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 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 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 The Effect of Medication Reconciliation Timeout on Patient Safety: An Evidence-Based Project

2020 ◽  
pp. 1-52
Author(s):  
Renante Dizon
Keyword(s):  
Medication Error ◽  
Acute Care ◽  
Medication Errors ◽  
Error Rate ◽  
Medication Reconciliation ◽  
Care Facility ◽  
High Rate ◽  
Evidence Based ◽  
Care Hospital

Practice Problem:There was a report of a high rate of medication errors from inaccurate medication reconciliation during admission to a local hospital in South Texas. The medication error rate was 14.88% on 20 reviewed charts, and 85% of all evaluated charts contained at least one medication discrepancy. PICOT: This evidence-based, system-change project was guided by the following PICOT question: For nurses administering medication in a long-term acute care hospital, does the implementation of Medication Reconciliation Timeout Process (MRTP) decrease the medication errors, compared to the usual medication practice, in one month? Evidence: Thirteen pertinent studies recommended the use of a combination of checklists and the timeout process to see a reduction in the number of medical errors and improvements in performance and safety. Intervention: The evidence-based intervention utilized MRTP with a checklist while performing medication reconciliation during admission. Two nurses checked the medication reconciliation for accuracy and completeness by comparing the medication list against transferring facility to physician’s admission orders. Outcome: The outcome of the project after the evidence-based intervention was a medication error rate of 3.77%, which was a significant reduction from 14.88%. Conclusion: The implementation of MRTP resulted in an 11.11% decrease in medication errors within four weeks in a long-term acute care facility.

scholarly journals Edukasi dan Sosialisasi Gerakan masyarakat Cerdas Menggunakan Obat (Gema Cermat)

2019 ◽  
Vol 5 (1) ◽  
pp. 36
Author(s):  
Nining Nining ◽  
Yeni Yeni
Keyword(s):  
Medication Errors ◽  
Test Score ◽  
Medication Management ◽  
Drug Reactions ◽  
Self Medication ◽  
Inappropriate Drugs ◽  
The People ◽  
Record Data ◽  
Post Test ◽  
Treatment Alternatives

Health problems are so complex today. It encourages the people to look for effective treatment alternatives and also efficient in terms of cost. Self medication is being an alternative that has been taken by the the people. Irrational self medication management could lead to disadvantages such as medication errors due to misdiagnosis, inappropriate drugs use due to bias of information from drug advertisements and unwanted drug reactions. Education and Socialization of  Gema Cermat was conducted by UHAMKA pharmacist lecturers on December 24th, 2017 in cooperation with PCPM Setu and pharmacists PC IAI Bekasi district as an effort in order to improve the concern, awareness, understanding and skill of people in using drugs properly and correctly. The methods used are CBIA, giving the brochure of Gema Cermat, the pocket books of drugs use and drugs classification, pre-test, post-test and materials about Gema Cermat through oral presentation by a pharmacist. The results of education and socialization of Gema Cermat are improving the values of the community regarding the proper and correct use of drugs. It could be seen from the increasing of average pre-test score, 72.5 to 89.7 on post-test. People could analyze and record data that they need to be considered on the drugs use so that  the proper and correct use of drugs can be achieved.

scholarly journals Descriptive Study on Reported Medication Error among Nurses in Queen Elizabeth II Hospital, Kota Kinabalu, Sabah

2020 ◽  
pp. 7
Author(s):  
Jenet Guan Chin ◽  
Mary Tan ◽  
Stephanie Yvonnesky Francis ◽  
Siti Rahmah Idris ◽  
Mary Padtong ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Continuous Monitoring ◽  
Descriptive Study ◽  
Precise Information ◽  
Root Cause ◽  
Preventative Measures ◽  
Global Issue ◽  
Reduce Medication Error

Introduction: Medication error is a global issue. Despite, the various impacts on health and non-health, continuous monitoring, assessment and intervention are required to reduce the number of medication error. Precise information on the root cause of medication error in Hospital Queen Elizabeth II, Kota Kinabalu will aid in the preventative measures to reduce medication error among nurses. Thus, this study aims to describe the incident of medication errors among nurses.

