Perceptions and factors contributing to medication errors amongst the health-care providers in a tertiary care hospital

Background: The use of drugs in the medical field (health care) to reduce the illness process and suffering in the patients is very common. The drugs used should not harm or introduce a new ailment in the patients, which will indirectly increase the burden to the patient, relatives, and also to the society in many ways. Aims and Objectives: The primary objective of the study is to assess the awareness about medication errors among various healthcare professionals – doctors, nurses, and pharmacist, also to spread the awareness on avoiding these medication error and suggest remedies to minimize these errors after analyzing the data. Materials and Methods: This is a descriptive study undertaken after ethical committee approval and conducted by self-reported questionnaires in health-care providers. The participants are grouped into three groups as: Group A: Postgraduates of clinical departments; Group B: Nurses in intensive care unit, casualty and OT; and Group C: Pharmacists. The responses are analyzed using SPSS 17 software. Results: The study shows all the three groups that are equally involved in the mediation errors in different levels of health administration starting from selection of drugs, prescription writing, dispensing of medicine, and also administration of drugs to the patients. Conclusion: Many issues are involved in medication errors done by the health-care providers in different levels of care giving which should be corrected and minimized using latest technologies, reducing the overworking, conducting the lectures, seminars regularly will reduce the occurrence of the incidence, and suffering in such patients.

Investigation of the Appropriate Threshold for Warning Dosage and Development of a Predictive Logistic Regression Model to Detect Dose- Error of Prednisolone Tablets / 医薬品情報学

Objective: The wrong dose of high-risk drugs such as oral steroids is a serious issue that needs to be addressed. This study aims to determine the appropriate upper tolerable dose threshold and to develop a multi-variable logistic regression model to detect dose-errors in oral prednisolone tablets.Methods: Data on Prednisolone prescriptions were obtained from a single center. Out of the data collected, positive cases consisted of cases where dose-related modifications were made. A univariate logistic regression model was developed with the current daily dose. In the model, the Youden Index was used to determine the upper tolerable dose threshold. The investigation was done to determine whether the performance of the multivariate model was improved by adding clinical department and previous prescription information as variables.Results: Univariate models (AUC: 0.645) with only current daily doses and estimated optimal thresholds of 6 mg/day or 11 mg/day, respectively were determined to be appropriate. Including variables improved the performance of the predictive model; the best performing model (AUC: 0.840) was derived when the following variables were entered: “current daily dose,” “current prescription days,” “clinical department,” “daily dose of the previous prescription,” and “prescription days of the previous prescription”.Conclusion: A single upper tolerance limit is insufficient to determine dose adequacy for prednisolone tablets owing to their broad clinical dose range. Itmay be possible to develop a high-performance dose audit support model by adding information.

Premezclados como alternativa para el uso seguro de medicamentos intravenosos en escenarios de atención en salud / Premixed products, an alternative for safe intravenous medications use in health care settings / As pré-misturas como alternativa para o uso seguro de drogas intravenosas em ambientes de saúde

RESUMEN Objetivo: presentar el panorama de errores de medicación, los recursos asociados a la preparación de medicamentos intravenosos y el uso de premezclados en la aten ción en salud. Metodología: se realizaron búsquedas en diferentes bases de datos, sin límite de fecha o tipo de estudio. Adicionalmente se realizó un análisis para estimar los costos, validando con expertos los recursos en central de mezclas. Resultados: los errores de medicación son un error médico común a nivel global. Los datos disponi bles son heterogéneos, pero sugieren que los errores de medicación pueden ser una causa considerable de morbilidad y mortalidad en ciertas poblaciones y contextos, con intervenciones adicionales, estancias hospitalarias prolongadas, mayores costos de atención y reducción en la probabilidad de que el tratamiento sea oportuno y eficaz. En medicinas intravenosas resultan escenarios de mayor gravedad y mayor nivel de costos. Los costos laborales anuales para una central de mezclas en Colombia se estiman entre 281,5 y 422,3 millones de pesos. La estandarización, como parte de los fármacos premezclados proporciona menor riesgo de contaminación, menor posibilidad de error en la preparación, menor incidencia de complicaciones rela cionadas con la terapia, disminución del desperdicio, mejora en la oportunidad de dispensación, optimización en el trabajo de los equipos de farmacia y reducción de costos asociados con este proceso. Conclusiones: el uso de premezclados, como parte de un programa de reducción de errores de medicación, puede mejorar los indicadores de calidad en administración de medicamentos y garantizar un uso más seguro de la terapia intravenosa.

SUMMARY Objective: To present an overview of medication preparation and administration errors, the resources implied in the preparation of intravenous medications, and the use of premixed drugs in healthcare settings. Methodology: We performed a litera ture review without limits by date or type of study. Additionally, analysis and vali dation by pharmaceutical experts were carried out to estimate the use of resources and related costs. Results: The available heterogeneous data suggest that medication errors are a significant cause of morbidity and mortality in specific populations and settings. Error medications cause additional interventions, prolonged hospitalization, higher costs of care, and a reduction in the treatment probability of success. Errors involving intravenously administered drugs have more severe consequences and generate higher costs. Annual labor costs for centralized medication mixing in Colombia are estimated between $281.5 and $422.3 million. Premixed drugs decrease the risk of contamination, the possibility of error in the preparation, and the incidence of complications related to therapy. Also, its use is related to the reduc tion of waste, improvement in the timing of dispensing, optimizing the pharmacy team, and reducing costs associated with this process. Conclusions: The use of premixes as part of a program to reduce medication errors can improve the quality indicators in drug administration and guarantee a safer use of intravenous therapy.

