Types Of Medication Errors Research Articles

Reducing medication errors in HIV-positive patients: Influence of a clinical pharmacist.

The roll-out of antiretroviral medicines has improved life expectancy in people living with HIV (PLHIV). This has resulted in more patients being hospitalised for non-communicable diseases, increasing risk for medication errors (MEs). Pharmacists, through medication reconciliation, may identify and reduce MEs in this population. To describe the importance of a pharmacist's involvement in identifying and quantifying types of MEs. A quantitative, prospective observational study was conducted over 14 weeks. A pharmacist reviewed HIV-positive, hospitalised patients' files, using a data collection instrument, to determine the prevalence of MEs in PLHIV. The study pharmacist recommended appropriate actions to the prescriber to resolve MEs and documented resolution of the MEs. The study population of n = 180 patient files were reviewed 453 times, identifying 466 MEs. Medication errors included incorrect medication reconciliation from history (19; 4.1%), prescription omission (17; 3.7%), duplication of therapy (10; 2.2%), missed doses (265; 57.1%), incorrect dosing (103; 22.2%), incorrect administration frequency (2; 0.4%), incorrect duration of therapy (15; 3.2%) and drug-drug interactions (18; 3.9%). More than half (58.2%) of the MEs were resolved in less than 24 h, with involvement of the pharmacist. This study demonstrates the magnitude of MEs experienced in hospitalised PLHIV and highlights the role clinical pharmacists play in identifying and resolving MEs to improve patient outcomes.

Medication Errors in Pediatric Emergency Departments: A Systematic Review and Recommendations for Enhancing Medication Safety.

This systematic review aims to investigate the prevalence, preventability, and severity of medication errors in pediatric emergency departments (P-EDs). It also aims to identify common types of medication errors, implicated medications, risk factors, and evaluate the effectiveness of interventions in preventing these errors. A systematic review analyzed 6 primary studies with sample sizes ranging from 96 to 5000 pediatric patients in P-EDs. The review followed Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and included observational studies and randomized controlled trials involving patients aged 18 years and younger. Comprehensive searches in biomedical databases were conducted, and conflicts in record screening were resolved by a third reviewer using systematic review software. Medication errors in P-EDs are prevalent, ranging from 10% to 15%, with dosing errors being the most common, accounting for 39% to 49% of reported errors. These errors primarily stem from inaccurate weight estimations or dosage miscalculations. Inadequate dosing frequency and documentation also contribute significantly to medication errors. Commonly implicated medications include acetaminophen, analgesics, corticosteroids, antibiotics, bronchodilators, and intravenous fluids. Most errors are categorized as insignificant/mild (51.7% to 94.5%) or moderate (47.5%). Risk factors associated with medication errors in P-EDs include less experienced physicians, severely ill patients, and weekend/specific-hour ordering. Human factors such as noncompliance with procedures and communication failures further contribute to medication errors. Interventions such as health information technology solutions like ParentLink and electronic medical alert systems, as well as structured ordering systems, have shown promise in reducing these errors, although their effectiveness varies. Overall, this systematic review provides valuable insights into the complexity of medication errors in the P-ED, emphasizes the need for targeted interventions, and offers recommendations to enhance medication safety and reduce preventable errors in this critical health care setting.

A cross sectional survey of nurses’ reasons for medication errors at private multispecialty hospitals in Madurai, India

