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Medication Errors (medication + error)
Selected AbstractsAN INVESTIGATION OF THE RELATIONSHIP BETWEEN SAFETY CLIMATE AND MEDICATION ERRORS AS WELL AS OTHER NURSE AND PATIENT OUTCOMESPERSONNEL PSYCHOLOGY, Issue 4 2006DAVID A. HOFMANN Safety climate has been shown to be associated with a number of important organizational outcomes. In this study, we take a broad view of safety climate,one that includes not only the development and adherence to safety protocols, but also open and constructive responses to errors,and investigate correlates within the health care industry. Drawing on a random, national sample of hospitals, the results revealed that safety climate predicted medication errors, nurse back injuries, urinary tract infections, patient satisfaction, patient perceptions of nurse responsiveness, and nurse satisfaction. As hypothesized, the relationship between safety climate and both medication errors and back injuries was moderated by the complexity of the patient conditions on the unit. Specifically, the effect of the overall safety climate of the unit was accentuated when dealing with more complex patient conditions. [source] Profiles in Patient Safety: Medication Errors in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 3 2004Pat Croskerry MD Abstract Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here. [source] Safe Prescribing Habits: Preventing Medication Errors in Primary CareNURSING FOR WOMENS HEALTH, Issue 4 2008Julie Freund PharmD First page of article [source] Medication Errors in the LDRPNURSING FOR WOMENS HEALTH, Issue 2 2004Identifying Common Errors Through MEDMARXSM Reporting Medication errors are perhaps the most common type of error occurring in health care settings; the effects of these types of errors span the gamut from no harm to death. It's widely held today that the majority of errors result from latent errors within a complex health care system, rather than from individual clinician performances. Open discussion of a medication error leads to a better understanding of the causes and contributing factors associated with the events, as well as provides essential elements required for the prevention of future medication errors. Here's a look at the most common medication errors in the labor, delivery, recovery and postpartum areas. [source] Response to ,Different Preparations of Tacrolimus and Medication Errors'AMERICAN JOURNAL OF TRANSPLANTATION, Issue 6 2009L. Chodoff No abstract is available for this article. [source] Profiles in Patient Safety: Medication Errors in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 3 2004Pat Croskerry MD Abstract Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here. [source] Medication errors in older people with mental health problems: a reviewINTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 6 2008Ian D Maidment Abstract Objective To review and summarise published data on medication errors in older people with mental health problems. Methods A systematic review was conducted to identify studies that investigated medication errors in older people with mental health problems. MEDLINE, EMBASE, PHARMLINE, COCHRANE COLLABORATION and PsycINFO were searched electronically. Any studies identified were scrutinized for further references. The title, abstract or full text was systematically reviewed for relevance. Results Data were extracted from eight studies. In total, information about 728 errors (459 administration, 248 prescribing, 7 dispensing, 12 transcribing, 2 unclassified) was available. The dataset related almost exclusively to inpatients, frequently involved non-psychotropics, and the majority of the errors were not serious. Conclusions Due to methodology issues it was impossible to calculate overall error rates. Future research should concentrate on serious errors within community settings, and clarify potential risk factors. Copyright © 2007 John Wiley & Sons, Ltd. [source] Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation)JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 2 2009Jonathan Karnon MSc PhD Abstract Rationale, Medication errors can lead to preventable adverse drug events (pADEs) that have significant cost and health implications. Errors often occur at care interfaces, and various interventions have been devised to reduce medication errors at the point of admission to hospital. The aim of this study is to assess the incremental costs and effects [measured as quality adjusted life years (QALYs)] of a range of such interventions for which evidence of effectiveness exists. Methods, A previously published medication errors model was adapted to describe the pathway of errors occurring at admission through to the occurrence of pADEs. The baseline model was populated using literature-based values, and then calibrated to observed outputs. Evidence of effects was derived from a systematic review of interventions aimed at preventing medication error at hospital admission. Results, All five interventions, for which evidence of effectiveness was identified, are estimated to be extremely cost-effective when compared with the baseline scenario. Pharmacist-led reconciliation intervention has the highest expected net benefits, and a probability of being cost-effective of over 60% by a QALY value of £10 