Medication Errors

However, such differences between countries may be due more to differences in the medical systems rather than differences in the quality of patient care. The United States has a very different medical environment, partly because of the highly litigious nature of US culture. 2 The fear of being sued may reduce the incidence of hindsight bias3 in US studies, since physicians may order more tests than are strictly necessary, which makes it more difficult for researchers such as Baker and associates to second-guess their decisions.

The Dutch multidisciplinary guideline on 'Polypharmacy in older people' advises performing an annual medication review for patients aged 65 or older who use five or more drugs and have at least one risk factor for negative outcomes of their drug usage. We describe a 79-year-old male patient with an indication for a medication review and identified drug-related problems (DRPs). Furthermore, we describe two female patients aged 97 and 91 who use fewer than five drugs, dispensed via an automated system, and also have DRPs. We suggest adding the use of a multidose drug-dispensing system as an indication for a medication review. This will also help to identify patients with undertreatment. In addition, we recommend improving collaboration with pharmacists, which may enhance the effect of a medication review by increasing the number of drug changes.

The legal framework in South Africa (SA) provides for strict requirements regarding prescriptions. However, pharmacists are still confronted daily with illegible handwritten scripts, increasing the risk of medication errors. E-prescribing is being implemented in SA to overcome these disadvantages. The general regulations made in terms of the Medicines and Related Substances Act as well as the Electronic Communications and Transactions Act must be read conjointly for the purposes of understanding the legal framework of electronic prescriptions in SA.

The aim was to investigate the effectiveness of significant event analyses (SEAs) undertaken by pharmacists as judged by a new system of independent peer feedback. The setting was a convenience sample of 37 pharmacists working in community pharmacy, secondary care and academic settings in NHS Scotland. Preliminary study involved the content analysis of pharmacists' SEAs and written feedback reports, which were generated by pharmacists trained in using a validated instrument to facilitate peer feedback. The content of reports and feedback letters were systematically coded and categorised by identifying and quantifying key words and phrases. Data collected included the range and severity of significant events identified; the reported reasons for the events occurring; types of learning needs identified; action(s) taken; and learning issues raised by peer feedback. A total of 37 pharmacists submitted 43 SEA reports during the study period. All events submitted were classified as hav...

Patients boarded in the emergency department (ED) with psychiatric complaints may be at risk for medication errors. However, no studies exist to characterize the types of errors and risk factors for errors in these patients. To characterize medication errors in psychiatric patients boarded in ED, and to identify risk factors associated with these errors. A prospective observational study conducted in a community ED included all patients seen in the ED for primary psychiatric complaints and remained in the ED pending transfer to a psychiatric facility. An investigator recorded all medication errors requiring an intervention by an emergency pharmacist. A total of 288 medication errors in 100 patients were observed. Overall, 65 patients had one or more medication errors. The majority of errors (n = 256, 89%) were due to errors of omission. The final severity classification of the medication errors was: Insignificant (n = 77), significant (n = 152), and serious (n = 3). In the multivari...

The objectives of the current study were to describe the different types of problems patients receiving adjunctive therapy reported having when taking their glaucoma medications and to examine the relationship between patient-reported problems in taking their glaucoma medications and patient adherence. Cross-sectional survey. A survey was distributed to glaucoma patients in 4 geographically distinct ophthalmology practices. We excluded patients using only 1 glaucoma medication. The survey was completed by 324 patients. For each patient, average percent adherence to his or her glaucoma medication regimen was calculated. Logistic regression was used to examine how patient characteristics and problems in using glaucoma medications were related to reported adherence. Whether patients were less than 100% adherent in the previous week. We found that 60% of patients reported 1 or more problems with taking their glaucoma medications. Fourteen percent of patients reported being less than 100% adherent to their glaucoma regimen medications during the previous week. Patients who had difficulty remembering to take their glaucoma medications and those who reported that they had other problems or concerns with their glaucoma medications were significantly less likely to be 100% adherent. Patient adherence to a glaucoma medication regimen could be improved among patients receiving adjunctive therapy. Ophthalmologists and their clinical colleagues should make sure to discuss the problems and concerns that patients may have in taking their glaucoma medications in an effort to improve adherence.

The aim of this study was to investigate the completeness and legibility of prescriptions dispensed in community pharmacies located at Sana'a, Yemen. A cross-sectional study was conducted at 23 randomly selected community pharmacies throughout the capital city of Sana'a, Yemen from May 2015 to January 2016. A total of 2178 prescriptions were analyzed for the essential elements of a complete prescription using a validated checklist. Of the 2178 prescriptions, 19 (0.87%) were considered as of good quality prescription. The remaining 2159 (99.12%) prescriptions were considered as being of very poor quality. Errors related to patients and prescribed medications were the most common prescription writing errors. In this study, the quality of prescription writing was found to be very poor. Hence, continuous professional development programs are recommended to improve the quality of prescription writing among physicians. Future studies in other cities and investigation of the impact...

