scholarly journals Review of medication errors that are new or likely to occur more frequently with electronic medication management systems

2019 ◽  
Vol 43 (3) ◽  
pp. 276 ◽  
Author(s):  
Melita Van de Vreede ◽  
Anne McGrath ◽  
Jan de Clifford
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Classification System ◽  
Medication Management ◽  
Management Systems ◽  
Prescribing Errors ◽  
New Classification ◽  
Severity Rating ◽  
Retrospective Audit ◽  
Error Types

Objective The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were ‘human factors’ and ‘unfamiliarity or training’ (70%) and ‘cross-encounter or hybrid system errors’ (22%). Conclusions Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.

scholarly journals Analysis of pharmacist interventions associated with insulin prescribing for hospital inpatients with diabetes

2021 ◽  
Author(s):  
Nathan Zipf ◽  
Lauren Grant ◽  
Brent Robinson ◽  
Trudy Teasdale ◽  
Gary Grant ◽  
...  
Keyword(s):  
High Risk ◽  
Medication Errors ◽  
Management System ◽  
Medication Management ◽  
Inpatient Unit ◽  
Prescribing Errors ◽  
Pharmacist Interventions ◽  
Retrospective Audit ◽  
Hospital Inpatients

Abstract Background: Insulin is a high-risk medicine, associated with hospital medication errors. Pharmacists play an important role in the monitoring of patients on insulin. Objective: To analyse interventions made by hospital pharmacists that were associated with insulin prescribing for inpatients with diabetes.Method: Retrospective audit of pharmacist interventions for adult inpatients for an 8-month period, 1 June 2019 to 31 January 2020. Pharmacist interventions recorded in the electronic medication management system by inpatient unit and dedicated high-risk medicine pharmacists were extracted, screened, and analysed.Results: Of 3,975 pharmacist interventions 3,356 (84.43%) were recorded by high-risk medicine pharmacists and 619 (15.57%) by inpatient unit pharmacists. July and August 2019 had the highest numbers of interventions with 628 and 643 (15.80% and 16.18%) respectively. Most of the interventions, namely 3,410 (85.79%) were classified as medicine optimisation interventions and 565 (14.21%) as prescribing errors. In the medicine optimisation intervention category, 2,985 (75.09%) were due to insulin not charted for ongoing administration.Conclusion: This study provides insights into pharmacist interventions for inpatients on insulin, showing that high-risk medicine pharmacists recorded most interventions. The classification of the insulin interventions into medicine optimisation and prescribing errors provides useful information for the training of prescribers in insulin management.

Preventing Medication Errors with Antineoplastic Agents, Part 1

2000 ◽  
Vol 35 (5) ◽  
pp. 511-526 ◽  
Author(s):  
M. Christina Beckwith ◽  
Linda S. Tyler
Keyword(s):  
Health Care ◽  
Medication Error ◽  
Medication Errors ◽  
Antineoplastic Agents ◽  
Health Care Systems ◽  
Medication Use ◽  
Prescribing Errors ◽  
Care Systems

Goal — The goal of this program is to present practical ways to prevent medication errors with antineoplastic agents, identify common types of medication errors, and describe a system for reducing the incidence of medication errors and responding appropriately to antineoplastic medication errors. Objectives — At the completion of this program, the participant will be able to: 1. Describe the scope and impact of medication errors 2. Define common terms used in medication error literature. 3. List four common types of prescribing errors made with anti-neoplastic agents. 4. Identify steps where medication errors may occur during the drug ordering, preparation, and administration process. 5. Describe ways to prevent errors at each step of the medication use process. 6. Recommend a procedure for reporting and monitoring antineoplastic medication errors within the institution. 7. Describe a system for the non-punitive management of antineoplastic medication errors in health care systems.

Electronic Medication Management Systems: Analysis of Enhancements to Reduce Errors and Improve Workflow

2021 ◽  
Vol 12 (05) ◽  
pp. 1049-1060
Author(s):  
Madaline Kinlay ◽  
Lai Mun Rebecca Ho ◽  
Wu Yi Zheng ◽  
Rosemary Burke ◽  
Ilona Juraskova ◽  
...  
Keyword(s):  
Medication Errors ◽  
Systems Analysis ◽  
Continuous Monitoring ◽  
Medication Management ◽  
Electronic System ◽  
Management Systems ◽  
Safety Risks ◽  
System Use ◽  
Changes Over Time ◽  
Over Time

Abstract Background Electronic medication management (eMM) has been shown to reduce medication errors; however, new safety risks have also been introduced that are associated with system use. No research has specifically examined the changes made to eMM systems to mitigate these risks. Objectives To (1) identify system-related medication errors or workflow blocks that were the target of eMM system updates, including the types of medications involved, and (2) describe and classify the system enhancements made to target these risks. Methods In this retrospective qualitative study, documents detailing updates made from November 2014 to December 2019 to an eMM system were reviewed. Medication-related updates were classified according to “rationale for changes” and “changes made to the system.” Results One hundred and seventeen updates, totaling 147 individual changes, were made to the eMM system over the 4-year period. The most frequent reasons for changes being made to the eMM were to prevent medication errors (24% of reasons), optimize workflow (22%), and support “work as done” on paper (16%). The most frequent changes made to the eMM were options added to lists (14% of all changes), extra information made available on the screen (8%), and the wording or phrasing of text modified (8%). Approximately a third of the updates (37%) related to high-risk medications. The reasons for system changes appeared to vary over time, as eMM functionality and use expanded. Conclusion To our knowledge, this is the first study to systematically review and categorize system updates made to overcome new safety risks associated with eMM use. Optimization of eMM is an ongoing process, which changes over time as users become more familiar with the system and use is expanded to more sites. Continuous monitoring of the system is necessary to detect areas for improvement and capitalize on the benefits an electronic system can provide.