RESUMO Objetivo: apresentar o panorama dos erros de medicação, os recursos associados ao preparo de medicamentos intravenosos e o uso de pré-misturas na assistência à saúde. Metodologia: as buscas foram realizadas em diferentes bases de dados, sem limite de data ou tipo de estudo. Além disso, foi realizada uma análise para estimar os custos, validando com especialistas os recursos no centro de mistura. Resultados: erros de medicação são um erro médico comum globalmente. Os dados disponíveis são heterogêneos, mas sugerem que os erros de medicação podem ser uma causa significativa de morbidade e mortalidade em certas populações e contextos, com intervenções adicionais, internações hospitalares mais longas, custos mais altos de atendimento e probabilidade reduzida de que o tratamento seja oportuno e eficaz. Nos medicamentos intravenosos, resultam cenários de maior gravidade e maior nível de custos. Os custos anuais de mão de obra para uma usina de mistura na Colômbia são estimados entre 281,5 e 422,3 milhões de pesos. A padronização, como parte dos medicamentos pré-misturados, proporciona menor risco de contaminação, menor possibilidade de erro no preparo, menor incidência de complicações relacionadas à terapêutica, redução de desperdícios, melhoria na oportunidade de dispensação, otimização no trabalho das equipes. da farmácia e redução dos custos associados a este processo. Conclusões: o uso de pré-misturas, como parte de um programa de redução de erros de medicação, pode melhorar os indicadores de qualidade na admi nistração de medicamentos e garantir um uso mais seguro da terapia intravenosa.

An evaluation of awareness about medication error among paramedical staff working at tertiary care hospital

Background: Medication error is most common medical error and which is also under-reported particularly in developing countries. It can cause serious harm to the patients in several settings, particularly in hospitals. Aim and Objective: The aim of the study was to bring awareness among paramedical staff about medication error and to encourage them to report medication. Materials and Methods: This was a questionnaire-based-cross sectional study conducted over 6 months of duration in tertiary care hospital in 100 paramedical staff. Results: Out of 100 participants, majority of them (91%) knows about term medication error. Only 26% participants know how to report medication error in our hospital. Three-fourth (75%) do not know where to report, while 22% believes that it is professional obligation to report medication error. The majority of participants 88% agree that proper communication between health-care professionals minimizes medication error. About 77% participants believe that there is a need of independent body/committee for medication error in hospital. About 87% participants recommended training or CME about medication error in health-care professionals. Conclusion: The majority of participants had basic knowledge about medication error but lacuna on the reporting of medication error was noted. Continued medication education among paramedical staff may improver reporting.

Evaluación de la gestión de recetas en un servicio farmacéutico de un hospital especializado

error de medicación es cualquier incidente prevenible que puede causar daño al paciente o dar lugar a una utilización inapropiada de los medicamentos, cuando estos están bajo el control de los profesionales sanitarios o del paciente, con potenciales consecuencias para estos últimos. En Paraguay las enfermedades respiratorias crónicas (EPOC, asma, etc.), junto con la diabetes, los problemas cardiovasculares y el cáncer son responsables de una alta morbi-mortalidad, registrando una prevalencia que va en aumento. Esta investigación tuvo el objetivo de evaluar las recetas prescriptas en el consultorio externo de un hospital especializado en enfermedades respiratorias y dispensadas en la farmacia, gracias a un estudio observacional de corte transversal, retrospectivo, y un muestreo no probabilístico que consistió en la revisión de recetas médicas de pacientes que acudieron al consultorio del Instituto Nacional de Enfermedades Respiratorias y del Ambiente durante los meses de septiembre de 2015 y 2016. Los datos se registraron en planillas. Se analizaron 4828 recetas, de las cuales 2421 corresponden al mes de septiembre del 2015, y 2407 recetas que corresponden al mes de septiembre del 2016. Los errores técnicos de prescripción más frecuentes fueron la ilegibilidad y la ausencia de dosis e indicación. Por ello, se plantea la importancia de establecer un programa de gestión de riesgos en los hospitales, para implementar nuevas tecnologías que faciliten la prescripción.

Medication error is any preventable incident that may cause harm to the patient or result in inappropriate use of medications when these are under the control of healthcare professionals or the patient, with potential consequences for patients. In Paraguay, chronic respiratory diseases (COPD, asthma, etc. ), together with diabetes, cardiovascular problems, and cancer, are responsible for a high morbi-mortality in the country, with an increasing prevalence; therefore, this research aimed to evaluate the prescriptions that were prescribed in the outpatient clinic of a hospital specialized in respiratory diseases and dispensed in the pharmacy through a cross-sectional, retrospective, observational study and a non-probabilistic sampling, by convenience, which consisted of the review of medical prescriptions issued to patients of both sexes who attended the adult outpatient clinic of the National Institute of Respiratory and Environmental Diseases, during the months of September 2015 and 2016. The data were recorded in spreadsheets designed for this purpose, and a total of 4828 prescriptions were analyzed, of which 2421 correspond to the month of September 2015, with a total of 5955 drugs prescribed, and 2407 prescriptions correspond to the month of September 2016, with 6195 drugs prescribed. The most frequent technical prescription errors found in the prescriptions were the illegibility of the prescriptions and the absence of dosage and indication, being the most frequent errors for September 2015, and the absence of dosage and therapeutic indication (79.76 %)and illegibility of the prescription in September 2016 (87.00 %). Considering the legal requirements, the absence of diagnosis was the prevalent error (Sep-15: 64.19 %; Sep-16:60.08 %). This is why it is important to establish a risk management program in hospitals to implement new technologies that facilitate prescribing.

