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Saito J, Nakamura H, Yamatani A. Issues on Powder Forms for Oral Solution and Suspension for Pediatric Patients in Japan: A Questionnaire-Based Observational Survey to Pediatric Pharmacists. Ther Innov Regul Sci 2022; 56:301-312. [PMID: 35088393 DOI: 10.1007/s43441-021-00361-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 12/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Powders for oral solutions and suspensions (POS) are commonly used as pediatric oral medicines worldwide, except for Japan. Although global pediatric formulation development accelerates POS importation to Japan without any formulation change, oral solid multiparticulates remain to be the preferred pediatric forms in the country. This study aimed to evaluate the acceptance situation of four typical POS form products (mycophenolate mofetil, sildenafil citrate, valganciclovir hydrochloride, and voriconazole) that were recently approved in Japan. METHODS A questionnaire on four products was completed by pharmacists in 29 children's hospitals with more than 100 beds each, between November and December of 2019. The questionnaire has six items on (#1) type of institution, (#2) formulary status, (#3) dispensing practice, (#4) reasons why POS form(s) were not selected as hospital formulary, (#5) advantages and disadvantages of POS form, and (#6) opinions for POS form. RESULTS Of the 29 institutions, 7 (24%), 9 (31%), 4 (13%), and 10 (34%) institutions used POS of mycophenolate mofetil, sildenafil citrate, valganciclovir hydrochloride, and voriconazole, respectively. Reasons for not using these products were dispensed drug loss, formulation issues, and management issues in the pharmaceutical department and pediatric ward. Pharmacists preferred drug compounding such as tablet crushing and capsule opening to POS form use. CONCLUSIONS POS forms might be an unsuitable formulation for the current hospital settings in Japan. Thus, appropriate dosage forms that reflect the current clinical settings are necessary.
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Affiliation(s)
- Jumpei Saito
- Department of Pharmacy, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, 157-8535, Japan.
- Department of Research and Development Supervision, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Hidefumi Nakamura
- Department of Research and Development Supervision, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Akimasa Yamatani
- Department of Pharmacy, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Research and Development Supervision, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, 157-8535, Japan
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Savva G, Papastavrou E, Charalambous A, Vryonides S, Merkouris A. Exploring Nurses' Perceptions of Medication Error Risk Factors: Findings From a Sequential Qualitative Study. Glob Qual Nurs Res 2022; 9:23333936221094857. [PMID: 35782105 PMCID: PMC9243474 DOI: 10.1177/23333936221094857] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 03/26/2022] [Accepted: 03/31/2022] [Indexed: 11/30/2022] Open
Abstract
A focus group study was conducted to explore nurses' perceptions of medication administration error associated factors in two medical wards of a tertiary hospital. Nurses were invited to participate in focus group discussions. Thematic analysis was employed and identified four themes: professional practice environment related factors, person-related factors, drug-related factors, and processes and procedures. Staffing, interruptions, system failures, insufficient leadership, and patient acuity were perceived as risk factors for medication errors. The findings of this study complement the findings of an observational study which investigated medication administration errors in the same setting. Although some findings were similar, important risk factors were identified only through focus group discussions with nurses. Nurses' perceptions of factors influencing medication administration errors provide important considerations in addressing factors that contribute to errors and for improving patient safety.
