Medication Error Reporting Research Articles

Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.

The aim of this study was to determine prevented harm and cost avoidance following pharmacist intervention utilizing a discharge medication reconciliation tool. A retrospective chart review was conducted to identify patients with pharmacist-initiated, provider-accepted discharge medication reconciliation interventions completed at a community teaching hospital in January 2021. Investigators assigned the discrepancies targeted for intervention a National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) category, probability of harm, and calculated cost avoidance. The primary endpoint was the total cost avoidance associated with discharge medication reconciliation. Pharmacists intervened 190 times in January 2021, avoiding an estimated $46,958 to $231,032 in cost. High-risk medications were associated with $33,920 to $147,203 in cost avoidance. The 3 high-risk therapeutic classes associated with the highest cost avoidance were insulin ($16,738-$70,793), antithrombotics ($13,884-$60,016), and opioids ($2,638-$11,834). Targeted pharmacist discharge medication reconciliation and related interventions avoid significant cost and patient harm.

Evaluation of medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals: a cross-sectional study in Iran.

Medication errors in nursing negatively affect the quality of the provided health-treatment services and society's mentality about the health system, threatening the patient's life. Therefore, this study evaluates medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals. All the nurses working at teaching hospitals affiliated with Ahvaz Jundishapur University of Medical Sciences (southwest of Iran) comprised the statistical population of this research (260 participants). Data were collected using three questionnaires: a demographic characteristics questionnaire, a medication error questionnaire, and the standard Circadian Type Inventory (CTI) for a normal physiological cycle. At least one medication error was observed in 83.1% of nurses during their work span. A medication error was found in 36.2% of nurses during the COVID-19 pandemic (over the past year). Most medication errors (65.8%) occurred during the night shift. A significant relationship was detected between medication errors and shift work. Medicating one patient's drug to another (28.84%) and giving the wrong dose of drugs (27.69) were the most common types of medication errors. The utmost medication error was reported in emergency wards. The fear of reporting (with an average of 33.06) was the most important reason for not reporting medication errors (p < 0.01). Most nurses experienced a history of medication errors, which were increased by shift work and the COVID-19 pandemic. Necessary plans are recommended to reduce the fatigue and anxiety of nurses and prevent their burnout, particularly in critical situations. Efforts to identify risky areas, setting up reporting systems and error reduction strategies can help to develop preventive medicine. On the other hand, since the quality of people's lives is considered the standard of countries' superiority, by clarifying medical errors, a higher level of health, satisfaction and safety of patients will be provided.

Medication overdose data analysis: a review of medication error reports in the FDA adverse event reporting system (FAERS)

Backgrounddrug overdose is a common type of medication error, which caused significant patient injuries and economic losses. To determine which drugs are reported most frequently in association with drug overdose, a comprehensive search was conducted in the FDA Adverse Event Reporting System (FAERS) database. The study also sought to determine the top 10 drugs reported with drug overdose.MethodsFAERS database was searched for drug overdose records submitted from the first quarter of 2017 to the fourth quarter of 2021. Descriptive analyses were conducted based on the total counts and percentages of reports associated with the drug. Subgroup analyses were performed on drugs of different pharmacological classifications.ResultsA total of 170,424 drug overdose reports were retrieved. The results revealed that antipyretics and analgesics took the highest risk for overdose, with 63,143 (37.05%) cases reported. Among them, opioids were associated with the most drug overdose events. The top 10 drug classes relating to drug overdose in FAERS were opioid analgesic, anilide antipyretic analgesic, 5-HT reuptake inhibitors, bronchodilators, monoclonal antibodies and antibody-drug conjugates, benzodiazepines, antipsychotics, GABA derivatives, antimanic agents, and propionic acid derivatives.Conclusionto reduce the occurrence of drug overdose events, some methods could be considered including applying a pre-prescription review system, drug safety education, developing warning lists, etc.