erro de medicação é qualquer incidente evitável que pode causar danos ao paciente ou resultar no uso inadequado de medicamentos, quando estes estão sob o controle dos profissionais de saúde ou do paciente, com potenciais consequências para os pacientes. No Paraguai, as doenças respiratórias crônicas (doença pulmonar obstrutiva crônica, asma etc.), juntamente com o diabetes, os problemas cardiovasculares e o câncer são responsáveis por uma alta taxa de morbidade e mortalidade no país, com uma prevalência crescente. Portanto, esta pesquisa teve como objetivo avaliar as prescrições feitas no ambulatório de um hospital especializado em doenças respiratórias e dispensadas na farmácia por meio de um estudo observacional transversal, retrospectivo e de amostragem não probabilística por conveniência, que consistiu em uma revisão das prescrições emitidas para pacientes de ambos os sexos que frequentaram o ambulatório de adultos do Instituto Nacional de Doenças Respiratórias e Ambientais, em setembro de 2015 e 2016. Os dados foram registrados em planilhas elaboradas para esse fim, e foi analisado um total de 4.828 prescrições, das quais 2.421 correspondem ao mês de setembro de 2015, com um total de 5.955 medicamentos prescritos, e 2.407 prescrições correspondem ao mês de setembro de 2016, com 6.195 medicamentos prescritos. Os erros mais frequentes encontrados nas prescrições foram a ilegibilidade destas e a ausência de dosagem e indicação, sendo que os erros mais frequentes em setembro de 2015 foram a ausência de dosagem e indicação terapêutica (79,76%) e em setembro de 2016, a ilegibilidade da prescrição (87%). Levando em conta os requisitos legais, a ausência de diagnóstico foi o erro prevalente (set.-15: 64,19%; set.-16:60,08%). Por isso, é importante estabelecer um programa de gestão de riscos nos hospitais para implementar novas tecnologias que facilitem a prescrição.

Joint pain liniments and gum lotion in the eye - A consecutive case series of mistaken identity

Purpose: Patient safety errors can arise due to similarity in packaging of medications. We aimed to describe the clinical features of patients presenting with accidental application of joint pain liniments and gum lotion in the eye due to confusion arising from similarity in packaging. Methods: This was a retrospective case series with eight consecutive patients presenting from December 2020 to August 2021 with history of accidental application of joint pain liniments or gum lotion in the eye instead of eye drops. All patients underwent visual acuity assessment and slit?lamp examination with fluorescein staining of the cornea to look for corneal involvement and was reassessed till complete resolution. Results: Of the eight patients, three were males and five were females. Seven had accidentally applied joint pain liniment, while one had applied gum lotion into the eye. Five of them had corneal involvement ranging from punctate erosions to near?total epithelial defects. Two patients needed referral to a tertiary center and hospital admission. Treatment duration ranged from 2 days to 1 month. Two patients were lost to follow?up. Conclusion: This study highlights patient safety errors arising from confusion of medication due to similar labeling and packaging of different drugs. While there was no permanent morbidity, such confusions lead to needless discomfort and waste of time, money, and effort for the patient as well as the health?care system.

Patients' medication reconciliation in a university hospital

Abstract Medication reconciliation is a strategy to minimize medication errors at the transition points of care. This study aimed to demonstrate the effectiveness of medication reconciliation in identifying and resolving drug discrepancies in the admission of adult patients to a university hospital. The study was carried out in a 300-bed large general public hospital, in which a reconciled list was created between drugs prescribed at admission and those used at pre-admission, adapting prescriptions from the pharmacotherapeutic guidelines of the hospital studied and the patients' clinical conditions. One hundred seven patients were included, of which 67,3% were women, with a mean age of 56 years. Two hundred twenty-nine discrepancies were found in 92 patients; of these, 21.4% were unintentional in 31.8% of patients. The pharmacist performed 49 interventions, and 47 were accepted. Medication omission was the highest occurrence (63.2%), followed by a different dose (24.5%). Thirteen (26.5%) of the 49 unintentional discrepancies included high-alert medications according to ISMP Brazil classification. Medication reconciliation emerges as an important opportunity for the review of pharmacotherapy at transition points of care, based on the high number of unintentional discrepancies identified and resolved. During the drug reconciliation process, the interventions prevented the drugs from being misused or omitted during the patient's hospitalization and possibly after discharge.

Estratégias para a redução de erros de medicação durante a hospitalização: revisão integrativa / Estrategias para la reducción de errores de medicación durante la hospitalización: revisión integradora / Strategies for reducing medication errors during hospitalization: integrative review

RESUMO Objetivo sintetizar o conhecimento relacionado às estratégias para redução de erros de medicação durante a hospitalização de pacientes adultos Método revisão integrativa da literatura realizada em outubro de 2020 por meio da busca de publicações nas bases de dados eletrônicas: Web of Science, Pubmed, Cumulative Index of Nursing and Allied Health Literature, Literatura Latino-Americana e do Caribe em Ciências da Saúde e Google Scholar Resultados amostra composta por 12 estudos, cujas estratégias para a redução de erros de medicação foram apresentadas de acordo com as categorias: envolvimento do farmacêutico clínico nas atividades clínicas, implantação de tecnologias da informação, estratégias educacionais mediadas por simulação e jogos, e redução da carga de trabalho Conclusão associado às tecnologias, o envolvimento do farmacêutico clínico com a equipe médica e de enfermagem resultará em melhorias na redução dos eventos adversos a medicamentos e na qualidade da assistência prestada ao paciente

RESUMEN Objetivo sintetizar el conocimiento relacionado a las estrategias para reducción de errores de medicación durante la hospitalización de pacientes adultos Método revisión integradora de la literatura realizada en octubre de 2020 por medio de la búsqueda de publicaciones en las bases de datos electrónicas: Web of Science, Pubmed, Cumulative Index of Nursing and Allied Health Literature, Literatura Latinoamericana y del Caribe en Ciencias de la Salud y Google Scholar Resultados muestra compuesta por 12 estudios, cuyas estrategias para reducir los errores de medicación se presentaron según las categorías: implicación del farmacéutico clínico en las actividades clínicas, implementación de tecnologías de la información, estrategias educativas mediadas por simulación y juegos, y reducción de la carga de trabajo Conclusión asociada a las tecnologías, la implicación del farmacéutico clínico con el equipo médico y de enfermería se traducirá en mejoras en la reducción de los efectos adversos de los medicamentos y en la calidad de la atención al paciente