000. Conclusions, The medication errors model provides reasonably strong evidence that some form of intervention to improve medicines reconciliation is a cost-effective use of NHS resources. The variation in the reported effectiveness of the few identified studies of medication error interventions illustrates the need for extreme attention to detail in the development of interventions, but also in their evaluation and may justify the primary evaluation of more than one specification of included interventions. [source] Implementation of an intravenous medication infusion pump system: implications for nursingJOURNAL OF NURSING MANAGEMENT, Issue 2 2008Marilyn Bowcutt MSN Aim, To assess perceptions of nurses regarding the implementation of intravenous medication infusion system technology and its impact on nursing care, reporting of medication errors and job satisfaction. Background, Medication errors are placing patients at high risk and creating an economic burden for hospitals and health care providers. Infusion pumps are available to decrease errors and promote safety. Methods, Survey of 1056 nurses in a tertiary care Magnet hospital, using the Infusion System Perception Scale. Response rate was 65.43%. Results, Nurses perceived the system would enhance their ability to provide quality nursing care, reduce medication errors. Job satisfaction was related to higher ratings of the management team and nursing staff. Perceptions verified the pump was designed to promote safe nursing practices. Conclusions, It is important to consider relationships with job satisfaction, safe nursing practice and the importance of ratings of nursing staff and management teams when implementing infusion technology. Implications for nursing management, Infusion pumps are perceived by nurses to enhance safe nursing practice. Results stress the importance of management teams in sociotechnological transformations and their impact on job satisfaction among nurses. [source] Rate, causes and reporting of medication errors in Jordan: nurses' perspectivesJOURNAL OF NURSING MANAGEMENT, Issue 6 2007MAJD T. MRAYYAN PhD Aim, The aim of the study was to describe Jordanian nurses' perceptions about various issues related to medication errors. Background, This is the first nursing study about medication errors in Jordan. Methods, This was a descriptive study. A convenient sample of 799 nurses from 24 hospitals was obtained. Descriptive and inferential statistics were used for data analysis. Results, Over the course of their nursing career, the average number of recalled committed medication errors per nurse was 2.2. Using incident reports, the rate of medication errors reported to nurse managers was 42.1%. Medication errors occurred mainly when medication labels/packaging were of poor quality or damaged. Nurses failed to report medication errors because they were afraid that they might be subjected to disciplinary actions or even lose their jobs. In the stepwise regression model, gender was the only predictor of medication errors in Jordan. Conclusions, Strategies to reduce or eliminate medication errors are required. [source] Medication Errors in the LDRPNURSING FOR WOMENS HEALTH, Issue 2 2004Identifying Common Errors Through MEDMARXSM Reporting Medication errors are perhaps the most common type of error occurring in health care settings; the effects of these types of errors span the gamut from no harm to death. It's widely held today that the majority of errors result from latent errors within a complex health care system, rather than from individual clinician performances. Open discussion of a medication error leads to a better understanding of the causes and contributing factors associated with the events, as well as provides essential elements required for the prevention of future medication errors. Here's a look at the most common medication errors in the labor, delivery, recovery and postpartum areas. [source] The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in a UK Intensive care unitANAESTHESIA, Issue 1 2007I. S. Sanghera Summary Our aim was to explore the attitudes and beliefs of healthcare professionals relating to the causes and reporting of medication errors in a UK intensive care unit. Medication errors were identified by the unit pharmacist and semi-structured qualitative interviews conducted with 13 members of staff involved with 12 errors. Interviews were analysed using a model of human error theory. Staff identified many contributing factors, including poor communication and frequent interruptions. Organisational factors included lack of clarity on the responsibility of the second nurse's check for medication administration, lack of feedback on medication errors, and a common and accepted practice of administering medication without a complete medication order. Barriers to reporting included administrative paperwork and lack of encouragement by management. Greater feedback on medication errors seems essential to improve current practice and increase reporting. [source] Medication errors: another important surgical problemANZ JOURNAL OF SURGERY, Issue 9 2009David G Bruce MD No abstract is available for this article. [source] Medication errors: EMERGing solutionsBRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 6 2009British Pharmacological Society, J K Aronson President No abstract is available for this article. [source] Medication errors: the role of the patientBRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 6 2009Nicky Britten 1. Patients and their carers will usually be the first to notice any observable problems resulting from medication errors. They will probably be unable to distinguish between medication errors, adverse drug reactions, or ,side effects'. 