Medication-related incidents in acute care hospitals among different age groups: An analysis of national patient safety report data.

PURPOSE: This study aimed to perform a nationwide analysis of medication errors (MEs) from hospitals using national reporting system data and to compare the ME patterns among different age groups. METHODS: We analyzed medication-related incidents in acute care hospitals reported to the Korean Patient Safety Reporting and Learning System (KOPS), which is a patient safety reporting system, from July 2016 to December 2020. The stages of the medication use process, type of errors, medication class involved in MEs, and degree of harm were analyzed. RESULTS: Among a total of 5071 medication-related incidents, 37.7% (1911 cases) were incidents that caused patient harm and 1.2% caused long-term, permanent, and fatal harm. The proportion of medication-related incidents that resulted in harm was the highest among the <1-year-old age group (67 cases, 51.5%), followed by the elderly (≥ 65 years) (828 cases, 40.9%). The cases leading to patient death were most frequently reported in patients aged ≥65 years. Medication-related incidents occurred mainly in the administration stage (2954 cases, 58.3%), and wrong dose was the most frequently reported ME type. The most prevalent medication class occurring in the 20-64-year age group (256 cases, 11.7%) was 'antibacterials for systemic use', whereas 'contrast media' (236 cases, 11.6%) and 'blood substitutes and perfusion solutions' (98 cases, 19.3%) were the most prevalent drug classes in the ≥65- and <20-year-old age groups, respectively. CONCLUSIONS: It is necessary to establish guidelines for the prevention of medication-related incidents according to the medication use process and patient age group.

Trends in dispensing errors reported in Finnish community pharmacies in 2015-2020: a national retrospective register-based study.

BACKGROUND: Community pharmacies are responsible for dispensing of medicines and related counselling in outpatient care. Dispensing practices have remarkably changed over time, but little is known about how the changes have influenced medication safety. This national study investigated trends in dispensing errors (DEs) related to prescribed medicines, which were reported in Finnish community pharmacies within a 6-year period. METHODS: This national retrospective register study included all DEs reported to a nationally coordinated voluntary DE reporting system by Finnish community pharmacies during 2015-2020. DE rates, DE types, prescription types, individuals who detected DEs and contributing factors to DEs were quantified as frequencies and percentages. Poisson regression was used to assess the statistical significance of the changes in annual DE rates by type. RESULTS: During the study period, altogether 19 550 DEs were reported, and the annual number of error reports showed a decreasing trend (n = 3 913 in 2015 vs. n = 2 117 in 2020, RR 0.54, p < 0.001). The greatest decrease in reported DEs occurred in 2019 after the national implementation of the Medicines Verification System (MVS) and the additional safety feature integrated into the MVS process. The most common error type was wrong dispensed strength (50% of all DEs), followed by wrong quantity or pack size (13%). The annual number of almost all DE types decreased, of which wrong strength errors decreased the most (n = 2121 in 2015 vs. n = 926 in 2020). Throughout the study period, DEs were most commonly detected by patients (50% of all DEs) and pharmacy personnel (30%). The most reported contributing factors were factors related to employees (36% of all DEs), similar packaging (26%) and similar names (21%) of medicinal products. CONCLUSIONS: An overall decreasing trend was identified in the reported DEs and almost all DE types. These changes seem to be associated with digitalisation and new technologies implemented in the dispensing process in Finnish community pharmacies, particularly, the implementation of the MVS and the safety feature integrated into the MVS process. The role of patients and pharmacy personnel in detecting DEs has remained central regardless of changes in dispensing practices.

Optimizing the Use of Dose Error Reduction Software on Intravenous Infusion Pumps.

BACKGROUND AND OBJECTIVES: Intravenous infusions have the potential to cause significant harm in patients and are associated with a high rate of adverse drug events and medication errors. Infusion pumps with dose error reduction software (DERS) can be used to reduce errors by establishing safe infusion parameters. In 2019, a quality improvement project was initiated with the aim to increase DERS compliance from 46% to 75% at our specialty institution by October 1, 2022. METHODS: An interdisciplinary group was tasked with improving compliance with DERS by identifying key drivers, including informed staff, engaged staff, and an accurate smart pump library. We used the Model for Improvement framework to guide this improvement project, and Plan-Do-Study-Act (PDSA) cycles were used to plan for interventions. PDSA cycles included drug library updates, education, and unit-level compliance reporting. Weekly average DERS compliance was monitored as the outcome measure, and weekly pump alerts per 100 infusions were monitored as a balancing measure; statistical process control charts were used to monitor measures from 2018 to 2022. RESULTS: Over the course of 25 months, 8 PDSA cycles resulted in 5 centerline improvements from a baseline mean of 46% to a final mean of 78%. Pump alerts per 100 infusions decreased from 15.9 to 6.4 with the first PDSA cycle and then continued to decrease to 3.9 with subsequent interventions. CONCLUSIONS: Although features like DERS can help ensure safe medication administration, continuous improvement efforts to increase DERS compliance without increasing alert burden are needed to ensure that benefits of this technology are optimized.