ABSTRACT Objective to synthesize the knowledge related to strategies to reduce medication errors during the hospitalization of adult patients Method integrative literature review carried out in October 2020 through the search for publications in electronic databases: Web of Science, Pubmed, Cumulative Index of Nursing and Allied Health Literature, Latin American and Caribbean literature in Health Sciences and Google Scholar Results sample composed of 12 studies, whose strategies for the reduction of medication errors were presented according to the categories: involvement of the clinical pharmacist in clinical activities, implementation of information technologies, educational strategies mediated by simulation and games, and workload reduction Conclusion associated with technologies, the involvement of the clinical pharmacist in the medical and nursing team will result in improvements in the reduction of adverse medication events and in the quality of care provided to the patient

Costs and root causes of medication errors and falls in a Teaching Hospital: cross-sectional study / Costos y causas principales de los errores y caídas de medicación y caídas en un Hospital Docente: un estudio transversal / Custos e causas-raízes de erros de medicação e quedas em Hospital de Ensino: estudo transversal

ABSTRACT Objectives to characterize accidents/falls and medication errors in the care process in a teaching hospital and to determine their root causes and variable direct costs. Method cross-sectional study implemented in two stages: the first, was based on the analysis of secondary sources (notifications, medical records and cost reports) and the second, on the application of root-cause analysis for incidents with moderate/severe harm. The study was carried out in a teaching hospital in Paraná, which exclusively serves the Brazilian Unified Health System and composes the Network of Sentinel Hospitals. Thirty reports of accidents/falls and 37 reports of medication errors were investigated. Descriptive statistical analysis and the methodology proposed by The Joint Commission International were applied. Results among the accidents/falls, 33.3% occurred in the emergency room; 40.0% were related to the bed, in similar proportions in the morning and night periods; 51.4% of medication errors occurred in the hospitalization unit, the majority in the night time (32.4%), with an emphasis on dose omissions (27.0%) and dispensing errors (21.6%). Most incidents did not cause additional harm or cost. The average cost was R$ 158.55 for the management of falls. Additional costs for medication errors ranged from R$ 31.16 to R$ 21,534.61. The contributing factors and root causes of the incidents were mainly related to the team, the professional and the execution of care. Conclusion accidents/falls and medication errors presented a low frequency of harm to the patient, but impacted costs to the hospital. Regarding root causes, aspects of the health work process related to direct patient care were highlighted.

RESUMEN Objetivos caracterizar accidentes/caídas y errores de medicación en el proceso asistencial en un hospital universitario y; determinar sus causas fundamentales y los costos directos variables. Método estudio transversal implementado en dos etapas: la primera, basada en el análisis de fuentes secundarias (notificaciones, historias clínicas e informes de costos) y; el segundo, en la aplicación del análisis raíz-raíz para incidentes con daños moderados / severos. Realizado en un hospital docente de Paraná, que atiende exclusivamente al Sistema Único de Salud y forma parte de la Red de Hospitales Centinelas. Se investigaron 30 notificaciones de accidentes / caídas y 37 de errores de medicación. Se aplicó el análisis estadístico descriptivo y la metodología propuesta por The Joint Commission International. Resultados entre los accidentes / caídas, el 33,3% ocurrió en urgencias; 40,0% estaban relacionados con la cama, en proporciones similares en los periodos de mañana y noche; El 51,4% de los errores de medicación ocurrieron en la unidad de internación, la mayoría durante la noche (32,4%), con énfasis en omisiones de dosis (27,0%) y errores de dispensación (21,6%). La mayoría de los incidentes no resultaron en daños o costos adicionales. El costo promedio fue de R$ 158,55 para el manejo de caídas. Los costos adicionales por errores de medicación oscilaron entre R$ 31,16 y R$ 21.534,61. Los factores contribuyentes y las causas fundamentales de los incidentes se relacionaron principalmente con el equipo, el profesional y la ejecución de la atención. Conclusión los accidentes / caídas y los errores de medicación tuvieron una baja frecuencia de daño al paciente, pero impactaron los costos hospitalarios. En relación a las causas raíz, se destacaron aspectos del proceso de trabajo en salud, relacionados con la atención directa al paciente.

RESUMO Objetivos caracterizar os acidentes/quedas e erros de medicação no processo de cuidado em um hospital de ensino e; determinar suas causas-raízes e os custos diretos variáveis. Método estudo transversal implementado em duas etapas: a primeira se pautou na análise de fontes secundárias (notificações, prontuários e relatórios de custos) e; a segunda, na aplicação de análise de cauza-raíz para incidentes com danos moderados/graves de julho a dezembro de 2019. Realizado em hospital de ensino do Paraná, que atende exclusivamente o Sistema Único de Saúde e compõe a Rede de Hospitais Sentinelas. Foram investigadas 30 notificações de acidentes/quedas e 37 de erros de medicação. Aplicaram-se a análise estatística descritiva e a metodologia proposta pela The Joint Comission International. Resultados dentre os acidentes/quedas, 33,3% ocorreram no pronto socorro; 40,0% tiveram relação com o leito, em proporções semelhantes nos períodos matutino e noturno; 51,4% dos erros de medicação ocorreram em unidade de internação, a maioria no período noturno (32,4%), com destaque para omissões de dose (27,0%) e erros de dispensação (21,6%). A maioria dos incidentes não ocasionou danos ou custo adicional. O custo médio foi R$ 158,55 para manejo das quedas. Os custos adicionais para erros de medicação variaram entre R$ 31,16 e R$ 21.534,61. Os fatores contribuintes e causas-raízes dos incidentes se relacionaram, principalmente, à equipe, ao profissional e à execução do cuidado. Conclusão os acidentes/quedas e erros de medicação apresentaram baixa frequência de danos ao paciente, porém impactaram no custo hospitalar. Em relação às causas-raízes, destacaram- se os aspectos do processo de trabalho em saúde, relacionados ao cuidado direto ao paciente.

