Relevant bibliographies by topics / Medication errors

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  1. Journal articles
  2. Dissertations / Theses
  3. Books
  4. Book chapters
  5. Conference papers
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Academic literature on the topic 'Medication errors'

Author: Grafiati
Published: 4 June 2021
Last updated: 29 July 2024

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Journal articles on the topic "Medication errors"

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Idris, Muhammad Usamah Bin Mohamed, Nursa'adah Binte Jamil, Xu Yi, Lim Su-Fee, Ang Shin Yuh, Fazila Aloweni, and Rachel Marie Towle. "Keeping patients safe through medication review and management in the community." British Journal of Community Nursing 29, no. 6 (June 2, 2024): 288–93. http://dx.doi.org/10.12968/bjcn.2024.29.6.288.

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Background: There are numerous publications on inpatient medication errors. However, little focus is given to medication errors that occur at home. Aims: To describe and analyse the types of medication errors among community-dwelling patients following their discharge from an acute care hospital in Singapore. Method: This is a retrospective review of a ‘good catch’ reporting system from December 2018 to March 2022. Medication-related errors were extracted and analysed. Findings: A total of 73 reported medication-related error incidents were reviewed. The mean age of the patients was 78 years old (SD=9). Most patients managed their medications independently at home (45.2%, n=33). The majority of medications involved were cardiovascular medications (51.5%, n=50). Incorrect dosing (41.1%, n=39) was the most common medication error reported. Poor understanding of medication usage (35.6%, n=26) and lack of awareness of medication changes after discharge (24.7%, n=18) were the primary causes of the errors. Conclusion: This study's findings provide valuable insights into reducing medication errors at home. More attention must be given to post-discharge care, especially to preventable medication errors. Medication administration and management education can be emphasised using teach-back methods.
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Clark, Henry, Delesha Carpenter, Kathleen Walsh, Scott A. Davis, Nacire Garcia, and Betsy Sleath. "Medication Errors in Adolescents Using Asthma Controller Medications." Global Pediatric Health 7 (January 2020): 2333794X2098134. http://dx.doi.org/10.1177/2333794x20981341.

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The purpose of this study was to describe the number and types of errors that adolescents and caregivers report making when using asthma controller medications. A total of 319 adolescents ages 11 to 17 with persistent asthma and their caregivers participated in this cross-sectional study. Adolescent and caregiver reports of asthma medication use were compared to the prescribed directions in the medical record. An error was defined as discrepancies between reported use and the prescribed directions. About 38% of adolescents reported 1 error in using asthma controller medications, 16% reported 2 errors, and 5% reported 3 or more errors. About 42% of caregivers reported 1 error in adolescents using asthma controller medications, 14% reported 2 errors, while 6% reported 3 or more errors. The type of error most frequently reported by both was not taking the medication at all. Providers should ask open-ended questions of adolescents with asthma during visits so they can detect and educate families on how to overcome errors in taking controller medication use.
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Tran, Tim, Simone E. Taylor, Andrew Hardidge, Elise Mitri, Parnaz Aminian, Johnson George, and Rohan A. Elliott. "The Prevalence and Nature of Medication Errors and Adverse Events Related to Preadmission Medications When Patients Are Admitted to an Orthopedic Inpatient Unit: An Observational Study." Annals of Pharmacotherapy 53, no. 3 (September 20, 2018): 252–60. http://dx.doi.org/10.1177/1060028018802472.

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Background: Medication errors commonly occur when patients move from the community into hospital. Whereas medication reconciliation by pharmacists can detect errors, delays in undertaking this can increase the risk that patients receive incorrect admission medication regimens. Orthopedic patients are an at-risk group because they are often elderly and use multiple medications. Objective: To evaluate the prevalence and nature of medication errors when patients are admitted to an orthopedic unit where pharmacists routinely undertake postprescribing medication reconciliation. Methods: A 10-week retrospective observational study was conducted at a major metropolitan hospital in Australia. Medication records of orthopedic inpatients were evaluated to determine the number of prescribing and administration errors associated with patients’ preadmission medications and the number of related adverse events that occurred within 72 hours of admission. Results: Preadmission, 198 patients were taking at least 1 regular medication, of whom 176 (88.9%) experienced at least 1 medication error. The median number of errors per patient was 6 (interquartile range 3-10). Unintended omission of a preadmission medication was the most common prescribing error (87.4%). There were 17 adverse events involving 24 medications in 16 (8.1%) patients that were potentially related to medication errors; 6 events were deemed moderate consequence (moderate injury or harm, increased length of stay, or cancelled/delayed treatment), and the remainder were minor. Conclusion and Relevance: Medication errors were common when orthopedic patients were admitted to hospital, despite postprescribing pharmacist medication reconciliation. Some of these errors led to patient harm. Interventions that ensure that medications are prescribed correctly at admission are required.
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Alboudi, Ayman, and Anna Bank. "Medication Reconciliation Errors on Discharge for Epilepsy Monitoring Unit Patients." Journal of Epilepsy Research 14, no. 1 (June 30, 2024): 17–20. http://dx.doi.org/10.14581/jer.24003.

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Background and Purpose: Medication errors are common in the inpatient setting. Epilepsy patients who miss doses of their antiseizure medications are at risk for breakthrough seizures and subsequent complications. The purpose of this study was to quantify and characterize anti-seizure medications reconciliation errors on discharge from the epilepsy monitoring unit (EMU).Methods: Consecutive admissions to an academic medical center EMU were retrospectively reviewed. Medication reconciliation errors on discharge, including drug errors, dosing errors, and dose timing errors, were recorded. Associations between medication errors and clinical and demographic variables were analyzed using binary logistic regression for continuous variables and Fisher exact tests for categorical variables.Results: One hundred and eleven admissions between January 1, 2021 and December 31, 2021 were identified. Fourteen anti-seizure medication reconciliation errors were recorded during 11 unique admissions (9.9% of admissions). The most common error type was dosing error (10/14 errors; 71.4%). Number of antiseizure medications on admission (<i>p</i>=0.004), total number of medications on admission (<i>p</i>=0.013), number of medication changes during admission (<i>p</i>=0.0007), and length of stay (<i>p</i>=0.0001) were associated with increased likelihood of errors.Conclusions: Medication reconciliation errors upon discharge from the EMU occur during approximately 10% of admissions. A higher number of preadmission antiseizure medications, higher total number of preadmission medications, higher number of medication changes during admission, and longer length of stay are associated with increased risk of discharge medication reconciliation errors. Careful attention should be paid to patients with these risk factors.
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Apsay, Khandy Lorraine Guerrero, Gianille Geselle Alvarado, Marlon Charles Paguntalan, and Sittie Hannah Tumog. "CONTRIBUTING FACTORS TO MEDICATION ERRORS AS PERCEIVED BY NURSING STUDENTS IN ILIGAN CITY, PHILIPPINES." Belitung Nursing Journal 4, no. 6 (November 7, 2018): 537–44. http://dx.doi.org/10.33546/bnj.566.