An observational study of root-cause analysis of medication errors in elderly with methotrexate toxicity.

INTRODUCTION: Medication errors are inherent in a healthcare system. This results in both time and cost burdens for both the patient and the health system. The aim of this study was to conduct a root-cause analysis of medication errors in elderly patients with methotrexate toxicity, analyze associated factors, and propose solutions. METHODS: This single-center prospective study was designed to identify medication errors in cases of methotrexate toxicity between November 2022 to May 2023. Categorical data and free-text data are used to describe incidents. Harm assessment, factors related to medication errors, and preventability were evaluated for each case. Possible strategies to prevent similar occurrences are discussed. RESULTS: Out of a total of 15 patients who presented during the study period, nine suffered from methotrexate toxicity due to medication errors. Most medication errors occurred during prescribing or dispensing (seven cases). Inadequate knowledge about medication and dosage, inadequate communication was identified as a contributing factor for all medication errors. Patients on long-term methotrexate treatment are at high risk of methotrexate toxicity. CONCLUSION: This study highlights the challenges of health literacy and lacking communication between healthcare providers and patients that can be met through community pharmacy programs for the elderly in lower-middle-income countries.

Medication errors in veterinary anesthesia: a literature review.

OBJECTIVE: To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction. DATABASES USED: PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗]. CONCLUSIONS: Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Delineating patient errors in an intracavernosal injection program.

BACKGROUND: Intracavernosal injection therapy (ICI) is a well-established therapeutic strategy for men with erectile dysfunction. Complications are often related to patient error when performong ICI. AIM: The objective of this study was to examine patient errors in an established patient training program for performing ICI and identify factors that could predict major errors. METHODS: Patients enrolled in our ICI program are trained on technical aspects, and dose titration is begun. Patients are given explicit instructions during training, both verbally and in written form. Records were reviewed for men using ICI for ≥6 months. Multivariable analysis was used to define predictors of major errors. OUTCOMES: Errors were listed as minor (zero-response injection, penile bruising, expired medication) and major (errors potentially leading to priapism: dose self-titration, double injecting). RESULTS: Overall, 1368 patients met the inclusion criteria and were included in the analysis. The mean patient age was 66 ± 22 (range 29-91) years. Regarding education, 41% of patients had graduate-level education, 48% had college education, and 11% high school education. Mean follow-up was 3.2 ± 7.6 (range 0.5-12) years. The agents used were trimix (62%), bimix (35%), papaverine (2%), and prostaglandin E1 monotherapy (1%). At least 1 error occurred during self-administration in 42% of patients during their time in the program. Errors included zero response to medication due to technical error (8% of patients), penile bruising (34%), use of an expired bottle (18%), self-titration (5%), and double injecting (4% of patients); 12% of men committed ≥1 error during their time in the program. On multivariable analysis, independent predictors of the occurrence of a major error included: young age, graduate-level education, and <12 months of injection use. CLINICAL IMPLICATIONS: To the best of our knowledge, this is the first reported study to investigate ICI errors and risk factors. The identification of factors predictive of major errors allows for more tailored and intensive training in this subset of patients. STRENGTHS AND LIMITATIONS: Strengths of this study include a large patient population (1386 men) with a considerable follow-up time. Additionally, the rigorous training, education, and monitoring of the participants, as well as the use of formal definitions, enhances the accuracy and reliability of the results. Despite the strengths of the study, recall bias may be a limitation concern. CONCLUSION: The majority of patients were error free, and the majority of the errors were minor in nature. Major errors occurred in <10% of patients. Younger age, graduate-level education, and less experience with ICI were independent predictors of major errors.

Risk Factors Associated with Medication Administration Errors in Children: A Prospective Direct Observational Study of Paediatric Inpatients.