Analysis of 240 Cases of Medical Damage Liability Disputes Caused by Medication Error / 中国药房

OBJECTIVE：To study general chara cteristics and medication of medical damage liability disputes cases caused by medication error ， and to provide references for related departments and medical staff for preventing and reducing medication-induced medical disputes. METHODS ：A total of 240 cases of medical damage liability disputes cases caused by medication error were collected from Peking University ’s Fabao Law Database during Jan. 2001 to Feb. 2020，and analyzed in terms of general situation ，damage outcome ，level of the hospital involved ，liability judgment and compensation ，types of medication error and drug types. RESULTS ：medication-related medical damage liability disputes accounted for 25.3％ of overall medical damage disputes ；the most damage result of patients was death （68.3％）；medical negligence forensic appraisal was conducted as the main appraisal pattern with a proportion of 57.9％；the average case compensation was 203，000 yuan；the hospitals involved were mainly tertiary hospitals （48.8％）；the main type of medication error involved was prescription error ； chemical medicine was mainly involved ，of which the top three categories were systemic antibacterial ，systemic corticosteroids and antipsychotics. CONCLUSIONS ：ADR caused by medication errors are the common causes of medical disputes. Medical institutions should focus on improving the relevant systems and processes ，strengthen the construction of pharmaceutical information and automation system ，and reduce the probability of medication errors ；at the same time ，great importance should be paid to the cultivation of pharmaceutical talents in hospital ，give full play to the role of pharmacists ，and strengthen the monitoring and intervention of medication errors. Finally ，the relevant national judicial departments should constantly improve the settlement mechanism of medical damage liability disputes to provide reasonable protection for both doctors and patients.

Prescription audit to evaluate the pattern and errors in a tertiary care hospital

Background: Medication errors are widespread public health issue. Prescription errors commonly results in medication error. Prescription error can be largely avoidable this study was performed with aim to point out the common mistake in the prescription which may endanger patients.Methods: Our study was cross-sectional and observational, performed in Index Medical College. 320 prescriptions were reviewed. Analysis was done for presence or absence of essential components of prescription like prescriber information’s, patients information’s, details of drug like its dosage form, strength, frequency, total duration of treatment, warnings or instruction for use. The observed data was expressed in number and percentage.Results: Patient information was complete 315 (98.44%) in prescriptions. Prescriber’s information were present in 284 (88.75%). Legibility was seen in 240 (75%). Use of generic drug, capital letters for drug name, warning are seen in 9 (2.81%), 39 (12.19%), 3 (0.94%) respectively. Completeness in terms of the name of drug, dose, strength, route, frequency, duration and dosage forms of prescribed drugs was seen in 252 (78.75%) prescriptions.Conclusions: Properly framed and written prescription can largely prevent medication error. Regular prescription audit must be carried out so that common mistake can be identified and corrective measure with the help of training session, workshop can be taken.

Polypharmacy Induced Drug Interactions, Adverse Drug Reactions (ADR) And Medication Errors In Tertiary Care South Indian Hospital

Objective: To study the pattern of drug interactions (DI) in our hospital and to identify whether it is associated with polypharmacy. To determine the level of severity of potential drug-drug interactions (PDDI), to detect, monitor and prevention of ADRs in the hospitalized patients and to identify the medication errors (ME). Methods: A prospective interventional study was conducted in a 300 bedded tertiary care South Indian hospital for a period of 6 mo. Prescriptions were analysed for PDDI using Micromedex software 2.2. The causality and severity of ADRs were assessed by using Naranjo’s, WHO UMC Scales and Hart wigs severity scales. ME was identified by review of patient drug charts. Results: Total 190 prescriptions were analyzed, in which 1028 drug interactions were seen. Out of which 718 were DDI, 198 DFI, 100 DEI, and 12 DTI were observed. More number of DI was seen in cardiovascular drugs, antibiotics followed by antacids and antiulcer agents. A total of 52 ADRs were identified in 43 patients. Diuretics, cardiovascular drugs were associated with a higher incidence of ADRs followed by Anti-Diabetic agents. 58 ME was seen in 190 prescriptions, among them omission error, prescribing errors and Wrong dose error was seen. Conclusion: Clinical pharmacist plays a potential role in the health care system in assisting the physician i.e. modifying the number of drugs taken, number of doses taken, medication adherence, identification of drug interactions, preventing, monitoring and detection of ADRs and identifying the medication errors.

Influencing Factors and Consequences of Near Miss Experience in Nurses' Medication Error

PURPOSE: This study aimed to predict the influencing factors and the consequences of near miss in nurses' medication error based upon Salazar & Primomo's ecological system theory. METHODS: A convenience sample of 198 nurses was recruited for the cross-sectional survey design. Data were collected from July to September 2016. Using the collected data, the developed model was verified by structural equation modeling analysis using SPSS and AMOS program. RESULTS: For the fitness of the hypothetical model, the results showed that χ² (χ²=258.50, p<.001) was not fit, but standardized χ² (χ²/df=2.35) was a good fit for this model. Additionally, absolute fit index RMR=.06, RMSEA=.08, GFI=.86, AGFI=.81 reached the recommended level, but the Incremental fit index TLI=.82, CFI=.85 was not enough to reach to the recommended level. With the path diagram of the hypothetical model, caution (β=−.29 p<.001), patient safety culture (β=−.20, p=.041), and work load (β=.18, p=.037) had a significant effect on the near miss experiences in nurses' medication error, while fatigue (β=−.06, p=.575) did not affect it. Moreover, the near miss experience had a significant effect on work productivity (β=−.25, p=.001). CONCLUSION: These results have shown that to decrease the near miss experience by nurses and increase their work productivity in hospital environments would require both personal and organizational effort.