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Affiliation(s)
| | | | - Andreas Charalambous
- Cyprus University of Technology,
Limassol, Republic of Cyprus
- University of Turku,
Finland
| | - Stavros Vryonides
- Cyprus University of Technology,
Limassol, Republic of Cyprus
- State Health Services
Organization, Limassol, Republic of Cyprus
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Koeck JA, Young NJ, Kontny U, Orlikowsky T, Bassler D, Eisert A. Interventions to Reduce Medication Dispensing, Administration, and Monitoring Errors in Pediatric Professional Healthcare Settings: A Systematic Review. Front Pediatr 2021; 9:633064. [PMID: 34123962 PMCID: PMC8187621 DOI: 10.3389/fped.2021.633064] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/12/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction: Pediatric patients cared for in professional healthcare settings are at high risk of medication errors. Interventions to improve patient safety often focus on prescribing; however, the subsequent stages in the medication use process (dispensing, drug administration, and monitoring) are also error-prone. This systematic review aims to identify and analyze interventions to reduce dispensing, drug administration, and monitoring errors in professional pediatric healthcare settings. Methods: Four databases were searched for experimental studies with separate control and intervention groups, published in English between 2011 and 2019. Interventions were classified for the first time in pediatric medication safety according to the "hierarchy of controls" model, which predicts that interventions at higher levels are more likely to bring about change. Higher-level interventions aim to reduce risks through elimination, substitution, or engineering controls. Examples of these include the introduction of smart pumps instead of standard pumps (a substitution control) and the introduction of mandatory barcode scanning for drug administration (an engineering control). Administrative controls such as guidelines, warning signs, and educational approaches are lower on the hierarchy and therefore predicted by this model to be less likely to be successful. Results: Twenty studies met the inclusion criteria, including 1 study of dispensing errors, 7 studies of drug administration errors, and 12 studies targeting multiple steps of the medication use process. A total of 44 interventions were identified. Eleven of these were considered higher-level controls (four substitution and seven engineering controls). The majority of interventions (n = 33) were considered "administrative controls" indicating a potential reliance on these measures. Studies that implemented higher-level controls were observed to be more likely to reduce errors, confirming that the hierarchy of controls model may be useful in this setting. Heterogeneous study methods, definitions, and outcome measures meant that a meta-analysis was not appropriate. Conclusions: When designing interventions to reduce pediatric dispensing, drug administration, and monitoring errors, the hierarchy of controls model should be considered, with a focus placed on the introduction of higher-level controls, which may be more likely to reduce errors than the administrative controls often seen in practice. Trial Registration Prospero Identifier: CRD42016047127.
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Affiliation(s)
- Joachim A Koeck
- Hospital Pharmacy, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany
| | - Nicola J Young
- Hospital Pharmacy, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany
| | - Udo Kontny
- Section of Pediatric Hematology, Department of Pediatric and Adolescent Medicine, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany
| | - Thorsten Orlikowsky
- Section of Neonatology, Department of Pediatric and Adolescent Medicine, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Albrecht Eisert
- Hospital Pharmacy, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany.,Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
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Farzi K, Mohammadipour F, Toulabi T, Heidarizadeh K, Heydari F. The Effect of Blended Learning on the Rate of Medication Administration Errors of Nurses in Medical Wards. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2020; 25:527-532. [PMID: 33747843 PMCID: PMC7968587 DOI: 10.4103/ijnmr.ijnmr_188_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 06/14/2020] [Accepted: 09/19/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Medication error is one of the most important and most common events threatening patient safety. This study was conducted with the aim to determine the effect of asynchronous hybrid/blended learning on the rate of medication administration errors of nurses in medical wards. MATERIALS AND METHODS This quasi-experimental study was conducted with a pretest-posttest design in 2019. The participants of this study included 57 clinical nurses working in the medical wards of a selected educational hospital affiliated to Lorestan University of Medical Sciences, Khorramabad, Iran. The study participants were selected through census method. An asynchronous hybrid/blended learning program was used in this study. Data collection was performed using a two-section researcher-made checklist. The collected data were analyzed using descriptive [Mean (SD)] and inferential (paired sample t-test) statistics in SPSS software. A p value of less than 0.05 was considered statistically significant. RESULTS The results showed that the mean score of total errors in medication administration in the medical wards after the intervention was significantly lower than before the intervention; the mean score of errors before and after the study was 61.67 and 50.09, respectively (t56= 11.41, p < 0.001). CONCLUSIONS Asynchronous hybrid/blended learning as a type of e-learning, simple, relatively inexpensive, and new educational strategy can improve nurses' performance and reduce medication errors.
