Source Of Medical Error Research Articles

Some issues of the quality of medical care

This article discusses the features of applying the theory of quality to medical science and practice. The methods of analytical medicine show the internal contradiction of the existing theory of diagnostics as a source of medical errors. Approaches to resolving this paradox are given.

A User-Centered Approach to Designing Secondary Anesthesia Medication Labels

Poorly designed and implemented medication labels have been identified as a source of medication errors within anesthesia delivery. Previous studies noted that simplified text and icons are useful in warning labels used for prescription drugs, especially for people with low literacy levels. In addition, Tallman lettering can reduce errors due to the custom capitalization of text. However, icons, color, and Tallman lettering have not been explored for improving the readability of anesthesia medication labels. This study utilizes a user- centered approach to design and evaluate icons and other graphical features to be included on secondary medication labels placed on infusion bags within anesthesia point-of-care. The study utilizes an iterative design process to examine the potential efficacy of these design characteristics by evaluating them with the anesthesia providers/clinicians through an online survey. Findings suggest that introducing graphical components like icons and color may be useful and accepted by clinicians to improve medication recognition.

Definition of Healthy Ranges for Alanine Aminotransferase Levels: A 2021 Update.

The changing epidemiology of liver disease, and modifications in the recommended analytical methodology call for a re‐evaluation of the upper reference limits (URLs) of alanine aminotransferase (ALT) levels. Using the same approach consolidated 20 years ago to define the healthy population, we defined the URL for the newly recommended International Federation of Clinical Chemistry (IFCC) standardized test. In a cross‐sectional study, we examined 21,296 apparently healthy blood donors (age 18‐65 years) and calculated the sex‐specific URL by the 95th percentile in individuals without risk factors for liver disease. These were tested for the ability to predict liver damage in a subset of 745 participants with dysmetabolism, in an independent cohort of 977 unselected donors, and in 899 patients with chronic liver disease. ALT levels were measured by the IFCC test. Male sex, body mass index, glucose, lipids, ferritin, hypertension, and younger age were independent ALT predictors (P < 0.001). Updated URLs were identified at 42/30 U/L in males/females, approximately 30% lower than those currently recommended by the IFCC. Due to improved sensitivity, they conferred the ability to detect steatosis and significant fibrosis in individuals with dysmetabolism (odds ratio [OR] = 2.31, range 1.40‐3.80, P = 0.001; and OR = 3.35, range 1.19‐9.42, P = 0.021; respectively), although with a limited accuracy, and significant fibrosis in unselected donors (OR = 2.32, 1.02‐5.31, P = 0.045). Updated URLs had a moderate to high accuracy to discriminate liver conditions (area under the receiver operating characteristic curve = 0.81, range 0.78‐0.91). Conclusion: Updated URLs by the IFCC method were lower than those calculated in initial studies, but higher than those in use with the recommended old, nonstandardized method, and were able to better predict liver disease. The limited awareness that different techniques are still in use should be regarded as a possible source of medical errors.

Medication Misadventures Among COVID-19 Patients in Saudi Arabia

Background: Due to the need for early and effective medications for coronavirus disease (COVID-19), less attention may have been paid to medication safety during this pandemic.Objectives: This study aimed to examine the incidence, nature, and seriousness of medication errors (MEs) and adverse drug reactions (ADRs) among hospitalized patients with COVID-19.Materials and methods: This is a retrospective study of MEs and ADRs reported at the King Saud Medical City (KSMC) between April 2020 and September 2020.Results: A total of 343 MEs and 416 ADRs were reported during the study period. The incidence of MEs was 19% (19/100). Seventy-five MEs (21.5%) reached the patient but did not cause any harm. Wrong dose (n=101, 29.4%) was the most common type of MEs. Physicians were the most common source of MEs (87.5%). Antibiotics (32%) and antineoplastics (25%) were the most common drug categories involved in MEs and ADRs, respectively. Thirty-nine percent (n=163) of the ADRs were of serious nature. 24% (n=100) required hospitalization, 5% (n=21) were life-threatening, 16 (3.8%) required intervention to prevent permanent impairment or damage, and 6.2% (n=26) resulted in the discontinuation of treatment.Conclusion: The reporting of MEs appears to be high among COVID-19 patients in a large tertiary care setting in the Kingdom of Saudi Arabia (KSA). The majority of MEs were caused by dosing errors and errors in drug frequency, mostly ascribed to physicians, which may be indicative of burnout or stress among them. The reporting of MEs and ADRs can be improved by providing incentives to healthcare professionals (HCPs) and promoting a non-punitive culture. Further studies should explore the clinical consequences of medication misadventures in hospitalized COVID-19 patients.