Multisite risk assessment to reduce mtx-use errors in childhood malignancy / 中国药学杂志

OBJECTIVE: Medication errors (ME) more frequently affect pediatric patients than adults. Chemotherapeutic drug MEs seems more serious and less detected, among which, the most commonly involved chemotherapeutic agent was methotrexate (MTX). To engage multidisciplinary teams of childhood malignancy in a multisite study using proactive risk assessment methods to identify how MTX errors occur and propose risk reduction strategies. METHODS: We recruited doctors, nurses, pharmacists and parents from three children's hospitals in the northeast and southeast China to participate in failure mode and effects analyses (FMEA). An FMEA is a systematic team-based proactive risk assessment approach in understanding ways a process can fail and develop prevention strategies. Steps included diagram the process, collect failure modes /risks and prioritize failure modes, and propose risk reduction strategies. We focused on MTX-use process in and out of hospitals. RESULTS: A multidisciplinary medication safety team was formed of total 66 members. They developed a four-stage flow diagram with four main phases, based on which, 56 potential risks were recognized and 17 were classified as higher risks by the hazard-scoring matrix. The highest priority failure modes in hospital included wrong solvents, wrong frequency label and lake of monitoring; furthermore, errors involving excessive intake of oral MTX after discharge were worth extra attention. Meanwhile, remediation strategies were developed, consisting of constrained and recommended strategies. CONCLUSION: FMEA is a useful tool to identify the risk of MTX MEs and several years later, with the concerted efforts of all the healthcare staff and technicians, we wish to see a reduction in the potential for errors being made and an improvement of children safety.

Impact of Psychosocial Factors on Occurrence of Medication Errors among Tehran Public Hospitals Nurses by Evaluating the Balance between Effort and Reward

BACKGROUND: Patient safety and accurate implementation of medication orders are among the essential requirements of par nursing profession. In this regard, it is necessary to determine and prevent factors influencing medications errors. Although many studies have investigated this issue, the effects of psychosocial factors have not been examined thoroughly. METHODS: The present study aimed at investigating the impact of psychosocial factors on nurses' medication errors by evaluating the balance between effort and reward. This cross-sectional descriptive study was conducted in public hospitals of Tehran in 2015. The population of this work consisted of 379 nurses. A multisection questionnaire was used for data collection. RESULTS: In this research, 29% of participating nurses reported medication errors in 2015. Most frequent errors were related to wrong dosage, drug, and patient. There were significant relationships between medications errors and the stress of imbalance between effort and reward (p < 0.02) and job commitment and stress (p < 0.027). CONCLUSION: It seems that several factors play a role in the occurrence of medication errors, and psychosocial factors play a crucial and major role in this regard. Therefore, it is necessary to investigate these factors in more detail and take them into account in the hospital management.

A Retrospective Analysis on Medication Error Monitoring Results in Our Hospital in Five Years / 中国药师

Objective: To explore the potential risks in hospital medication management system and propose the preventive meas-ures. Methods: The medication error (ME) cases reported from Jan 1st2012 to Dec 31st2016 in our hospital were retrospectively ana-lyzed in terms of ME category, classification, occurrence link, cause, influencing factors, detecting person and the proportion of high-alert medication MEs. Results: A total of 425 ME reports were collected, and among them, 311 cases were related to western medi-cines (73. 18% ), and 114 cases were related to traditional Chinese medicines (26. 82% ). The proportion of ME in category A, B and C was 4. 24% , 89. 65% and 5. 41% , respectively; the proportion of ME in category D, E and F was 0. 24% . ME in category G, H and I was not reported. In terms of the ME classification, the proportion of drug variety error was the highest (23. 29% ) followed by the repeated medication error (9. 41% ) and the dosage error (8. 94% ). As for the ME occurrence link, the proportion of prescription error was the highest (73. 18% ) followed by the dispensing error (16. 94% ). The top factor to trigger ME was lack of knowledge (26. 82% ) followed by the similar drug name (21. 41% ). The main person who detected ME was pharmacists (93. 88% ). Among of the 425 ME reports, 81 cases were related to high-alert medication, and the top two were insulin errors (48. 15% ) and oral hypoglyce-mic agents errors (23. 46% ). Conclusion: It can partly prevent ME by improving selection and management of new drugs, improving drug information system, enhancing drug quality management and strengthening safe medication knowledge education.

Design and evaluation of clinical scenario cases with simulation-based learning on medication errors for novice / 中国实用护理杂志

Objective To improve fresh nurses′ implementation rate of standard clinical administration checking by applying situational simulation method, and enhancetheir ability of identifying hidden perils in nursing. Methods Totally 75 fresh nurses who graduated in 2016 were enrolled and divided into two groups (36 in control group and 39 in experimental group) according to randomized digital table method. Situational simulation method was applied in the experimental group, while the control group applied traditional nursing safety check training method. Then both groups′ satisfaction rate of lessons and self-confidence after training were recorded. Besides, their clinical administration checking behaviors after 3 months, the errors, hidden perilsand examining situations related to administration checking after 6 months,were also evaluated. Results Significant statistical differences were shown in satisfaction score (23.62 ± 2.02 in experimental group vs. 21.39 ± 1.98 in control group, t=4.818, P<0.01) and self-confidential evaluating score (35.67±2.02 in experimental group vs. 21.39±1.98 in control group, t=2.768, P<0.01). Observation of clinical administration checking behaviors 3 months after training had indicated significant differences in the number of nurses who check drug concentration (33 vs. 8, χ2=29.406, P<0.05) and executing time (30vs. 12, χ2=14.436, P<0.05).Statistical differences (χ2= 5.080-29.545, P< 0.01 or < 0.05) were also observed in the number of nurses checking bed number, patient name, drug name, dose, drug concentration and methods in and after operation. The potential nursing perils identified, and the number of nurses who identify hidden nursing perils 3 months and 6 months after training were significantly larger (χ2=50.591, 23.658, 3.914, P<0.05) in experimental group (33, 2, 10) than in control group (18, 1, 3),and there were no significant differences in the rate of potential perils and nursing error between both groups. Conclusion Situational method of administration, which is applied for fresh nurses in their initial working phase, transforms the basic and core checking system into clinical real-situation cases. It also shows an advantage of boosting their self-confidence of learning, improving the implementation rate of standard clinical administration checking and the ability of avoiding potential nursing perils.

