73.3% between pre- and posttraining mean for the experimental group was observed. This study may add to the limited body of research related to mindfulness and the resultant reduction in medication errors.

Perceptions of Clinical Nurses About the Causes of Medication Administration Errors: A Cross-Sectional Study.

AIMThis study was conducted to determine the perceptions of nurses about the causes of medication administration errors and the rates of reporting errors made or witnessed by them.METHODThis methodological, descriptive, multicenter, and cross-sectional study sample of this study included 590 clinical nurses working in an inpatient setting in Turkey. The data were collected using the Medication Administration Error Reporting Survey, which is a self-report questionnaire.RESULTSIn the study, it was determined that insufficient number of nurses, heavy workloads, and illegible medication orders of physicians were the most common causes leading to medication errors as stated by the nurses. Moreover, 26.1% of the nurses reported that they had made an medication error, and more than half of the nurses reported that they had witnessed medication errors. It was found that 68.8% of medication errors were not reported.CONCLUSIONIt is important to determine the nurses’ perceptions about the causes of medication errors to prevent repetition of medication errors and to establish standards for medication safety. Therefore, it may be recommended to reduce workloads of nurses and develop methods to increase the rate of reporting medication errors.

Outpatient insulin-related adverse events due to mix-up errors: Findings from two national surveillance systems, United States, 2012-2017.

We used data from two public health surveillance systems for national estimates and detailed descriptions of insulin mix-up errors resulting in emergency department (ED) visits and other serious adverse events to help inform prevention efforts. ED visits involving patients seeking care for insulin medication errors collected by the NEISS-CADES project in 2012-2017 and voluntary reports of serious insulin medication errors submitted to the US Food and Drug Administration (FDA) in 2016-2017 were analyzed. National estimates of insulin product prescriptions dispensed from retail pharmacies were obtained from IQVIA National Prescription Audit. Between 2012 and 2017, based on 514 NEISS-CADES cases, there were an estimated 5636 (95% CI, 4143-7128) ED visits annually for insulin mix-up errors; overall, over three-quarters (77.5%; 95% CI, 71.6%-83.3%) involved taking rapid-acting instead of long-acting insulin. Between 2012 and 2017, the proportion of mix-up errors among all estimated ED visits for all insulin errors decreased by 60%; concurrently, the proportion of pens among all insulin package types dispensed increased by 50%. Among 58 voluntary reports submitted to FAERS, over one-half (56.9%) of cases involved taking rapid- instead of long-acting insulin. Among 27 cases with documented contributing factors, approximately one-half involved patients having difficulty differentiating products. Among all ED visits for insulin errors collected by NEISS-CADES in 2012-2017, the proportion involving mix-up errors has declined. Continued reductions may require additional prevention strategies, including improving insulin distinctiveness, particularly for rapid- vs long-acting insulins. Ongoing national surveillance is important for identifying the impact of interventions.

Perceptions of Nurses about Medication Errors: A Cross-Sectional Study

Purpose: The aim of this study is to assess nurses’ perception of medication errors nurses in Maternity and Child Hospital in Najran city, Saudi Arabia. Study Design: A cross-sectional study. Subjects and Methods: This descriptive study was carried out among 72 nurses in Maternity and child Hospital in Najran city, Saudi Arabia. Data were collected through a questionnaire, consisting of two parts: Part 1 covers demographical data, which includes age, gender, educational level, and years of experience and place of work in the hospital. Part 2 of the questionnaire consists of (23) questions about the nurses' perception of the causes, reporting medication error, and perceptions of barriers to reporting medication errors. Data were analyzed by using a statistical package for social science (SPSS) version 20. Results: The results of the study indicate that most of the participants had a good perception of the causes of medication errors. Nevertheless, the data analysis showed that many of the participants had reporting medication errors. More importantly, the participants indicated that there exist multiple barriers to reporting medication errors. Two-thirds of them had moderate barriers to concerns over the consequences of reporting. More than half of them had minor barriers to blaming nurses if patients are harmed, while, about one-quarter of them had major barriers to fear of punishment. There was no statistically significant relationship between the studied nurses’ perception of the causes of medication errors and their characteristics (P value &gt; 0.05). Conclusions: It is concluded that nurses at Maternity and Child Hospital in Najran city, Saudi Arabia, Had a good perception of the causes of medication errors. In addition, there was no statistically significant relationship between the participants’ reporting medication errors and their characteristics except age and years of experience.

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy.