A study on identification of medication error in a Tertiary Care Hospital, Chennai

Background: Medication errors have become an increasing threat in compromising patient’s quality of life. This study sought to identify the occurrence of medication error in a tertiary care hospital. The objective behind the study is to find out the prevalence of medication error, their source and reasons behind its occurrence in a tertiary hospital care setting in Chennai. Method: A prospective observational study was done for six months duration with the help of patient treatment chart, prescriptions and nursing administration records. Data was collected using a medication error identification form. A total of 174 records were collected from cardiology, general medicine, gynaecology, gastroenterology, neurology, nephrology, orthopaedics, oncology and pulmonology departments. Among the 174 patient records, 120 medication error came into notice. Results: Among 120 medication errors, 32.5% (39) error happened during documentation of the patient medical records. Administration error were of 30% (36) followed by prescription error 25.83% (31), transcription error 7.5% (9) and dispensing error 4.16% (5). The source of medication error were studied during the survey and found that 70% of medication error were happened by nurses as they contributed for a large population of healthcare workers. 26% (31) medication error by physicians during prescribing medical orders and 4% (5) medication errors by pharmacist during drug dispensing occurred. Reasons behind the prevalence of medication error was also observed during the study and found that negligence/carelessness (41.6%) by the healthcare professionals was the ultimate reason for the occurrence of medication error followed by illegible prescriptions (32.5%), improper documentations (17.5%) and other miscellaneous factors (8.3%) during a hospital stay.

A review of medication errors in iran: sources, underreporting reasons and preventive measures.

Medication error (ME) is the most common preventable cause of adverse drug events which negatively affects patient safety. Inadequate, low-quality studies plus wide estimation variations in ME from developing countries including Iran, decreases the reliability of ME evaluations. To clarify sources, underreporting reasons and preventive measures of MEs, we reviewed Iran current available literature. We searched Scopus, WOS, PubMed, CINAHL, EBSCOHOST and Persian databases (IranMedex, and SID) up to October 2012. Two authors independently selected and one reviewed and extracted data. Results reported by more than 30% of studies considered as the most important topics. Finally 25 articles were included. All study designs were cross-sectional (except for two interventional studies) and in hospital settings. Nursing staff and students were the most observed populations. Individual factor, with "inadequate knowledge of medication" as its most frequent reason, were the mostly reported source of MEs. Fear and reporting process were two most important reporting barriers. The sense of being reprimanded and ignoring to report respectively were their most frequent factors. Anti-infectives were the most frequent drugs involved in MEs. Preventive measures were varied and reporting of their effectiveness was inconsistent. There are still many research gaps which need to be explored by further studies. Based on our findings, further researches may be focused on design, implementation, and evaluation of a ME reporting system as groundwork, assessing systems-related factors to ME alongside individual factors and evaluating the effectiveness of preventive measures for MEs in trials.