2. Little is known about how patients understand drug related problems or how they make attributions of adverse effects. Some research suggests that patients' cognitive models of adverse drug reactions bear a close relationship to models of illness perception. 3. Attributions of adverse drug reactions are related to people's previous experiences and to their level of education. The evidence suggests that on the whole patients' reports of adverse drug reactions are accurate. However, patients do not report all the problems they perceive and are more likely to report those that they do perceive as severe. Patients may not report problems attributed to their medications if they are fearful of doctors' reactions. Doctors may respond inappropriately to patients' concerns, for example by ignoring them. Some authors have proposed the use of a symptom checklist to elicit patients' reports of suspected adverse drug reactions. 4. Many patients want information about adverse drug effects, and the challenge for the professional is to judge how much information to provide and the best way of doing so. Professionals' inappropriate emphasis on adherence may be dangerous when a medication error has occurred. 5. Recent NICE guidelines recommend that professionals should ask patients if they have any concerns about their medicines, and this approach is likely to yield information conducive to the identification of medication errors. [source] Prevention of medication errors: detection and auditBRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 6 2009Germana Montesi 1. Medication errors have important implications for patient safety, and their identification is a main target in improving clinical practice errors, in order to prevent adverse events. 2. Error detection is the first crucial step. Approaches to this are likely to be different in research and routine care, and the most suitable must be chosen according to the setting. 3. The major methods for detecting medication errors and associated adverse drug-related events are chart review, computerized monitoring, administrative databases, and claims data, using direct observation, incident reporting, and patient monitoring. All of these methods have both advantages and limitations. 4. Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of a culture of safe practice. Combining and comparing data from various and encourages the diffusion of a culture of safe practice sources increases the reliability of the system. 5. Error prevention can be planned by means of retroactive and proactive tools, such as audit and Failure Mode, Effect, and Criticality Analysis (FMECA). Audit is also an educational activity, which promotes high-quality care; it should be carried out regularly. In an audit cycle we can compare what is actually done against reference standards and put in place corrective actions to improve the performances of individuals and systems. 6. Patient safety must be the first aim in every setting, in order to build safer systems, learning from errors and reducing the human and fiscal costs. [source] Educational strategy to reduce medication errors in a neonatal intensive care unitACTA PAEDIATRICA, Issue 5 2009Ainara Campino Abstract Objective: We aimed to evaluate the effect of a comprehensive preventive educational strategy on the number and type of drug errors in the prescription process in a regional neonatal intensive care unit (NICU). Design: Medication errors during prescription were recorded in a 41 bed, level III regional neonatal unit by a pharmacist. Data were retrieved from handwritten doctor's orders and introduced at bedsite into an e-database. Each prescription, not related to enteral and parenteral nutrition and blood products, was evaluated for dosage, units, route and dosing interval. The study was developed in three phases: pilot phase to know the baseline drug error rate and estimate sample size; pre-intervention (4182 drug orders reviewed); and post-intervention seven months after a comprehensive preventive educational intervention consisting sessions about drug errors and study's aims was implemented. Results: After the preventive educational intervention was implemented, the prescription error rate and the percentage of registers with one or more incident decreased significantly from 20.7 to 3% (p < 0.001) and from 19.2 to 2.9% (p < 0.001), respectively. Simultaneously, an improvement in correct identification of the prescribing physician was registered (from 1.3 to 78.2%). The rest of items analysed were similar in both periods. Conclusion: The implementation of a structured preventive educational intervention for health professionals in a regional NICU reduced the medication error rate, possibly by the dissemination of a patient safety culture. [source] Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation)JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 2 2009Jonathan Karnon MSc PhD Abstract