Abstract Introduction Healthcare services should eliminate errors, but any human-involved tasks are prone to error and healthcare is no exception.1 Medication errors are possible in hospitals though they should be eliminated with utmost care. Such medication errors would lead to an increased fatality rate, the emergence of new diseases, increased mediation costs and extended hospital stays.2,3 Aim This cross-sectional study aimed to classify and to identify the reasons for medication error as reported by the nurses and the impact of the collaborative work of Nurses, Pharmacists and Doctors in reducing medication errors and improving patient safety. Methods An exploratory (cross-sectional) study was conducted to classify and to identify the reasons for medication error among 474 nurses working in private multispecialty hospitals in Madurai between January to May 2023. The data for the study was collected using a questionnaire which included demographic variables and questions on medication errors. The questionnaire was filled through a one-to-one interview method and the data collected were analysed using SPSS 21.0. Results The results of analyses done using SPSS revealed that 58.2% of nurses reported having made medication errors and 88.4% of them said they had reported these immediately on the occurrence of such errors to their nursing superintendents. The most common type of medication errors reported were wrong infusion rates and wrong medicines, especially for medicines with similar sounding names (sound-alike drugs). Lack of awareness of the causes of medication errors was found to be the major reason for the occurrence of such errors in hospitals. The analyses showed that there was a significant relationship between age, years of experience and medication errors. One-way ANOVA analysis revealed that the greater the age and experience, the lesser the occurrence of medication errors. However, there was no significant relationship between working shifts and medication errors. The findings also highlighted that the greater the number of patients in the ward, the higher the error in oral administration of drugs. The finding reveals that teamwork between nurses, pharmacists and doctors was reported to help to drastically reduce the number of errors. Discussion/Conclusion Whilst a small-scale study only and reliant on accurate self-reporting, the findings suggest that not all nurses report medication errors, which could result in adverse outcomes for patients. Hence the nursing managers or nursing superintendents should encourage nurses to report medication errors to ensure patient safety. The findings also suggest that collaborative work between nurses, pharmacists, and doctors can reduce medication errors, hence collaborative work and appointing clinical Pharmacists is important to reducing medication errors.

Medication error and associated factors among adults admitted to emergency ward at the university of Gondar comprehensive specialized hospital, North-West Ethiopia: a cross-sectional study, 2022

BackgroundMedication errors are the most common cause of preventable adverse drug events at the emergency ward.ObjectivesThis study assessed medication errors and associated factors among adult patients admitted to the emergency ward at the University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia.MethodsA cross-sectional study was conducted from June 1, 2022, to August 30, 2022. Data were entered into EpiData Manager 4.6.0.0 for clearing and exported to SPSS version 24 for analysis. Descriptive statistics such as frequencies, medians with an interquartile range and inferential statistics like binary logistic regression were used for data analysis. The level of significance was declared at a p value less than 0.05 with a 95% confidence interval.ResultsFrom 422 study participants, medication errors were found in three-fourths (74.4%) of study participants. The most frequent type of medication error was omitted dose (26.27%). From a total of 491 medication errors, 97.75% were not prevented before reaching patients. More than one-third (38.9%) of medication errors had potentially moderate harmful outcomes. More than half (55.15%) of possible causes of medication errors committed by staff are due to behavioral factors. Physicians accepted 99.16% and nurses accepted 98.71% of clinical pharmacist intervention. Hospital stay ≥ 6 days (AOR: 3.00 95% CI 1.65–5.45, p < 0.001), polypharmacy (AOR: 5.47, 95% CI 2.77–10.81 p < 0.001), and Charlson comorbidity index ≥ 3 (AOR: 1.94, 95% CI (1.02–3.68), p < 0.04) significantly associated with medication error.ConclusionsAbout three-fourths of adult patients admitted to the emergency ward experienced medication errors. A considerable amount of medication errors were potentially moderately harmful. Most medication errors were due to behavioral factors. Most clinical pharmacists’ interventions were accepted by physicians and nurses. Patients who stayed longer at the emergency ward, had a Charlson comorbidity index value of ≥ 3, and were on polypharmacy were at high risk of medication error. The hospital should strive to reduce medication errors at the emergency ward.