320 Assessment of Medication Prescribing using Test your Care Metrics

Abstract Background Medication records are essential components of patient care and a source of medical error. The HSE Code of Practice for Healthcare Records Management has highlighted criteria which must be complied with in these records. In the HSE Clinical Strategy and Programmes Division, “Test your care” is used to promote a code of practice and a set of metrics which need to be adhered to. Methods We reviewed all drug kardexes in 14 wards both medical and surgical in a 48 hour period. We assessed the drug kardexes based on 9 different metrics. (Generic names used, capital letters used, start date recorded, legible dosing, route and frequency of medication documented, minimum dosing documented, legible prescriptions and discontinued drugs crossed off) Results 285 drug kardexes were reviewed. No drug kardex was fully compliant with the 9 standards. The main deficits were in relation to use of brand names, no documentation of frequency and omission of IMC numbers. The average number of metrics met was lower on surgical wards than medical wards - 3.6 vs 4.7 respectively, and this difference was statistically significant (p&lt; .00001; 2 sample t test). Conclusion The universal poor compliance with these standards highlights both the poor design of the current drug kardex and poor awareness with prescribers of these standards. In the current drug kardex, there is no dedicated space for frequency or IMC number and therefore these are often forgotten. The use of brand names consistently highlights poor prescribing practice and more education is required to improve this. We plan to improve current prescribing education sessions for all doctors to highlight the current deficiencies and to increase compliance with standards.

Inpatient Medication Errors and Pharmacist Intervention at Ministry of Health Public Hospital, Riyadh, Saudi Arabia

Pharmacology, Toxicology and Biomedical Reports,2019,5,1,44-48.DOI:10.5530/PTB.2019.5.8Published:January 2019Type:Research ArticleAuthors:Yousef Ahmed Alomi, Nesreen Alshabaar, Nadia Lubad, and Fatimah Ali Albusalih Author(s) affiliations:Yousef Ahmed Alomi*, The Past General Manager of General Administration of Pharmaceutical Care Head, National Clinical Pharmacy and Pharmacy Practice Head, Pharmacy R & D Administration, Ministry of Health, Riyadh 11392, SAUDI ARABIA. Nesreen Alshabaar, King Salman Hospital, Ministry of Health, Riyadh 11392, SAUDI ARABIA. Nadia Lubad, King Salman Hospital, Ministry of Health, Riyadh 11392, Riyadh, SAUDI ARABIA. Fatimah Ali Albusalih, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University (University of Dammam) Dammam, SAUDI ARABIA. Abstract:Objectives: To explore the inpatient medication errors and pharmacist intervention at Ministry of Health Hospital, Riyadh, Saudi Arabia. Methods: This is a 9-month cross-sectional study conducted at a 300-bed public hospital to evaluate pharmacist response and prevention of inpatient medication errors in adult and pediatric patients. There is a medication safety officer in the hospital along with a medication safety committee. The following information on medication errors were documented in the form available at the hospital: patient’s demographic information, sources of medication errors, time of errors, type of errors, description of errors, causes of errors, recommendation to prevent such errors and the outcome of errors. The form was developed by using the National Coordinating Council (NCC) for Medication Error Reporting and Prevention (MERP) system. Results: According to the results, the pharmacist prevented a total of 3089 medication errors within 805 patients. About 3.8 errors per prescription were prevented. Most of the prevention occurred during prescribing stage (705 (99.2%)). Patient-related errors (1564 (50.63%)) and prescriber-related errors (1435 (46.46%)) were the most type of prevented errors. Allergy was the most prevented subtype of errors (560 (91.4%)) followed by patient’s body weight (543 (88.6%)) and prescriber data missing/unclear (347 (56.6%)). Most of the errors that were prevented were near miss (93.3%) followed by 6.3% of the errors that reached the patient but did not cause any harm. The highest percentage with respect to the causes of medication errors was missing clinical information (649 (83.7%)) and miscommunication of drug order (627 (80.9%)). The top 20 medications involved in medication errors were oral and intravenous injections (Paracetamol and enoxaparin injection, respectively). Conclusion: The pharmacist plays a very crucial role in preventing medication errors. In order to prevent medication errors and improve patient outcome, the pharmacist provides education to the healthcare professional about medication safety and establishes the intravenous medication guidelines. Keywords:Inpatient, Intervention, Medication errors, Ministry of Health, Pharmacist, Riyadh, Saudi ArabiaView:PDF (192.53 KB) PDF PDF Images Table 2A: Pharmacist intervention of stage of medication operation.