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Background: Nursing students are allowed to give medication with clinical supervision to give medications with clinical supervision to enhance skills in medication administration. However, studies suggest that some students commit medication errors due to knowledge, personal, administrative and environmental factors.Objective: This study will identify factors that cause student nurses to commit medication errors and correlate it to the number of perceived medication errors committed.Methods: A correlational design was used to correlate the factors contributing to medication administration and the number of medication errors committed by the students. 388 randomly selected nursing students were asked to answer a Modified Medication Error Questionnaire which measures the knowledge, administrative, personal and environmental factors which may contribute to medication administration errors. Medication administration errors are measured according to the number of times a student commits as perceived by them.Results: Lack of knowledge of the drug and equipment to be used for administration, decrease in confidence, poor clinical assessment of patients; conditions, and poor follow ups from clinical instructor are identified concerns under knowledge factor. Poor positive feedback, inadequate supervision and belittling ways of clinical instructors are identified under the administrative factor. Fear of administering an injection or giving medications is a common problem under personal factor. Inappropriate labelling of medications, unfavorable room temperature, lack of space, inadequate lighting, disorganized medication administration schedule and noise are problems found under environmental factor. A minority of 17.3% claimed that they have encountered a medication error in any of their clinical duties.Conclusion: Knowledge, administrative, personal and environmental factors have no effect towards medication errors. However, the relationship between age and the number of perceived medications errors is established. More in-depth investigation is recommended to determine the type of medication errors committed and its detrimental effects towards patient safety.
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Walsh, Kathleen E., Katherine S. Dodd, Kala Seetharaman, Douglas W. Roblin, Lisa J. Herrinton, Ann Von Worley, G. Naheed Usmani, David Baer, and Jerry H. Gurwitz. "Medication Errors Among Adults and Children With Cancer in the Outpatient Setting." Journal of Clinical Oncology 27, no. 6 (February 20, 2009): 891–96. http://dx.doi.org/10.1200/jco.2008.18.6072.

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Purpose Outpatients with cancer receive complicated medication regimens in the clinic and home. Medication errors in this setting are not well described. We aimed to determine rates and types of medication errors and systems factors associated with error in outpatients with cancer. Methods We retrospectively reviewed records from visits to three adult and one pediatric oncology clinic in the Southeast, Southwest, Northeast, and Northwest for medication errors using established methods. Two physicians independently judged whether an error occurred (κ = 0.65), identified its severity (κ = 0.76), and listed possible interventions. Results Of 1,262 adult patient visits involving 10,995 medications, 7.1% (n = 90; 95% CI, 5.7% to 8.6%) were associated with a medication error. Of 117 pediatric visits involving 913 medications, 18.8% (n = 22; 95% CI, 12.5% to 26.9%) were associated with a medication error. Among all visits, 64 of the 112 errors had the potential to cause harm, and 15 errors resulted in injury. There was a range in the rates of chemotherapy errors (0.3 to 5.8 per 100 visits) and home medication errors (0 to 14.5 per 100 visits in children) at different sites. Errors most commonly occurred in administration (56%). Administration errors were often due to confusion over two sets of orders, one written at diagnosis and another adjusted dose on the day of administration. Physician reviewers selected improved communication most often to prevent error. Conclusion Medication error rates are high among adult and pediatric outpatients with cancer. Our findings suggest some practical targets for intervention, including improved communication about medication administration in the clinic and home.
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Allison, Geneve M., Bernard Weigel, and Christina Holcroft. "Does electronic medication reconciliation at hospital discharge decrease prescription medication errors?" International Journal of Health Care Quality Assurance 28, no. 6 (July 13, 2015): 564–73. http://dx.doi.org/10.1108/ijhcqa-12-2014-0113.

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Purpose – Medication errors are an important patient safety issue. Electronic medication reconciliation is a system designed to correct medication discrepancies at transitions in healthcare. The purpose of this paper is to measure types and prevalence of intravenous antibiotic errors at hospital discharge before and after the addition of an electronic discharge medication reconciliation tool (EDMRT). Design/methodology/approach – A retrospective study was conducted at a tertiary hospital where house officers order discharge medications. In total, 100 pre-EDMRT and 100 post-EDMRT subjects were randomly recruited from the study center’s clinical Outpatient Parenteral Antimicrobial Therapy (OPAT) program. Using infectious disease consultant recommendations as gold standard, each antibiotic listed in these consultant notes was compared to the hospital discharge orders to ascertain the primary outcome: presence of an intravenous antibiotic error in the discharge orders. The primary covariate of interest was pre- vs post-EDMRT group. After generating the crude prevalence of antibiotic errors, logistic regression accounted for potential confounding: discharge day (weekend vs weekday), average years of practice by prescribing physician, inpatient service (medicine vs surgery) and number of discharge mediations per patient. Findings – Prevalence of medication errors decreased from 30 percent (30/100) among pre-EDMRT subjects to 15 percent (15/100) errors among post-EDMRT subjects. Dosage errors were the most common type of medication error. The adjusted odds ratio of discharge with intravenous antibiotic error in the post-EDMRT era was 0.39 (0.18, 0.87) compared to the pre-EDMRT era. In the adjusted model, the total number of discharge medications was associated with increased OR of discharge error. Originality/value – To the authors’ knowledge, no other study has examined the impact of reconciliation on types and prevalence of medication errors at hospital discharge. The focus on intravenous antibiotics as a class of high-stakes medications with serious risks to patient safety during error events highlights the clinical importance of the findings. Electronic medication reconciliation may be an important tool in efforts to improve patient safety.
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Henry Basil, Josephine, Nurul Ain Mohd Tahir, Chandini Menon Premakumar, Adliah Mhd Ali, Zamtira Seman, Shareena Ishak, Kwee Ching See, et al. "Clinical and economic impact of medication administration errors among neonates in neonatal intensive care units." PLOS ONE 19, no. 7 (July 11, 2024): e0305538. http://dx.doi.org/10.1371/journal.pone.0305538.

