Evaluación de las prácticas de seguridad de los sistemas de utilización de medicamentos en los hospitales españoles (2007) / Assessment of safety practices for medication-use systems in Spanish hospitals (2007)

Fundamento y Objetivo: Conocer la situación de las prácticas de seguridad de los sistemas de utilización de medicamentos en los hospitales españoles e identificar las áreas de mayor riesgo. Material y Método: Se incluyeron los hospitales que cumplimentaron, del 1 de junio de 2007 al 15 de julio del 2007, el «Cuestionario de autoevaluación de la seguridad del sistema de utilización de los medicamentos», que contiene 232 ítems de evaluación agrupados en 20 criterios esenciales. Resultados: Participaron 105 hospitales de las 17 comunidades autó- nomas. La puntuación media del cuestionario en el total de hospitales fue de 612,7 (39,7% del valor máximo posible) y no se encontraron diferencias según tamaño, capacidad docente o finalidad asistencial. Al analizar los criterios esenciales, los valores más bajos (< 25%) correspondieron a 3 criterios relacionados con formación y competencia de los profesionales, y establecimiento de un sistema de notificación de errores. Otros 9 criterios, con porcentajes del 25 al 50%, se referían a prácticas de: acceso a información sobre pacientes y medicamentos; comunicación de prescripciones; prevención de errores por nombres, etiquetado y envasado; restricción de medicamentos en unidades asistenciales; estandarización de dispositivos de infusión; educación al paciente, y cultura de seguridad y procedimientos de doble chequeo. Conclusiones: Se han identificado numerosas oportunidades de mejora, especialmente en áreas relacionadas con formación, gestión de riesgos, incorporación de nuevas tecnologías y participación de pacientes. La información obtenida puede ser útil para priorizar las prácticas a abordar en las estrategias en seguridad del paciente y como línea basal para efectuar un seguimiento de la implantación de las iniciativas que se acometan (AU)

Material and Method: Those hospitals that completed the «Medication use-system safety self-assessment for hospitals» between June 1 and July 15, 2007, were included in the study. The survey contained 232 items for evaluation grouped into 20 core characteristics. Results: A total of 105 hospitals from the 17 autonomous communities in Spain participated in the study. The average aggregate score for the survey of all the participating hospitals was 612.7 (39.7% of the maximum possible score) and there were no differences found with regard to number of beds, training activity or type of hospital. When core characteristics were analyzed, there were 3 criteria with the lowest values (< 25%), associated with professional training, skills, and the establishment of a system for reporting errors. Another 9 criteria, with percentages between 25% and 50%, reflected practices related to: access to information regarding patients and medications; communication of medication orders; prevention of errors due to naming, labeling, and packaging problems; standardization of medication delivery devices; restriction of medications in patient care units; and safety culture and double-checking procedures. Conclusions: Many opportunities for improvement have been identified, particularly in areas related to training, risk management, incorporating new technologies and patient participation. The information obtained may prove useful for prioritizing practices when establishing patient safety strategies, and as a baseline for successfully monitoring the effectiveness of the initiatives and programs consequently set into motion (AU)

[Updated classification for medication errors by the Ruiz-Jarabo 2000 Group]. / Actualización de la clasificación de errores de medicación del grupo Ruiz-Jarabo 2000.

OBJECTIVE: To update the classification system created by the Ruiz-Jarabo 2000 group to standardize detection, analysis, and recording of medication errors, with the aim of improving its capacity and functionality. METHOD: The classification update was carried out by the Ruiz-Jarabo 2000 working group considering: a) other classifications used by incident reporting systems initiated after the original version had been created; b) suggestions offered by healthcare professionals with respect to the original version; and c) the experiences of the working group itself based on analyses of medication errors gathered in hospitals, and on analyses of reports notified to the ISMP-Spain medication error reporting and learning program. RESULTS: This article presents the updated version of the medication error classification system and describes the main changes made on to the different sections and categories. CONCLUSIONS: The new version may prove to be a useful tool for analyzing and reporting errors with regard to those detected within the framework of activities for improving safety in hospitals and primary care, as well as for those detected as a direct result of patient safety research. Thus, this document is expected to improve medication safety information management in such a way as to allow data to be used ever more efficiently for making medication use systems safer for patients.