INTRODUCTION: Limited evidence exists regarding medication administration errors (MAEs) on general paediatric wards or associated risk factors exists. OBJECTIVE: The aim of this study was to identify nurse, medication, and work-environment factors associated with MAEs among paediatric inpatients. METHODS: This was a prospective, direct observational study of 298 nurses in a paediatric referral hospital in Sydney, Australia. Trained observers recorded details of 5137 doses prepared and administered to 1530 children between 07:00 h and 22:00 h on weekdays and weekends. Observation data were compared with medication charts to identify errors. Clinical errors, potential severity and actual harm were assessed. Nurse characteristics (e.g. age, sex, experience), medication type (route, high-risk medications, use of solvent/diluent), and work variables (e.g. time of administration, weekday/weekend, use of an electronic medication management system [eMM], presence of a parent/carer) were collected. Multivariable models assessed MAE risk factors for any error, errors by route, potentially serious errors, and errors involving high-risk medication or causing actual harm. RESULTS: Errors occurred in 37.0% (n = 1899; 95% confidence interval [CI] 35.7-38.3) of administrations, 25.8% (n = 489; 95% CI 23.8-27.9) of which were rated as potentially serious. Intravenous infusions and injections had high error rates (64.7% [n = 514], 95% CI 61.3-68.0; and 77.4% [n = 188], 95% CI 71.7-82.2, respectively). For intravenous injections, 59.7% (95% CI 53.4-65.6) had potentially serious errors. No nurse characteristics were associated with MAEs. Intravenous route, early morning and weekend administrations, patient age ≥ 11 years, oral medications requiring solvents/diluents and eMM use were all significant risk factors. MAEs causing actual harm were 45% lower using an eMM compared with paper charts. CONCLUSION: Medication error prevention strategies should target intravenous administrations and not neglect older children in hospital. Attention to nurses' work environments, including improved design and integration of medication technologies, is warranted.

Drug-Drug Interactions and Actual Harm to Hospitalized Patients: A Multicentre Study Examining the Prevalence Pre- and Post-Electronic Medication System Implementation.

INTRODUCTION: Drug-drug interactions (DDIs) have potential to cause patient harm, including lowering therapeutic efficacy. This study aimed to (i) determine the prevalence of potential DDIs (pDDIs); clinically relevant DDIs (cDDIs), that is, DDIs that could lead to patient harm, taking into account a patient's individual clinical profile, drug effects and severity of potential harmful outcome; and subsequent actual harm among hospitalized patients and (ii) examine the impact of transitioning from paper-based medication charts to electronic medication management (eMM) on DDIs and patient harms. METHODS: This was a secondary analysis of the control arm of a controlled pre-post study. Patients were randomly selected from three Australian hospitals. Retrospective chart review was conducted before and after the implementation of an eMM system, without accompanying clinical decision support alerts for DDIs. Harm was assessed by an expert panel. RESULTS: Of 1186 patient admissions, 70.1% (n = 831) experienced a pDDI, 42.6% (n = 505) a cDDI and 0.9% (n = 11) an actual harm in hospital. Of 15,860 pDDIs identified, 27.0% (n = 4285) were classified as cDDIs. The median number of pDDIs and cDDIs per 10 drugs were 6 [interquartile range (IQR) 2-13] and 0 (IQR 0-2), respectively. In cases where a cDDI was identified, both drugs were 44% less likely to be co-administered following eMM (adjusted odds ratio 0.56, 95% confidence interval 0.46-0.73). CONCLUSION: Although most patients experienced a pDDI during their hospital stay, less than one-third of pDDIs were clinically relevant. The low prevalence of harm identified raises questions about the value of incorporating DDI decision support into systems given the potential negative impacts of DDI alerts.

Developing a Diabetes Discharge Order Set for Patients With Diabetes on Insulin.

BACKGROUND: Insulin, a high-risk medication, is prone to prescribing errors. Patients with diabetes experience higher hospitalization rates and extended hospital stays. Prescription errors, such as missing orders, inappropriate insulin type, missing instructions, and lack of appropriate intensification of insulin regimens are common issues. This project explored the use of system-based interventions and educational tools to minimize errors and improve the quality of insulin discharge regimens. METHODS: A needs assessment and baseline chart review were conducted before adapting a diabetes order set obtained from the University of California, San Diego. Subsequent beta testing and broader implementation were followed by repeat chart reviews to assess the impact. RESULTS: Providers strongly desired an insulin discharge order set, with 98% of those surveyed expressing this preference. Those who were high utilizers of the order set showed increased rates of ordering all supplies (55%), compared with pre-intervention rates (27%). However, no change was observed in the practice of intensifying insulin regimens in patients with uncontrolled diabetes upon discharge. DISCUSSION: Insulin prescribing is prone to error. A diabetes discharge order set may improve the percentage of patients who receive necessary insulin supplies at discharge and provide educational resources to encourage appropriate insulin regimens at hospital discharge.

