Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Determining Medication Errors in an Adult Intensive Care Unit

INTRODUCTION

Research addressing the costs of Medication errors (MEs) is still scarce despite issues related to patient safety having significant economic and health impacts, making it imperative to analyze the costs and adverse events related to MEs for a better patient, professional, and institutional safety.

AIM

To identify the number of medication errors and verify whether this number was associated with increased hospitalization costs for patients in an Intensive Care Unit (ICU).

METHOD

This retrospective cross-sectional cohort study evaluated secondary data from patients' electronic medical records to compile variables, create a model, and survey hospitalization costs. The statistical analysis included calculating medication error rates, descriptive analysis, and simple and multivariate regression.

RESULTS

The omission error rate showed the highest number of errors per drug dose (59.8%) and total errors observed in the sample (55.31%), followed by the time error rate (26.97%; 24.95%). The omission error had the highest average when analyzing the entire hospitalization (170.40) and day of hospitalization (13.79). Hospitalization costs were significantly and positively correlated with scheduling errors, with an increase of BRL 121.92 (about USD $25.00) (95% CI 43.09; 200.74), and to prescription errors, with an increase of BRL 63.51 (about USD $3.00) (95% CI 29.93; 97.09).

CONCLUSION

We observed an association between two types of medication errors and increased hospitalization costs in an adult ICU (scheduling and prescription errors).

Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study

Purpose

This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting.

Patients and Methods

We performed a 10-year retrospective study (January 2011–December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome.

Results

In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour–14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs.

Conclusion

Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.

COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY

ABSTRACT Objectives to characterize accidents/falls and medication errors in the care process in a teaching hospital and to determine their root causes and variable direct costs. Method cross-sectional study implemented in two stages: the first, was based on the analysis of secondary sources (notifications, medical records and cost reports) and the second, on the application of root-cause analysis for incidents with moderate/severe harm. The study was carried out in a teaching hospital in Paraná, which exclusively serves the Brazilian Unified Health System and composes the Network of Sentinel Hospitals. Thirty reports of accidents/falls and 37 reports of medication errors were investigated. Descriptive statistical analysis and the methodology proposed by The Joint Commission International were applied. Results among the accidents/falls, 33.3% occurred in the emergency room; 40.0% were related to the bed, in similar proportions in the morning and night periods; 51.4% of medication errors occurred in the hospitalization unit, the majority in the night time (32.4%), with an emphasis on dose omissions (27.0%) and dispensing errors (21.6%). Most incidents did not cause additional harm or cost. The average cost was R$ 158.55 for the management of falls. Additional costs for medication errors ranged from R$ 31.16 to R$ 21,534.61. The contributing factors and root causes of the incidents were mainly related to the team, the professional and the execution of care. Conclusion accidents/falls and medication errors presented a low frequency of harm to the patient, but impacted costs to the hospital. Regarding root causes, aspects of the health work process related to direct patient care were highlighted.

Drug Therapy Problems and the Role of Clinical Pharmacist in Surgery Ward: Prospective Observational and Interventional Study

BACKGROUND

Drug therapy problems (DTPs) are of major concern in health care because of the associated increased cost of treatment, morbidity, and mortality. Thus, clinical practice should constitute the mainstream practice of clinical pharmacy in every ward. However, nothing is known about DTPs and the role of clinical pharmacist in the surgical ward of Ethiopia (the neglected ward).

OBJECTIVE

To assess the prevalence of DTP among patients hospitalized at the surgical ward and the role of clinical pharmacists in their identification and resolution.

METHODS

Hospital-based prospective observational and interventional study design was used with daily patients' chart review using a semi-structured questionnaire among hospitalized adult patients at the surgical ward. After identification of DTP, verbal communication was used as a means of intervention with the treating physician. Acceptance of clinical pharmacist's intervention was considered only if a change was made to the patients' medication order. To identify determinants of DTPs, multiple stepwise forward logistic regression analysis was done by SPSS version 20.0. Statistical significance was considered at p-value < 0.05. Written informed consent was sought and the data were secured.