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Despite efforts in improving medication safety, medication administration errors are still common, resulting in significant clinical and economic impact. Studies conducted using a valid and reliable tool to assess clinical impact are lacking, and to the best of our knowledge, studies evaluating the economic impact of medication administration errors among neonates are not yet available. Therefore, this study aimed to determine the potential clinical and economic impact of medication administration errors in neonatal intensive care units and identify the factors associated with these errors. A national level, multi centre, prospective direct observational study was conducted in the neonatal intensive care units of five Malaysian public hospitals. The nurses preparing and administering the medications were directly observed. After the data were collected, two clinical pharmacists conducted independent assessments to identify errors. An expert panel of healthcare professionals assessed each medication administration error for its potential clinical and economic outcome. A validated visual analogue scale was used to ascertain the potential clinical outcome. The mean severity index for each error was subsequently calculated. The potential economic impact of each error was determined by averaging each expert’s input. Multinomial logistic regression and multiple linear regression were used to identify factors associated with the severity and cost of the errors, respectively. A total of 1,018 out of 1,288 (79.0%) errors were found to be potentially moderate in severity, while only 30 (2.3%) were found to be potentially severe. The potential economic impact was estimated at USD 27,452.10. Factors significantly associated with severe medication administration errors were the medications administered intravenously, the presence of high-alert medications, unavailability of a protocol, and younger neonates. Moreover, factors significantly associated with moderately severe errors were intravenous medication administration, younger neonates, and an increased number of medications administered. In the multiple linear regression analysis, the independent variables found to be significantly associated with cost were the intravenous route of administration and the use of high-alert medications. In conclusion, medication administration errors were judged to be mainly moderate in severity costing USD 14.04 (2.22–22.53) per error. This study revealed important insights and highlights the need to implement effective error reducing strategies to improve patient safety among neonates in the neonatal intensive care unit.
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Cochran, Gary L., Ryan S. Barrett, and Susan D. Horn. "Comparison of medication safety systems in critical access hospitals: Combined analysis of two studies." American Journal of Health-System Pharmacy 73, no. 15 (August 1, 2016): 1167–73. http://dx.doi.org/10.2146/ajhp150760.

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Abstract Purpose The role of pharmacist transcription, onsite pharmacist dispensing, use of automated dispensing cabinets (ADCs), nurse–nurse double checks, or barcode-assisted medication administration (BCMA) in reducing medication error rates in critical access hospitals (CAHs) was evaluated. Methods Investigators used the practice-based evidence methodology to identify predictors of medication errors in 12 Nebraska CAHs. Detailed information about each medication administered was recorded through direct observation. Errors were identified by comparing the observed medication administered with the physician’s order. Chi-square analysis and Fisher’s exact test were used to measure differences between groups of medication-dispensing procedures. Results Nurses observed 6497 medications being administered to 1374 patients. The overall error rate was 1.2%. The transcription error rates for orders transcribed by an onsite pharmacist were slightly lower than for orders transcribed by a telepharmacy service (0.10% and 0.33%, respectively). Fewer dispensing errors occurred when medications were dispensed by an onsite pharmacist versus any other method of medication acquisition (0.10% versus 0.44%, p = 0.0085). The rates of dispensing errors for medications that were retrieved from a single-cell ADC (0.19%), a multicell ADC (0.45%), or a drug closet or general supply (0.77%) did not differ significantly. BCMA was associated with a higher proportion of dispensing and administration errors intercepted before reaching the patient (66.7%) compared with either manual double checks (10%) or no BCMA or double check (30.4%) of the medication before administration (p = 0.0167). Conclusion Onsite pharmacist dispensing and BCMA were associated with fewer medication errors and are important components of a medication safety strategy in CAHs.
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Huq, Nishat, Eimeira Padilla-Tolentino, and Brandy McGinnis. "Identifying Potential High-Risk Medication Errors Using Telepharmacy and a Web-Based Survey Tool." INNOVATIONS in pharmacy 12, no. 1 (February 12, 2021): 9. http://dx.doi.org/10.24926/iip.v12i1.3377.

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Background and Introduction: Obtaining patient medication histories during emergency department (ED) admissions is an important step towards identifying potential errors that could otherwise remain in the patient’s active medication list. This is a descriptive report of a standardized, electronic data collection tool created to document potential medication errors in patients receiving high-risk medications during ED admissions. Materials and Methods: Trained pharmacy technicians completed a survey following medication history collection using a secure web platform called REDCap®. Data collected included patient-specific information, the number and type of high-risk medications, and potential medication errors identified in the collection process. Results: During a pilot period of April 2019 to October 2020, 191 patient records were completed using the survey tool. Out of a total of 1088 medications recorded, 41% were considered high-risk medications. 42% of potential medication errors were classified as high-risk medication errors. Results from this survey tool demonstrated that 58% of high-risk medication orders could potentially result in a medication error that can be carried through patient admission and discharge. Discussion: Accurate medication history and transitions of care can significantly impact patient quality of life. The cost of addressing a medication related-adverse event is also substantial. Based on published reports, annual gross savings to a hospital is estimated to be $4532 per harmful error in 2020, after adjusting for inflation. This equated to approximately $1,182,852 in estimated savings for Ascension Texas in 18 months. Nationwide, preventing potential medication errors in an outpatient setting can save on average $3.5 billion per year. Conclusion: This web-based survey tool has improved the quality and efficiency of potential error identification during medication history collection by pharmacy technicians. This information can be easily retrieved and aid in discussions regarding medication reconciliation at the leadership level and impact patient treatment outcomes by developing virtual processes that may result in fewer medication related events.
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More sources

Dissertations / Theses on the topic "Medication errors"

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Walsh, Marie Helen. "Automated Medication Dispensing Cabinet and Medication Errors." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/305.

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The number of deaths due to medical errors in hospitals ranges from 44,000 to 98,000 yearly. More than 7,000 of these deaths have taken place due to medication errors. This project evaluated the implementation of an automated medication dispensing cabinet or PYXIS machine in a 25-bed upper Midwestern critical access hospital. Lewin's stage theory of organizational change and Roger's diffusion of innovations theory supported the project. Nursing staff members were asked to complete an anonymous, qualitative survey approximately 1 month after the implementation of the PYXIS and again 1 year later. Questions were focused on the device and its use in preventing medication errors in the hospital. In addition to the surveys that were completed, interviews were conducted with the pharmacist, the pharmacy techs, and the director of nursing 1 year after implementation to ascertain perceptions of the change from paper-based medication administration to use of the automated medication dispensing cabinet. Medication errors before, during, and after the PYXIS implementation were analyzed. The small sample and the small number of medication errors allowed simple counts and qualitative analysis of the data. The staff members were generally satisfied with the change, although they acknowledged workflow disruption and increased medication errors. The increase in medication errors may be due in part to better documentation of errors during the transition and after implementation. Social change in practice was supported through the patient safety mechanisms and ongoing process changes that were put in place to support the new technology. This project provides direction to other critical access hospitals regarding planning considerations and best practices in implementing a PYXIS machine.
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Alsulami, Zayed Nama F. "Medication errors in children." Thesis, University of Nottingham, 2013. http://eprints.nottingham.ac.uk/27843/.