scholarly journals To err is human: medication patient safety in aged care, a case study

2018 ◽  
Vol 19 (2) ◽  
pp. 126-134
Author(s):  
Julia Gilbert ◽  
Jeong-ah Kim
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Management ◽  
Care Facility ◽  
Root Cause Analysis ◽  
Aged Care ◽  
Cause Analysis ◽  
Content Type ◽  
Root Cause

Purpose The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study. Design/methodology/approach In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility. Findings Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013). Originality/value Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

scholarly journals Medication Management System: An Approach to Reduce Medication Error In Apollo Hospitals Dhaka

Pulse ◽  
2014 ◽  
Vol 5 (2) ◽  
pp. 41-47
Author(s):  
A Mahmud ◽  
F Noor ◽  
M Nasrullah
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Reconciliation ◽  
Medication Management ◽  
Drug Reactions ◽  
Acceptable Range ◽  
Rational Drug ◽  
Reduce Medication Error ◽  
Proper Training ◽  
Dispensing Errors

Apollo Hospitals Dhaka surely stepped ahead than any other hospital of Bangladesh for reducing medication errors significantly. From the very beginning of its establishment, reducing medication errors was taken as a major challenge and effective and approved strategies were developed when no other hospital took efforts in this regard. Strategies included tracking incidents of medication errors, analyzing, reporting & arranging proper training sessions for hospital staffs etc. All four types of errors like Prescription errors, Transcription errors, Dispensing errors and Administration errors are rectified and officially reported by hospital pharmacists. Along with these, Prescription Reviewing, Medication Reconciliation, incidents of Adverse Drug Reactions (ADR) are also monitored to ensure rational drug use for patients. With all its efforts, Apollo Hospitals Dhaka was able to reduce the rate of medication errors within the internationally acceptable range. DOI: http://dx.doi.org/10.3329/pulse.v5i2.20265 Pulse Vol.5 July 2011 p.41-47

scholarly journals Identifying Medication Errors in a Tertiary Care Teaching Hospital: A Prospective Observational Study

2019 ◽  
Vol 9 (6-s) ◽  
pp. 103-106
Author(s):  
Peddolla Sushma Reddy ◽  
Vidya Biju ◽  
Inuganti Bhavana
Keyword(s):  
Health Care ◽  
Observational Study ◽  
Medication Error ◽  
Medication Errors ◽  
Teaching Hospital ◽  
Prospective Observational Study ◽  
Tertiary Care ◽  
Medication Use ◽  
Prescribing Errors ◽  
Tertiary Care Teaching Hospital

Background: Medication error is defined as any avertable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient and consumer. Medication errors may occur at any stage of the medication use process including ordering, transcription, dispensing, administering and monitoring.  Objective: The objective of the study is to assess the medication errors in a tertiary care hospital and to categorize them based on their nature and type. Methodology: A prospective observational study was conducted over a period of 3 months in a tertiary care teaching hospital. This study was carried out among 240 inpatients, admitted in General Medicine department of the hospital, who were selected randomly. During the study, inpatients case records were reviewed, which includes patient’s case history, diagnosis, medication order sheets, progress chart, laboratory investigations. The data collected were analyzed for identifying medication errors such as prescribing errors and administration errors. Each reported medication error was assessed using the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) proposed index for categorizing medication errors. Results: A total number of 240 inpatients were enrolled in the study, out of which 82 patients have developed medication errors. The overall percentage of observed medication error was 34.16%. In our study medication errors were found more in males (70.7%) than in the females (29.3%). Prescribing errors (62.19%) were the most frequently occurring type of error, which was followed by administration errors (37.8%). In our study, we found that medication errors were more with antibiotics (37) followed by NSAIDs (19). 96 prescriptions were found having drug interactions. Conclusion: This study concludes that the overall incidence of medication error was found to be 34.16%. Most of the medication errors are clinically significant and it can prevent by working together in a health care team.  

Preventing Medication Prescribing Errors

DICP ◽  
1991 ◽  
Vol 25 (12) ◽  
pp. 1388-1394 ◽  
Author(s):  
Josephine A. Vitillo ◽  
Timothy S. Lesar
Keyword(s):  
Patient Care ◽  
Patient Outcomes ◽  
Medication Errors ◽  
Prescribing Errors ◽  
Error Prevention ◽  
Prevention Services ◽  
Quality Of Patient Care ◽  
Physician Prescribing ◽  
Error Types

Medication errors may arise in the manufacture, preparation, distribution, and administration of drugs. Physician prescribing errors are of particular importance as such errors have been associated with significant adverse patient outcomes. The pharmacist plays an important role in preventing such errors from reaching the patient. The purpose of this article is to define and illustrate the various error types and the mental attitudes that cause individuals to prescribe errant orders. Through better understanding of the cause of prescribing errors, pharmacists may be able to improve the error prevention services they provide. Based on the error types discussed and their causes, recommendations are proposed to decrease the frequency of such errors and thereby improve the quality of patient care.

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