What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.Objective To investigate the epidemiology of medication errors and error-related adverse events in adults in primary care, ambulatory care and patients’ homes. Design Systematic review. Data source Six international databases were searched for publications between 1 January 2006 and 31 December 2015. Data extraction and analysis Two researchers independently extracted data from eligible studies and assessed the quality of these using established instruments. Synthesis of data was informed by an appreciation of the medicines’ management process and the conceptual framework from the International Classification for Patient Safety. Results 60 studies met the inclusion criteria, of which 53 studies focused on medication errors, 3 on error-related adverse events and 4 on risk factors only. The prevalence of prescribing errors was reported in 46 studies: prevalence estimates ranged widely from 2% to 94%. Inappropriate prescribing was the most common type of error reported. Only one study reported the prevalence of monitoring errors, finding that incomplete therapeutic/safety laboratory-test monitoring occurred in 73% of patients. The incidence of preventable adverse drug events (ADEs) was estimated as 15/1000 person-years, the prevalence of drug–drug interaction-related adverse drug reactions as 7% and the prevalence of preventable ADE as 0.4%. A number of patient, healthcare professional and medication-related risk factors were identified, including the number of medications used by the patient, increased patient age, the number of comorbidities, use of anticoagulants, cases where more than one physician was involved in patients’ care and care being provided by family physicians/general practitioners. Conclusion A very wide variation in the medication error and error-related adverse events rates is reported in the studies, this reflecting heterogeneity in the populations studied, study designs employed and outcomes evaluated. This review has identified important limitations and discrepancies in the methodologies used and gaps in the literature on the epidemiology and outcomes of medication errors in community settings.Peer reviewe

The Effects of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) on Blood Pressure in Patients with Hypertension

Dysregulation of blood pressure control in hypertensive patients using nonsteroidal anti-inflammatory drugs (NSAIDs) could increase morbidity, mortality, and health care costs. The aims of this research were to examine the association between NSAIDs and blood pressure in hypertensive patients, compare the effects of various NSAIDs on blood pressure, and determine if NSAIDs were associated with changes in antihypertensive therapy. This retrospective cohort study included hypertensive patients who received their first prescription for any NSAID and met the inclusion criteria. Patients included in this research received their care from the medicine practice clinics at Wishard Health Services in Indianapolis, Indiana between 1993 and 2006. Patients were followed for one year after the first prescription or 30 days after the last prescription that was dispensed, whichever was less. Patients meeting the same criteria but who were prescribed acetaminophen formed the control group. The primary outcomes were first systolic blood pressure and intensification of antihypertensive therapy. Covariates affecting blood pressure or the prescribing of NSAIDs were included in the statistical models. Propensity score matching techniques were used to balance background characteristics between comparison groups. A total of 3,928 eligible patients were prescribed NSAIDs or acetaminophen. Compared to acetaminophen, prescription for NSAID was associated with a 2 mmHg increase in systolic blood pressure (P = 0.004), and a 6 mmHg increase in those concurrently prescribed beta-adrenergic blocker (P = 0.008). Ibuprofen was associated with a 3 mmHg increase in systolic blood pressure compared to naproxen (P = 0.015), and a 5 mmHg increase compared to celecoxib (P = 0.035). Ibuprofen was associated with a higher risk of systolic blood pressure increase of ≥ 20 mmHg compared to naproxen (odds ratio, 1.57; 95% confidence interval, 1.10 to 2.25; P = 0.014). Dose effects were not observed for either ibuprofen or naproxen. There was no evidence of intensification in antihypertensive therapy in patients prescribed NSAIDs. In conclusion, NSAIDs were associated with a small increase in systolic blood pressure in hypertensive patients compared to acetaminophen. The increase in systolic blood pressure from NSAIDs did not increase the risk of intensification of antihypertensive treatment. Confirmatory studies will be needed to affirm these results.Doctor of Philosoph

Healthcare professionals’ consensus on prescribing errors in hospital settings in Riyadh, Saudi Arabia