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Medication errors are a significant global concern and can cause serious medical consequences in children. Double checking of medicines by two nurses is one strategy used by many children's hospitals to prevent errors from reaching paediatric patients. This thesis involves different studies that evaluated the effectiveness of the double checking process in reducing and preventing medication administration errors in a children's hospital. In addition, a systematic review was conducted of medication errors studies in the Middle East. A systematic review was also conducted of published studies of double checking. Six electronic databases were searched for articles that assessed the double checking process during the administration of medicines. Sixteen articles were identified. Only one of them was a randomised controlled clinical trial in a clinical setting. Only one study was conducted in a children's hospital. The review found that there is insufficient evidence to either support or refute the practice of double checking and more clinical trials are needed to evaluate the double checking process in children's hospitals. Based on the findings that were highlighted from the systematic review, a prospective observational study of paediatric nurses using the double checking process for medication administration was undertaken. The study aimed to evaluate how closely double checking policies are followed by nurses in different paediatric areas, and also to identify any. medication administration errors during the study period. 2,000 drug dose administration events were observed. There was variation between paediatric nurses adherence to double checking steps and different medication administration errors were identified. Based on the observational study, a semi-structured questionnaire study was developed. It was designed to explore the paediatric nurses' knowledge and opinions about the double checking process. The study showed that many nurses have insufficient knowledge on the double checking process and the hospital policy for medication administration. A simulation study was conducted to examine whether single or double checking is more effective in detecting and reducing medication errors in children. Each participant in this study was required to prepare and administer medicines in scenarios for two "dummy patients" either with another nurse (double checking) or alone (single checking). Different confounders were built into each scenario (prescribing and administration) for nurses to identify and address during the administration process. Errors in drug preparation, administration and failure to address confounders were observed and documented. The main findings from this study were that the double checking process is more likely to identify medication administration errors and contraindicated drugs than single checking. The time taken for drug administration was similar for both processes. Another systematic review was conducted to identify the published medication errors studies that have been undertaken in the Middle East. The review identified 45 studies from 10 Middle Eastern countries. Nine of the studies focused on medication errors in paediatric patients. Educational programmes on drug therapy for doctors and nurses are urgently needed in the Middle East. These studies have contributed to the field of medication safety by providing more information about double and single checking medication administration processes in paediatric hospitals. More educational and training programmes for nurses about the importance of double checking and improving their adherence rate to the double checking steps during medication administration are required to improve its effectiveness.
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Samaranayake, Nithushi Rajitha. "Medication safety in hospitals : medication errors and interventions to improve the medication use process." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2013. http://hdl.handle.net/10722/193507.

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Medication errors are an unnecessary threat to patient safety. The aim of this study was to assess the epidemiology of medication errors and to assess the effectiveness of interventions intended to avoid medication errors in a tertiary-care hospital in Hong Kong. The epidemiology of medication errors included the study of the pattern of interception of medication errors and the study of technology-related medication errors using medication incidents reported during years 2006–2010. 34.1% of all medication errors that were reported in the study hospital were not intercepted and 92.4% of all drug administration errors reached the patient. 17.1% of all reported medication errors were technology-related and, most were due to human interaction with technology. The effects of a bar-code assisted medication administration (BCMA) system when used without the support of computerised prescribing (stand-alone), on its users and the dispensing process was studied using direct observations, questionnaires (Likert scale) and interviews. It was found that this system increased the number of dispensing steps from 5 to 8 and dispensing time by 1.9 times. Potential dispensing errors also increased (P<0.001). The perceived usefulness of the technology decreased among pharmacy staff (P=0.008) after implementation and they (N=16) felt that the system offered less benefit to the dispensing process (8/16) without the support of computerised prescribing. Nurses (N=10) felt that the stand-alone BCMA system was useful in improving the accuracy of drug administration (8/10). Avoiding the use of inappropriate abbreviations in prescriptions will help to reduce medication errors. Therefore the effectiveness of a ‘Do Not Use’ list (a list of error-prone abbreviations used in the study hospital) and attitudes of health care professionals on using abbreviations in prescriptions was studied using prescription review and questionnaires respectively. The use of abbreviations included in the ‘Do Not Use’ list decreased significantly (P<0.001) after its introduction but other unapproved abbreviations to denote drug names and instructions were commonly used. 96% of doctors, and all pharmacists and nurses, believed that avoiding inappropriate abbreviations will help to reduce medication errors. The use of abbreviations in prescriptions and attitudes of pharmacists in the study hospital was compared with a different medical system to determine the appropriateness of developing a universal error-prone abbreviation list. It was found that the types and frequencies of using inappropriate abbreviations vary among different medical systems. In conclusion, additional interventions such as technological interventions are needed to minimise drug administration errors, but proper planning and careful monitoring are needed to avoid unintended errors when using technologies. Implementing a stand-alone BCMA system aimed at reducing drug administration errors may affect the dispensing process. Therefore effects of a technology on all related processes need to be considered before implementation, and monitored after implementation. The introduction of a ‘Do Not Use’ list is effective in reducing inappropriate abbreviations in prescriptions and most health care professionals agree that avoiding inappropriate abbreviations may help to reduce medication errors. However, formulating in-house error-prone and standard abbreviation lists in hospitals, continuous updating of the lists and frequent reminders to prescribers are recommended.
published_or_final_version
Medicine
Doctoral
Doctor of Philosophy
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Maurer, Mary Jo. "Nurses’ Perceptions of and Experiences with Medication Errors." University of Toledo / OhioLINK, 2010. http://rave.ohiolink.edu/etdc/view?acc_num=toledo1279243109.

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Panozzo, Stacey Joy. "Nurses' perceptions of medication administration errors /." Title page, abstract and contents only, 2001. http://web4.library.adelaide.edu.au/theses/09S.PS/09s.psp195.pdf.

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Becker, Kathleen Ann. "Efficacy of a behavioral intervention to decrease medication transcription errors among professional nurses." [Milwaukee, Wis.] : e-Publications@Marquette, 2009. http://epublications.marquette.edu/dissertations_mu/2.

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Tomlin, Mark. "Medication errors : capture and prevention by pharmacy." Thesis, University of Portsmouth, 2011. https://researchportal.port.ac.uk/portal/en/theses/medication-errors(e0042fad-f3a5-46bf-9281-d97c1fe3f531).html.