Rationale, Medication errors can lead to preventable adverse drug events (pADEs) that have significant cost and health implications. Errors often occur at care interfaces, and various interventions have been devised to reduce medication errors at the point of admission to hospital. The aim of this study is to assess the incremental costs and effects [measured as quality adjusted life years (QALYs)] of a range of such interventions for which evidence of effectiveness exists. Methods, A previously published medication errors model was adapted to describe the pathway of errors occurring at admission through to the occurrence of pADEs. The baseline model was populated using literature-based values, and then calibrated to observed outputs. Evidence of effects was derived from a systematic review of interventions aimed at preventing medication error at hospital admission. Results, All five interventions, for which evidence of effectiveness was identified, are estimated to be extremely cost-effective when compared with the baseline scenario. Pharmacist-led reconciliation intervention has the highest expected net benefits, and a probability of being cost-effective of over 60% by a QALY value of £10 000. Conclusions, The medication errors model provides reasonably strong evidence that some form of intervention to improve medicines reconciliation is a cost-effective use of NHS resources. The variation in the reported effectiveness of the few identified studies of medication error interventions illustrates the need for extreme attention to detail in the development of interventions, but also in their evaluation and may justify the primary evaluation of more than one specification of included interventions. [source] Severe labetalol overdose in an 8-month-old infantPEDIATRIC ANESTHESIA, Issue 5 2008ADALBJÖRN THORSTEINSSON MD Summary We report a case of a large labetalol overdose in an eight-month-old infant that was being treated for hypertension following surgery for coarctation of the aorta. Labetalol, both alpha and beta adrenergic blocking agent was used for treating postoperative hypertension. By mistake, the patient was given an extremely high dose of labetalol intravenously (17.2 mg·kg,1). Remarkably, the medication error had a surprisingly limited clinical effect on the infant who survived the incident. We discuss the pharmacokinetic, pharmocodynamic and possible explanations for this fortunate turn of events. [source] Medication errors: the role of the patientBRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 6 2009Nicky Britten 1. Patients and their carers will usually be the first to notice any observable problems resulting from medication errors. They will probably be unable to distinguish between medication errors, adverse drug reactions, or ,side effects'. 2. Little is known about how patients understand drug related problems or how they make attributions of adverse effects. Some research suggests that patients' cognitive models of adverse drug reactions bear a close relationship to models of illness perception. 3. Attributions of adverse drug reactions are related to people's previous experiences and to their level of education. The evidence suggests that on the whole patients' reports of adverse drug reactions are accurate. However, patients do not report all the problems they perceive and are more likely to report those that they do perceive as severe. Patients may not report problems attributed to their medications if they are fearful of doctors' reactions. Doctors may respond inappropriately to patients' concerns, for example by ignoring them. Some authors have proposed the use of a symptom checklist to elicit patients' reports of suspected adverse drug reactions. 4. Many patients want information about adverse drug effects, and the challenge for the professional is to judge how much information to provide and the best way of doing so. Professionals' inappropriate emphasis on adherence may be dangerous when a medication error has occurred. 5. Recent NICE guidelines recommend that professionals should ask patients if they have any concerns about their medicines, and this approach is likely to yield information conducive to the identification of medication errors. [source] Strategies to reduce medication errors with reference to older adultsINTERNATIONAL JOURNAL OF EVIDENCE BASED HEALTHCARE, Issue 1 2006Brent Hodgkinson BSc (Hons) MSc GradCertPH GradCertEcon(Health) Abstract Background, In Australia, around 59% of the general population uses prescription medication with this number increasing to about 86% in those aged 65 and over and 83% of the population over 85 using two or more medications simultaneously. A recent report suggests that between 2% and 3% of all hospital admissions in Australia may be medication related with older Australians at higher risk because of higher levels of medicine intake and increased likelihood of being admitted to hospital. The most common medication errors encountered in hospitals in Australia are prescription/medication ordering errors, dispensing, administration and medication recording errors. Contributing factors to these errors have largely not been reported in the hospital environment. In the community, inappropriate drugs, prescribing errors, administration errors, and inappropriate dose errors are most