Purpose: To create a consensus on definition and scenarios of prescribing errors in Saudi Arabia hospital practice.Methods: A two-round Delphi technique was used to reach a consensus on a definition and 42 scenarios of prescribing errors. Thirty-five evaluators  (healthcare professionals) were asked to indicate the extent to which they agree or disagree with the definition and scenarios of prescribing errors in a score of 1 (“total disagreement”) to 9 (“total agreement”) and were given a space to comment or modify the content of the survey.Results: The study tool was initially given to 35 evaluators of whom 31 (88.6 %) responded in the first round. In the second round only 24 (77.4 %) evaluators responded. A consensus was reached to accept the definition of prescribing error modified from a previous study conducted in the UK. Regarding the types of prescribing errors, a consensus was reached to include 34 scenarios, to exclude 5 scenarios and to include 3 scenarios depending on the individual clinical situation.Conclusion: The evaluators agreed to the definition of prescribing errors developed in the United Kingdom (UK) with minor modifications. However, some types of prescribing errors might be considered as errors in Saudi Arabia but not in the UK and vice versa. It is anticipated that this definition could be utilized in future studies, particularly in Saudi Arabia, and act as a guide for future research on prescribing errors.Keywords: Prescribing error scenario, Hospital settings, Consensus, Delphi techniqu

Culture of Safety among Nurses in a Tertiary Teaching Hospital in Saudi Arabia

Purpose: To assess the culture of safety among nurses in a tertiary teaching hospital in Saudi Arabia.Methods: A cross-sectional survey was conducted in King Khaled University Hospital in Riyadh, Saudi Arabia. A random sample of 492 nurses was included in the survey using a pre-validated instrument, Safety Attitudes Questionnaire (SAQ).Results: Of the questionnaires given to 492 nurses, only 418 complete ones were returned, giving a response rate of 84.9 %. Most of the participants (354, 84.7 %) were staff nurses and the majority, 112 (26.8 %), had working experience of ≥ 20 years. Job satisfaction was perceived as the most common dimension of culture of safety among nurse participants (92.7 ± 14.6) followed by working conditions (82.1 ± 16.6) and safety (75.5 ± 15.5) and teamwork (75.5 ± 16.7). Stress recognition (41.9 ± 25.2) and perception of management (68.1 ± 19.1) ranked as the least common dimensions of safety culture among study subjects. A significant difference in mean score was found between males and females for both working conditions (p = 0.035) and teamwork (p = 0.045). Significant differences were also observed in terms of job satisfaction dimension scores with regard to years of work experience (p = 0.045). A significant differences was also observed in terms of stress recognition dimension scores in terms of years of work experience (p = 0.007).Conclusion: Efforts are needed from healthcare authorities to increase nurses’ perception of management and stress recognition in order to improve safety culture among nurses in Saudi Arabia.Keywords: Nurses, Safety Attitudes Questionnaire (SAQ), Safety culture, Working conditions, Teamwork, Job satisfactio

Pharmacy education in Saudi Arabia: A vision of the future

Background: Pharmacy education in developing countries faces many challenges. An assessment of the challenges and opportunities for the future of pharmacy education in Saudi Arabia has not been conducted. Objectives: The purpose of the study was to ascertain the views and opinions of pharmacy education stakeholders regarding the current issues challenging pharmacy education, and to discuss the future of pharmacy education in Saudi Arabia. Methods: A total of 48 participants attended a one-day meeting in October 2011, designed especially for the purpose of this study. The participants were divided into six round-table discussion sessions with eight persons in each group. Six major themes were explored in these sessions, including the need to improve pharmacy education, program educational outcomes, adoption of an integrated curriculum, the use of advanced teaching methodologies, the need to review assessment methods, and challenges and opportunities to improve pharmacy experiential training. The round-table discussion sessions were videotaped and transcribed verbatim and analyzed by two independent researchers. Results: Participants agreed that pharmacy education in the country needs improvement. Participants agreed on the need for clear, measureable, and national educational outcomes for pharmacy programs in the Kingdom. Participants raised the importance of collaboration between faculty members and departments to design and implement an integrated curriculum. They also emphasized the use of new teaching methodologies focusing on student self-learning and active learning. Assessments were discussed with a focus on the use of new tools, confidentiality of examinations, and providing feedback to students. Several points were raised regarding the opportunities to improve pharmacy experiential training, including the need for more experiential sites and qualified preceptors, addressing variations in training quality between experiential sites, the need for accreditation of experiential sites, and the use of technology to track experiential activities and assessments. Conclusion: Several challenges for improving pharmacy education in Saudi Arabia were discussed by stakeholders. To tackle these challenges facing most pharmacy schools in the Kingdom, national efforts need to be considered by involving all stakeholders

Perceptions of thalassemia and its treatment among Malaysian thalassemia patients: A qualitative study