Structured Radiology Reporting: Addressing the Communication Quality Gap

Ineffective communication in healthcare contributes to patient morbidity and mortality. Understanding why failures in communication occur requires an understanding of how healthcare professionals communicate and models explaining the communication process. Radiologists communicate most commonly using the radiology report. Worldwide it is estimated that billions of radiological examinations are performed annually. The quality of each radiology report can contribute to patient care either in a positive manner leading to better outcomes or can be a source of medical error. Recent articles highlight quality gaps in radiology reports related not only to accuracy but also to clarity and completeness. We review and highlight the gaps related to the quality of radiology reports and discuss strategies to improve effective communication.

GAMBARAN PIO SWAMEDIKASI APOTEKER DALAM PENATALAKSANAAN FLU

&#x0D; Abstract&#x0D; &#x0D; Self-medication is a human effort to treat diseases or symptoms of minor ailments such as fever, cough, flu, pain and others without a doctor's prescription. In practice, limited knowledge of drugs and their use can be a source of medication errors (medication error). This research was conducted with a cross sectional descriptive research method. Data was collected through a validated questionnaire filling technique. A total of 300 respondents involved in this study were selected by consecutive sampling method from 3 pharmacies in the city of Purwokerto which were determined proportionally according to the population of each pharmacy. Data were analyzed by Chi-square test and Fisher's test used Statistical Product and Servicer Solution (SPSS) version 17. The results showed that the patient's knowledge level was 22.6% classified as poor, 48% classified as moderate, and 29.4% classified as good. The use of self-medication is 26.3% irrational and 73.7% rational. Based on the results of the study, it was found that the patient's level of knowledge was classified as moderate with a percentage of 48%. While self-administered rationality is classified as rational with a percentage of 73.7%.&#x0D; &#x0D; Keywords: Self-medication, Pharmacy, Knowledge, Rationality of drug use

TINGKAT PENGETAHUAN PASIEN TENTANG SWAMEDIKASI OBAT

Abstract&#x0D; Self-medication is a human effort to treat diseases or symptoms of minor ailments such as fever, cough, flu, pain and others without a doctor's prescription. In practice, limited knowledge of drugs and their use can be a source of medication errors (medication error). This research was conducted with a cross sectional descriptive research method. Data was collected through a validated questionnaire filling technique. A total of 300 respondents involved in this study were selected by consecutive sampling method from 3 pharmacies in the city of Purwokerto which were determined proportionally according to the population of each pharmacy. Data were analyzed by Chi-square test and Fisher's test used Statistical Product and Servicer Solution (SPSS) version 17. The results showed that the patient's knowledge level was 22.6% classified as poor, 48% classified as moderate, and 29.4% classified as good. The use of self-medication is 26.3% irrational and 73.7% rational. Based on the results of the study, it was found that the patient's level of knowledge was classified as moderate with a percentage of 48%. While self-administered rationality is classified as rational with a percentage of 73.7%. &#x0D; &#x0D; Keywords: Self-medication, Pharmacy, Knowledge, Rationality of drug use

PENGARUH FAKTOR USIA, JENIS KELAMIN, DAN PENGETAHUAN TERHADAP SWAMEDIKASI OBAT

Abstract&#x0D; &#x0D; Self-medication is a human effort to treat diseases or symptoms of minor ailments such as fever, cough, flu, pain and others without a doctor's prescription. In practice, limited knowledge of drugs and their use can be a source of medication errors (medication error). This research was conducted with a cross sectional descriptive research method. Data was collected through a validated questionnaire filling technique. A total of 300 respondents involved in this study were selected by consecutive sampling method from 3 pharmacies in the city of Purwokerto which were determined proportionally according to the population of each pharmacy. Data were analyzed by Chi-square test and Fisher's test used Statistical Product and Servicer Solution (SPSS) version 17. The results showed that the patient's knowledge level was 22.6% classified as poor, 48% classified as moderate, and 29.4% classified as good. The use of self-medication is 26.3% irrational and 73.7% rational. Based on the results of the Chi-square and Fisher test, the level of knowledge is influenced by age, recent education, and occupation. While self-medication rationality is not influenced by gender, education and employment. Based on the results of the study, it was found that the patient's level of knowledge was classified as moderate with a percentage of 48%. While self-administered rationality is classified as rational with a percentage of 73.7%.&#x0D; &#x0D; Keywords: self-medication, pharmacy, rationality of drug use

Predrawn prehospital medications are microbiologically safe for up to 48 hours

BackgroundPrehospital medical teams are commonly required to administer a range of medications for urgent stabilisation and treatment. The safe preparation of medications during resuscitation requires attention, time and resources, and...

Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study

BackgroundOperating room (OR) to the intensive care unit (ICU) handoffs are known sources of medical error, yet little is known about the relationship between process failures and patient harm. MethodsInterviews were conducted with clinicians involved in the OR-to-ICU handoff to characterize the relationship between handoff process failures and patient harm. Qualitative analysis was used to inductively identify key themes. ResultsA total of 38 interviews were conducted. Dominant themes included early communication from the OR to the ICU, team member participation in the handoff, and relationships between clinicians; clinician perspectives varied depending substantially on role within the team. ConclusionsThe findings suggest that ambiguous roles and conflicting expectations of team members during the OR-to-ICU handoff can increase risk of patient harm. Future studies should investigate early postoperative ICU care as outcome markers of handoff quality and the effect of interprofessional education on clinician adherence to interventions.

Talking Back: A Review of Handoffs in Pediatric Emergency Care

Incomplete communication is a critical source of medical error and subsequent patient harm within the health care system. Patient handoffs in health care require the coordinated transfer of information, responsibility, and authority between providers. In pediatric emergency medicine, there are specific cultural and structural factors that contribute to the need for evidenced-based and standardized handoff practices. This review presents an overview of the existing literature on handoffs to inform guidance for the development and implementation of high-efficacy handoff tools in pediatric emergency medicine.

Design and Delivery of a Tailored Intervention to Implement Recommendations for Multimorbid Patients Receiving Polypharmacy into Primary Care Practices

Introduction. Managing polypharmacy is particularly demanding for general practitioners as coordinators of care. Recently, a German guideline for polypharmacy in primary care has been published. This paper describes the content and delivery of a tailored intervention, which aims at improving the implementation of guideline recommendations for polypharmacy into practice, considering individual barriers. Materials and Methods. Firstly, barriers for implementation and the corresponding strategies to address them have been identified. On this basis, an intervention consisting of a workshop for health care professionals and educational materials for patients has been developed. The workshop focused on knowledge, awareness, and skills. The educational materials included a tablet computer. Practice teams will elaborate individual concepts of how to implement the recommendations into their practice. The workshop has been evaluated by the participants by means of a questionnaire. Results. During the workshop 41 possible sources of medication errors and 41 strategies to improve medication management have been identified. Participants evaluated the workshop overall positively, certifying its relevancy to practice. Discussion. The concept of the workshop seemed appropriate to impart knowledge about medication management to the participants. It will have to be evaluated, if the intervention finally resulted in an improved implementation of the guideline recommendations.

Opportunities and limitations in using google glass to assist drug dispensing.

The administration of intravenous drugs is a significant source of medical errors. Protocol based care are have been demonstrated to be an efficient way to favor best practices and to avoid simple errors such as those related to expiration date, hygiene regulation among other. The recent availability of the Google Glass, a hands free wearable device offers new opportunities to access care protocols at patients' bedside. In this article, we present a prototype application for displaying care protocols developed through a user centered design. The software enables the navigation through the different steps of care protocols and their validation using barcodes. Three interactions paradigms, tactile, vocal and by eye blink are proposed in order to provide hands free manipulation when necessary. The realization of a concrete project revealed some limitations that should be taken in account in order to ensure the proper behavior of the tool. If no formal evaluation has been performed, the first feedbacks are very positive and encourage us to go forward and test the tool in real care situations.