A text mining approach to categorize patient safety event reports by medication error type

Patient safety reporting systems give healthcare provider staff the ability to report medication related safety events and errors; however, many of these reports go unanalyzed and safety hazards go undetected. The objective of this study is to examine whether natural language processing can be used to better categorize medication related patient safety event reports. 3,861 medication related patient safety event reports that were previously annotated using a consolidated medication error taxonomy were used to develop three models using the following algorithms: (1) logistic regression, (2) elastic net, and (3) XGBoost. After development, models were tested, and model performance was analyzed. We found the XGBoost model performed best across all medication error categories. ‘Wrong Drug’, ‘Wrong Dosage Form or Technique or Route’, and ‘Improper Dose/Dose Omission’ categories performed best across the three models. In addition, we identified five words most closely associated with each medication error category and which medication error categories were most likely to co-occur. Machine learning techniques offer a semi-automated method for identifying specific medication error types from the free text of patient safety event reports. These algorithms have the potential to improve the categorization of medication related patient safety event reports which may lead to better identification of important medication safety patterns and trends.

The Nature, Causes, and Clinical Impact of Errors in the Clinical Laboratory Testing Process Leading to Diagnostic Error: A Voluntary Incident Report Analysis.

Diagnostic errors, that is, missed, delayed, or wrong diagnoses, are a common type of medical errors and preventable iatrogenic harm. Errors in the laboratory testing process can lead to diagnostic errors. This retrospective analysis of voluntary incident reports aimed to investigate the nature, causes, and clinical impact of errors, including diagnostic errors, in the clinical laboratory testing process. We used a sample of 600 voluntary incident reports concerning diagnostic testing selected from all incident reports filed at the University Medical Center Utrecht in 2017-2018. From these incident reports, we included all reports concerning the clinical laboratory testing process. For these incidents, we determined the following: nature: in which phase of the testing process the error occurred; cause: human, technical, organizational; and clinical impact: the type and severity of the harm to the patient, including diagnostic error. Three hundred twenty-seven reports were included in the analysis. In 77.1%, the error occurred in the preanalytical phase, 13.5% in the analytical phase and 8.0% in the postanalytical phase (1.5% undetermined). Human factors were the most frequent cause (58.7%). Severe clinical impact occurred relatively more often in the analytical and postanalytical phase, 32% and 28%, respectively, compared with the preanalytical phase (40%). In 195 cases (60%), there was a potential diagnostic error as consequence, mainly a potential delay in the diagnostic process (50.5%). Errors in the laboratory testing process often lead to potential diagnostic errors. Although prone to incomplete information on causes and clinical impact, voluntary incident reports are a valuable source for research on diagnostic error related to errors in the clinical laboratory testing process.

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.

Determining Medication Errors in an Adult Intensive Care Unit.

Research addressing the costs of Medication errors (MEs) is still scarce despite issues related to patient safety having significant economic and health impacts, making it imperative to analyze the costs and adverse events related to MEs for a better patient, professional, and institutional safety. To identify the number of medication errors and verify whether this number was associated with increased hospitalization costs for patients in an Intensive Care Unit (ICU). This retrospective cross-sectional cohort study evaluated secondary data from patients' electronic medical records to compile variables, create a model, and survey hospitalization costs. The statistical analysis included calculating medication error rates, descriptive analysis, and simple and multivariate regression. The omission error rate showed the highest number of errors per drug dose (59.8%) and total errors observed in the sample (55.31%), followed by the time error rate (26.97%; 24.95%). The omission error had the highest average when analyzing the entire hospitalization (170.40) and day of hospitalization (13.79). Hospitalization costs were significantly and positively correlated with scheduling errors, with an increase of BRL 121.92 (about USD $25.00) (95% CI 43.09; 200.74), and to prescription errors, with an increase of BRL 63.51 (about USD $3.00) (95% CI 29.93; 97.09). We observed an association between two types of medication errors and increased hospitalization costs in an adult ICU (scheduling and prescription errors).

What to learn from analysis of medical disputes related to medication errors in nursing care.