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Introduction This thesis looks at the pharmacist’s contribution to the capture of medication errors and preventing harm reaching patients. It has several components: an analysis of annual surveys of interventions made by pharmacists at a large teaching hospital, a re-coding of these surveys to see how many interventions were the result of prescribing errors, and an experiment in A&E where the pharmacist drafted the first prescription chart. Methods One-week surveys of pharmacist interventions were regularly made at Southampton General Hospital between 1999 and 2009. These were analysed for trends, then recoded to identify the proportion that were caused by prescribing errors. In addition, a controlled trial was conducted to investigate the effects on prescribing error rate, of a pharmacist obtaining an accurate medication history in A&E, then transcribing the data onto the first inpatient prescription. Key findings In the period 1999-2001, the average number of interventions in each week long survey was 575 and during 2005-9 it was 973. This was a statistically significant increase. More interventions were recorded as serious in the latter period. The rate of interventions also increased from between one per every five and seven patients (31 to 45 prescribed items) to one per every one to two patients (8 to 20 items). The severity of interventions also increased, with between one and five deaths avoided each week. Almost three quarters of pharmacists’ interventions (73.9%) were triggered by prescribing errors, giving an error rate of 644 prescribing errors per week, or 6.2 per 100 prescribed items. These data are in contrast to the Trust submitting 918 error reports per year to the NPSA, the majority of which were administration errors reported by nurses. Nearly a half (45.3%) of all prescribing errors occurred during the admission phase of the hospital episode. Two thirds (67.1%) of prescribing errors detected were errors of omission - things that had not been done. Prescribing errors of commission occurred mainly during the inpatient phase and errors of omission during the admission phase. A quarter of prescribing errors were planning errors. These were failures to follow guidelines, failures to review patients’ prescriptions, manage interactions, and adjust dosage in liver or renal failure or in response to TDM results. One fifth (21.7%) of the patients had events or symptoms that contributed to the admission that could be explained by the medicines they were consuming. Over half of these were potentially avoidable by better monitoring or product selection. A pharmacist working in A&E to obtain complete and accurate drug histories, then transcribing the data onto the first prescription, produced a trend to reduction in the generation of errors throughout the whole hospital episode. Conclusions Analysing pharmacist’s interventions is a useful method of investigation prescribing errors and ways to stop them happening. First prescriptions written by pharmacists should provide an effective means of reducing errors which may be promulgated throughout the hospital stay.
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Hawthorne-Kanife, Rita Chinyere. "Staff Educational Program to Prevent Medication Errors." ScholarWorks, 2018. https://scholarworks.waldenu.edu/dissertations/6040.

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Medication administration errors (MAEs) may lead to adverse drug events, patient morbidity, prolonged hospital stays, and increased readmission rates, and may contribute to major financial losses for the health system. MAEs are the most common type of error occurring within the health care setting leading to an estimated 7,000 patient deaths every year. Interventions have been designed to prevent MAEs including education for nurses who administer medications; however, little effort has been made to design systematic educational programs that are based on local needs and contexts. The purpose of this project was to identify internal and external factors related to MAEs at the practice site, develop an education program tailored to the factors contributing to MAEs, and implement the program using a pretest posttest design. The Iowa model was used to guide the project. The 26 nurse participants who responded to an initial survey indicated that nurses felt distractions and interruptions during medication administration, and hesitancy to ask for help or to report medication errors increased MAE risks. After the education program, the pretest and posttest results were analyzed and revealed improvement in knowledge and confidence of medication administration (M = 3.2 pre, M = 3.7 post, p < .05). Open-ended question responses suggested a need for dedicated time for preparation and administration of medications without interruptions. Positive social change is possible as nurses become knowledgeable and confident about medication administration safety and as patients are protected from injury secondary to MAEs.
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Mekonnen, Alemayehu B. "Medication Reconciliation as a Medication Safety Initiative." Thesis, The University of Sydney, 2017. http://hdl.handle.net/2123/18050.

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Medication errors and their adverse outcomes are the most common cause of patient injuries in hospitals. Medication reconciliation is the safety strategy usually called for, to prevent medication errors that occur at care transitions. This strategy has been adopted as a standard practice in many developed countries. However, in Ethiopia, there were no published studies on medication reconciliation, nor evidence-based interventions aimed to tackle the burden of medication errors. This thesis was a medication safety initiative focusing on medication reconciliation intervention overall, and explored the journey to medication reconciliation service implementation as a medication safety strategy in Ethiopian public hospitals. Given the lack of consistent reports regarding the impact of this strategy, the journey to implementation was guided by synthesise of the evidence supporting the effectiveness of this intervention. The findings of our systematic reviews have shown that medication reconciliation interventions carried out through pharmacist assessment at hospital transitions were found to be an effective strategy for improving clinical outcomes (e.g. adverse drug event-related hospital visits, all-cause readmissions, and emergency department visits), as well as process outcomes, such as the occurrence of medication errors. Therefore, the overarching aim of this thesis was to implement a pharmacist-led medication reconciliation intervention in resource-limited settings. Implementation of medication reconciliation is not an ultimate end but sustainability is an issue, and this should be corroborated by corresponding changes in attitudes, teamwork, communication, culture and leadership. For this purpose, the thesis employed methods from both safety and implementation sciences for successful implementation of the medication reconciliation program. System approaches to patient safety, such as patient safety culture has been explored, and patients’ experiences of medication-related adverse events have been discussed followed by a theoretically robust evidence-based exploration of the barriers to implementation. Patient safety culture in Ethiopian public hospitals has been found lower than the benchmark studies. Importantly, understaffing followed by problems during handoffs and care transitions and punitive response to error were identified as major safety problems. Particularly, handoffs and care transitions were largely affected by the lack of teamwork across units, punitive response to error reporting and managerial inaction for promoting patient safety. In addition to system factors presumed to affect patient safety, other factors such as individual healthcare professionals, patient, and task factors have been identified as challenges to achieve an optimal patient safety in the Ethiopian public hospitals. Resource limitations (e.g. material deficiencies, poor infrastructure) have been indicated as the greatest barriers for patient safety. Patients expressed a range of perceived experiences related to their medication, and a number of strategies required to improve patient safety practices have been suggested. Changes in practice, processes, structure, and systems were believed to help improve patient safety in the Ethiopian health care system. The results of this thesis have demonstrated that hospital pharmacists were very much enthusiastic for their extended roles and were positive towards the future of the profession; however, there were many factors that likely influenced their behaviour in the clinical practice, and these behavioural determinants were predominantly related to ‘Knowledge’, ‘Skills’, ‘Environmental constraints’, ‘Motivation and goals’, ‘Social influences’, and ‘Social/professional role’. While medication errors were highly prevalent at the time of hospital admission, this thesis has also found that pharmacist-led medication reconciliation was able to minimize medication errors significantly. Thus, implementation of medication reconciliation as a medication safety strategy is feasible, and pharmacists may be regarded as key resource personnel for the safe use of medications at the time of hospital admission. However, the sustainability of this service utilization is highly dependent on other behavioural determinants, such as knowledge and skill, competing priorities, and reimbursement for clinical services.
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Dolly, Avril. "Effectiveness of a Medication Administration Protocol on Medication Errors and Inpatient Falls." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/4511.