Medication error reporting – An insight among final-year MBBS students and interns

Background: Medication errors can be defined as avoidable errors that can occur while prescribing, transcribing, dispensing, or administering a drug to a patient. Medication errors lead to mortality and morbidity of varying severities in patients. They also impose a heavy financial burden on the health-care sector. This study was conducted to compare three aspects of medication errors – Awareness, Outlook, and reporting, between two demographic groups, namely, interns and final-year MBBS students. Aims and Objectives: The objectives of this study were to evaluate the level of awareness about medication errors, the outlook toward medication errors and the medication errors reporting among MBBS students and Interns. Materials and Methods: A questionnaire was handed out to 500 people and it had questions related to awareness, outlook, and reporting of medication errors. Out of these 500 people, the number of respondents was 425 and they were grouped into various sub-categories based on their responses. Results: 30.6% of the respondents had sufficient awareness, 44.9% of the respondents had a good outlook, and 27.5% were reporting medication errors. The results also depicted that the Interns have better awareness and better practice of reporting when compared to final-year MBBS students. On the other hand, final-year MBBS students had a better outlook toward medication errors than Interns. Conclusion: It can be concluded from this study that more education and training in medication error reporting is essential right from the undergraduate level. There should also be well-established reporting systems in hospitals.

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.

Management of Medication Error Reporting in HIV/AIDS Patients

Background: One of the most frequent medical mistakes that lower patient safety and mortality is medication errors in HIV/AIDS patients. A structured reporting system is necessary for the efficient avoidance of these kinds of mistakes. In order to discover parameters influencing the management of medication mistake reporting in HIV-infected patients, the current research was carried out.&#x0D; Methods: The current research is an example of an applied study that was carried out between 2010 and 2019 utilizing a hybrid (quantitative-qualitative) methodology. First, the primary factors impacting the management of medication mistake reporting in HIV positive patients were collected from a study of the research literature and 35 interviews with experts in the area of treating HIV patients, and a research questionnaire was created utilizing them. Using the Lawshe approach, the questionnaire was sent to and collected from 31 experts in order to assess its content validity. SPSS23 was then used to determine the questionnaire's reliability, which resulted in a Cronbach's alpha value of 0.920. 400 workers who treated HIV/AIDS patients provided information for the data collection. Exploratory factor analysis was used to analyze the data, together with SPSS23 and Lisrel software.&#x0D; Results: Four factors were found to be important in managing medication mistake reporting in HIV patients, including organizational factors (18 variables), person factors (9 variables), educational factors (10 variables), and communication factors (6 variables). The management of medication mistake reporting in HIV patients was impacted most and least by personal and educational variables, with factor loadings of 0.784 and 0.754, respectively.&#x0D; Conclusion: It is preferable to concentrate on individual variables (employee-related hurdles, fear of the repercussions of reporting, and others' reactions) rather than addressing all four aspects at once in order to manage medication mistake reporting in HIV positive patients (managers, colleagues, patients). Managers, policymakers, specialists from behavioral disease counseling centers, and attending physicians should pay greater attention to both the individual (application and development of the integrated HIV management system).

Improving Medication Safety in an ICU

ABSTRACT Reported medication errors in an ICU at an academic teaching hospital raised concerns about adherence to safety protocols, including barcode scanning before medication administration. A group of nurse leaders, bedside nurses, and pharmacists formed a medication safety task force to increase compliance with barcode scanning and reduce reported medication errors in which failure to scan was a contributing factor. Three task force members observed nurses' workflow in ICU medication administration. The members observed three nurses administer medications before scanning the barcode and three other nurses scan medications in a location where they were unable to see alerts on the computer. After the observations, the task force implemented three interventions: medication tables to provide a surface in front of the computer where medications could be placed when scanning; standardized workflow; and nursing staff education. Task force members then conducted postimplementation observations to evaluate improvement in barcode scanning compliance. In the postintervention observations, all medications were scanned in front of the computer before administration, an increase of 27.3 percentage points (from 72.7% preintervention) in the barcode scanning compliance rate. The ICU also went 17 months in the postintervention period without a reported medication administration error in which failure to scan was a contributing factor. The task force's observation of medication administration led to interventions that made it easier for nurses to adhere to best practice. Medication tables were a simple, sustainable intervention that used human factors principles to increase barcode scanning compliance.

Characterization of Pediatric Reports in the US Food and Drug Administration Adverse Event Reporting System from 2010-2020: A Cross-Sectional Study.