Travelling with Multiple Medicines: A Source of Medication Error and non-Adherent ‘Forgetting’

One commonly cited reason for medication non-adherence and errors is ‘forgetting’ to take medicines. Research has identified the difficulty of remembering to take medicines whilst away from home, yet little in-depth research exists that explores people’s own perspectives. This study examined the experiences of people taking multiple medicines to improve understanding of their daily use and management. Methods Participants were 34 Australians taking 5+ prescription or over-the-counter medicines, recruited through GPs, pharmacies, e-newsletters, consumer organisations and snowballing. Semi-structured narrative interviews explored: multiple medicines use, medicines management, maintaining usual life, and messages for others taking multiple medicines. Interviews were video- and/or audio-recorded and transcribed verbatim. Constant comparative thematic analysis was conducted. Results Travel was a key reason for forgetting to take medicines and making mistakes. Overseas travel and complex regimens posed particular challenges, such as crossing international datelines and maintaining medication routines when other daily routines were suspended. Packing medicines was complex, time-consuming and vulnerable to mistakes. The main challenges in travelling with medicines included: packing the correct doses for the period of travel; storage; availability of medicines at destination; language barriers; access to health services. Effective strategies for travelling with multiple medicines came with experience and knowledge gained from mishaps. Conclusions People who take multiple medicines face challenges adhering to their medication regimen when travelling and devise many useful strategies from which others can learn. Patient’s experiences of travelling with multiple medicines can be informative for the community pharmacist who receives customer requests for advice about travelling with medicines, and from out-of-town customers with medication concerns.

Conflits en période périopératoire : un enjeu collectif, éthique et professionnel

In the perioperative period, several potential conflicts between anaesthetists/intensive care specialists and surgeons may exist. They are detrimental to the quality of patient care and to the well-being of the teams. They are a source of medical errors and contribute to burn-out. Patients can become the victims of such conflicts, which deserve ethical reflection. Their resolution through analysis and shared solutions is necessary. This article seeks to analyse these conflicts, taking into account their specificities and constraints. In order to understand this context, it is important to consider the specificities of each group involved and the records of such situations. Several factors can prevent these conflicts, first and foremost the patients themselves and the quality of the care that is provided. Medical deontology aims mainly at preventing and resolving these conflicts. Generally speaking, the quality approach which is increasingly applied in health care institutions (involving declarations of adverse events, morbidity/mortality reviews, benchmarking, analysis and improvement of practices, etc.) also contributes to the prevention and resolution of disagreements. The teaching of communication techniques that begins with the initial training, the evaluation of team behaviours (through simulation training for example), the respect of others’ constraints, particularly when it comes to learning, as well as transparency regarding conflicts of interests, are all additional elements of conflict prevention. Lastly, conflicts may at times be caused by deviant behaviours, which must be met with a clear and uncompromising collective and institutional approach. This article concludes by offering a standardised approach for conflict resolution.

Management of the Hospitalized Patient With Type I Diabetes Mellitus

Patients with type 1 diabetes mellitus (T1DM) have minimal to absent pancreatic β-cell function and rely on the exogenous delivery of insulin to obtain adequate and life-sustaining glucose homeostasis. Maintaining glycemic control is challenging in hospitalized patients with T1DM, as insulin requirements are influenced by the presence of acute medical or surgical conditions, as well as altered nutritional intake. The risks of hyperglycemia, ketoacidosis, hypoglycemia, and glycemic variability are increased in hospitalized patients with T1DM. Diabetic ketoacidosis and severe hypoglycemia are the 2 most common emergency conditions that account for the majority of hospital admissions in patients with T1DM. The association between hyperglycemia and increased risk of complications and mortality in patients with type 2 diabetes (T2DM) is well established; however, the impact of glycemic control on clinical outcomes has not been determined in patients with T1DM who present without ketoacidosis. To decrease complications associated with insulin therapy, health care professionals must be well versed in the use of insulin because it is a common source of medication error. For non-critically ill, hospitalized patients, subcutaneous insulin given to cover basal and prandial needs instead of sliding scale is the preferred method of insulin dosing. Protocols are available for initiating and titrating insulin doses, as well as for transitioning from an insulin infusion to a subcutaneous regimen. In our review, we identify and discuss special considerations related to inpatient glycemic control of non-ketotic patients with T1DM. Additionally, point differences and similarities associated with the management of patients with T2DM are discussed.