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Effectiveness of a Medication Administration Protocol on Medication Errors and Inpatient Falls By Avril Dolly MS, University of the West Indies, 2010 BS, University of the West Indies, 2009 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University November 2017 Adverse events such as medication errors and inpatient falls have been reported as the leading cause of safety incidences at the acute care facility in Trinidad and Tobago where this project was conducted. These mishaps aroused concerns about patient safety and led to a quality improvement (QI) initiative at the hospital. The QI project included establishing an evidence-based medication administration protocol in one unit in the hospital and a plan to examine the medication errors and the patient fall rates at the site. While multiple factors were noted to affect the risk for patient falls, this project was recognized as a starting point for a health system QI initiative that was to continue beyond the student's project. The purpose of this project was to evaluate the effectiveness of the medication administration protocol and determine if a corresponding change in the hospital patient fall rates occurred. An outcome impact evaluation model was used to examine both the medication error rate and the patient fall rates 3 months prior to and 3 months after implementation of the QI initiative. Results of a 2-tailed paired t-test show significant reductions in medication errors (p = .039) and patient fall rates (p = .033). While the results are statistically significant, the findings must be interpreted cautiously in view of the variables that could not be considered in this QI initiative. The findings of this project offer a beginning to a much-needed surveillance of patient fall rates and an ongoing promotion of safety through medication administration protocol used. The project offers an opportunity to promote positive social change by raising awareness of the need for a culture of patient safety.
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Books on the topic "Medication errors"

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1944-, Cohen Michael R., and American Pharmacists Association, eds. Medication errors. 2nd ed. Washington, DC: American Pharmacists Association, 2007.

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1944-, Cohen Michael R., and American Pharmacists Association, eds. Medication errors. 2nd ed. Washington, D.C: American Pharmacists Association, 2007.

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1944-, Cohen Michael R., and American Pharmaceutical Association, eds. Medication errors. Washington, D.C: American Pharmaceutical Association, 1999.

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1944-, Cohen Michael R., and American Pharmaceutical Association, eds. Medication errors. Washington, D.C: American Pharmaceutical Association, 1999.

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1944-, Cohen Michael R., and American Pharmaceutical Association, eds. Medication errors. Washington, D.C: American Pharmaceutical Association, 1999.

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Philip, Aspden, and Institute of Medicine (U.S.). Committee on Identifying and Preventing Medication Errors., eds. Preventing medication errors. Washington, DC: National Academies Press, 2007.

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Medcom, inc. Medical errors: Part 3 : Preventing medication errors. Cypress, CA: Medcom Trainex, 2008.

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Wolf, Zane Robinson. Medication errors: The nursing experience. Albany, NY: Delmar Publishers, 1995.

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Karch, Amy Morrison. Lippincott's guide to preventing medication errors. Philadelphia, Pa: Lippincott Williams & Wilkins, 2003.

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A, Porché Robert, ed. Medication use: A systems approach to reducing errors. 2nd ed. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 2008.

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Book chapters on the topic "Medication errors"

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Ng, Kwee Peng. "Medication Errors." In Pharmacological Basis of Acute Care, 251–57. Cham: Springer International Publishing, 2014. http://dx.doi.org/10.1007/978-3-319-10386-0_30.

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Poole, Robert L., and Phuong-Tan Nguyen-Ha. "Medication Errors." In Handbook of Pediatric Cardiovascular Drugs, 597–613. London: Springer London, 2014. http://dx.doi.org/10.1007/978-1-4471-2464-1_19.

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Gluyas, Heather, and Paul Morrison. "Medication Errors." In Patient Safety, 58–79. London: Macmillan Education UK, 2013. http://dx.doi.org/10.1007/978-1-137-31632-5_5.

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Barmecha, Jitendra, Z. Last, and A. Zaman. "Medication Errors." In Health Informatics, 103–13. New York: Productivity Press, 2022. http://dx.doi.org/10.4324/9780429423109-6.

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Catalani, Blas, Steven Boggs, and Ezekiel Tayler. "Perioperative Medication Errors." In Catastrophic Perioperative Complications and Management, 317–26. Cham: Springer International Publishing, 2019. http://dx.doi.org/10.1007/978-3-319-96125-5_22.

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Viamonte, Manuel. "Medication Simulating Urinary Stones." In Errors in Uroradiology, 20–23. Berlin, Heidelberg: Springer Berlin Heidelberg, 1992. http://dx.doi.org/10.1007/978-3-642-86645-6_3.

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Soon, Hooi Cheng, Pierangelo Geppetti, Chiara Lupi, and Boon Phiaw Kho. "Medication Safety." In Textbook of Patient Safety and Clinical Risk Management, 435–53. Cham: Springer International Publishing, 2020. http://dx.doi.org/10.1007/978-3-030-59403-9_31.

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AbstractPharmacotherapy is the most common therapeutic intervention in healthcare to improve health outcomes of patients. However, there are many instances where prescribed medications resulted in patient morbidity and mortality instead. Medication errors can happen at any step of the medication use process, but a substantial burden of medication-related harm is focused primarily on three priority areas of healthcare delivery: transitions of care, polypharmacy and high-risk situations. This chapter highlights prevalence of issues concerning these three core areas and describes common medication errors as well as risk mitigation strategies to improve service delivery. An appreciation of these inherent risks will enable healthcare providers to navigate the pitfalls better and make efforts to ensure medication safety while providing health services.
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Poole, Robert L. "Medication Errors in Children." In Handbook of Pediatric Cardiovascular Drugs, 334–42. London: Springer London, 2008. http://dx.doi.org/10.1007/978-1-84628-953-8_14.

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Niv, Yaron, and Yossi Tal. "Errors in Medication Administration." In Patient Safety and Risk Management in Medicine, 87–93. Cham: Springer Nature Switzerland, 2023. http://dx.doi.org/10.1007/978-3-031-49865-7_7.

