Introduction to medication errors and the error prevention initiatives in a teaching hospital in Western Nepal (original) (raw)
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https://www.ijhsr.org/IJHSR\_Vol.13\_Issue.5\_May2023/IJHSR-Abstract16.html, 2023
To explore and estimate the frequency of medication error, a study conducted in a tertiary care teaching hospital of East India. The medication error can be divided into Prescribing errors, Dispatching Error, Drug Administration Errors, and Indenting Errors. The purpose of this study is to determine the prevalence and nature of medication errors; to explore the causes and to study corrective actions for such medication error. Identifying and evaluating the failures of medication errors and its severity analysis in a Tertiary care teaching hospital, Kolkata and suggesting solutions on reducing medication errors. It is a prospective study of patients receiving medication during treatment. The techniques that were used to identify the medication errors the study was carried out in a Tertiary Care 320 bedded Teaching hospital at Kolkata. Data was taken from Medication Error reporting form and medicine card of patients. Proper monitoring and capturing of medication error data has been initiated. Staff has been counselled and sensitized regarding safe medication practices and proper reporting of medication errors. Regular training on medication error has been conducted by Clinical Pharmacy Department, which improve the knowledge of monitoring, capturing, reporting and prevention of medication errors by the physicians, nurses, and clinical pharmacist.
Review of medication errors in a tertiary health care center in the capital city of India
International Journal of Current Research in Medical Sciences
The problem of Medication Errors in a tertiary care center is multi factorial and may involve more than an individual. All healthcare professionals have a responsibility in identifying the contributing factors of medication errors and use that information to further reduce their occurrence. Human errors must be considered as an intrinsic component of socio-technical system. Usage of drugs is a complex process and there are many drug related complications at various levels, which involve doctors, pharmacists, nurses and patients. Some medication errors are preventable and pharmacists have an active role in the appropriate use of drugs. In our systematic review,we have found that the poor knowledge of drugs, dosages and administration route amongst physicians and staff nurses were one of the most dominant contributing factors towards medication errors. Developing countries like ours, calls for the need to introduce educational programs to improve drug prescribing skills and knowledge of physicians, as well as to encourage nurses to improve their standard of drug administration.
Medication prescribing errors in a public teaching hospital in India: A prospective study
Pharmacy Practice (internet), 2007
Background: To prevent medication errors in prescribing, one needs to know their types and relative occurrence. Such errors are a great cause of concern as they have the potential to cause patient harm. The aim of this study was to determine the nature and types of medication prescribing errors in an Indian setting. Methods: The medication errors were analyzed in a prospective observational study conducted in 3 medical wards of a public teaching hospital in India. The medication errors were analyzed by means of Micromedex Drug-Reax database. Results: Out of 312 patients, only 304 were included in the study. Of the 304 cases, 103 (34%) cases had at least one error. The total number of errors found was 157. The drug-drug interactions were the most frequently (68.2%) occurring type of error, which was followed by incorrect dosing interval (12%) and dosing errors (9.5%). The medication classes involved most were antimicrobial agents (29.4%), cardiovascular agents (15.4%), GI agents (8.6%) and CNS agents (8.2%). The moderate errors contributed maximum (61.8%) to the total errors when compared to the major (25.5%) and minor (12.7%) errors. The results showed that the number of errors increases with age and number of medicines prescribed. Conclusion: The results point to the establishment of medication error reporting at each hospital and to share the data with other hospitals. The role of clinical pharmacist in this situation appears to be a strong intervention; and the clinical pharmacist, initially, could confine to identification of the medication errors.
Medication administration errors account for 34% of all medication errors and identified as one of the important reasons for patients' morbidity and mortality. NPSA statistics show that 59.3% of medication errors occur during the administration stage. Thus identifying and resolving the administration errors will improve the patient care and decreases the health care costs. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) taxonomy was used to analyse the frequency, types, severity and factors responsible for medication administration errors. The findings of the study reveal that the frequency of medication administration errors is 15.34%, omission errors (33.02%), improper dose (17.43%) and wrong time (12.84%) errors were the major types of errors occurred and the majority administration errors belonged to categoty C (112), B (46) and D (35). Frequent interruptions and distractions, lack of communication between health care professionals, performance deficit and work stress on duty nurses are identified as major factors responsible for administration errors.
Monitoring and Evaluation of Medication Error in a Tertiary Care Hospital
South Asian Research Journal of Pharmaceutical Sciences
Background: A medication error is a failure in the treatment process that leads to potential harm to the patient. Objectives: The study aimed to detect common prescribing and dispensing medication errors and frequency of medication errors reported by healthcare providers (HCP). Methodology: This observational prospective study was conducted for 10 months from January 2019 to October 2019 in an inpatient setting of a tertiary care hospital in Mangalore using Incident reporting form. The severity levels of medication errors have been analyzed by using the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) proposed index for categorizing medication errors. Results: On evaluating the medication errors, 30.18% were prescribing errors, 22.64% were dispensing errors. Majority of the errors were reported by Clinical pharmacist (62.6%), followed by Nurses (24.52%).The drugs acting on CVS were the most common class of drugs in which errors occurred (27 %). Most of the errors in our study resulted in (Error No Harm) 86.3% (category B, C and D), (No Error) 13.5% (category A), 1.2 % (category E, F, G, H) resulted in (Error Harm). No incidence of Error Death was reported. Conclusion: The incidence of medication errors was significantly high and it is essential to establish medication error reporting system and the educational programme for drug prescribers and nurses concerning drug therapy are urgently needed to avoid medication errors and to improve patient safety by clinical pharmacists.
