Reducing Medication Errors Through Workflow Redesign

Lack of medication reconciliation at the point of transitions between skilled nursing facilities/nursing homes (SNF/NHs) and acute care hospitals (ACHs) is a common point of origin for medical errors that cause harm to patients. The goal of this quality improvement initiative was to improve medication reconciliation at the point of transition from the SNF/NH to the ACH which in turn would reduce medication errors, adverse drug events, and medication-induced injury to the vulnerable elderly population. We implemented a workflow redesign process to reconcile the accuracy of residents’ medications at the time of transfer from the SNF/NH to the ACH. After the initiation of a medication reconciliation protocol, 72% (n=13/18) of the medication administration records (MARs) had no medication errors

Safety of medication use in primary care

© 2014 Royal Pharmaceutical Society.BACKGROUND: Medication errors are one of the leading causes of harmin health care. Review and analysis of errors have often emphasized their preventable nature and potential for reoccurrence. Of the few error studies conducted in primary care to date, most have focused on evaluating individual parts of the medicines management system. Studying individual parts of the system does not provide a complete perspective and may further weaken the evidence and undermine interventions.AIM AND OBJECTIVES: The aim of this review is to estimate the scale of medication errors as a problem across the medicines management system in primary care. Objectives were: To review studies addressing the rates of medication errors, and To identify studies on interventions to prevent medication errors in primary care.METHODS: A systematic search of the literature was performed in PubMed (MEDLINE), International Pharmaceutical Abstracts (IPA), Embase, PsycINFO, PASCAL, Science Direct, Scopus, Web of Knowledge, and CINAHL PLUS from 1999 to November, 2012. Bibliographies of relevant publications were searched for additional studies.KEY FINDINGS: Thirty-three studies estimating the incidence of medication errors and thirty-six studies evaluating the impact of error-prevention interventions in primary care were reviewed. This review demonstrated that medication errors are common, with error rates between 90%, depending on the part of the system studied, and the definitions and methods used. The prescribing stage is the most susceptible, and that the elderly (over 65 years), and children (under 18 years) are more likely to experience significant errors. Individual interventions demonstrated marginal improvements in medication safety when implemented on their own.CONCLUSION: Targeting the more susceptible population groups and the most dangerous aspects of the system may be a more effective approach to error management and prevention. Co-implementation of existing interventions at points within the system may offer time- and cost-effective options to improving medication safety in primary care.Peer reviewe

Can the Heinrich ratio be used to predict harm from medication errors?

The purpose of this study was to establish whether, for medication errors, there exists a fixed Heinrich ratio between the number of incidents which did not result in harm, the number that caused minor harm, and the number that caused serious harm. If this were the case then it would be very useful in estimating any changes in harm following an intervention. Serious harm resulting from medication errors is relatively rare, so it can take a great deal of time and resource to detect a significant change. If the Heinrich ratio exists for medication errors, then it would be possible, and far easier, to measure the much more frequent number of incidents that did not result in harm and the extent to which they changed following an intervention; any reduction in harm could be extrapolated from this

Nurse\u27s Perceptions of Causes of Medication Errors and Barriers to Reporting

Objective: To describe medical-surgical nurses\u27 perceptions of frequent causes of medication errors, of what constitutes a medication error, and of what are the barriers and empowerments to reporting. The study also explored the nurses\u27 perceptions of the effect of physician order entry (POE) and barcode medication administration (BCMA) on medication errors. Background: Causes of medication errors have been investigated by numerous researchers in an attempt to determine safe medication administration process. Information technology (IT) systems enhance patient safety. No published studies were found on nurses\u27 perceptions of medication errors in a setting with IT systems in place. Method: A descriptive design was used to survey a convenience sample of 61 medical-surgical nurses at a Veterans Affairs Medical Center utilizing the Nurses\u27 Perceptions of Medication Errors Modified Ulanimo 2005 tool. Results: The primary perceived cause of medication errors based on 25 responses was nurse\u27s failure to correctly identify the patient before medication administration. Less than one third of medication errors are reported. Respondents\u27 perception of their knowledge of medication errors does not correlate with their actual knowledge. All nurses surveyed perceived POE and BCMA decrease medication errors. Conclusions: Medication errors continue to happen despite sophisticated IT systems available. Empowerment to reporting medication errors is critical to ensuring safe quality care

