Errors in the medication process: frequency, type, and potential clinical consequences.
ABSTRACT To investigate the frequency, type, and consequences of medication errors in more stages of the medication process, including discharge summaries.
A cross-sectional study using three methods to detect errors in the medication process: direct observations, unannounced control visits, and chart reviews. With the exception of errors in discharge summaries all potential medication error consequences were evaluated by physicians and pharmacists.
A randomly selected medical and surgical department at Aarhus University Hospital, Denmark.
Eligible in-hospital patients aged 18 or over (n = 64), physicians prescribing drugs and nurses dispensing and administering drugs.
Frequency, type, and potential clinical consequences of all detected errors compared with the total number of opportunities for error.
We detected a total of 1065 errors in 2467 opportunities for errors (43%). In worst case scenario 20-30% of all evaluated medication errors were assessed as potential adverse drug events. In each stage the frequency of medication errors were-ordering: 167/433 (39%), transcription: 310/558 (56%), dispensing: 22/538 (4%), administration: 166/412 (41%), and finally discharge summaries: 401/526 (76%). The most common types of error throughout the medication process were: lack of drug form, unordered drug, omission of drug/dose, and lack of identity control.
There is a need for quality improvement, as almost 50% of all errors in doses and prescriptions in the medication process were caused by missing actions. We assume that the number of errors could be reduced by simple changes of existing procedures or by implementing automated technologies in the medication process.
- SourceAvailable from: Amir Salari[show abstract] [hide abstract]
ABSTRACT: Background and purpose: Medication errors today is discussed as a main concern in the health09/2013;
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ABSTRACT: Prescribing errors are common. It has been suggested that the severity as well as the frequency of errors should be assessed when measuring prescribing error rates. This would provide more clinically relevant information, and allow more complete evaluation of the effectiveness of interventions designed to reduce errors. The objective of this systematic review was to describe the tools used to assess prescribing error severity in studies reporting hospital prescribing error rates. The following databases were searched: MEDLINE, EMBASE, International Pharmaceutical Abstracts, and CINAHL (January 1985-January 2013). We included studies that reported the detection and rate of prescribing errors in prescriptions for adult and/or pediatric hospital inpatients, or elaborated on the properties of severity assessment tools used by these studies. Studies not published in English, or that evaluated errors for only one disease or drug class, one route of administration, or one type of prescribing error, were excluded, as were letters and conference abstracts. One reviewer screened all abstracts and obtained complete articles. A second reviewer assessed 10 % of all abstracts and complete articles to check reliability of the screening process. Tools were appraised for country and method of development, whether the tool assessed actual or potential harm, levels of severity assessed, and results of any validity and reliability studies. Fifty-seven percent of 107 studies measuring prescribing error rates included an assessment of severity. Forty tools were identified that assessed severity, only two of which had acceptable reliability and validity. In general, little information was given on the method of development or ease of use of the tools, although one tool required four reviewers and was thus potentially time consuming. The review was limited to studies written in English. One of the review authors was also the author of one of the tools, giving a potential source of bias. A wide range of severity assessment tools are used in the literature. Developing a basis of comparison between tools would potentially be helpful in comparing findings across studies. There is a potential need to establish a less time-consuming method of measuring severity of prescribing error, with acceptable international reliability and validity.Drug Safety 08/2013; · 3.41 Impact Factor
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ABSTRACT: Relatively little is known about how scorecards presenting performance indicators influence medication safety. We evaluated the effects of implementing a ward-level medication safety scorecard piloted in two English NHS hospitals and factors influencing these. We used a mixed methods, controlled before and after design. At baseline, wards were audited on medication safety indicators; during the 'feedback' phase scorecard results were presented to intervention wards on a weekly basis over 7 weeks. We interviewed 49 staff, including clinicians and managers, about scorecard implementation. At baseline, 18.7% of patients (total n=630) had incomplete allergy documentation; 53.4% of patients (n=574) experienced a drug omission in the preceding 24 h; 22.5% of omitted doses were classified as 'critical'; 22.1% of patients (n=482) either had ID wristbands not reflecting their allergy status or no ID wristband; and 45.3% of patients (n=237) had drugs that were either unlabelled or labelled for another patient in their drug lockers. The quantitative analysis found no significant improvement in intervention wards following scorecard feedback. Interviews suggested staff were interested in scorecard feedback and described process and culture changes. Factors influencing scorecard implementation included 'normalisation' of errors, study duration, ward leadership, capacity to engage and learning preferences. Presenting evidence-based performance indicators may potentially influence staff behaviour. Several practical and cultural factors may limit feedback effectiveness and should be considered when developing improvement interventions. Quality scorecards should be designed with care, attending to evidence of indicators' effectiveness and how indicators and overall scorecard composition fit the intended audience.BMJ quality & safety 09/2013; · 2.39 Impact Factor