Pharmacist’s intervention on serious prescription errors has promoted treatment effectiveness, decreased treatment cost and reduced potential harm. We aim to evaluate the prescription errors and pharmacist’s intervention at the outpatient pharmacies of two private tertiary care teaching hospitals of Central Nepal. A cross-sectional study was conducted for six working days in August 2014. Medication-prescribing errors were recorded by pharmacists using a checklist and discussed with the prescribers. The prescriptions that were corrected, changed or discontinued by the prescriber were considered as pharmacist intervened prescription. Frequency distribution and 2-test were performed. The daily rate of prescription error was 4.25% (N=106). The commonest type of errors were dose and dosing frequency error (43, 40.6%), and therapy error (36, 34.0%) with the highest prevalence of errors in general medicine (27, 25.5%) and more errors by the prescribers who were residents. 2-test showed a significant association of prescription errors with the prescriber (P=0.005) and pharmacist intervention (P=0.013). Prescription errors routinely occur in the outpatient settings showing the need for competent pharmacists. Both the prescriber and pharmacist need to work collectively in reducing prescribing errors, error related health hazards and economic burden to patients.
International Journal for Pharmaceutical Research Scholars, 2018
Medication Related errors are serious problems in health care and can be a source of significant mortality and morbidity. Hence, reporting is encouraged to know the incidence rates which helps in preventing them. The aim of this study was to identify and document Medication Related errors in hospitalized patients at a tertiary care center and to review the updated case sheets on prescribed medications, regularly. A prospective observational case analysis study was conducted between November 2013 and April 2014 at Gandhi Hospital, Secunderabad. A structured data collection form was prepared to document the case details for identification and documentation of drug(s) involved in Medication Related errors. Collected data was summarized categorically and analyzed to conclude the final outcome. Total of 71 of Medication Related errors were observed and documented. Patients with maximum Medication Related errors were male (70.42%). The study reported maximum errors of untreated indication (18) followed by a wrong dose (14). Route of administration showing maximum errors was in case of tablets 28 errors followed by 19 errors due to injections. Seven Point Severity scale (0-6) showed maximum Medication Related errors found to be of level 1 and level 2 (21 errors each). The study showed Medication Related Errors occur frequently in inpatient medical wards. Clinical pharmacist's interventions can effectively prevent these errors by identification and documentation at the early stage. This indicates the need for a continuous educational program to healthcare professionals on drug therapy problems which will help for better patient safety.
An Analysis of Medication Errors in a Tertiary Care Teaching Hospital
Journal of Research in Medical and Dental Science, 2020
Introduction: Medication errors can occur at any step while handling a medication from prescribing, indenting, dispensing to administration. Medication errors have the potential to cause patient harm to the extent of serious morbidity or even mortality and can have a substantial cost impact on the healthcare system. It can also lead to patient dissatisfaction and loss of confidence on the medical care. This study done with the objective of analysis of medication errors in a teaching hospital with an aim towards process improvement is thus justified. Materials and methods: This were a retrospective study done on the reported inpatient Medication Errors between January 2018 to December 2019 in a 600-bed tertiary care teaching hospital in Bihar. The total number of Medication errors reported during the study period was 1501 and the total number of orders during the said period was 28,472 as retrieved from the pharmacy software. The data from the Incident Report Form was entered in the ...
International Journal of Basic and Clinical Pharmacology
Background: Medication errors are preventable causes of medical error. These errors may happen at various steps of medication process. This study tries to find common errors during four stages i.e. prescribing, transcribing, dispensing and administration. Methods: It was a cross sectional study in a tertiary care teaching hospital in north India. Five hundred patients were randomly selected for the study. Medication error was checked at different level by a medication audit tool. Direct observation, chart reviews and personal communication with patients, nurses and pharmacist were done to complete the details of tool. Root cause analysis was done after discussing with concerned professionals. Severity of the medication errors were assessed using national coordinating council for medication error reporting and prevention (NCCMERP) proposed medication error index. Results: Medication error rate was found to be around 50%. i.e. every one of two patients received some form of error. Prescribing error were most common cause of error followed by administration error and transcription error. Dispensing error was least common. Root cause analysis indicated casual attitude, inadequate knowledge and training as the main causes. Conclusions: This study was an initial step in recognising error prone areas of medication management. It can be used to develop standard procedures and formulating guidelines for prevention of such errors.
Medication error: The role of health care professionals, sources of error and prevention strategies
The primary goal of medicine is to achieve positive therapeutic outcome while carefully minimizing patient risk. However, with the advancement made in the technology of drug discovery and formulation new medicines are flooding to the drug-market. Although newly launched medicines are opening lot more avenues and opportunities for patient care but also harboring new hazards. Medication errors (MEs) are common in health care system all over world. These errors are more dangerous especially in developing countries were patients’ right is not well protected. It contributes significantly to drug-related complications which range from mild damage to more severe event leading to hospitalization. Various health care professionals’ attitudes as well as system failure contribute to MEs. It has become necessary for every health care professional to understand the nature and sources of MEs and try to find solution. Sources of MEs are multi-factorials and multi-disciplinary that require careful detection, assessment and intervention. Several MEs preventive strategies were identified which if properly implemented will significantly improve health care delivery services. The purpose of this work is to highlight the role of health care professionals in MEs; identify the common sources of MEs and discuss the proper MEs preventive strategies.