Comparison between proactive and retroactive models of medication reconciliation in patients hospitalized for acute decompensated heart failure.

BACKGROUND: Most research on the impact of medication reconciliation on patient safety focused on the retroactive model, with limited attention given to the proactive model. OBJECTIVE: This study was conducted to compare the proactive and retroactive models in patients hospitalized for acute decompensated heart failure. METHODS: This prospective, quasi-experimental study was conducted over six months, from June to November 2022, at the cardiology unit of an academic hospital in Iran. Eligible patients were those hospitalized for acute decompensated heart failure using a minimum of five regular medications before admission. Medication reconciliation was performed in 81 cases using the proactive model and in 81 using the retroactive model. RESULTS: 556 medications were reconciled using the retroactive model, and 581 were reconciled using the proactive model. In the retroactive cases, 341 discrepancies (both intentional and unintentional) were identified, compared to 231 in the proactive cases. The proportion of patients with at least one unintentional discrepancy was significantly lower in the proactive cases than in the retroactive cases (23.80% versus 74.03%). Moreover, the number of unintentional discrepancies was significantly lower in the proactive cases compared to the retroactive cases (22 out of 231 discrepancies versus 150 out of 341 discrepancies). In the retroactive cases, medication omission was the most frequent type of unintentional discrepancy (44.00). About, 42.70% of reconciliation errors detected in the retroactive cases were judged to have the potential to cause moderate to severe harm. While the average time spent obtaining medication history was similar in both models (00:27 [h: min] versus 00:30), the average time needed to complete the entire process was significantly shorter in the proactive model compared to the retroactive model (00:41 min versus 00:51). CONCLUSION: This study highlighted that the proactive model is a timely and effective method of medication reconciliation, particularly in improving medication safety for high-risk patients.

Look-alike sound-alike (LASA) medication errors in Thai hospitals / Errores de medicación por sonido similar (LASA) en hospitales tailandeses

Look-alike sound-alike (LASA) drugs cause a high proportion of medication errors in hospitals. Drug lists available in hospitals are diverse and complicated. Presently, each hospital has its own LASA drug list and unique management strategies to minimize and prevent LASA errors. Objective: This study aimed to explore the prevalence of LASA drug lists, types of LASA drugs, and categories of medication errors in hospitals in Thailand. Methods: For this crosssectional study, questionnaires were developed and distributed along with a letter to 500 government hospitals (selected from a total of 1,309 hospitals) in Thailand via mail from April to June 2021. Data were analyzed using descriptive statistics (frequencies and percentages). Results: A total of 128 hospitals participated in this study (response rate: 25.60%), including 12 tertiary hospitals (9.38%), 33 secondary hospitals (25.78%), 24 large primary hospitals (18.75%), 51 small primary hospitals (39.84%), and eight private hospitals (6.25%). A total of 2,510 pairs of LASA drugs were identified, which included 1,674 (66.69%) tablets/capsules (Simvastatin 10-Simvastatin 20 pair had the highest frequency), 427 injections (17.01%) (Ceftriaxone-Ceftazidime pair had the highest frequency), 85 liquid dosage forms (3.39%) (Milk of magnesia-alum milk pair had the highest frequency), 74 special techniques in medicine (2.95%) (Seretide evohaler®-Seretide accuhaler® pair had the highest frequency), 49 external used drugs (1.95%) (Clotrimazole cream-Clobetasol cream pair had the highest frequency), and 28 powder dosage forms (1.12%) (ORS for pediatrics-ORS for adult pair had the highest frequency). Conclusion: Despite relevant awareness among healthcare professionals, LASA medication errors occur in hospitals. The most frequent similarities among LASA drugs were detected in their names/pronunciations, and the most common errors belonged to Category B.(AU)

Advanced prescription of injectable anticancer drugs: Safety assessment in a European Comprehensive Cancer Centre using the risk matrix approach.