Analisis Faktor Perawat Dalam Pelaksanakan Keselamatan Pasien Terhadap Kejadian Medication Administration Error di Rumah Sakit

2020 ◽  
Author(s):  
Bintang Marsondang Rambe
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Prescribing Error ◽  
Medication Administration Error ◽  
Administration Error

Latar Belakang Keselamatan pasien (patient safety) rumah sakit adalah suatu sistem dimana rumah sakit membuat asuhan pasien lebih aman yang meliputi assessment risiko, identifikasi dan pengelolaan hal yang berhubungan dengan risiko pasien, pelaporan dan analisis insiden, kemampuan belajar dari insiden dan tindak lanjutnya serta implementasi solusi untuk meminimalkan timbulnya risiko dan mencegah terjadinya cedera yang disebabkan oleh kesalahan akibat melaksanakan suatu tindakan atau tidak mengambil tindakan yang seharusnya diambil yang dilakukan oleh perawat (Kemenkes, 2011).Salah satu kesalahan yang dapat merugikan pasien adalah medication error. Menurut WHO (2016) medication error adalah setiap kejadian yang dapat dicegah yang menyebabkan penggunaan obat yang tidak tepat yang menyebabkan bahaya kepasien, dimana obat berada dalam kendali profesional perawatan kesehatan. proses terjadi medication error dimulai dari tahap prescribing, transcribing, dispensing,dan administration. Kesalahan peresepan (prescribing error), kesalahan penerjemahan resep (transcribing erorr), kesalahan menyiapkan dan meracik obat (dispensing erorr), dan kesalahan penyerahan obat kepada pasien (administration error). Medication error yang paling sering terjadi adalah pada fase administration / pemberian obat yang dilakukan oleh perawat.Administration error terjadi ketika pemberian obat kepada pasien tidak sesuai dengan prinsip enam benar yaitu benar obat, benar pasien, benar dosis, benar rute pemberian, benar waktu pemberian dan benar pendokumentasian. Secara global, kesalahan pemberian obat (medication errors) sampai saat ini masih menjadi isu keselamatan pasien dan kualitas pelayanan di beberapa rumah sakit (Depkes RI, 2015; AHRQ, 2015). Perawat sebagai bagian terbesar dari tenaga kesehatan di rumah sakit, mempunyai peranan dalam kejadian medication error. Perawat berkontribusi karena perawat banyak berperan dalam proses pemberian obat. Pemberian obat/ Medication Administration adalah salah satu intervensi keperawatan yang paling banyak dilakukan, dengan sekitar 5- 20% waktu perawat dialokasikan untuk kegiatan ini (Härkänen et al.,, 2019). Pemberian obat juga mencakup tugas-tugas lain, seperti menyiapkan dan memeriksa obat obatan, memantau efek obat-obatan, mengedukasi pasien tentang pengobatan, dan memperdalam pengetahuan perawat tentang obat – obatan sendiri (DrachZahavy et al., 2014 dalam Yulianti et al., 2019)Berdasarkan isu tersebut, penulis tertarik untuk melakukan literature review terkait faktor perawat dalam pelaksanakan keselamatan pasien terhadap kejadian medication administration error di Rumah Sakit.

scholarly journals How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

2020 ◽  
Author(s):  
Peter J Gates ◽  
Rae-Anne Hardie ◽  
Magdalena Z Raban ◽  
Ling Li ◽  
Johanna I Westbrook
Keyword(s):  
Systematic Review ◽  
Medication Error ◽  
Medication Errors ◽  
Meta Analysis ◽  
Error Rates ◽  
Prescribing Error ◽  
Before And After ◽  
Actual Harm ◽  
Computer Based ◽  
Wide Scale

Abstract Objective To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS. Materials and Methods We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed. Results There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18–8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72–0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence. Discussion and Conclusion Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.

scholarly journals Medication Error in Anaesthesia – A Review

2016 ◽  
Vol 27 (1) ◽  
pp. 31-35
Author(s):  
Montosh Kumar Mondal ◽  
Beauty Rani Roy ◽  
Shibani Banik ◽  
Debabrata Banik
Keyword(s):  
Public Health ◽  
Risk Factors ◽  
Medication Error ◽  
Medication Errors ◽  
Health Problem ◽  
Preventive Measures ◽  
Medical Profession ◽  
Public Health Problem ◽  
Global Public Health ◽  
Global Public Health Problem

Medication error is a major cause of morbidity and mortality in medical profession . There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers.Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 31-35

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