Background Thalassemia is a common public health problem in Malaysia and one of the most common chronic and genetic disorders. Aims The present qualitative study explores knowledge about thalassemia, perceptions about conventional therapies and the points that affect Malaysian patients with thalassemia in taking medications correctly. Methods This study used a qualitative method. Purposive and theoretical samplings were combined to explore the issues related to thalassaemia and its perceptions. Twenty-one patients with thalassemia were recruited from the Thalassemia Society, Kedah, Malaysia from July to October 2015. The semi-structured interviews were audio taped, transcribed verbatim and translated into English for thematic content analysis. Results Participants perceived thalassemia as an incurable disease which is due to genetic and blood related disorders. A positive perception was shown towards conventional therapies considering it as effective for their condition. High treatment cost was given as a reason why patients perceived conventional therapies as effective. Fear of side effects was the main reason the patients gave for their delay in looking for treatment. However, due to limited treatment options, patients were reported to show positive attitude towards the side effects due to thalassemia treatment. Conclusion This explanatory investigation suggests that thalassemia patients’ understanding about thalassemia is complex in nature. The findings may help healthcare providers remove myths about the fear of the treatment. It may also help in improving patient’s compliance towards the thalassemia therapies. Main focus for future research should be on those patients who declined the conventional therapies

A cross sectional assessment of health related quality of life among patients with Hepatitis-B in Pakistan

OBJECTIVE: The study aims to assess Health Related Quality of Life (HRQoL) among Hepatitis B (HB) patients and to identify significant predictors of the HRQoL in HB patients of Quetta, Pakistan. METHODS: A cross sectional study by adopting European Quality of Life scale (EQ-5D) for the assessment of HRQoL was conducted. All registered HB patients attending two public hospitals in Quetta, Pakistan were approached for study. Descriptive statistics were used to describe demographic and disease related characteristics of the patients. HRQoL was scored using values adapted from the United Kingdom general population survey. EQ-5D scale scores were compared with Mann–Whitney and Kruskal-Wallis test. Standard multiple regression analysis was performed to identify predictors of HRQoL. All analyses were performed using SPSS v 16.0. RESULTS: Three hundred and ninety HB patients were enrolled in the study. Majority of the participants (n = 126, 32.3%) were categorized in the age group of 18-27 years (36.07 ± 9.23). HRQoL was measured as poor in the current study patients (0.3498 ± 0.31785). The multivariate analysis revealed a significant model (F(10, 380) = 40.04, P < 0.001, adjusted r(2) = 0.401). Educational level (β = 0.399, p = 0.025) emerged as a positive predictor of HRQoL. Age, gender, occupation, income and locality were not predictive of better quality of life in HB patients. CONCLUSIONS: Hepatitis B has an adverse affect on patients’ well-being and over all HRQoL. The study findings implicate the need of health promotion among HB patients. Improving the educational status and imparting disease related information for the local population can results in better control and management of HB

Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries

Background Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries. Methods A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included. Results Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5–16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists’ interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists’ recommendations. Conclusions Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.Peer reviewe

Retrospective descriptive assessment of clinical decision support medication-related alerts in two Saudi Arabian hospitals

OBJECTIVES: To determine the frequency of clinical decision support system (CDSS) medication-related alerts generated, accepted, or overridden, to assess appropriateness of alert display and overrides, and to characterise the documentation of clinician justification for these overrides in an academic medical centre in Saudi Arabia. MATERIALS AND METHODS: System-generated CDSS reports for the period June 2015 to December 2017 were retrospectively reviewed and analysed. Alerts were classified into different types, and rates of alert overrides calculated as percentages of all generated alerts. A subset of 307 overridden alerts was assessed for appropriateness of display and override by two clinical pharmacists. Physician documentation of reasons for overriding alerts were categorised. RESULTS: A total of 4,446,730 medication-related alerts were generated from both inpatient and outpatient settings, and 4,231,743 (95.2%) were overridden. The most common alert type was 'duplicate drug', accounting for 3,549,736 (79.8%) of alerts. Of 307 alerts assessed for appropriateness, 246 (80%) were judged to be appropriately displayed and 244 (79%) were overridden appropriately. New drug allergy and drug allergy alerts had the highest percentage of being judged as inappropriately overridden. For 1,594,313 alerts (37.7%), 'no overridden reason selected' was chosen from the drop-down menu. CONCLUSIONS: The alert generation and override rate were higher than reported previously in the literature. The small sample size of 307 alerts assessed for appropriateness of alert display and override is a potential limitation. Revision of the CDSS rules for alerts (focusing on specificity and relevance for the local context) is now recommended. Future research should prospectively assess providers' perspectives, and determine patient harm associated with overridden alerts