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Affiliation(s)
- Kolsoum Farzi
- School of Nursing and Midwifery, Student Research Committee, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fatemeh Mohammadipour
- Department of Medical Surgical, School of Nursing and Midwifery, Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Tahereh Toulabi
- Department of Critical Care, School of Nursing and Midwifery, Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Khadijeh Heidarizadeh
- Department of Critical Care, School of Nursing and Midwifery, Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fardin Heydari
- School of Nursing and Midwifery, Student Research Committee, Lorestan University of Medical Sciences, Khorramabad, Iran
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Gates PJ, Baysari MT, Gazarian M, Raban MZ, Meyerson S, Westbrook JI. Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis. Drug Saf 2020; 42:1329-1342. [PMID: 31290127 DOI: 10.1007/s40264-019-00850-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The risk of medication errors is high in paediatric inpatient settings. However, estimates of the prevalence of medication errors have not accounted for heterogeneity across studies in error identification methods and definitions, nor contextual differences across wards and the use of electronic or paper medication charts. OBJECTIVE Our aim was to conduct a systematic review and meta-analysis to provide separate estimates of the prevalence of medication errors among paediatric inpatients, depending on hospital ward and the use of electronic or paper medication charts, that address differences in error identification methods and definitions. METHODS We systematically searched five databases to identify studies published between January 2000 and December 2018 that assessed medication error rates by medication chart audit, direct observation or a combination of methods. RESULTS We identified 71 studies, 19 involved paediatric wards using electronic charts. Most studies assessed prescribing errors with few studies assessing administration errors. Estimates varied by ward type. Studies of paediatric wards using electronic charts generally reported a reduced error prevalence compared to those using paper, although there were some inconsistencies. Error detection methods impacted the rate of administration errors in studies of multiple wards, however, no other difference was found. Definition of medication error did not have a consistent impact on reported error rates. CONCLUSIONS Medication errors are a frequent occurrence in paediatric inpatient settings, particularly in intensive care wards and emergency departments. Hospitals using electronic charts tended to have a lower rate of medication errors compared to those using paper charts. Future research employing controlled designs is needed to determine the true impact of electronic charts and other interventions on medication errors and associated harm among hospitalized children.
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Affiliation(s)
- Peter J Gates
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia.
| | - Melissa T Baysari
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Madlen Gazarian
- School of Medical Sciences, Faculty of Medicine, University of NSW Sydney, Sydney, Australia
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia
| | - Sophie Meyerson
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia
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Naseralallah LM, Hussain TA, Jaam M, Pawluk SA. Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis. Int J Clin Pharm 2020; 42:979-994. [PMID: 32328958 DOI: 10.1007/s11096-020-01034-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
Abstract
Background Medication errors are avoidable events that may occur at any stage of the medication use process. Implementing a clinical pharmacist is one strategy that is believed to reduce the number of medication errors. Pediatric patients, who are more vulnerable to medication errors due to several contributing factors, may benefit from the interventions of a pharmacist. Aim of the review To qualitatively and quantitatively evaluate the impact of clinical pharmacist interventions on medication error rates for hospitalized pediatric patients. Methods PubMed, EMBASE, Cochrane Controlled Trials Register and Google Scholar search engines were searched from database inception to February 2020. Study selection, data extraction and quality assessment was conducted by two independent reviewers. Observational and interventional studies were included. Data extraction was done manually and the Crowe Critical Appraisal Tool was used to critically appraise eligible articles. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Results 19 studies were systematically reviewed and 6 studies (29,291 patients) were included in the meta-analysis. Pharmacist interventions involved delivering educational sessions, reviewing prescriptions, attending rounds and implementing a unit-based clinical pharmacist. The systematic review indicated that the most common trigger for pharmacist interventions was inappropriate dosing. Pharmacist involvement was associated with significant reductions in the overall rate of medication errors occurrence (OR 0.27; 95% CI 0.15 to 0.49). Conclusion Pharmacist interventions are effective for reducing medication error rates in hospitalized pediatric patients.