Seguridad en anestesia: error en la administración de fármacos LASA / Safety in anesthesia: an error in the administration of LASA drugs / Segurança na anestesia: um erro na administração de drogas LASA

La seguridad del paciente es prioritaria en el ámbito anestésico quirúrgico. El error en la administración de fármacos es una causa frecuente de incidentes críticos en el perioperatorio. Una forma de error, es la administración del medicamento equivocado debido a las presentaciones similares. El objetivo de este trabajo es la descripción de fallas en las barreras de prevención de incidentes críticos con medicamentos, en base al estudio de un caso clínico y al análisis de sus consecuencias. Metodología : Descripción de un caso clínico y estudio sistemático de la situación de riesgo en base al análisis taxonómico del paciente, individuo, tarea, equipo humano, lugar de trabajo y organización (PITELO) sugerido por el Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR). Resultados : Mujer sana que presentó paro respiratorio luego de la administración intravenosa de un fármaco en el postoperatorio. Se requirió 24 hs de terapia intensiva y múltiples estudios, luego de lo cual se diagnosticó un error en la administración de fármaco. La confusión se presentó con una dupla de ampollas LASA (del inglés: look-alike, sound-alike) de los fármacos atracurio y ranitidina. La documentación fotográfica evidencia la similitud y el diagrama identifica fallas latentes del sistema. Se estimaron los costos del error y se realizaron propuestas de mejora. Discusión y conclusiones : Se evidencia una falla en las barreras de prevención de eventos adversos y en el sistema de reporte de los mismos. Es necesario incrementar la cultura de seguridad en todos los niveles del sistema: regulatorio, institucional y personal.

Patient safety is a priority in the surgical anesthetic area, and errors in drug administration area frequent cause of critical incidents in the perioperative period. One type of error is the administration of the wrong medication due to similar presentations. The objective of this study is to describe the failure of barriers to prevent critical drug incidents; this is based on the study of a clinical case and an analysis of its consequences. Methodology . Description of a clinical case and systematic study of the risk situation based on the taxonomic analysis of the patient, individual, task, human team, workplace, and organization (PITELO), as suggested by the Spanish System of Safety Notification in Anesthesia and Resuscitation (SENSAR). Results . A healthy woman presented in respiratory arrest after the intravenous administration of a drug in the postoperative period. It took 24 hours of intensive care and multiple studies before an error in drug administration was diagnosed. The confusion was presented with a pair of LASA (look-alike, sound-alike) ampoules of atracurium and ranitidine drugs. Photographic documentation evidences the similarity of the ampoules themselves, and the diagram identifies latent system failures. The costs of the error are estimated and proposals for improvement are provided. Discussion and Conclusions . There is evidence of a failure in the barriers to the prevention of adverse events and in the reporting system. It is necessary to increase the safety culture at all levels of the system: regulatory, institutional, and personal.

A segurança do paciente é prioritária no âmbito anestésico cirúrgico. O erro na administração de fármacos é uma causa frequente de incidentes críticos no perioperatório. Uma forma de erro é a administração de medicação errada devido a uma apresentação similar. O objetivo deste trabalho é a descrição de falhas nas barreiras de prevenção de incidentes críticos com medicamentos, em base no estudo de um caso clínico e ao análise de suas consequências. Metodologia . Descrição de um caso clínico e estudo sistemático da situação de risco em base ao análises taxonômico do doente, tarefa, equipamento humano, lugar de trabalho e organização (PITELO) sugerido pelo Sistema Espanhol de Notificação em Segurança em Anestesia e Reanimação (SENSAR). Resultados . Mulher sem patologia que apresentou paro respiratório a pois a administração intravenosa de um fármacos no pós-operatório. Requereu-se de 24 hs na UTI e múltiplos estudos, logo dos quais foi diagnosticado um erro na administração do fármaco. A confusão se apresentou como causa deduplas ampolas LASA (do inglês: aparência parecida com o som) dos fármacos atracurio y ranitidina. A documentação fotográfica evidencia a similitude e o diagrama identificafalhas latentes no sistema. Foram analisados os custos do erro e realizou-se propostas de melhora. Discussão y conclusões . Evidencia-se uma falla nas barreiras de prevenção de eventos adversos e no sistema de reporte dos mesmos. É necessário incrementar a cultura de segurança em todos os níveis do sistema: regulatório, institucional e pessoal.

Evento adverso pós-vacinação e erro de imunização: da perspectiva epidemiológica à percepção dos profissionais da saúde / Adverse event following immunization and immunization error: from the epidemiological perspective to the perception of health professionals

Introdução: o aumento da cobertura vacinal reduziu a incidência das doenças imunopreveníveis, elevando os casos de Evento Adverso Pós-Vacinação e Erro de imunização. Objetivo: analisar os erros de imunização e a percepção de vacinadores sobre os fatores que contribuem para a sua ocorrência. Método: abordagem mista, desenvolvida em duas fases: primeira, quantitativa, descritiva, documental, retrospectiva, no período de 2003 a 2013. Utilizados dados secundários do Brasil e primários e secundários do Paraná Sistema de Informação de Eventos Adversos Pós-Vacinação e relatório de erros de imunização do Programa de Imunização. A segunda, qualitativa, exploratória, prospectiva, tendo como referencial a Teoria do Erro Humano, realizada com vacinadores da Região Metropolitana de Curitiba que notificaram erro de imunização em 2013. Classificação do erro de imunização: com evento adverso e sem evento adverso. Para o cálculo das taxas de incidência de erro e diagrama de dispersão, foi utilizado o software SPSS versão 23.0 ajustados pelo Modelo de Regressão Linear Simples. Na fase II, os dados foram coletados por meio de entrevistas e observação não participante, analisados segundo Bardin, utilizando o Web Qualitative Data Analysis WebQDA. Resultados: de 2003 a 2013, no Brasil e no Paraná, o abscesso subcutâneo quente foi o erro de imunização com evento adverso mais frequente. Os menores de um ano foram os mais atingidos pelos erros e a BCG teve taxa de incidência mais elevada. A incidência do erro de imunização com evento adverso aumentou ao longo do período, enquanto o sem evento adverso, elevou-se expressivamente em 2012. A análise da tendência no Paraná de 2003 a 2018, revelou crescimento anual, com elevação contínua da incidência, para ambos, mostrando ainda que a elevação dos percentuais e taxas ocorreu nas campanhas de vacinação, introdução de novas vacinas e mudanças no Calendário Nacional de Vacinação. Nas observações das 26 salas de vacinação, identificou-se: refrigerador não exclusivo, falhas na higienização das mãos (78%), não abordagem sobre possíveis contraindicações ou adiamento da vacinação. Foram entrevistados 115 vacinadores, 96% mulheres, 42% entre 30 a 39 anos, 54% com nível médio de escolaridade e 53% formados há cinco anos ou mais. Atuavam na sala de vacinação entre 3 a 11 anos, 71% realizavam atividades concomitantes em outros setores e 76% não tinham outro emprego. A entrevista revelou que 47% dos vacinadores tinham conhecimento de erro de imunização no seu trabalho, 8,7% estiveram envolvidos em erros e 1,7% referiram haver subnotificação. Dos discursos dos vacinadores emergiram três categorias analíticas: fatores humanos (57,3%), institucionais/organizacionais (34%) e ambientais (8,7%). Das categorias empíricas, destacou-se fatores psicológicos (43,2%) e das subcategorias: distração (21,4%) e estresse (20,9%). Conclusões: o erro de imunização é causado pela interação de múltiplos fatores. Mantendo-se os cenários, as incidências de erro de imunização, com ou sem evento adverso, tendem a continuar ascendentes até 2018. Campanhas, novas vacinas e mudanças no calendário de vacinação aumentam o risco de erro de imunização. Na visão dos vacinadores, a ocorrência de erro de imunização está relacionada, principalmente, a fatores psicológicos e gestão de pessoas. A maioria dos erros de imunização é potencialmente prevenível, desde que a sua ocorrência e causas sejam identificadas.