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Seidling, Hanna M., and David W. Bates. "The Pharmacoepidemiology of Medication Errors." In Pharmacoepidemiology, 840–51. Oxford, UK: Wiley-Blackwell, 2012. http://dx.doi.org/10.1002/9781119959946.ch45.

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Conference papers on the topic "Medication errors"

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Mustafa, Mariam, Najlaa Al-Qahtani, and Kazeem B. Yusuff. "Types and Severity of Medication-Errors with Automated Systems within Medication-Use Process: Systematic-Review." In Qatar University Annual Research Forum & Exhibition. Qatar University Press, 2021. http://dx.doi.org/10.29117/quarfe.2021.0124.

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Automated systems have been crucial to reducing medication errors and improving patient safety. However, their use has increased medication-errors associated with other factors:socio-technical interactions, automation bias, workarounds, and overrides. This comprehensive systematic review was conducted to identify types and severity of medication-errors associated with the use of automated system in all stages of the medication use process. This provides new perspectives that contribute significantly to global knowledge in the research area. Three databases were searched to include English-language observational and experimental studies(from 2000-2019) focused on types and severity of medication errors. A data-extraction form was developed, and quality was assessed using Hoy-et-al tool. The search yielded 860 articles after deduplication and thirteen were eligible. The bias risk was low for eight studies(62%) and moderate for five(38%). The medication-error types, and prevalence were omitted information(4-61%), wrong dose(4-30%), incorrect medication(1-18%), incorrect administration time(3-18%), and incorrect frequency(0.6%-21%) and occurred in the prescribing(62%) and administration(69%) stage. The error severity assessment used was NCC-MERP-index(46%), other(23%), or not conducted(31%). Omitted information and incorrect dose were the most common errors associated with automated systems in the prescribing and administration stages. However, the error severity and classification was inconclusive due to differences in study design and assessment criteria.
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López Mancha, MT, R. Sánchez del Moral, MB Contreras Rey, E. Rodriguez Molins, MM Romero Alonso, and J. Estaire Gutiérrez. "5PSQ-117 Preventing medication errors regarding high-alert medication." In 24th EAHP Congress, 27th–29th March 2019, Barcelona, Spain. British Medical Journal Publishing Group, 2019. http://dx.doi.org/10.1136/ejhpharm-2019-eahpconf.550.

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"Nurses' Opinions on Medication Errors." In 1st Annual Worldwide Nursing Conference (WNC 2013). Global Science and Technology Forum Pte Ltd, 2013. http://dx.doi.org/10.5176/2315-4330_wnc13.68.

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Lee, Eva K., Deniz Cinalioglu, Hyojung Kang, Niquelle Brown, Lisa Davis, and Gary Frank. "Systems modeling for reducing medication errors." In 2014 IEEE International Conference on Bioinformatics and Biomedicine (BIBM). IEEE, 2014. http://dx.doi.org/10.1109/bibm.2014.6999265.

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Pawluk, Shane, Myriam Jaam, Fatima Mustafa, Moza Al Hail, Wessam El Kassem, Binny Thomas, Hanan Khalifa, and Palli Valapila Abdulrouf. "NICU Medication Errors: Describing the Cause and Nature of Medication Errors in a NICU in Qatar." In Qatar Foundation Annual Research Conference Proceedings. Hamad bin Khalifa University Press (HBKU Press), 2016. http://dx.doi.org/10.5339/qfarc.2016.hbpp2322.

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Naseralallah, Lina Mohammad, Tarteel Ali Hussain, Shane Pawluk, and Myriam Eljaam. "The Impact of Pharmacist Interventions on Reducing Medication Errors in Pediatric Patients: A Systematic Review and Meta-analysis." In Qatar University Annual Research Forum & Exhibition. Qatar University Press, 2020. http://dx.doi.org/10.29117/quarfe.2020.0153.

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Background: Medication errors are avoidable events that could occur at any stage of the medication use process. They are widespread in the healthcare system and are associated with increased risk of morbidity and mortality. Implementing a clinical pharmacist is one strategy that is believed to reduce medication errors in the general population including pediatric patients who are more vulnerable to medication errors due to several contributing factors including the challenges of weight-based dosing. Aim: The aim of this study is to qualitatively and quantitatively evaluate the impact of clinical pharmacist interventions on medication error rates for hospitalized pediatric patients. Methodology: PubMed, Embase, Cochrane and Google Scholar search engines were searched from database inception to February 2019. 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 (CCAT) was used to critically appraise eligible articles. Summary odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Results: A total of 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 showed 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: The most common cause for pharmacist interventions in pediatric patients at hospital settings was inappropriate dosing. Overall, pharmacist interventions are effective at reducing medication error rates.
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Whitney, Paul, Jonathan Young, John Santell, Rodney Hicks, Christian Posse, and Barbara Fecht. "Analysis of Medication Error Reports." In ASME 2004 International Mechanical Engineering Congress and Exposition. ASMEDC, 2004. http://dx.doi.org/10.1115/imece2004-61182.

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In medicine, as in many areas of research and society, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been a corresponding lag in our abilities to analyze this mass of data, and traditional forms and expressions of statistical analysis do not allow researchers and practitioners to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports are approached as data comparisons, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Additionally, the “types” of information objects that can be the objects of data analysis have been extended to include text [8][9]. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. USP conducts an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.
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Crook, J., H. Yorke, and R. Cooper. "G107(P) Reducing paracetamol medication errors in children." In Royal College of Paediatrics and Child Health, Abstracts of the RCPCH Conference–Online, 25 September 2020–13 November 2020. BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health, 2020. http://dx.doi.org/10.1136/archdischild-2020-rcpch.84.

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Bouallegue, Linda, Rafika Thabet, Chabane Mazri, Adrien Defossez, Marie-Hélène Cleostrate, and Elyes Lamine. "Effective Tool for Reporting and Analyzing Medication Errors." In 2023 20th ACS/IEEE International Conference on Computer Systems and Applications (AICCSA). IEEE, 2023. http://dx.doi.org/10.1109/aiccsa59173.2023.10479338.

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Maestro, A., V. Saavedra, and A. Sánchez. "PS-083 Medication review and medication reconciliation: most frequent errors in elderly polymedicated patients." In 22nd EAHP Congress 22–24 March 2017 Cannes, France. British Medical Journal Publishing Group, 2017. http://dx.doi.org/10.1136/ejhpharm-2017-000640.589.