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Affiliation(s)
| | | | - Myriam Jaam
- Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Shane Ashley Pawluk
- Department of Pharmacy, Clinical Pharmacy, Children's & Women's Health Centre of British Columbia, Vancouver, BC, Canada. .,Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
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Gates PJ, Meyerson SA, Baysari MT, Westbrook JI. The Prevalence of Dose Errors Among Paediatric Patients in Hospital Wards with and without Health Information Technology: A Systematic Review and Meta-Analysis. Drug Saf 2019; 42:13-25. [PMID: 30117051 DOI: 10.1007/s40264-018-0715-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The risk of dose errors is high in paediatric inpatient settings. Computerized provider order entry (CPOE) systems with clinical decision support (CDS) may assist in reducing the risk of dosing errors. Although a frequent type of medication error, the prevalence of dose errors is not well described. Dosing error rates in hospitals with or without CPOE have not been compared. OBJECTIVE Our aim was to conduct a systematic review assessing the prevalence and impact of dose errors in paediatric wards with and without CPOE and/or CDS. METHODS We systematically searched five databases to identify studies published between January 2000 and December 2017 that assessed dose error rates by medication chart audit or direct observation. RESULTS We identified 39 studies, nine of which involved paediatric wards using CPOE with or without CDS. Studies of paediatric wards using paper medication charts reported approximately 8-25% of patients experiencing a dose error, and approximately 2-6% of medication orders and approximately 3-8% of dose administrations contained a dose error, with estimates varying by ward type. The nine studies of paediatric wards using CPOE reported approximately 22% of patients experiencing a dose error, and approximately 1-6% of medication orders and approximately 3-8% of dose administrations contained a dose error. Few studies provided data for individual wards. The severity and prevalence of harm associated with dose errors was rarely assessed and showed inconsistent results. CONCLUSIONS Dose errors occur in approximately 1 in 20 medication orders. Hospitals using CPOE with or without CDS had a lower rate of dose errors compared with those using paper charts. However, few pre/post studies have been conducted and none reported a significant reduction in dose error rates associated with the introduction of CPOE. Future research employing controlled designs is needed to determine the true impact of CPOE on dosing errors among children, and any associated patient harm.
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Affiliation(s)
- Peter J Gates
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia.
| | - Sophie A Meyerson
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia
| | - Melissa T Baysari
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia
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Hermanspann T, van der Linden E, Schoberer M, Fitzner C, Orlikowsky T, Marx G, Eisert A. Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units. DRUG HEALTHCARE AND PATIENT SAFETY 2019; 11:11-18. [PMID: 30936751 PMCID: PMC6429998 DOI: 10.2147/dhps.s184479] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose To determine the type, frequency, and factors associated with medication preparation and administration errors in adult intensive care units (ICUs) and neonatal ICUs (NICUs)/pediatric ICUs (PICUs). Patients and methods We conducted a prospective direct observation study in an adult ICU and NICU/PICU in a tertiary university hospital. Between June 2012 and June 2013, a clinical pharmacist and medical student observed the nursing care staff on weekdays during the preparation and administration of intravenous drugs. We analyzed the frequency and type of preparation and administration errors and factors associated with errors. Results Six hundred and three preparations in the adult ICU and 281 in the NICU/PICU were observed. Three hundred and eighty-five errors occurred in the adult ICU and 38 in the NICU/PICU. There were 5,040 and 2,514 error opportunities, with overall error rates of 7.6% and 1.5%, respectively. The total opportunities for error meant each single step of preparation and administration that was relevant for the drug. Most errors applied to the category “uniform mixing” (adult ICU: n=227, 59%; NICU/PICU: n=14, 37%). The multivariate logistic regression results showed a significantly different influence of the “preparation type” for the adult ICU compared with the NICU/PICU with regard to the occurrence of an error. Preparations for adult patients of the LCD type (liquid concentrate with diluent into syringe or infusion bag) were more often associated with errors than the P (powder in a glass vial that must be reconstituted and diluted if necessary), P=0.012, and LC (liquid concentrate into syringe), P=0.002 type. Conclusion “Uniform mixing” was the most erroneous preparation step in intravenous drug preparations in two ICUs. Improvement of nurse training and the preparation of prefilled syringes in the pharmacy might reduce errors and improve the quality and safety of drug therapy.