AIMS: The purpose of this work was to assess failures in the advanced prescription of parenteral anticancer agents in an adult day oncology care unit with more than 100 patients per day. METHODS: An a priori descriptive analysis was carried out by using the risk matrix approach. After defining the scope in a multidisciplinary meeting, we determined at each step the failure modes (FMs), their effects (E) and their associated causes (C). A severity score (S) was assigned to all effects and a probability of occurrence (O) to all causes. These S and O indicators, were used to obtain a criticality index (CI) matrix. We assessed the risk control (RC) of each failure in order to define a residual criticality index (rCI) matrix. RESULTS: During risk analysis, 14 FMs were detected, and 61 scenarios were identified considering all possible effects and causes. Nine situations (15%) were highlighted with the maximum CI, 18 (30%) with a medium CI, and 34 (55%) with a negligible CI. Nevertheless, among all these critical situations, only three (5%) had an rCI to process (i.e., missed dose adjustment, multiple prescriptions and abnormal biology data); the others required monitoring only. Clinicians' and pharmacists' knowledge of these critical situations enables them to manage the associated risks. CONCLUSIONS: Advanced prescription of injectable anticancer drugs appears to be a safe practice for patients when combined with risk management. The major risks identified concerned missed dose adjustment, prescription duplication and lack of consideration for abnormal biology data.

Errores de medicación en niños que acuden a los servicios de urgencias pediátricas / Medication errors in children visiting pediatric emergency departments

Objetivos: la seguridad de los medicamentos en pediatría supone un verdadero reto. Se dispone de escasos estudios que hayan analizado los errores de medicación en los pacientes pediátricos que acuden a los servicios de urgencias. El objetivo de este estudio ha sido caracterizar los errores detectados en estos pacientes, determinando su gravedad, los procesos afectados, los medicamentos implicados y los tipos de errores y causas asociados. Métodos: estudio multicéntrico observacional prospectivo realizado en los servicios de urgencias de 8 hospitales públicos españoles durante 4 meses. Los errores de medicación detectados por los pediatras de urgencias en pacientes entre 0 y 16 años fueron evaluados por un farmacéutico y un pediatra. Los errores de medicación fueron analizados utilizando la Taxonomía Española de Errores de Medicación actualizada. Resultados: en 99.797 visitas a urgencias se detectaron 218 (0,2%) errores de medicación, de los cuales 74 (33,9%) causaron daños (eventos adversos por medicamentos). Los preescolares fueron el grupo poblacional con mayor número de errores de medicación (126/218). Los errores se originaron mayoritariamente en la prescripción (66,1%), por automedicación (16,5%) y por administración equivocada por parte de los familiares (15,6%). Los tipos de errores más frecuentes fueron: «dosis incorrectas» (51,4%) y «medicamento inapropiado» (46,8%). Los antiinfecciosos (63,5%) fueron los fármacos más comúnmente implicados en los errores con daño. Las causas subyacentes asociadas a una mayor proporción de errores de medicación fueron: «falta de conocimiento del medicamento» (63,8%), «falta de seguimiento de los procedimientos» (48,6%) y «falta de información del paciente» (30,3%). Conclusiones: los errores de medicación en la población pediátrica que acude a urgencias se producen en la prescripción, por automedicación y en la administración, provocando daños a los pacientes en un tercio de las ocasiones. ...(AU)

Objectives: Medication safety represents an important challenge in children. There are limited studies on medication errors in pediatric patients visiting emergency departments. To help bridge this gap, we characterized the medication errors detected in these patients, determining their severity, the stages of the medication process in which they occurred, the drugs involved, and the types and causes associated with the errors. Methods: We conducted a multicenter prospective observational study in the pediatric emergency departments of 8 Spanish public hospitals over a 4-month period. Medication errors detected by emergency pediatricians in patients between 0 and 16 years of age were evaluated by a clinical pharmacist and a pediatrician. Each medication error was analyzed according to the updated Spanish Taxonomy of Medication Errors. Results: In 99,797 visits to pediatric emergency departments, 218 (0.2%) medication errors were detected, of which 74 (33.9%) resulted in harm (adverse drug events). Preschoolers were the age group with the most medication errors (126/218). Errors originated mainly in the prescribing stage (66.1%), and also by self-medication (16.5%) and due to wrong administration of the medication by family members (15.6%). Dosing errors (51.4%) and wrong/improper drugs (46.8%) were the most frequent error types. Anti-infective drugs (63.5%) were the most common drugs implicated in medication errors with harm. Underlying causes associated with a higher proportion of medication errors were “medication knowledge deficit” (63.8%), “deviation from procedures/guidelines” (48.6%) and “lack of patient information” (30.3%). Conclusions: Medication errors presented by children attending emergency departments arise from prescriptions, self-medication, and administration, and lead to patient harm in one third of cases. Developing effective interventions based on the types of errors and the underlying causes identified will improve patient safety. (AU)

[Prescription errors and drug interactions in adults hospitalized in an intensive care unit in Barranquilla (Colombia).] / Errores de prescripción e interacciones farmacológicas en personas adultas hospitalizadas en una unidad de cuidados intensivos en Barranquilla (Colombia).