The Food and Drug Administration Adverse Event Reporting System (FAERS) is a database of adverse event (AE) and medication error reports for drugs and therapeutic biologics. Examining trends of reported individual case safety reports (ICSRs) provides context for evaluating safety concerns. Characterize pediatric FAERS ICSRs and compare trends (1) to adult reports; (2) within pediatric subgroups. This cross-sectional study examined FAERS ICSRs received between January 1, 2010, through December 31, 2020. Stratified age bands were neonates, infants, younger children, older children, adolescents, and adults. We characterized groups by patient demographic information, suspect products, AEs, and reporter type. From 2010 to 2020, there were 11,258,995 FAERS ICSRs; 3.1% described pediatric patients. Compared to adults, pediatric ICSRs had higher proportions of all serious outcomes except death. Within pediatric subgroups, neonates had the highest proportions of serious outcomes (96.2%) compared to infants, younger children, older children, and adolescents (79.8%, 67.9%, 59.5%, and 52.7%, respectively). Younger pediatric age groups were more likely to have weight information than older age groups but were less likely to include gender information. The most frequently reported AE was off label use for pediatrics and drug ineffective for adults. Products and AEs reported also differed among pediatric subgroups. Neonates, infants, and adolescents had entirely distinct sets of top five product-event combinations. Pediatric ICSRs represent a minority of FAERS reports but have distinctly different attributes relative to adult ICSRs. Reporting trends also vary within pediatric subgroups, which highlights the need for unique considerations for pediatric safety surveillance.

Medication use optimization in critical care through a pharmacy morbidity, mortality, and improvement program

AbstractPharmacy‐led morbidity, mortality, and improvement (MMI) programs enhance practitioner education and improve patient‐safety culture. The impact of MMI programs on process improvement (PI) outcomes is lacking, particularly within critical care. The purpose of this retrospective report was to describe PI interventions from critical care medication errors evaluated through a pharmacy MMI program. Medication errors reported between June 2013 and August 2022 that occurred in an intensive care unit, emergency department, or procedural area were included. Error severity and potential were assessed using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index and Harm Associated with Medication Error Classification (HAMEC), respectively. The primary outcome of PI interventions was classified as clinical update, operations change, pharmacy or hospital administration change, and/or informatics and technology (IT) updates. Electronic medical record (EMR) were further classified as best practice advisory, medication order build/change, order set build/change, dose limit/alert, or infusion smart pump change. Institute for Healthcare Improvement (IHI) reliability level was evaluated as a secondary outcome. A total of 54 errors were included. Most errors were classified as NCC MERP category D (13 [24.1%]) and C (12 [22.2%]) with severe harm potential (HAMEC 4, 26 [48.1%]; median score 3 [interquartile range, IQR, 3–4]) error potential. A total of 88 PI interventions were identified (median 1.5 [IQR 1–2] per error); clinical (30 [34.1%]) and IT (26 [29.5%]) updates were the most common. Order set build or change (20 [45.5%]) was the most common EMR enhancement. PI interventions were a median IHI level 1 reliability (IQR, 1–2). EMR enhancements had a median IHI level of reliability of 2 (IQR, 1–2). Critical care medication errors addressed through a formal Pharmacy MMI program have high harm potential and often involve multiple PI interventions. EMR interventions generally had higher levels of empiric reliability.

Healthcare professional’s knowledge and awareness of the medication error reporting systems in the Kuwaiti hospitals

Abstract Objective. A survey was conducted to explore healthcare professional’s (HCPs) knowledge and attitude towards medication errors reporting processes and systems used in their local hospitals. Methods. There were 696 respondents and the observational survey showed the diverse perspectives of HCPs from diverse professions (doctors, pharmacists and nurses) who are at different stages in their career. The survey results highlighted the deficiencies in the medication safety management process, including the follow-up on witnessed or discovered medication errors, the effectiveness of the used reporting systems for medication errors, the standardisation of electronic prescribing software, and the training of HCPs at the six hospitals on medication safety. Key finding. Only 46% of the surveyed stated that their hospital had a mechanism in place for reporting medication errors and 60.7% of the participants agreed that they would submit reports provided the system is not used for performance management and only those need to know will be able to identify their name. Regarding prescription writing, 51% of surveyed HCPs said they utilise electronic prescribing software; however, the overall usage rate of electronic prescribing systems was 49%, with handwritten prescriptions remaining the option used in the majority of the time. In terms of HCP training, 20% of the survey respondents said they did not receive any instruction or direction in the hospitals on pharmacovigilance and patient safety. Conclusions. The Kuwaiti MoH should build a national electronic incident reporting system and establish standardised rules and protocols for incident reporting that is to be anonymous and of compulsory use by all government and private hospitals.

Medication Dispensing by Pharmacy Technicians Improves Efficiency and Patient Safety at a Geriatric Ward at a Danish Hospital: A Pilot Study.