common. Objectives, To present the best available evidence for strategies to prevent or reduce the incidence of medication errors associated with the prescribing, dispensing and administration of medicines in the older persons in the acute, subacute and residential care settings, with specific attention to persons aged 65 years and over. Search strategy, Bibliographic databases PubMed, Embase, Current contents, The Cochrane Library and others were searched from 1986 to present along with existing health technology websites. The reference lists of included studies and reviews were searched for any additional literature. Selection criteria, Systematic reviews, randomised controlled trials and other research methods such as non-randomised controlled trials, longitudinal studies, cohort or case,control studies, or descriptive studies that evaluate strategies to identify and manage medication incidents. Those people who are involved in the prescribing, dispensing or administering of medication to the older persons (aged 65 years and older) in the acute, subacute or residential care settings were included. Where these studies were limited, evidence available on the general patient population was used. Data collection and analysis, Study design and quality were tabulated and relative risks, odds ratios, mean differences and associated 95% confidence intervals were calculated from individual comparative studies containing count data where possible. All other data were presented in a narrative summary. Results, Strategies that have some evidence for reducing medication incidents are: ,,computerised physician ordering entry systems combined with clinical decision support systems; ,,individual medication supply systems when compared with other dispensing systems such as ward stock approaches; ,,use of clinical pharmacists in the inpatient setting; ,,checking of medication orders by two nurses before dispensing medication; ,,a Medication Administration Review and Safety committee; and ,,providing bedside glucose monitors and educating nurses on importance of timely insulin administration. In general, the evidence for the effectiveness of intervention strategies to reduce the incidence of medication errors is weak and high-quality controlled trials are needed in all areas of medication prescription and delivery. [source] Medication errors in older people with mental health problems: a reviewINTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 6 2008Ian D Maidment Abstract Objective To review and summarise published data on medication errors in older people with mental health problems. Methods A systematic review was conducted to identify studies that investigated medication errors in older people with mental health problems. MEDLINE, EMBASE, PHARMLINE, COCHRANE COLLABORATION and PsycINFO were searched electronically. Any studies identified were scrutinized for further references. The title, abstract or full text was systematically reviewed for relevance. Results Data were extracted from eight studies. In total, information about 728 errors (459 administration, 248 prescribing, 7 dispensing, 12 transcribing, 2 unclassified) was available. The dataset related almost exclusively to inpatients, frequently involved non-psychotropics, and the majority of the errors were not serious. Conclusions Due to methodology issues it was impossible to calculate overall error rates. Future research should concentrate on serious errors within community settings, and clarify potential risk factors. Copyright © 2007 John Wiley & Sons, Ltd. [source] Nursing care quality and adverse events in US hospitalsJOURNAL OF CLINICAL NURSING, Issue 15-16 2010Robert J Lucero Aim., To examine the association between nurses' reports of unmet nursing care needs and their reports of patients' receipt of the wrong medication or dose, nosocomial infections and patient falls with injury in hospitals. Background., Because nursing activities are often difficult to measure, and data are typically not collected by health care organisations, there are few studies that have addressed the association between nursing activities and patient outcomes. Design., Secondary analysis of cross-sectional data collected in 1999 from 10,184 staff nurses and 168 acute care hospitals in the US. Methods., Multivariate linear regression models estimated the effect of unmet nursing care needs on adverse events given the influence of patient factors and the care environment. Results., The proportion of necessary nursing care left undone ranged from 26% for preparing patients and families for discharge to as high as 74% for developing or updating nursing care plans. A majority of nurses reported that patients received the wrong medication or dose, acquired nosocomial infections, or had a fall with injury infrequently. However, nurses who reported that these adverse events occurred frequently varied considerably [i.e. medication errors (15%), patient falls with injury (20%), nosocomial infection (31%)]. After adjusting for patient factors and the care environment, there remained a significant association between unmet nursing care needs and each adverse event. Conclusion., The findings suggest that attention to optimising patient care delivery could result in a reduction in the occurrence of adverse events in hospitals. Relevance to clinical