OBJECTIVE: Prescribing errors and drug-drug interactions constitute a relevant topic for health professionals in these hospital settings and for the strengthening of strategies to mitigate these errors. The aim of this article was to determine the prescribing errors and drug-drug interactions present in adult patients hospitalized in an intensive care unit in the city of Barranquilla (Colombia). METHODS: A quantitative study was conducted in which 158 medical records of adult patients who were hospitalized in an Intensive Care Unit (ICU) in the city of Barranquilla during 2019 were analyzed. Medication errors and drug-drug interactions were determined by means of the Medscape application. Statistical analysis was performed using the RStudio program, descriptive and inferential statistics were applied to the data. RESULTS: Sociodemographically, male sex prevailed, the most frequent pathological history was arterial hypertension, most patients were receiving between one±five drugs, the most common errors were related to omission of dosage, route and time of administration. Drug-drug interactions were reported in 64.5% (102) of the histories and, in terms of the level of severity of the interactions, moderate interactions predominated in 32.9% (52). CONCLUSIONS: It is evident that there is a high number of medication prescription errors in hospitalized adults, among which pharmacological interactions associated mainly with the number of medications received by individuals in the ICUs stand out.

OBJETIVO: Los errores de prescripción y las interacciones farmacológicas constituyen un tema relevante para los profesionales de salud que se encuentran en estos ámbitos hospitalarios y para el fortalecimiento de estrategias que permitan mitigar estos errores. El objetivo del artículo fue determinar los errores de prescripción e interacciones medicamentosas presentes en pacientes adultos hospitalizados en una unidad de cuidados intensivos en la ciudad de Barranquilla (Colombia). METODOS: Se realizó un estudio cuantitativo en el que se analizaron 158 historias clínicas de pacientes adultos que estuvieron hospitalizados en una Unidad de Cuidados Intensivos (UCI) de la ciudad de Barranquilla durante el año 2019. Se determinaron errores de medicación e interacciones medicamentosas por medio de la aplicación Medscape. El análisis estadístico se realizó mediante el programa RStudio, se aplicó estadística descriptiva e inferencial a los datos. RESULTADOS: Sociodemográficamente prevaleció el sexo masculino, el antecedente patológico con mayor frecuencia fue la hipertensión arterial, la mayoría de los pacientes estaban recibiendo entre uno±cinco medicamentos, los errores más comunes estaban relacionados con la omisión de la dosis, vía y horario de administración. Se reportaron interacciones medicamentosas en el 64,5% (102) de las historias y, en cuanto al nivel de gravedad de las interacciones, predominaron las moderadas en un 32,9% (52). CONCLUSIONES: Se evidencia que existe un alto número de errores de prescripción de medicamentos en los adultos hospitalizados, entre los que se destacan las interacciones farmacológicas asociadas principalmente con el número de medicamentos que reciben las personas en las UCI.

Análisis de un algoritmo de riesgo de errores de medicación: una experiencia portuguesa / Analysis of a medication error risk algorithm: a portuguese experience

Los errores de medicación son cada vez más comunes lo cual pone en peligro la salud de los pacientes, de ahí la importancia de prevenirlos y controlarlos. El concepto de crear una herramienta de decisión clínica que permita gestionar mejor estos eventos no es nuevo. Utilizando una experiencia danesa, decidimos aplicar el algoritmo de MERIS (Medication Risk Score) en un servicio de accidente cerebrovascular de un hospital portugués con el fin de probar su aplicabilidad, determinar volumen de pacientes de riesgo y comprobar cual variable del algoritmo se correlaciona más con paciente de riesgo. Con una muestra de 65 pacientes con sus respectivos reportes MERIS se determinó que durante dos meses más de la mitad de los pacientes admitidos eran de alto riesgo para errores en su medicación. Se seleccionó la prueba de correlación de Spearman para determinar cuál de todas las variables de MERIS estaba más relacionada a un puntaje alto. Encontramos correlaciones positivas fuertes y estadísticamente significativas entre el puntaje de Meris y: función renal reducida, número de fármacos con bajo riesgo de daño, número de fármacos con alto riesgo de daño, número de fármacos, número de fármacos con riesgo medio de daño y número de fármacos con riesgo de interacción bajo a medio, siendo estos últimos tres los más significativos. No hubo una correlación estadísticamente significativa entre el puntaje MERIS y el número de fármacos con alto riesgo de interacción. Finalmente, modificamos la lista de medicamentos propuesta por los autores anteriores adaptada a nuestro hospital. (AU)