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Affiliation(s)
- Theresa Hermanspann
- Hospital Pharmacy, RWTH Aachen University Hospital, Aachen, Germany, .,Department of Pediatric and Adolescent Medicine, Section of Neonatology, RWTH Aachen University Hospital, Aachen, Germany,
| | - Eva van der Linden
- Department of Pediatric and Adolescent Medicine, Section of Neonatology, RWTH Aachen University Hospital, Aachen, Germany,
| | - Mark Schoberer
- Department of Pediatric and Adolescent Medicine, Section of Neonatology, RWTH Aachen University Hospital, Aachen, Germany,
| | - Christina Fitzner
- Department of Medical Statistics, Medical Faculty RWTH Aachen University, Aachen, Germany.,Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Thorsten Orlikowsky
- Department of Pediatric and Adolescent Medicine, Section of Neonatology, RWTH Aachen University Hospital, Aachen, Germany,
| | - Gernot Marx
- Department of Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Albrecht Eisert
- Hospital Pharmacy, RWTH Aachen University Hospital, Aachen, Germany, .,Institute of Pharmacology and Toxicology, Medical Faculty RWTH Aachen University, Aachen, Germany
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Rishoej RM, Almarsdóttir AB, Thybo Christesen H, Hallas J, Juel Kjeldsen L. Identifying and assessing potential harm of medication errors and potentially unsafe medication practices in paediatric hospital settings: a field study. Ther Adv Drug Saf 2018; 9:509-522. [PMID: 30181859 PMCID: PMC6116774 DOI: 10.1177/2042098618781521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/16/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hospitalized children are prone to experience harm from medication errors (MEs). Strategies to prevent MEs can be developed from identified malfunctioning practices and conditions in the medication use process. In this study, we aimed to identify MEs and potentially unsafe medication practices (PUMPs) in hospitalized children, and to assess the potential harm of these, using raters of different professions. METHODS A 1-week observation using an undisguised technique was conducted on four paediatric hospital wards. One observer followed ward staff during medication prescribing, preparation and administration. MEs and PUMPs were documented using field notes. Three raters including a physician, a nurse and a clinical pharmacist assessed the potential harm of each ME and PUMP using a six-point Likert scale. Agreement was analysed using Fleiss' Kappa. RESULTS A total of 16 MEs and 809 PUMPs were identified involving a preparation and administration error rate of 8%. No actual harm to patients was observed during the study. Raters assessed the potential harm of 318 unique MEs and PUMPs. Only slight agreement was found (Kappa = 0.26-0.33). A 4-hour delay in the administration of intravenous cefuroxime received the highest harm score. Observations involving no information during prescribing and variations in medication preparation were considered potentially fatal for medications such as digoxin, morphine, enoxaparin and insulin. CONCLUSIONS MEs and potentially unsafe practices and conditions may affect medication safety of hospitalized children. However, observed MEs did not result in any harm. The agreement among raters assessing the potential harm of observations was low. Alternative methods to determine the clinical relevance of errors are needed.
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Affiliation(s)
- Rikke Mie Rishoej
- Clinical Pharmacology and Pharmacy, Department
of Public Health, University of Southern Denmark, JB Winsløws Vej 19, 2,
Odense C, Funen 5000, Denmark
| | | | - Henrik Thybo Christesen
- Hans Christian Andersen Children’s Hospital,
Odense University Hospital, Odense, Denmark; Department of Clinical
Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Department of Public Health, University of
Southern Denmark, Odense, Denmark
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Azizi S, Siddiqui F, Iqbal I. Changing health care culture: a prerequisite to improving patient safety. Ther Clin Risk Manag 2017; 13:623-624. [PMID: 28507437 PMCID: PMC5428755 DOI: 10.2147/tcrm.s138896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Saeed Azizi
- Faculty of Medicine, St George’s Hospital Medical School, London, UK
| | - Faisal Siddiqui
- Faculty of Medicine, St George’s Hospital Medical School, London, UK
| | - Ithsham Iqbal
- Faculty of Medicine, St George’s Hospital Medical School, London, UK
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