Actualización de la clasificación de errores de medicación del grupo Ruiz-Jarabo 2000 / Updated classification for medication errors by the Ruiz-Jarabo 2000 Group

Objetivo: Actualizar la clasificación elaborada por el grupo Ruiz-Jarabo2000 para estandarizar la detección, análisis y registro de loserrores de medicación, con el fin de mejorar su capacidad y operatividad.Método: La actualización de la clasificación se efectuó por el grupo detrabajo Ruiz-Jarabo 2000 considerando: a) otras clasificaciones utilizadaspor sistemas de notificación de incidentes iniciados con posterioridada la realización de la versión inicial; b) las sugerencias formuladaspor profesionales sanitarios acerca de la versión inicial, y c) la experienciagenerada por el propio grupo de trabajo a partir del análisis de loserrores de medicación recogidos en los hospitales y de los errores remitidosal sistema de notificación y aprendizaje del ISMP-España.Resultados: Se presenta la versión actualizada de la clasificación deerrores de medicación y se describen los principales cambios introducidosen los diferentes apartados y categorías.Conclusiones: La nueva versión puede ser un instrumento de utilidadpara el análisis y registro de los errores de medicación, tanto de aquellosdetectados en el marco de las actividades de mejora de la seguridaden hospitales y en atención primaria como de los detectados conpropósitos de investigación acerca de la seguridad del paciente. Asimismo,pretende mejorar la gestión de la información acerca de la seguridaden el uso de los medicamentos, de forma que pueda ser empleadade manera más eficaz para desarrollar sistemas de utilizaciónde medicamentos cada vez más seguros para los pacientes

Objective: To update the classification system created by the Ruiz-Jarabo2000 group to standardize detection, analysis, and recording ofmedication errors, with the aim of improving its capacity and functionality.Method: The classification update was carried out by the Ruiz-Jarabo2000 working group considering: a) other classifications used by incidentreporting systems initiated after the original version had beencreated; b) suggestions offered by healthcare professionals with respectto the original version; and c) the experiences of the workinggroup itself based on analyses of medication errors gathered in hospitals,and on analyses of reports notified to the ISMP-Spain medicationerror reporting and learning program.Results: This article presents the updated version of the medicationerror classification system and describes the main changes made onto the different sections and categories.Conclusions: The new version may prove to be a useful tool for analyzingand reporting errors with regard to those detected within the frameworkof activities for improving safety in hospitals and primary care,as well as for those detected as a direct result of patient safety research.Thus, this document is expected to improve medication safety informationmanagement in such a way as to allow data to be used ever moreefficiently for making medication use systems safer for patients

[Assessment of safety practices for medication-use systems in Spanish hospitals (2007)]. / Evaluación de las prácticas de seguridad de los sistemas de utilización de medicamentos en los hospitales españoles (2007).

BACKGROUND AND OBJECTIVE: To examine the current status of safety practices for medication-use systems in Spanish hospitals and to identify major areas of risk. MATERIAL AND METHOD: Those hospitals that completed the "Medication use-system safety self-assessment for hospitals" between June 1 and July 15, 2007, were included in the study. The survey contained 232 items for evaluation grouped into 20 core characteristics. RESULTS: A total of 105 hospitals from the 17 autonomous communities in Spain participated in the study. The average aggregate score for the survey of all the participating hospitals was 612.7 (39.7% of the maximum possible score) and there were no differences found with regard to number of beds, training activity or type of hospital. When core characteristics were analyzed, there were 3 criteria with the lowest values (< 25%), associated with professional training, skills, and the establishment of a system for reporting errors. Another 9 criteria, with percentages between 25% and 50%, reflected practices related to: access to information regarding patients and medications; communication of medication orders; prevention of errors due to naming, labeling, and packaging problems; standardization of medication delivery devices; restriction of medications in patient care units; and safety culture and double-checking procedures. CONCLUSIONS: Many opportunities for improvement have been identified, particularly in areas related to training, risk management, incorporating new technologies and patient participation. The information obtained may prove useful for prioritizing practices when establishing patient safety strategies, and as a baseline for successfully monitoring the effectiveness of the initiatives and programs consequently set into motion.