Nurses, who are the last safeguard against and have the final opportunity to prevent medication errors (MEs), play a vital role in patient safety by managing medications. This study described the characteristics of medical dispute cases, medication information, and stage and types of MEs in Korea. We performed a descriptive analysis of 27 medical dispute cases related to MEs in nursing care in Korea. Around 77.7% of patients suffered serious harm or died due to MEs in this study. The types of medications included anxiolytics and analgesics, and 51.9% of them were high-alert medications. Among cases of administration errors, failure to patient assessment before and after administration was the most common error followed by administering the wrong dose. Nurses should perform their duties to ensure safety and improve the quality of nursing care by monitoring patients after administering medications and should be prepared to take quick action to reduce harm.

A 10-Year Retrospective Analysis of Medication Errors among Adult Patients: Characteristics and Outcomes.

Medication errors (MEs) are a global health problem. We conducted this study to clarify the clinical characteristics, outcomes, and factors associated with MEs that caused harm to adult patients (>15 years of age) who were managed in hospitals or healthcare facilities. We performed a 10-year retrospective study (2011-2020) by analyzing data from the Ramathibodi Poison Center (RPC) database (RPC Toxic Exposure Surveillance System). There were a total of 112 patients included in this study. Most were women (59.8%) and had underlying diseases (53.6%). The mean patient age was 50.5 years. Most MEs occurred during the afternoon shift (51.8%) and in the outpatient department (65.2%). The most common type of ME was a dose error (40.2%). Local anesthetic was the most common class of ME-related drug. Five patients died due to MEs. We analyzed the factors associated with MEs that caused patient harm, including death (categories E-I). The presence of underlying diseases was the single factor that was statistically significantly different between groups. Clinical characteristics showed no significant difference between patients aged 15-65 years and those aged >65 years. In conclusion, our findings emphasized that MEs can cause harm and even death in some adult patients. Local anesthetics were the most commonly involved in MEs. Having an underlying disease might contribute to severe consequences from MEs. Preventive measures and safety systems must be highlighted and applied to prevent or minimize the occurrence of MEs.

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.

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.

Medication error during nonoperating room anesthesia—a case report

Despite a lot has already been done in the field of safety improvement during anesthesia, medication errors still occur during everyday practice. Syringe or ampule swaps are usually the most frequent type of medication error. Recent studies prove that nearly 80% of these errors are preventable. In our case, 30 mg (3 ml) of dopamine (Dopamin Fresenius 10 mg/ml) was injected to the patient’s intravenous line instead of 3 mg (3 ml) midazolam (Midazolam Accord 1 mg/ml) during the preparation for the carotid artery stenting procedure in nonoperating room environment. The error was realized immediately after the application. Besides temporary fulminant hypertensive reaction, tachycardia, restlessness, skin rush, troponin leak, and temporary ST-segment depression, there were no permanent consequences to the patient's health. The team was able to perform the planned procedure 30 min after the event. This medication error of ampule swap, packages of which were stored in the medication cupboard one above the other, was caused by alignment of the latent vulnerable layers of the safety system (Swiss Cheese Model of System Error and Hot Cheese Model) plus the influence of the environmental factors and active failures done by the anesthesia staff. After this event, new safety measures were established by introducing color-coded ISO 26825:2020 syringe labeling, new anesthesia trolleys with color-coded medication compartments, and color-coded medication storage cupboards. Besides this safety committee was formed for the promotion of medication safety education programs.

Design and Implementation of Online Medical Laboratory Diagnostic System

The laboratory testing method in today's world, is inefficient and error-prone. Laboratory errors are inherently enigmatic because they are difficult to detect and, once discovered, are more difficult to comprehend than other types of medical errors. Medical errors, such as the loss of patient data and the mixing up of patient findings, can no longer be considered unavoidable, but can instead be actively minimized and prevented. In light of the COVID epidemic, this approach eliminates the necessity for direct physical contact between the laboratory technician and the patient being tested, as well as the resources and time spent bringing oneself to the hospital and waiting for a test that takes only a few minutes. This paper proffers a solution for the above stated issues and also provided a foundational framework for scalability. Prototyping software development model was adopted and use cases was for modelling of the system.

Analysis of medical malpractice liability disputes related to novel antineoplastic drugs and research on risk prevention and control strategies.