Medication error reporting (MER) is an effective way used to identify the causes of Medication Errors (MEs) and to prevent repeating them in future. The underreporting of MEs is a challenge generally in all MER systems. The current research aimed to explore nurses’ knowledge on MER by determining their attitudes towards reporting and studying the implicated barriers and facilitators. A total of 23 nurses were interviewed using a semi-structured interview guide. The saturation point was attained after 21 interviews. All the interviews were tape-recorded and transcribed verbatim, and analysed using inductive thematic analysis. Four major themes and 17 sub-themes were identified. Almost all the interviewees were aware about the existence of the MER system. They showed a positive attitude towards MER. The main barriers for MER were the impacts of time and workload, fear of investigation, impacts on the job, and negative reactions from the person in charge. The nurses were knowledgeable ...

Objective To determine the incidence of errors in preparing and administering intravenous (i.v.) drugs, identify the stages in the process at which errors occurred and evaluate their clinical importance. Methods A prospective ethnographic study using disguised observation was carried out on two wards in one German non-university hospital. Results We observed 22 nurses administering 122 i.v. drug preparations and administrations. One or more errors occurred in the preparation and administration of 58 of 122 i.v. drug doses (error rate 48%, 95% confidence interval 39–57%). In total, 65 errors were identified. Of doses, 4 had potentially severe errors (3%), 38 (31%) potentially moderate errors and 16 (13%) potentially minor errors. Common errors included multiple step preparations and the co-administration of potentially incompatible drugs as intermittent infusions. Conclusion A high incidence of i.v. drug errors was found in the study hospital. Effective strategies to reduce potentially harmful errors are urgently needed. Measures could include a reduction in the number of ward-based i.v. drug preparations, improvement of staff training and the introduction of ward-based clinical pharmacy services.

Medication administration omissions (MAO) are usually considered medication errors but not all MAO are clinically relevant. We determined the frequency of clinically relevant MAO of antimicrobial drugs in adult hospitals in Calgary, Alberta, Canada based on electronic medication administration record (eMAR). We examined 2011 data from eMAR records on medical wards and developed a reproducible assessment scheme to categorize and determine clinical relevance of MAO. We applied this scheme to records from 2012 in a retrospective cohort study to quantify clinically relevant MAO. Significant predictors of clinically relevant MAO were identified. A total of 294,718 dose records were assessed of which 10,282 (3.49%) were for doses not administered. Among these 4903 (1.66% of total); 47.68% of MAO were considered clinically relevant. Significant positive predictors of clinically relevant MAO included inhaled (OR 4.90, 95% CI 3.54-6.94) and liquid oral (OR 1.32, 95% CI 1.18-1.47) route of me...

Drug-drug interactions (DDIs) are preventable medical errors, yet exposure to DDIs continues despite systems that are designed to prevent such exposures. The purpose of this study was to examine pharmacy characteristics that may be associated with dispensed potential DDIs. This study combined survey data from community pharmacies in 18 metropolitan statistical areas with pharmacy claims submitted to 4 pharmacy benefit managers (PBMs) over a 3-month period from January 1, 2003 to March 31, 2003. Pharmacy characteristics of interest included prescription volume, the number of full-time equivalent pharmacists and pharmacy staff, computer software programs, and the ability to modify those programs with respect to DDI alerts, the use of technologies to assist in receiving, filling and dispensing medication orders, and prescription volume. The dependent variable in this study was the rate of dispensed medications that may interact. A total of 672 pharmacies were included in the analysis. ...

Medication prescribing errors are made all over the world. However, exact data about them are lacking in Lebanon. Our objective was to describe medication errors, including drug-drug interactions in medication orders given to patients admitted to Lebanese hospitals. A prospective study was carried out on 313 patients taken from seven Lebanese hospitals; 1826 medication orders were assessed for errors and 456 drug-drug interactions were found. Data was entered and analyzed on SPSS. Around 40% of medication orders were judged to comprise at least one prescribing error, mainly no ordering of parameters monitoring (20%), unnecessary medication (9%), and no indication (7%). Errors occurred mainly in the pediatrics (50%) and internal medicine wards (40%). Having an infectious or gastrointestinal problem almost doubled the risk of medication prescribing error. Antiulcer agents, NSAIDs, antibiotics and steroidal agents were the medications mainly involved. Meanwhile, 12 adverse medication e...

Medication errors commonly involve confusion between drug names that look or sound alike. One possible method of reducing these errors is to print sections of the names in ‘‘Tall Man’’ (capital) letters, in order to emphasise differences between similar products. This paper reports an eye-tracking experiment that evaluates this strategy. Participants had their eye movements monitored while they searched for a target product amongst an array of product packs. The target pack was replaced by a similar distractor in the array. Participants made fewer errors when the appearance of the names had been altered, that is, they were less likely to incorrectly identify a distractor as the target drug. This result was reflected in the eye movement data.