This study aims to evaluate medication dispensing by pharmacy technicians at a geriatric inpatient ward at a Danish hospital. Four pharmacy technicians were trained in delivering a dispensing service at a geriatric ward. At baseline, the ward nurses recorded the time spent dispensing the medication and the number of interruptions. Similar recordings were completed twice during the period in which the pharmacy technicians delivered the dispensing service. Satisfaction among the ward staff with the dispensing service was assessed by a questionnaire. Reported medication errors were collected during the dispensing service period and compared to a similar time period during the previous two years. The time spent on dispensing medications was on average reduced with 1.4 h per day ranging from 4.7 to 3.3 h per day when the pharmacy technicians performed the service. Interruptions during the dispensing process decreased from a daily average of more than 19 times to an average of 2-3 per day. The nursing staff reported positive feedback on the medication dispensing service provided, especially about easing their workload. There was a tendency toward decreased reporting of medication errors. The medication dispensing service performed by the pharmacy technicians reduced time spent on dispensing medication and increased patient safety by reducing interruptions during the process and decreasing the number of medication errors reported.

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.

THE VIEWS OF NURSES WORKING IN SURGICAL CLINICS AND SURGICAL INTENSIVE CARE UNITS ON MEDICATION ADMINISTRATION ERRORS AND ERROR REPORTING

Aim: This study aims to identify the causes of medication administration errors and the reasons stated by nurses working in surgical clinics and surgical intensive care units for not reporting these errors, and to compare the number of errors nurses witness and the number of errors actually reported. Method: The research sample of this descriptive cross-sectional study consists of 125 nurses working in surgical clinics and surgical intensive care units. Data were collected using the face-to-face survey method. The Nurse Personal Information Form and the Medication Administration Error Scale were used to collect data. Results: The perceived medication administration error rate was found to be 59%; however, 61.6% of the nurses reported that only 0-20% of medication administration errors were actually reported. The main reasons for not reporting medication errors are administrative response (4.10±1.18) and fear (3.28±0.99). The most important reason for not reporting errors due to the administrative response is that no positive feedback is given after correct medication administration (4.18±1.53). The perceived cause of medication administration error is pharmacy-related and system-related, which explains 26% of the reason for not reporting the error due to fear. The fact that the reason for medication administration error originates from the physician, pharmacy and system explains 51% of the reason for not reporting the error due to disagreement over the error. Conclusion: There is a major difference between the medication administration errors nurses witness and the errors they actually report. The errors are not reported due to administrative response and fear.

Reducing Medication Errors by Adopting Automatic Dispensing Cabinets in Critical Care Units

Medication errors can have severe consequences and threaten patient safety. The patient safety-related benefits of automated dispensing cabinets (ADCs) have been reported by several previous studies, including a reduction in medication errors in intensive care units (ICUs) and emergency departments. However, the benefits of ADCs need to be assessed, given the different healthcare practice models. This study aimed to compare the rates of medication errors, including prescription, dispensing, and administrative, before and after using ADCs in intensive care units. The prescription, dispensing, and administrative error data before and after the adoption of ADCs were retrospectively collected from the medication error report system. The severity of medication errors was classified according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. The study outcome was the rate of medication errors. After the adoption of ADCs in the intensive care units, the rates of prescription and dispensing errors reduced from 3.03 to 1.75 per 100,000 prescriptions and 3.87 to 0 per 100,000 dispensations, respectively. The administrative error rate decreased from 0.046 to 0.026%. The ADCs decreased National Coordinating Council for Medication Error Reporting and Prevention category B and D errors by 75% and category C errors by 43%. To improve medication safety, multidisciplinary collaboration and strategies, such as the use of automated dispensing cabinets, education, and training programs from a systems perspective, are warranted.

Quality of MedDRA® Coding in a Sample of COVID-19 Vaccine Medication Error Data.