Medication errors are gradually more common, risking patients health, hence the importance of preventing and controlling them. The concept of creating a clinical decision tool to better manage these events is not new. Using a Danish experience, we applied the MERIS (Medication Risk Score) algorithm in a stroke unit of a Portuguese hospital in order to test its applicability, determine the volume of patients at risk and check which variable of the algorithm correlates more with patient risk. Using a sample of 65 patients with their respective MERIS reports, we determined that for two months more than half of the admitted patients were at high risk of errors in their medication. The Spearman correlation test was selected to determine which MERIS variable was most related to a high score. We found strong and statistically significant positive correlations between the Meris score and: reduced kidney function, number of drugs with low risk of damage, number of drugs with high risk of damage, number of drugs, number of drugs with medium risk of damage and number of drugs with low to medium risk of interaction, the latter three being the most significant. There was no statistically significant correlation between the MERIS score and the number of drugs with a high risk of interaction. Finally, we modify the list of medications proposed by the previous authors adapted to our hospital. (AU)

Disminución de errores de medicación Look-Alike Sound-Alike, mediante la implementación de estrategias preventivas en una clínica de III nivel Barranquilla-Colombia / Decrease in Look-Alike Sound-Alike, medication errors through the implementation of preventive strategies in a third level clinic from Barranquilla-Colombia

Los medicamentos Look-Alike and Sound-Alike (LASA) son frecuentemente causantes de errores de medicación en el proceso de dispensación, con importantes repercusiones desde el punto de vista humano, asistencial y económico.Objetivo: Determinar la disminución de tasa de estos errores de medicación LASA, posterior a la implementación de estrategias de prevención en una clínica de tercer nivel en Barranquilla, Colombia.Método: La investigación fue de tipo experimental, prospectivo; el periodo de estudio fue de 3 meses (enero-marzo 2021); el criterio de inclusión para el estudio fueron los medicamentos del listado básico de medicamentos LASA y los errores de medicación ocasionados por estos. Se implementaron estrategias de prevención de errores tipo LASA, se cuantificó y comparó los errores de medicación presentados antes y después de la implementación de las estrategias. Resultados: En la etapa de pre-implementación de las estrategias se dispensaron 24.300 medicamentos, entre los cuales se presentaron 80 (0,33%) errores de medicación por medicamentos LASA. En la etapa de post-implementación se dispensaron 23.760 medicamentos, y se presentaron 48 (0,20%) errores de medicación por medicamentos LASA, evidenciando una reducción significativa (P-valor: 0,0366314; IC: 95%). Los medicamentos con mismo principio activo y diferente concentración fueron los de mayor incidencia de errores de medicación en el Servicio Farmacéutico, con 37 errores en la etapa de pre-implementación y 19 errores en la etapa de post-implementación.Conclusión: La reducción de la tasa de errores de medicación fue del 40% al implementar las estrategias propuestas, lo que demuestra su efectividad y su potencial para ofrecer una atención más segura y de mayor calidad a los pacientes, a bajo costo. (AU)

Look-Alike and Sound-Alike (LASA) drugs are frequently the cause of medication errors in the dispensing process, with important repercussions from the human, healthcare and economic point of view.Objective: To determine the decrease in the rate of these LASA medication errors, after the implementation of prevention strategies in a third-level clinic in Barranquilla, Colombia. Method: The research was experimental, prospective; the study period was 3 months (January-March 2021); the inclusion criteria for the study were drugs from the clinic’s basic list of drugs that were LASA and the medication errors caused by these. LASA error prevention strategies were implemented; the medication errors presented before and after the implementation of the strategies were quantified and compared.Results: In the pre-implementation stage of the strategies, 24,300 medications were dispensed, among which there were 80 (0.33%) medication errors due to LASA medications. In the post-implementation stage, 23,760 medications were dispensed, and 48 (0.20%) medication errors occurred due to LASA medications, showing a significant reduction (P-valor: 0.0366314; IC: 95%). Medicines with the same active ingredient and different concentrations were those with the highest incidence of medication errors in the Pharmaceutical Service, with 37 errors in the pre-implementation stage and 19 errors in the post-implementation stage.Conclusion: The reduction in the rate of medication errors was 40% after implementing the proposed strategies, which demonstrates their effectiveness and their potential to offer a safer and higher quality care to patients, at low cost. (AU)

Occurrence and types of medication error and its associated factors in a reference teaching hospital in northeastern Iran: a retrospective study of medical records.

