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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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Abu-Saksaka, Yousef Ahmed. "Trends and reporting of medication administration errors among nursing students at a higher education institution in the Western Cape." Thesis, Cape Peninsula University of Technology, 2019. http://hdl.handle.net/20.500.11838/3085.
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Thesis (Master of Nursing)--Cape Peninsula University of Technology, 2019One of the most important issues in the provision of healthcare services which threaten the patient's safety, is medication administration errors. These could compromise patient safety and may lead to patient disability or even death, besides the financial cost of these errors. Nurses are responsible for administering medication to numerous patients. They thus are the last defence line against medication administration errors. All student nurses are trained very early in their courses on how to administer medication and all the complications and implications that accompany this important procedure. Although lecturers spend time and effort in teaching nursing students about protocols for safe medication administration, nurses still commit medication administration errors. The aim of the study was to determine awareness and perception of the occurrence and reporting of medication administration errors (MAEs) among nursing students. A descriptive quantitative design was employed. A questionnaire was used to collect data. Responses were collected from 291 nursing students at a higher education institution in the Western Cape, South Africa. Nonprobability proportional quota sampling was used in this study for data collection. Data was analysed with IBM SPSS® software. Data was presented in graphs, percentages, means, and standard deviation, while inferential statistics were conducted. The findings of the study reveal that 85.2% of the respondents were aware of MAE occurrence, but 40.1% were unaware of reporting of these errors. The top and most significant subscale for MAE occurrence was the physician communication subscale, while the top and only significant barrier to reporting these errors was the fear subscale. In conclusion, most of the respondents were aware of MAE occurrence, while more than a third were unaware of the reporting of these errors. The study recommended building non-punitive blame-free reporting systems to emphasise the importance of reporting errors.
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Abranches, Maria Madalena Trindade. "Caracterização dos incidentes na administração de medicamentos num serviço de Medicina Interna." Master's thesis, Escola Nacional de Saúde Pública. Universidade Nova de Lisboa, 2013. http://hdl.handle.net/10362/12296.
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RESUMO - O problema do erro de medicação tem vindo a adquirir uma importância e um
interesse crescentes nos últimos anos. As consequências directas no doente
que condicionam frequentemente o prolongamento do internamento, a
necessidade de utilização adicional de recursos e a diminuição de satisfação
por parte dos doentes, são alguns dos aspectos que importa analisar no
sentido de se aumentar a segurança do doente. No circuito do medicamento
em meio hospitalar estão envolvidos diversos profissionais, estando o
enfermeiro no final da cadeia quando administra a medicação ao doente. Na
bibliografia internacional, são referidas incidências elevadas de eventos
adversos relacionados com o medicamento. Em Portugal, não existem estudos
disponíveis que nos permitam conhecer, nem o tipo de incidentes, nem a
dimensão do problema do erro de medicação.
Efectuamos um estudo descritivo, prospectivo, exploratório, utilizando a técnica
de observação não participante, da administração de medicamentos. Os
objectivos são, por um lado, determinar a frequência de incidentes na
administração de medicação num Serviço de Medicina Interna e, por outro,
caracterizar o tipo de incidentes na administração da medicação e identificar as
suas possíveis causas. A população em estudo foi constituída pelos
enfermeiros que administraram medicamentos aos doentes internados no
Serviço de Medicina Interna seleccionado, durante os meses de junho a agosto
de 2012, sendo observadas 1521 administrações. Foi utilizada uma grelha de
observação, que incluiu os seguintes elementos: doente certo; medicamento
certo; dose certa; hora certa; via certa; técnica de administração correcta
(assépsia); tempo de infusão; monitorização correcta.