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Reports on the topic "Medication errors"

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Alzahrani, Maha, Ahlam Almaabad, Dalia Sunari, Nada Alqarawi, and Omar Baker. Impact of Simulation on Medication Errors Among Nursing Undergraduates: meta-analysis. INPLASY - International Platform of Registered Systematic Review and Meta-analysis Protocols, February 2023. http://dx.doi.org/10.37766/inplasy2023.2.0029.

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Syrowatka, Ania, Aneesa Motala, Emily Lawson, and Paul Shekelle. Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events. Agency for Healthcare Research and Quality (AHRQ), February 2024. http://dx.doi.org/10.23970/ahrqepc_mhs4mederror.

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Objectives. To assess the evidence on the effects of computerized clinical decision support systems (CDSSs) on the prevention of medication errors and adverse drug events, related implementation outcomes such as rates of medication alert overrides, and unintended consequences of use. We also summarized the literature around the effective implementation of a CDSS. Methods. We followed the rapid review processes of the Agency for Healthcare Research and Quality Evidence-based Practice Center Program. We queried PubMed and the Cochrane Library to locate relevant systematic reviews and primary studies published from 2015 to April 2023, supplemented by a targeted review of the grey literature. We narratively synthesized the evidence and assessed the overall strength of evidence for the outcomes of interest. The protocol for the review has been registered in PROSPERO (CRD42023449710). Findings. Our search yielded 1,335 unique abstracts, of which 33 articles met the target criteria and were included in the review (27 systematic reviews, one overview of reviews, and five primary studies). Twenty reviews (out of 22) reporting on effectiveness were rated “good” or “fair” quality. One primary study included in the narrative synthesis was rated as having a “low” risk of bias. The evidence covered the effects of CDSSs across various healthcare settings and specialties. The type of decision support provided by the CDSSs and outcomes were heterogeneous between studies. Overall, computerized provider order entry with medication-related CDSSs were associated with reduced medication errors (moderate strength of evidence) and prevention of adverse drug events (low strength of evidence). Improved or targeted medication-related CDSSs were associated with reductions of medication errors and adverse drug events (moderate strength of evidence). However, alert override rates were high and varied between studies, and the appropriateness of the overrides was largely influenced by the type of alert. Other unintended consequences included CDSS-related errors, overdependence on alerts, alert fatigue, inappropriate alert overrides, and provider burnout. An additional 48 articles focused on barriers and facilitators of CDSS implementation. 2 Making Healthcare Safer IV – Computerized Clinical Decision Support Conclusions. Overall, CDSSs reduce medication errors and adverse drug events, with moderate- and low-certainty evidence, respectively. However, there were several unintended consequences of CDSS implementation and use. The evidence of benefits and harms was generally reported in different studies with varying contexts, making the net benefit difficult to estimate. Future research should focus on measuring these outcomes and unintended consequences in the same study to generate evidence on both the benefits and harms associated with using a CDSS in the same context.
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Scheirman, Katherine. An Analysis of Medication Errors at the Military Medical Center: Implications for a Systems Approach for Error Reduction. Fort Belvoir, VA: Defense Technical Information Center, April 2001. http://dx.doi.org/10.21236/ada420601.

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Almulihi, Qasem, and Asaad Shujaa. Does Departmental Simulation and Team Training Program Reduce Medical Error and Improve Quality of Patient Care? A Systemic Review. INPLASY - International Platform of Registered Systematic Review and Meta-analysis Protocols, March 2022. http://dx.doi.org/10.37766/inplasy2022.3.0006.

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Review question / Objective: This systematic review aimed to assess whether human simulations or machine stimulations programs would help to prevent medical errors and improve patient safety. Information sources: The search terms “Medical Simulation” [Mesh], “Medication Errors” [Mesh], “Patient safety” [Mesh] were implemented, to be as specific and selective as possible. We searched for all the publications in the Medline database, Web of Science, and Google Scholar from 2000 (when the idea of simulation in healthcare to prevent ME was employed for the first time by the Institute of Medicine (IOM)) to Feb 2022 with only English language-based literature Electronic databases.
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Rosen, Michael, C. Matthew Stewart, Hadi Kharrazi, Ritu Sharma, Montrell Vass, Allen Zhang, and Eric B. Bass. Potential Harms Resulting From Patient-Clinician Real-Time Clinical Encounters Using Video-based Telehealth: A Rapid Evidence Review. Agency for Healthcare Research and Quality (AHRQ), September 2023. http://dx.doi.org/10.23970/ahrqepc_mhs4telehealth.

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Objectives. To review the evidence on harms associated with patient-clinician real time encounters using video-based telehealth and determine the effectiveness of any related patient safety practices (PSPs). PSPs are interventions, strategies, or approaches intended to prevent or mitigate unintended consequences of healthcare delivery and improve patient safety. This review provides information that clinicians and health system leaders need to determine how to minimize harms from increasing real-time use of telehealth. Methods. We followed rapid review processes of the Agency for Healthcare Research and Quality Evidence-based Practice Center Program. We searched PubMed, EMBASE, and Cochrane to identify eligible studies published from 2012 to 2022, supplemented by a search for unpublished evaluations and white papers. Outcomes of interest included: adverse events (any harm to patients due to medical care), other specified harms (i.e., preventable hospitalizations, inappropriate treatment, missed or delayed diagnoses, duplication of services, privacy breaches), and implementation factors for any PSPs. Findings. Our search retrieved 7,155 citations, of which 23 studies (including 6 randomized controlled trials [RCTs]) were eligible for review. Fourteen studies reported on adverse events or unintended effects of telehealth; these studies were conducted in diverse settings, with four studies in behavioral health, two each in rehabilitation, transplant, and Parkinson’s care, and one each in postoperative, termination of pregnancy, community health, and hospital-at-home settings. Adverse events such as death, reoperation, infection, or major complications were infrequent in both telehealth and usual care groups, making it difficult to find statistically significant differences. One RCT found telehealth resulted in fewer medication errors than standard care. Thirteen studies examined preventable hospitalizations or emergency department (ED) visits and reported mixed findings; six of these studies were in postoperative care and two were in urological care. Of the 6 RCTs, 3 showed no difference in risk of hospitalization or ED visits for telehealth compared to usual care, and 3 showed reduced risk for patients receiving telehealth. We found no studies on the effectiveness of PSPs in reducing harms associated with real-time telehealth. Conclusions. Studies have evaluated the frequency and severity of harms associated with real-time video-based telehealth encounters between clinicians and patients, examining a variety of patient safety measures. Telehealth was not inferior to usual care in terms of hospitalizations or ED visits. No studies evaluated a specific PSP. More research is needed to improve understanding of harms associated with real-time use of telehealth and how to prevent or mitigate those harms.
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