In recent years, there has been increasing interest from regulatory agencies and scientific organisations into the recording, coding and reporting of medication errors. Accuracy and consistency in the handling of medication error reports ensure the safety and effectiveness of medicines and provide reliable information to both healthcare professionals and patients. The authors have examined a sample of Medical Dictionary for Regulatory Activities (MedDRA®) coded reports that describe medication errors to assess the accuracy and consistency of MedDRA® coding, and to identify the main types of coding errors for the newly introduced COVID-19 vaccines. The sample of coded terms was assessed by two MedDRA® experts applying the Four Eyes Principle. It included 1500 reported terms drawn from the Uppsala Monitoring Centre database reported up to 25 August, 2021, describing medication errors for COVID-19 vaccines with their assigned MedDRA® terms. One third of the records could not be assessed because of incomplete or unclear verbatims. In one third, MedDRA® term assignments were correct, but another third of the sample was not adequately coded. The most frequent coding errors corresponded to vague MedDRA® Preferred Term assignments despite more detailed information being available in the verbatim for a more precise coding. This observation is similar to findings in the EudraVigilance database, where some of the most frequently assigned MedDRA® terms for medication errors also represent vague concepts. The findings indicate that understanding of medication error documentation and of the importance of accurate extraction of information from case narratives, as well as knowledge of MedDRA® content and coding guidelines need to be reinforced. The authors provide useful references to training opportunities and to the applicable International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use-Endorsed Guides for MedDRA® users.

Adherence, helpfulness and barriers to treatment in juvenile idiopathic arthritis – data from a German Inception cohort

ObjectivesTo develop and evaluate German versions of the Parent Adherence Report Questionnaire (PARQ) and Child Adherence Report Questionnaire (CARQ) and to evaluate adherence in patients with juvenile idiopathic arthritis (JIA).MethodsThe PARQ and CARQ were translated into German, cross-culturally adapted and administered to patients (age ≥ 8 years) and their parents enrolled in the Inception Cohort Study of newly diagnosed JIA patients (ICON).The psychometric issues were explored by analyzing their test–retest reliability and construct validity.ResultsFour hundred eighty-one parents and their children with JIA (n = 465) completed the PARQ and CARQ at the 4-year follow-up. Mean age and disease duration of patients were 10.1 ± 3.7 and 4.7 ± 0.8 years, respectively. The rate of missing values for PARQ/CARQ was generally satisfactory, test-retesting showed sufficient reliability. PARQ/CARQ mean child ability total scores (0–100, 100 = best) for medication were 73.1 ± 23.3/76.5 ± 24.2, for exercise: 85.6 ± 16.5/90.3 ± 15.0, for splints: 72.9 ± 24.2/82.9 ± 16.5. Construct validity was supported by PARQ and CARQ scores for medications, exercise and splints showing a fair to good correlation with the Global Adherence Assessment (GAA) and selected PedsQL scales. Adolescents showed poorer adherence than children. About one third of the parents and children reported medication errors. Perceived helpfulness was highest for medication, and adverse effects were reported the greatest barrier to treatment adherence.ConclusionsThe German versions of the PARQ and CARQ appear to have a good reliability and sufficient construct validity. These questionnaires are valuable tools for measuring treatment adherence, identifying potential barriers and evaluating helpfulness of treatments in patients with JIA.

Identification and Introduction of a New Classification of Key Performance Shaping Factors in Staff Performance in the Healthcare System

Background and Purpose: Selection of the appropriate performance shaping factors (PSFs) is a vital challenge encountered by all experts in human reliability analysis (HRA) and plays a significant role in achieving reliable results. The main purpose of this research is to present a comprehensive set of staff PSFs that affect the emergence of errors and incidents in the healthcare system, referred to as healthcare- (H)-PSFs. Materials and Methods: In this study, the set of H-PSFs was extracted using the PSFs presented for other fields and through consultation with HRA and healthcare experts. For investigation of whether the set of H-PSFs was comprehensive and appropriate, 318 reports of errors and incidents that had arisen at 14 hospitals during 12 months were examined, and the frequency values of each factor were obtained in two modes: where a PSF could and where it could not be repeated in an incident. The most significant H-PSFs were identified using Pareto charts. Also, using Minitab software, the Chi-square goodness of fit test was used to validate the proposed set of PSFs and demonstrate the appropriate accuracy of their frequency of occurrence. Results: According to experts, 43 PSFs were identified for the healthcare system. Using the medical error reports, the number of times that errors and mistakes were related to each PSF was calculated in two cases with and without repetition. To identify the most important PSFs, the Pareto principle has been used. According to the Pareto principle, 14 out of the 43 presented PSFs affected 80% of the errors and incidents that had arisen where PSF repetition was allowed, which amounted to 15 where repetition was not allowed. Conclusion: The Chi-square goodness of fit test result showed that the proposed H-PSFs have sufficient validity to be generalized to other healthcare systems. The results of this article can be of great help to healthcare system managers so that they can make better decisions with the help of the results of this article in formulating general and healthcare system policies. Also, the findings of this study can be used in the healthcare system to analyze and improve human reliability, direct resources more efficiently to improve the performance of safety management systems, and reduce errors and incidents.