Constatou-se que em 43% das doses administradas apresentavam pelo menos
um erro, num total de 764 erros. Não foi observado nenhum erro de doente, de
medicamento, de dose extra, de via, de forma farmacêutica, nem a
administração de medicamento não prescrito. Detectaram-se 0,19% de erros
na preparação, 0,72% de erros de dose, 1,7% erros de omissão, 1,97% de
erros de administração, 13,52% de erros de monitorização, 28,73% de erros de
v
horário. O tempo de infusão da terapêutica parentérica não foi cumprida em
27,69% das oportunidades, tendo sido sempre administrado em tempo inferior
ao preconizado.
Não encontramos relação entre as interrupções durante a administração de
terapêutica e os erros. Pelo contrário constatou-se haver relação entre o
número de doses com erro e o turno em que ocorreram, sendo mais frequentes
no turno da noite.
Constatamos também que aos fins de semana os erros eram mais frequentes e
o risco da ocorrência de um erro na administração de medicação aumenta 1,5
vezes quando o número de enfermeiros é insuficiente.ABSTRACT - The problem of medication error has developed a growing interest and importance in recent years. The direct consequences to the patient, that often affect the prolongation of hospitalization, the need for additional resources and the decrease of satisfaction from the patients are some of the aspects that matter to analyze in order to increase patient safety. In the drugs circuit in a hospital environment, several professionals are involved, and nurses are at the end of the string as far as administering medication to patients is concerned. International bibliography refers high incidences of adverse events related to drugs. In Portugal, there are no available studies that let us know either the type of incidents, or the extent of the medication error issue. We conducted a prospective, descriptive, exploratory survey, using the technique of a non-participant observation of the administration of drugs, using the technique of non-participant observation, administration of medications. We aimed to determine the frequency of in medication administration incidents within the internal medicine department and, on the other hand, to depict the type of incidents which occurred in the administration of medication and identify their possible causes. The population under study was constituted by the nurses who administered medicines to patients hospitalized in the internal medicine department from June to August 2012, and 1521 administrations were observed. The following observation grid was used: right patient; right drug; right dose; right time; right route; right administration technique; asepsis, infusion time and correct monitoring. We found that in 43% of the doses administered there was at least one error, leading to a total of 764 errors. No patient, medication, extra dose, route, pharmaceutical form, administration of not prescribed medication errors were observed. 0.19% were errors in preparation, 0.72% dose errors, 1.7% errors of omission, 1.97% of wrong administration technique, 13.52% monitoring errors, 28.73% of wrong time. The infusion time of parenteral therapy has not been met vii in 27.69% of opportunities, having always been administered ahead of the recommended time. We found no relation between interruptions during the administration of therapy and errors. On the contrary, there is a relation between the number of doses with error and shifts occurred, being more frequent in night shifts. We also noted that errors were more frequent on weekends and that the risk of the occurrence of an error in the administration of medication increases 1.5 times when the number of nurses is scarce.
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Doyle, Mary Davis. "Impact of the Bar Code Medication Administration (BCMA) System on Medication Administration Errors." Diss., Tucson, Arizona : University of Arizona, 2005. http://etd.library.arizona.edu/etd/GetFileServlet?file=file:///data1/pdf/etd/azu%5Fetd%5F1093%5F1%5Fm.pdf&type=application/pdf.
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Chang, Yun Kyung Mark Barbara A. "Testing a theoretical model for severe medication errors." Chapel Hill, N.C. : University of North Carolina at Chapel Hill, 2007. http://dc.lib.unc.edu/u?/etd,1361.
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Thesis (Ph. D.)--University of North Carolina at Chapel Hill, 2007.Title from electronic title page (viewed Apr. 25, 2008). "... in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of Nursing." Discipline: Nursing; Department/School: Nursing.
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Arndt, G. Marianne D. F. "Nurses' medication errors : an interpretive study of experiences." Thesis, University of Edinburgh, 1993. http://hdl.handle.net/1842/19804.