practice., The occurrence of adverse events may be mitigated when nurses complete care activities that require them to spend time with their patients. Hospitals should engage staff nurses in the creation of policies that influence human resources management to enhance their awareness of the care environment and patient care delivery. [source] An evaluation of a Diabetes Specialist Nurse prescriber on the system of delivering medicines to patients with diabetesJOURNAL OF CLINICAL NURSING, Issue 12 2008Nicola Carey BSc Aim., To evaluate the impact of a Diabetes Specialist Nurse prescriber on insulin and oral hypoglycaemic agent medication errors and length of stay. Background., The National Health Service has committed to a 40% reduction in the number of drug errors in the use of prescribed medicines. Drug errors in diabetes care are a common cause of significant morbidity and complications. Nurse prescribing creates an opportunity for nurses to improve care for these patients. Design., A quasi-experiment using six wards in a single hospital trust. Methods., Inpatient care of a convenience sample of patients with diabetes was evaluated before (n = 27) and after (n = 29) the intervention of a Diabetes Specialist Nurse prescriber. Prospective data were collected to measure insulin and oral hypoglycaemic medication errors and length of stay. Results., There was a significant reduction in the total number of errors between the pre-intervention and intervention group (mean reduction 21 errors) (p = 0·016). The median length of stay was reduced by three days. The total number of errors and length of stay were affected by admission category (p = 0·0004). Conclusions., A medicines management intervention, provided by a Diabetes Specialist Nurse prescriber, had a positive effect on the system of delivering medicines to patients with diabetes and significantly reduced the number of errors. This reduction had some effect on length of stay. The cost saving was sufficient to finance a Diabetes Specialist Nurse prescriber post. Relevance to clinical practice., (i) Errors frequently occur in the prescription and administration of medicines to patients with diabetes. (ii) The education of healthcare professionals is a factor contributing to these errors. (iii) Nurse prescribing provides a new system by which to educate patients and staff about their medicines. (iv) A Diabetes Specialist Nurse prescriber can reduce insulin and OHA MEs. This reduction had some effect on LOS. [source] A 3-year study of medication incidents in an acute general hospitalJOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 2 2008L. Song MPhil Summary Background and objective:, Inappropriate medication use may harm patients. We analysed medication incident reports (MIRs) as part of the feedback loop for quality assurance. Methods:, From all MIRs in a university-affiliated acute general hospital in Hong Kong in the period January 2004,December 2006, we analysed the time, nature, source and severity of medication errors. Results:, There were 1278 MIRs with 36 (range 15,107) MIRs per month on average. The number of MIRs fell from 649 in 2004, to 353 in 2005, and to 276 in 2006. The most common type was wrong strength/dosage (36·5%), followed by wrong drug (16·7%), wrong frequency (7·7%), wrong formulation (7·0%), wrong patient (6·9%) and wrong instruction (3·1%). 60·9%, 53·7% and 84·0% of MIRs arose from handwritten prescription (HP) rather than the computerized medication order entry in 2004, 2005 and 2006 respectively. In 43·1% of MIRs, preregistration house officers were involved. Most errors (80·2%) were detected before any drug was wrongly administered. The medications were administered in 212 cases (19·7%), which resulted in an untoward effect in nine cases (0·8%). Conclusions:, The most common errors were wrong dosage and wrong drug. Many incidents involved preregistration house officers and HPs. Our computerized systems appeared to reduce medication incidents. [source] Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation)JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 2 2009Jonathan Karnon MSc PhD Abstract Rationale, Medication errors can lead to preventable adverse drug events (pADEs) that have significant cost and health implications. Errors often occur at care interfaces, and various interventions have been devised to reduce medication errors at the point of admission to hospital. The aim of this study is to assess the incremental costs and effects [measured as quality adjusted life years (QALYs)] of a range of such interventions for which evidence of effectiveness exists. Methods, A previously published medication errors model was adapted to describe the pathway of errors occurring at admission through to the occurrence of pADEs. The baseline model was populated using literature-based values, and then calibrated to observed outputs. Evidence of effects was derived from a systematic review of interventions aimed at preventing medication error at hospital admission. Results, All five interventions, for which evidence of effectiveness was identified, are estimated to be extremely cost-effective when compared with the baseline scenario. Pharmacist-led reconciliation intervention has the highest expected net benefits, and a probability of being cost-effective of over 60% by a QALY