To describe pharmacist interventions as a result of an independent double check during cognitive order verification of outpatient parenteral anti-cancer therapy. A single-center, retrospective analysis of all individual orders for outpatient, parenteral anti-cancer agents within a hematology/oncology infusion center during a 30 day period was conducted. The primary endpoint was error identification rates during first and second verification. Secondary endpoints included the type, frequency, and severity of errors identified during second verification using a modified National Coordinating Council for Medication Error Reporting and Prevention Index. A total of 1970 anti-cancer parenteral orders were screened, from which 1645 received an independent double check and were included. The number of errors identified during first and second verification were 30 (1.8%) and 10 (0.6%) respectively; second verification resulted in a 33.3% increase in corrected errors. The 10 errors identified during second verification included: four rate transcriptions to optimize pump interoperability, three rate and/or volume modifications, two dosage adjustments, and one treatment deferral due to toxicity. The severity was classified as Category A for four (40%), Category C for three (30%), and Category D for three (30%) errors. This correlated to a low capacity for harm for seven (70%) and a serious capacity for three (30%) errors. Second verification of outpatient, parenteral anti-cancer medication orders resulted in a 33.3% increase in corrected errors. Three errors detected during second verification were determined to have a serious capacity for harm, supporting the value of independent double checks during pharmacist cognitive order verification.

Continuous quality improvement regulations for community pharmacy practice in the United States

ObjectivesIn the United States, medication errors are considered to be the cause of 7000 deaths annually. Continuous quality improvement (CQI) is a management process that focuses on continually and systematically evaluating the organization’s work process. In community pharmacy, CQI leads to enhanced patient safety through a reduction in medication errors and quality-related events (QREs). There is limited information about the variations in CQI regulations required by State Boards of Pharmacy (SBPs) for community pharmacy across the country. The objective of this study is to comprehensively describe CQI regulations required by SBPs for community pharmacy practice in the United States. MethodsThis was a cross-sectional study. Information regarding SBPs community pharmacy CQI regulations was collected electronically by surveying a representative of each SBP. In addition, a review of State Pharmacy Laws published online complemented the survey data. The percentage of states with CQI regulations for community pharmacy was estimated. ResultsOf the 50 Boards, 16 require pharmacies to maintain CQI programs to monitor and prevent QREs in community pharmacy. The most common elements of CQI programs include the management of known, alleged, and suspected medication errors that reach the patient (73%) and regular reviews of the pharmacy’s aggregate data of medication errors or incidents (73%). The North Dakota SBP regulation is the most comprehensive, followed by that of Iowa, Maryland, Massachusetts, and Montana. ConclusionThere is wide variation among SBP CQI regulations for community pharmacy practice. Standardization of CQI programs across Boards, including a national database for reporting medication errors and QREs would enhance patient safety.

Construction and analysis of a database for medication errors in a pharmacovigilance centre-the Moroccan experience.

The study aimed to describe the epidemiological profile of medication errors (MEs) reported to the Moroccan Pharmacovigilance Center (MPVC), to determine factors associated with serious MEs, and to describe signals related to them. We carried out a retrospective descriptive analysis of MEs reported to the MPVC from 2006 to 2016 and a secondary analysis of the seriousness of MEs with adverse drug reactions (ADRs). The reports were sorted by demographic profile and by ME and ADR characteristics. For signal detection, a quantitative approach was adopted, and the root cause analysis was completed. Epi info 7 software was used to perform descriptive and analytical statistics. The statistical significance level was set at p < 0.05. A total of 1618 ME reports were retrieved. The proportion of MEs associated with serious ADRs was 23.9%. The factors statistically associated with serious MEs were as follows: (i) the age group 16 years old and less (p < 0.001), (ii) the gender (p = 0.01), (iii) the administration and the prescription stages (p < 0.001), and (iv) the ME types related to inappropriate schedule of drug administration, drug prescribing error (p < 0.001), and incorrect drug administration dosage form (p = 0.04). Fourteen signals related to MEs were detected, for which risk minimization actions were implemented. The establishment of a ME unit within the MPVC was an opportunity to further improve the pharmacovigilance centre performance and consequently its contribution to medication safety. The lessons learned from MEs should be shared through pharmacovigilance networks and with institutions involved in medication safety for synergistic results to achieve patient safety worldwide.

Drug-Related Problems among Hospitalized Surgical Elderly Patients in China.

There is a lack of data on drug-related problems (DRPs) among elderly patients from surgical departments. The current study is aimed at identifying and categorizing types of DRPs and assessing the severities of the DRPs. Medication orders for hospitalized patients aged ≥65 years from six surgery departments were reviewed to determine DRPs over 6 months in a tertiary teaching hospital of Chongqing, China. DRPs were classified based on the Pharmaceutical Care Network Europe classification V8.02. The severity ratings of the DRPs were assessed using the National Coordinating Council for Medication Error Reporting and Prevention classification. A total of 53,231 medication orders from 1,707 elderly patients were reviewed, and 1,061 DRPs were identified. Treatment safety (44.9%) was the most common DRP type. Drug selection (43.1%) and dose selection (43.1%) were the major causes of DRPs. A total of 75.1% of the DRPs were classified into severity categories B to D (causing no or potential harm), and 24.9% were classified as categories E to H (causing actual harm). DRPs are common in hospitalized elderly surgical patients. Pharmacists should provide medication order reviews in this vulnerable patient population.