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The meaning that nurses assign to their experiences with medication errors is at the centre of this study. Using discourse analysis within a framework of an interpretive research design, the phenomenon of a not all too uncommon occurrence in nursing practice is examined. The decisions made in such situations have moral implications on a personal, an institutional, and a professional level. Insight into nurses' involvement with medication errors was gained from various data sources. Twelve senior nurses were interviewed and asked about their experiences. In two group discussions, one in Germany, the other in Scotland, ward sisters shared their knowledge and their feelings. Six senior nurses provided written self reports. The participants were asked to talk and write about what helped and what hindered in the situations they have lived through. These interviews, group discussions and self reports provided data on retrospectively recounted experiences. Furthermore, six documents of disciplinary proceedings where the Professional Conduct Committee of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting has dealt with incidents of medication errors supplemented the data. The literature on medication errors provided a fertile backdrop to the study as did the literature on ethics in nursing and on the teaching of ethics in basic and post-basic nurse education. Three key issues are discussed in this study as they evolve from the analysis of the data: The first issue deals with identification and change. Identification, in its various forms, with the image of nursing, with the nursing heirarchy and with the social reality of the health care services, either results in the perpetuation of prevailing practices, or leads to changes in and development of the same. Guilt and reconciliation with human precariousness is addressed as the second issue. Personal failure and the limits of an imperfect world can be come to terms with by regaining professional confidence and by seeing the value basically inherent in nurses' work. The third issue is taken from the areas of teaching and learning.
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Boone, Amanda Carrie. "Methodology for evaluating and reducing medication administration errors." Master's thesis, Mississippi State : Mississippi State University, 2003. http://library.msstate.edu/etd/show.asp?etd=etd-07202003-190139.
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Garrett, Timothy Stuart. "Factors influencing hospital pharmacists reporting of medication errors." Thesis, The University of Sydney, 2016. http://hdl.handle.net/2123/17179.
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Over a decade ago, the Institute of Medicine report “to err is human” focused widespread public and healthcare attention on avoidable patient harm from medication misadventure. Subsequently, the reporting of medication errors has become established as a principal safety initiative to inform strategies to reduce patient harm. However the under-reporting of error compromises this objective, with international estimates suggesting less than 1% of errors are reported. Within Australia, hospitals pharmacists’ are often central to the coordination and implementation of medication safety improvements. As a result, the under-reporting of error by pharmacists’ is likely to be an important omission in our ability to understand and minimise harm. Despite earlier research assessing the attitudes of other health professions, little is known about the factors influencing hospital pharmacists’ reporting of medication error. Our investigations have included the identification of key modifiable barriers to error reporting and the development and implementation of a streamlined web-based error reporting system to mitigate these key disincentives. This reporting tool produced a sustained increase in pharmacist initiated error reports, enabled quantification of the frequency of under-reporting, and a more detailed understanding of the ‘nature’ of errors as perceived by pharmacists’. However, there was wide variation in the use of this streamlined reporting tool even after accounting for a range of factors identified as influencing its use in the workplace. These observations generated further investigation into the contribution of ‘non-traditional’ drivers of variation in practice, such as ‘profiling’ of individual pharmacists’ error reports, and perspectives of workplace ‘safety culture’. 12 In our investigation across a range of public hospitals we observed that hospital pharmacy staff identify with a positive safety culture, with this overall perception influenced by factors including; hospital type, professional group (within pharmacy) and by individual staff affiliation with professional organisations. Participants ‘decisively’ reported a positive culture for ‘identifying the causes of safety incidents’ and ‘incident reporting’ but there remained significant individual variation in reporting behaviours. Upon exploring clinical practice variation further, we identified more complex and diverse individual ‘profiles’ of pharmacists’ medication error reporting than would have been expected from the commonly reported ’overview’ of medication error reports. Taken collectively our investigations support aspects of earlier research from the medical and nursing professions, with traditional workplace factors influencing hospital pharmacists’ reporting of medication error. However, there remains significant variation in clinical practice with is not fully explained by functional aspects of the workplace or its safety culture. These findings provide a rationale for further investigation into non-workplace factors that drive individual behavior, such as; personality ‘traits’, beliefs and values, and their influence on medication error reporting.