value of £10 000. Conclusions, The medication errors model provides reasonably strong evidence that some form of intervention to improve medicines reconciliation is a cost-effective use of NHS resources. The variation in the reported effectiveness of the few identified studies of medication error interventions illustrates the need for extreme attention to detail in the development of interventions, but also in their evaluation and may justify the primary evaluation of more than one specification of included interventions. [source] Implementation of a patient-friendly medication schedule to improve patient safety within a healthcare systemJOURNAL OF HEALTHCARE RISK MANAGEMENT, Issue 4 2010Jodi E. Fredericks PharmD Preventable adverse drug events have a direct impact on the well-being of patients. The creation and implementation of a patient-friendly daily medication schedule improved the way care is delivered at Memorial Healthcare System. The staff collaborated with patients and families and empowered them with the knowledge and tools needed to make their healthcare safer. Patient and family participation, a critical component of patient- and family-centered care, is a vital part of making healthcare safer. This tool enhances communication with patients and family members and enables patients to better understand the medications they receive while hospitalized. An additional welcomed byproduct is the prevention of potential medication errors. [source] Developing an optimal approach to global drug safetyJOURNAL OF INTERNAL MEDICINE, Issue 4 2001R. Balkrishnan Abstract.,Balkrishnan R, Furberg CD (Wake Forest University School of Medicine, Winston-Salem, NC, USA). Developing an optimal approach to global drug safety (Review). J Intern Med 2001: 250; 271,279. An increasing number of media reports on a number of marketed drugs withdrawn because of harmful effects, a scientific report on epidemic proportions of serious adverse drug reactions in hospitalized patients, and a disturbing report on medical mistakes that includes medication errors have recently all brought drug safety into intense focus and placed it under greater scrutiny. Concerted efforts are now being made to understand the causes of drug safety problems and to find ways to reduce their frequency. An international symposium, ,Developing an Optimal Approach to Drug Safety' was held at Wake Forest University in the Fall of 2000 to identify the issues and solutions to extant problems in this area. This report summarizes the resulting discussions of global postmarketing surveillance initiatives and describes efforts to reduce medication errors, and improve global communication about drug safety. [source] Implementation of an intravenous medication infusion pump system: implications for nursingJOURNAL OF NURSING MANAGEMENT, Issue 2 2008Marilyn Bowcutt MSN Aim, To assess perceptions of nurses regarding the implementation of intravenous medication infusion system technology and its impact on nursing care, reporting of medication errors and job satisfaction. Background, Medication errors are placing patients at high risk and creating an economic burden for hospitals and health care providers. Infusion pumps are available to decrease errors and promote safety. Methods, Survey of 1056 nurses in a tertiary care Magnet hospital, using the Infusion System Perception Scale. Response rate was 65.43%. Results, Nurses perceived the system would enhance their ability to provide quality nursing care, reduce medication errors. Job satisfaction was related to higher ratings of the management team and nursing staff. Perceptions verified the pump was designed to promote safe nursing practices. Conclusions, It is important to consider relationships with job satisfaction, safe nursing practice and the importance of ratings of nursing staff and management teams when implementing infusion technology. Implications for nursing management, Infusion pumps are perceived by nurses to enhance safe nursing practice. Results stress the importance of management teams in sociotechnological transformations and their impact on job satisfaction among nurses. [source] Rate, causes and reporting of medication errors in Jordan: nurses' perspectivesJOURNAL OF NURSING MANAGEMENT, Issue 6 2007MAJD T. MRAYYAN PhD Aim, The aim of the study was to describe Jordanian nurses' perceptions about various issues related to medication errors. Background, This is the first nursing study about medication errors in Jordan. Methods, This was a descriptive study. A convenient sample of 799 nurses from 24 hospitals was obtained. Descriptive and inferential statistics were used for data analysis. Results, Over the course of their nursing career, the average number of recalled committed medication errors per nurse was 2.2. Using incident reports, the rate of medication errors reported to nurse managers was 42.1%. Medication errors occurred mainly when medication labels/packaging were of poor quality or damaged. Nurses failed to report medication errors because they were afraid that they might be subjected to disciplinary actions or even lose their jobs. In the stepwise regression model, gender was the only predictor of medication errors in Jordan. Conclusions, Strategies to reduce or eliminate medication errors are required. [source] | ||||||||||||||||||||||||||||