To investigate the general characteristics of litigation cases of medical malpractice liability disputes (MMLDs) related to novel antineoplastic drugs (NADs), the drugs involved, as well as the common types of medical errors related to NADs and their damages in the process of diagnosis and treatment, with the aims of improving the level of rational medication use in the clinical application of NADs and actively prevent medical disputes. The China Judgments Online was searched for the cause of action using the key word "MMLDs" along with the name of 77 kinds of NADs. A total of 39 NAD litigation cases meeting the inclusion criteria from 1 January 2009 to 31 December 2021 were analyzed, and each potential adverse drug reaction (ADR) was reviewed to determine a causality assessment using the Naranjo algorithm for non-drug-induced liver injury (DILI) cases and the updated Roussel Uclaf Causality Assessment Method (RUCAM) for the DILI cases. Risk prevention and control strategies were recommended. Cases that met the inclusion criteria increased substantially each year during the last six years, from three cases in 2009-2015 to 36 cases in 2016-2021. There were more cases in Eastern China than in other geographic regions. Most cases involved tertiary hospitals, patients between 25 and 60 years of age, and patients who were predominately male. There were 18 kinds of NADs involved in medical errors. The most common consequences of NADs were closely related to the death, disability, and increased treatment costs caused by ADRs, inadequate indications, delayed diagnosis and treatment, and misdiagnosis and mistreatment. The most frequent medical errors were medical technology errors, medical ethics errors and medical record writing/safekeeping errors. In two cases involving DILI, one case was unable to undergo further RUCAM scoring because the liver function indicators of the patient before and after treatment were not published. The establishment of mechanisms to reduce the risks associated with the clinical application of NADs is warranted. Healthcare services must maintain strict adherence to the specific requirements of GPCANADs and drug instructions and strictly grasp the indications, contraindications, usage, and dosage of drugs, and strengthen the notification and management of off-label drug use. Monitoring patients for ADRs and preparing rescue and treatment measures for high-risk drugs may serve to reduce damages related to NADs. For DILI cases, medical and appraisal institutions should use RUCAM score to assess causal relationships.

Perception of Medical Error Among Resident Doctors at the University College Hospital (Uch), Ibadan

To enhance the standard of patient care, it is necessary to look into the complex issue of resident doctors' perceptions of medical error at tertiary hospitals. To foster a culture of safety in medical practice, medical mistake must be addressed in Nigeria, where it is a major contributor to patient mortality and morbidity. Therefore, this study aimed to determine the perception of medical error among resident doctors in the University College Hospital, Ibadan. In order to choose a sample of 302 resident doctors from a pool of 515 at the University College Hospital (UCH), a two-stage sampling approach was used. The research methodology used in this study was a cross-sectional survey employing a pretested self-administered semi-structured questionnaire. At the 0.05 level of significance, data were analyzed using descriptive statistics as well as inferential statistics like chi-square 228 (75.5%) of the responders were men, and 74 (24.5%) were women. Approximately 33.4% of the respondents were pre-part 1, 64.9% of resident doctors were post-part 1, and 1.7% were post-part 2 of their fellowship tests. The majority of responders (82.1%) had between one and three years of resident doctor experience. A majority (70.2%) of the respondents reported that misdiagnosis generally often occur in a medical setting. About 40.4% of the respondents said that delayed diagnosis is the most common type of medical error in the institution. There was a statistical significant association between the frequency of occurrence of delayed diagnosis and the departments of the resident doctors (X²=16.892, P&lt;0.001). A majority (62.3%) of respondents reported that high work load, ill-equipped facility, work environment, patient factor and institutional factors influence their daily medical practice. Most (88.1%) of the respondents believed prevention of medical error is very crucial in the healthcare system. About 31.5% of the respondents indicated that continuous education on preventing and managing medical error was not adequately provided for resident medical doctors. The institution needs to invest in better-equipped facilities that will support high-quality patient care, continue medical education to advance medical knowledge and skills related to medical error, deploy more medical personnel to lessen the burdensome workload on current staff members, and establish proactive error avoidance strategies for the management of medical malpractice. This will thus improve the quality of healthcare delivery and reinforce possible standards of care that are evidence-based against medical error.