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Carruthers, Samanthan Jane. "Latent preconditions of medication administration errors : development of a proactive error-management tool." Thesis, University of Leeds, 2008. http://etheses.whiterose.ac.uk/623/.
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latrogenic injury has been found to occur in around 10% of UK hospital admissions, equating to the harm of approximately 850,000 patients each year. The Department of Health has made repeated calls for NHS research to learn from proactive error management techniques (EMTs) employed within other 'safety-critical' organisations (DOH 2000,2001). The aim of this research was to develop a valid and reliable proactive measure of latent organisational failures (EMT) for use in secondary care using a psychological theory of organisational accidents (Reason, 1990,1997). This theory purports that errors occur as a result of a complex interaction between unsafe acts and systemic organisational weaknesses known as latent failures. This tool will be used to measure and monitor organisational safety in health care and predict the likelihood of medication administration errors (MAEs). Twenty semi-structured interviews were conducted in study I with qualified nurses from several general medical wards and senior managers from Bradford Teaching Hospitals NHS Foundation Trust. Using error vignettes, participants were asked to discuss their perceptions of error causation. Additional qualitative data was collected using clinical observations and incident report review. Using thematic content analysis, ten latent workplace and organisational causes of MAEs were identified, consistent with psychological error theory and error causes evidenced within other safety-critical industries (Reason, 1997; Groeneweg, 1992; Helmreich, 2000; Colla et al., 2005), including team functioning, human resources, culture and training. In ternis of Reason's organisational accident model, combining three pools of independent qualitative data afforded an in-depth exploration of latent error causes at an individual (e. g. unsafe practices), workplace (e. g. team functioning) and organisational level (e. g. use of policies and protocols). Study 2 was conducted to conceptualize identified latent preconditions of MAE within a proactive questionnaire measure; the Organisational Safety Questionnaire (OSQ). Revisiting qualitative data collected in Study 1, this study explored the ways in which each latent organisational failure would manifest at a hospital ward level. One hundred and forty-five safety indicators were generated based on these manifestations of poor safety. Pilot studies to test the face validity of indicators and content analysis to remove less commonly endorsed items led to refinement of the tool to 82 items. Given several notable drawbacks to using NHS formal incident reporting systems as an outcome measure, study 3 was conducted to develop an independent measure of MAEs against which to test the predictive validity of the OSQ (the Drug Round Behaviour questionnaire; DRBQ). This study explored the types of MAEs which can arise in secondary care as a direct or indirect result of the ten latent preconditions. Using the qualitative data obtained in study 1, a 27-item measure of 10 types of MAE (NCC MERP, 1995) was developed which was not reliant upon adverse patient outcomes and intended to also capture near misses. After a pilot study was conducted to improve the construct and face validity of the tool, 13 items which reflected 7 types of MAE had good face validity and were retained for study 4. The final study was conducted to measure the validity and reliability of the OSQ. The 82-item OSQ was administered to qualified and unqualified nurses working in 54 clinical areas across 2 two Bradford hospitals. Analysis revealed that the OSQ was relevant for all qualified nurses working in 34 of these clinical areas. Although developed as 10 subscales representing 10 latent preconditions of MAE, factor analysis yielded only one overall construct from 28 items named 'organisational safety'. However, these items reflected 8 of the 10 proposed predictors of MAE which supports their role in the occurrence of MAE. The 28-item OSQ had good internal consistency and concurrent validity (with an independent 9-item measure of local safety culture; Vogus & Sutcliffe, 2007). While the OSQ was significantly predictive of MAEs measured by the DRBQ, it did not significantly predict formally reported incidents. However, this may have been an artefact of low statistical power which may have been improved with a larger sample. Finally, high safety risk wards said they were less likely to formally report their errors than lower risk wards, yet all wards reported a similar number of incidents. It is proposed that high risk wards report a comparatively smaller percentage of the errors which actually occur compared to lower risk wards due to poorer safety cultures. Interestingly, high safety risk wards admitted making significantly more MAEs on the DRBQ than 'safer' wards suggesting the DRBQ was a more sensitive measure of the actual number of drug administration errors occurring on wards. The Organisational Safety Questionnaire represents a novel, valid and reliable proactive measure of safety which is not currently available in health care which would be useful in measuring the effects on systems interventions and other organisational changes. This thesis has explored and identified latent organisational causes of medication administration errors in secondary care and used methodological techniques used in other safety-critical industries to develop a valid and reliable measure of organisational safety which was successful in predicting medication administration errors. Findings are discussed in terms of the benefit of rigorous qualitative methods in this type of research and the direction of future research which could examine the generaliseability of the tool to other health care professionals or fields of medicine
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Cruickshank, Deborah Claire. "Medication errors in a private hospital closed intensive care unit: a retrospective analysis of process change." Thesis, Nelson Mandela University, 2017. http://hdl.handle.net/10948/15501.