RESULTS

The response rate was 97.1% (300) for the final analysis. The mean (±SD = standard deviation) age of the participants was 42.62 ±18.29 with male (67%) predominance. DTP was identified in 76% of study participants. A total of 449 DTPs were identified, which equates with an average of 1.97 per patient. Dose too low 124/449 (27.6%) and dose too high 81/449 (18.0%) were found to be the most common types of DTPs. The intervention rate was 86.0% (196/228 per patients) and 86.2% (387/449 DTPs), with the acceptance rate of 85.2% (167/196 per patients) and 78% (302/387 per DTP) which mean (67.3%) 302/449 of the problems were fully resolved by the clinical pharmacist. Poly-pharmacy [AOR, 7.23; 95% CI, 2.29-22.13: P-value < 0.001] and hospital stay > 20 days [AOR, 5.42; 95% CI, 2.74-10.70; p < 0.001] were the only independent predictors for DTPs.

CONCLUSION AND RECOMMENDATION

This study identified a high prevalence of DTP which was independently predicted by the presence of poly-pharmacy and >20 days of hospital stay. The rate of intervention provided and acceptance from the physician was high, which is one indicator that the role of clinical pharmacists in the identification and resolution of DTP was paramount in the surgery ward and should be implemented as a must not as optional.

The implementation of a Technician Enhanced Administration of Medications [TEAM] model: An evaluative study of impact on working practices in a children's hospital

BACKGROUND

Children are frequently prescribed unlicensed and off-label medicines meaning dosing and administration of medicines to children is often based on poor quality guidance. In UK hospitals, nursing staff are often responsible for administering medications. Medication Errors [MEs] are problematic for health services, though are poorly reported and therefore difficult to quantify with confidence. In the UK, children's medicines require administration by at least two members of ward staff, known as a 'second check' system, thought to reduce Medication Administration Errors [MAEs].

OBJECTIVES

To assess the impact on working practices of the introduction of a new way of working, using Technician Enhanced Administration of Medications [TEAM] on two specialist wards within a children's' hospital. To evidence any potential impact of a TEAM ward-based pharmacy technician [PhT] on the reporting of MEs.

METHODS

A TEAM PhT was employed on two wards within the children's hospital and trained in medicines administration. Firstly, an observational pre-and-post cohort design was used to identify the effect of TEAM on MEs. We analysed the hospital's official reporting system for incidents and 'near misses', as well as the personal incident log of the TEAM PhT. Secondly, after implementation, we interviewed staff about their perceptions of TEAM and its impact on working practices.

RESULTS

We affirm MEs are considerably under-reported in hospital settings, but TEAM PhTs can readily identify them. Further, placing TEAM PhTs on wards may create opportunities for inter-professional knowledge exchange and increase nurses' awareness of potential MAEs, although this requires facilitation.

CONCLUSIONS

TEAM PhT roles may be beneficial for pharmacy technicians' motivation, job satisfaction, and career development. Hospitals will need to consider the balance between resources invested in TEAM PhTs and the level of impact on reporting MEs. Health economic analyses could provide evidence to fully endorse integration of TEAM PhTs for all hospital settings.

Análise das ocorrências de incidentes relacionados aos medicamentos potencialmente perigosos dispensados em hospital de ensino

Resumo OBJETIVO Analisar as notificações de incidentes relacionados aos medicamentos potencialmente perigosos dispensados em um hospital de ensino do interior de São Paulo. MÉTODOS Estudo descritivo, retrospectivo com abordagem quantitativa dos dados provenientes da análise das notificações em farmacovigilância que ocorreram no período de janeiro de 2009 a dezembro de 2014, a partir de tabelas e gráficos, apresentando as frequências absolutas/relativas. RESULTADOS Das 786 notificações de farmacovigilância, 188 foram relacionadas aos medicamentos potencialmente perigosos, sendo 36,7% de ineficácia terapêutica, 32,44% queixa técnica, 15,95% reação adversa, 7,44% flebite, 5,13% extravasamento, 1,06% erro de dispensação, 0,53% erro de administração e 0,53% erro de medicação. Os profissionais que mais notificaram foram enfermeiros. Os grupos farmacológicos de maior notificação foram drogas com ação sobre sistema nervoso (35,63%). CONCLUSÃO A análise demonstrou que houve um número de notificações expressivo e necessidade de adoção de estratégias a fim de garantir maior segurança do paciente.