Content analysis of nurses’ reflections on medication errors in a regional hospital

Background Medication errors [MEs] continue to be an area of concern both nationally and internationally. Methods Sixty-eight reflective summaries detailing reasons for medication errors completed by nurses at an Australian regional teaching hospital during a five-year period were analysed. Results Fifteen codes emerged from the data that aligned to three main categories of the Human Factors Framework. They were: Individual characteristics such as inexperience, stress and lack of knowledge (5 codes), Nature of the work such as prescription errors, time pressure, miscommunication, poor handover and documentation errors (9 codes) and Physical environment such as distractions (1 code). Individual characteristics were the most frequently reported (51.6%) reasons for the error. Conclusions Provision of medicine information resources and management of nurses’ workload as well as enhancing graduate nurse education with simulation of ‘real life’ clinical settings appear to be the main targets for intervention.

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.

Artículo traducido] Conciliación de la medicación en el alta desde la unidad de cuidados intensivos a la planta de hospitalización

ObjectivesThe aim of this study was to determine whether the transition of care from the intensive care unit to the ward would pose a high risk for reconciliation errors. The primary outcome of this study was to describe and quantify the discrepancies and reconciliation errors. Secondary outcomes included classification of the reconciliation errors by type of medication error, therapeutic group of the drugs involved and grade of potential severity. MethodsWe conducted a retrospective observational study of reconciliated adult patients discharged from the Intensive Care Unit to the ward. Before a patient was discharged from the intensive care unit, their last intensive care unit’s prescriptions were compared with their proposed medication list in the ward. The discrepancies between these were classified as justified discrepancies or reconciliation errors. Reconciliation errors were classified by type of error, potential severity, and therapeutic group. ResultsWe found that 452 patients were reconciliated. At least one discrepancy was detected in 34.29% (155/452), and 18.14% (82/452) had at least one reconciliation errors. The most found error types were a different dose or administration route (31.79% [48/151]) and omission errors (31.79% [48/151]). High alert medication was involved in 19.20% of reconciliation errors (29/151). ConclusionsOur study shows that intensive care unit to non-intensive care unit transitions are high-risk processes for reconciliation error. They frequently occur and occasionally involve high alert medication, and their severity could require additional monitoring or cause temporary harm. Medication reconciliation can reduce reconciliation errors.

Medication reconciliation for patients after their discharge from intensive care unit to the hospital ward

ObjectivesThe aim of this study was to determine whether the transition of care from the intensive care unit to the ward would pose a high risk for reconciliation errors. The primary outcome of this study was to describe and quantify the discrepancies and reconciliation errors. Secondary outcomes included classification of the reconciliation errors by type of medication error, therapeutic group of the drugs involved and grade of potential severity. MethodsWe conducted a retrospective observational study of reconciliated adult patients discharged from the Intensive Care Unit to the ward. Before a patient was discharged from the intensive care unit, their last intensive care unit's prescriptions were compared with their proposed medication list in the ward. The discrepancies between these were classified as justified discrepancies or reconciliation errors. Reconciliation errors were classified by type of error, potential severity, and therapeutic group. ResultsWe found that 452 patients were reconciliated. At least one discrepancy was detected in 34.29% (155/452), and 18.14% (82/452) had at least one reconciliation errors. The most found error types were a different dose or administration route (31.79% (48/151)) and omission errors (31.79% (48/151)). High alert medication was involved in 19.20% of reconciliation errors (29/151). ConclusionsOur study shows that intensive care unit to non-intensive care unit transitions are high-risk processes for reconciliation error. They frequently occur and occasionally involve high alert medication, and their severity could require additional monitoring or cause temporary harm. Medication reconciliation can reduce reconciliation errors.