Introduction: the increase in vaccination coverage reduced the incidence of vaccine-preventable diseases, increasing the number of cases of Adverse Events Following Vaccination and Immunization Error. Objective: to analyze the immunization errors and the perception of vaccinators on the factors that contribute to their occurrence. Method: mixed approach, developed in two phases: the first being quantitative, descriptive, documentary, retrospective, in the period from 2003 to 2013. Secondary data from Brazil and primary data from Paraná were used Surveillance System of Adverse Events Following Vaccination and immunization error reports of the Immunization Program. The second, qualitative, exploratory, prospective phase had as reference the Theory of Human Error, performed with vaccinators of the Metropolitan Region of Curitiba who reported immunization errors in 2013. Classification of immunization error: with and without adverse event. For the calculation of the incidence rates of error and dispersion diagram, the SPSS software version 23.0 was used, adjusted through the Simple Linear Regression Model. In phase II, the data were collected through interviews and non-participant observation, analyzed according to Bardin, using the Web Qualitative Data Analysis WebQDA software. Results: from 2003 to 2013, in Brazil and Paraná, warm subcutaneous abscess was the most frequent immunization error with adverse event. Children under one year old were the most affected by the errors and BCG had higher incidence rate. The incidence of immunization error with adverse event increased over the period, while its incidence without adverse event increased significantly in 2012. The analysis of the trend in Paraná from 2003 to 2018 showed annual growth, with continuous increase in incidence, for both, also showing that the increase of the percentages and rates occurred during the vaccination campaigns, introduction of new vaccines and changes in the National Vaccination Calendar. During the observation of the 26 vaccination rooms, the following were identified: non-exclusive cooler, failures in the sanitation of hands (78%), no addressing of the possible contraindications or postponement of vaccination. 115 vaccinators were interviewed, 96% women, 42% between 30 and 39 years of age, 54% with average level of education and 53% graduated for five years or more. They had been working in the vaccination room for 3 to 11 years, 71% performed concomitant activities in other sectors and 76% did not have another job. The interview revealed that 47% of vaccinators were aware of immunization errors in their work, 8.7% were involved in errors and 1.7% declared there being underreporting. The speeches of the vaccinators resulted in three analytical categories: human (57.3%), institutional/organizational (34%) and environmental (8.7%) factors. Those which stood out, of the empirical categories, were the psychological factors (43.2%), and of the subcategories, distraction (21.4%) and stress (20.9%). Immunization error is caused by the interaction between multiple factors. Conclusions: if kept constant, the scenarios and incidence of immunization errors, with or without adverse event, tend to continue increasing up to 2018. Campaigns, new vaccines and changes in the vaccination calendar increase the risk of immunization error. For the vaccinators, the occurrence of immunization error is related mainly to psychological factors and people management. Most immunization errors are potentially preventable, provided their occurrence and causes are identified.

Pharmaceutical Care Practice for Admission Medication Reconciliation in the Internal Medicine Inpatient by Clinical Pharmacists / 中国药房

OBJECTIVE:To explore the importance and necessity of clinical pharmacists in drug therapy for chronic disease patients,the feasibility of developing medication reconciliation (MR),and to provide reference for establishing the internal medicine working model of clinical pharmacy.METHODS:During May to Jul.2016,inpatients were selected from respiratory department of our hospital as subjects.After detailed pharmaceutical consultation,clinical pharmacist conducted MR for newly inpatients at the first day in the hospital.RESULTS:Through clinical pharmacists classified and organized the problems of drug use in the inpatients during medication,MR records of 98 inpatients were collected,involving 296 medical orders and 96 items of medication errors.Among MR patients,there were only 44 cases of good compliance (44.9％);some problems about drug use existed in other cases,including optional medication,improper usage and dosage,fearing of drug side effects and refusing to use drugs,drug withdrawal due to ADR,follow-up failure of special disease leading to excessive or inadequate dose,poor communication with doctors leading to medication errors,forgetting to take medication or missing,excessive medical treatment and so on.Most common medication error-inducing drugs type was cardiovascular drug,followed by respiratory drug and endocrine system drug.CONCLUSIONS:The development of MR by clinical pharmacists is helpful to identify and correct medication error,avoid potential medication error,and control disease.It can be used as a project of pharmaceutical care in department of internal medicine.