MEDICATION ERRORS IN OUTPATIENTS OF A GOVERNMENT HOSPITAL IN YOGYAKARTA INDONESIA

Background. Medication errors are important problems in hospitalized patients. Medication errors are inevitable and are affected by human factors. Nevertheless, the epidemiological data about medication errors in outpatients in Indonesia is still limited. Objectives. This study was purposed to know the occurrence of medication errors including prescribing error, pharmaceutical error and dispensing error and the occurrence of the most type happened in these errors. Methods. A prospective study with outpatients of a government hospital in Yogyakarta, Indonesia as study subjects. The study was carried out from June to September 2007 start at 9 am-12 am. Results. We observed the prescription of 229 outpatients. We found 226 prescriptions with medication errors. Of the 226 medication errors, 99.12% were prescribing errors, 3.02% were pharmaceutical errors and 3.66% were dispensing errors. The most type of prescribing error was incomplete prescription orders. Physician ordering was the most common stage of errors (99.12%). The pharmaceutical errors were including over dose and under dose of drugs. The dispensing errors were including improper drug preparation and incomplete or no drug information. Conclusion. Medication errors are still common problem in outpatients in Yogyakarta, Indonesia. Pharmacists needed to prevent and to overcome the medication errors

Heavy Eyes, Medication Errors, and Night-shift Nursing

Heavy Eyes, Medication Errors, and Night-shift Nursing Recorded Video Upload Undergraduate Student(s): Kat Wallace, Doonya Mereby, Randolph Rich, Mackenzie Hull Research Mentor(s): Karen Armstrong Background: Medication errors occur in every hospital setting, but the question is always how can they be avoided? Night shift and day shift differences play a significant role in medication errors. Further research is needed to delineate specific causes of medical errors between the two types of nursing work shift types. This study aims to identify whether night shift nurses working 12-hour shifts (7pm-7am) experience more medication errors than their day shift counterparts (7am-7pm), as well as the reasoning behind the medication errors. Methods: Research was guided by the Johns Hopkins Evidence-Based Practice Model. Google Scholar, EBSCOHost, and Elsevier were the databases used to search for keywords. Only relevant data from the past five years were analyzed to ensure the validity of the study. This systematic review was used to uncover the best evidence-based practice to implement. Results: After analyzing twelve peer-reviewed articles about medication errors and shift-type, researchers provided evidence that night shift nurses are more prone to sleep deprivation, medication errors, and decreased cognitive performance. Conclusion: By evaluating contributing factors to night-shift medication errors, clinicians and organizations may develop practice models to promote and increase patient safety through targeted interventions and safe scheduling. Keywords: night shift medication errors, medication errors, sleep deprivation and medication error

Assessment of the Role of Pharmacists in Preventing Medication Errors in Hospital Settings

Medication errors can have serious consequences for patients in hospital settings. As medication experts, pharmacists play a critical role in preventing medication errors. This literature review examines the roles of pharmacists in preventing medication errors in hospital settings. The review identified several roles of pharmacists in preventing medication errors, including medication order review, medication reconciliation, providing drug information and education, and participation in interdisciplinary teams. The review also identified barriers to pharmacist involvement in preventing medication errors, such as limited access to patient information and limited communication with other healthcare professionals. Overall, the literature suggests that pharmacists can play a crucial role in preventing medication errors in hospital settings and that efforts should be made to overcome the barriers to their involvement

Medication Errors in Hospitals

In hospitals, the issue of medication errors poses a serious problem, often leading to substantial health complications and, in some cases, even deaths among hospitalized as well as discharged patients. This health challenge not only imposes a substantial financial burden on patients, insurance providers, and Federal/State governments but also contributes to elevated healthcare expenses, hindering the effective allocation of resources to address other healthcare issues. Understanding the triggers of medication errors in hospitals is critical in solving this problem. The purpose of this integrative review is to determine the causes/triggers of medication errors in hospitals. This review will highlight the conditions that providers and clinicians face, including the routine processes during prescription and medication administration to determine specific areas where discrepancies occur, which in turn, creates the inevitability of medication errors. The review will reveal that poor collaboration between healthcare providers and clinicians is a significant contributing factor to medication errors within hospital settings. Also, illegible handwritten orders, and in some cases, poor understanding of verbal orders in emergency situations are also reasons for wrong dosage medication errors. The review will also reveal an elevated incidence of medication errors among night shift nurses in comparison to those on day shifts, primarily due to burnout resulting from holding multiple jobs during the day, sometimes leading to difficulties in reaching healthcare providers at night. Furthermore, the review will provide applicable approaches that increase team collaboration during patient admission and discharge in order to decrease medication errors. Also, the review will encourage clinicians to repeat verbal orders for clarification and to confirm written orders before administering medications to reduce dosing errors. Finally, the review will show that collaboration through active listening, change of behaviors, and communication are critical in reducing medications errors in hospitals