BACKGROUND: Medication errors are categorized among the most common medical errors that may lead to irreparable damages to patients and impose huge costs on the health system. A correct understanding of the prevalence of medication errors and the factors affecting their occurrence is indispensable to prevent such errors. The purpose of this study was to investigate the prevalence and types of medication errors among nurses in a hospital in northeastern Iran. METHODS: The present descriptive-analytical research was conducted on 147 medical records of patients admitted to the Department of Internal Medicine at a hospital in northeastern Iran in 2019, selected by systematic sampling. The data were collected through a researcher-made checklist containing the demographic profiles of the nurses, the number of doctor's orders, the number of medication errors and the type of medication error, and were finally analyzed using STATA version 11 software at a significance level of 0.05. RESULTS: Based on the findings of this study, the mean prevalence of medication error per each medical case was 2.42. Giving non-prescription medicine (47.8%) was the highest and using the wrong form of the drug (3.9%) was the lowest medication error. In addition, there was no statistically significant relationship between medication error and the age, gender and marital status of nurses (p > 0.05), while the prevalence of medication error in corporate nurses was 1.76 times higher than that of nurses with permanent employment status (IRR = 1.76, p = 0.009). The prevalence of medication error in the morning shift (IRR = 0.65, p = 0.001) and evening shift (IRR = 0.69, p = 0.011) was significantly lower than that in the night shift. CONCLUSION: Estimating the prevalence and types of medication errors and identified risk factors allows for more targeted interventions. According to the findings of the study, training nurses, adopting an evidence-based care approach and creating interaction and coordination between nurses and pharmacists in the hospital can play an effective role in reducing the medication error of nurses. However, further research is needed to evaluate the effectiveness of interventions to reduce the prevalence of medication errors.

Retrospective identification of medication related adverse events in the emergency medical services through the analysis of a patient safety register.

Adverse drug events encompass a wide range of potential unintended and harmful events, from adverse drug reactions to medication errors, many of which in retrospect, are considered preventable. However, the primary challenge towards reducing their burden lies in consistently identifying and monitoring these occurrences, a challenge faced across the spectrum of healthcare, including the emergency medical services. The aim of this study was to identify and describe medication related adverse events (AEs) in the out-of-hospital setting. The medication components of a dedicated patient safety register were analysed and described for the period Jan 2017-Sept 2020. Univariate descriptive analysis was used to summarize and report on basic case and patient demographics, intervention related AEs, medication related AEs, and AE severity. Multivariable logistic regression was used to assess the odds of AE severity, by AE type. A total of 3475 patient records were assessed where 161 individual medication AEs were found in 150 (4.32%), 12 of which were categorised as harmful. Failure to provide a required medication was found to be the most common error (1.67%), followed by the administration of medications outside of prescribed practice guidelines (1.18%). There was evidence to suggest a 63% increase in crude odds of any AE severity [OR 1.63 (95% CI 1.03-2.6), p = 0.035] with the medication only AEs when compared to the intervention only AEs. Prehospital medication related adverse events remain a significant threat to patient safety in this setting and warrant greater widespread attention and future identification of strategies aimed at their reduction.

Hospitalizations and deaths related to adverse drug events worldwide: Systematic review of studies with national coverage.

PURPOSE: Adverse drug events are related to negative outcomes in healthcare, including hospitalization, increased duration of hospital stay and death. The aim of this study was to conduct a systematic review to evaluate hospitalizations and deaths related to adverse drug events worldwide, reported in studies with national coverage. METHODS: The protocol was registered in PROSPERO (CRD42020157008). We performed a systematic search on Medline, Embase, CINAHL, LILACS, and the Cochrane Library (until March 2020) using pre-specified terms. We included published studies that reported data on hospitalizations and/or deaths related to adverse drug events from a national perspective and the use of secondary data as a source of information. Two reviewers independently extracted and synthesized data. The quality of the studies was assessed using an adapted version of the Joanna Briggs Institute critical appraisal checklist for prevalence studies. Narrative summaries of findings were undertaken. RESULTS: Among 59,336 citations, 62 studies were included for data extraction and synthesis. Among these studies, 41 studies included the outcome of hospitalization, 16 included the death outcome, and five included both outcomes. Administrative databases regarding discharges and registries of vital statistics were the most common sources of information. The relative frequency of hospitalizations ranged from 0.03% to 7.3%, and from 9.7 to 383.0/100,000 population, whereas mortality rate ranged from 0.1 to 7.88/100,000 population. CONCLUSION: Our study highlights information about adverse drug events using large administrative databases in a national scenario and provides an overview of databases and methods implemented to detect adverse drug events.