Development and Interrater Agreement of a Novel Classification System Combining Medical and Surgical Adverse Event Reporting

Categorization systems for adverse events are not standardized across care settings and specialties and do not always include near miss events (events where there was potential for patient harm, but where no actual harm occurred), making it difficult to effectively assess patient safety for quality improvement. To develop and assess interrater agreement on a classification system for adverse events reporting that incorporates events in both inpatient and outpatient settings across medical and surgical subspecialties including near miss events. A cross-sectional study in a tertiary care center including 174 patient cases occurring from 2018 to 2020 was carried out. Data were abstracted from a Department of Otorhinolaryngology-Head and Neck Surgery Quality Assurance database. The cases were comprised of near miss and adverse events occurring in adult and pediatric patients in inpatient, outpatient, and emergency department settings. The ratings took place in March and April of 2022. Four raters (2 attending physicians and 2 senior resident physicians) were recruited to classify these cases according to 3 classification systems: the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Clavien-Dindo, and our novel Quality Improvement Classification System (QICS). The primary outcome was overall interrater agreements using Fleiss κ. Across all 4 raters grading 174 cases, the NCC-MERP, Clavien-Dindo, and QICS received a κ score. Fair-to-moderate interrater reliability was observed between the resident and attending physician groups across the 3 classification systems: NCC-MERP (κ = 0.33; 95% CI, 0.30-0.35), Clavien-Dindo (κ = 0.47; 95% CI, 0.43-0.50), and QICS (κ = 0.42; 95% CI, 0.39-0.44). Strong interrater concordance was observed for complications across all scenarios. This cross-sectional study found that the new QICS classification scheme was applicable to wide-ranging clinical scenarios with a focus on patient-centered outcomes including near miss events. In addition, QICS allowed for the comparison of patient outcome data in a multitude of settings.

Types, trends, and patterns of the reported antimicrobial errors to the eastern region’s medical centers in Saudi Arabia: A cross-sectional study

IntroductionMedication errors (MEs) are a huge burden on any healthcare system and have been associated with significant morbidity and mortality. The medical literature reported heavily on MEs but lacked focus on analyzing high-risk medications such as antimicrobials. Research design and methodsThis was a retrospective analysis of the MEs database reported by the eastern region’s medical centers in Saudi Arabia from January 1, 2019 to December 31, 2019. We used descriptive analysis to identify most common antimicrobials with errors, the stage of antimicrobial errors, type of the errors, contributing factors to the errors, and categories of errors based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) classification of errors. ResultsA total of 1422 (22.1%) antimicrobial errors were identified out of 6412 MEs. Amoxicillin/Clavulanate (18%) was the most common antimicrobial reported in the database. Most errors occurred in the prescribing phase (87.6%) and included mainly incorrect doses (32.1%) and duplicate therapy (20.5%). In addition, most errors were identified as category B (72.5%). Finally, inexperienced personnel (57.9%) was the most cited contributing factor. ConclusionThis study revealed that antimicrobial errors occur primarily during prescription and that policy gaps and inexperienced staff were contributory factors. To improve, the focus should shift to physician education, clear dosing guidelines, efficient workload management, and implementing antimicrobial stewardship programs to promote appropriate antimicrobial use.

Thực trạng báo cáo sự cố y khoa và một số yếu tố ảnh hưởng tại bệnh viện C Đà Nẵng năm 2021 - 2022

This study describes the current situation of medical error reporting and some influencing factors at C Hospital in Da Nang in 2021-2022. Secondary data from 269 error reports were analyzed and 12 in-depth interviews and 3 focus group discussions were conducted. Results showed that 72,1% risk cases and 27,9% of errors had occurred; Nurses reported errors (89,2%); Most errors were reported by clinical units (88,8%); Report a problem after 24 hours (67,3%); Some health workers have limited knowledge, are afraid of reporting, and report errors not on time; Operations manager reported medical errors well; Simple process that is easy to implement; Error reporting is encouraged; Training has not yet reached all staff. Keywords: Medical error report, influencing factors, C Hospital Da Nang