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Healthcare professionals should be concerned about the safety of the patients in their care and the references to patient safety go back as far as the Hippocratic Oath. Study of literature however shows that medical errors are still of concern and the majority of medical errors are medication errors. The aim of the study was to determine whether process changes introduced reduced both the medication prescribing and medication administration errors in the intensive care unit, thereby contributing to an increase in overall patient safety in the intensive care unit. This study retrospectively analysed the effect of the process changes on medication prescribing and administration errors. The research objectives were to: Identify the number and type of prescribing medication errors prior to the implementation of process changes; Identify the number and type of administration medication errors prior to the implementation of process changes; Identify the process changes implemented; o Determine number and type of prescribing medication errors post the implementation of process changes; Determine number and type of administration medication errors post the implementation of process changes; Assess whether the process changes affected the number and type of prescribing medication errors; and o Assess whether the process changes affected the number and type of administration medication errors. In the Phase One (1 November 2013 to 31 January 2014) 534 patient prescription charts for 172 patients were examined. Medication error rates of 57.6% (n=99) of individual patients reviewed and 18.4% of total patient prescription charts reviewed were found. A total of 69 medication prescribing errors were found in Phase One. This equates to an error percentage of 12.9% per patient chart reviewed and 40.1% per patient reviewed. Thirty medication administration errors were identified in Phase One of the study representing 17.4% of patients reviewed and 5.6% of patient prescription charts reviewed. Medication administration errors included both errors of commission, incorrect doses administered, (n=19) and omission, dose missed, (n=11). Process changes were then introduced and the results of these changes analysed in Phase Two (1 April 2014 to 31 December 2014) show an overall reduction in total medication errors with relation to number of patients reviewed from 57.6% in Phase One to 40.5% in Phase Two. In relation to number of prescription charts reviewed the medication error rate in Phase One was 18.4% and in Phase Two 14.4%. Prescribing errors in relation to number of patients reviewed reduced from 40.1% in Phase One to 26.19% in Phase Two. Overall reductions in percentage of errors were seen in all categories of prescribing errors except duplication of therapy which showed a slight increase. Based on the number of patients reviewed a reduction of prescribing errors was seen in the following categories: transcription errors (13.3% to 7.6%), anticoagulant not prescribed when indicated (3.5% to 2.4%), medication safety (5.2% to 2.9%), dose errors (9.3% to 6.6%) and duration of therapy (6.3% to 3.6%). An increase in the duplication of therapy error rate was seen (2.3% to 3.1%). There was also a reduction in administration errors in relation to number of patients reviewed with a total number of errors of 17.4% in Phase One and 15.8% in Phase Two. The number of prescribing errors per medication chart in Phase Two showed a statistically significant reduction (p=.002). A statistically significant reduction was also seen when the number of errors per patient was reviewed (p=.008). The total number of medication administration errors per medication chart showed a significant reduction (p=.042) as did the number of administration errors per patient (p=.003). When combining the total number of medication errors (both prescriobing and administration) a significant reduction was seen for both the number of charts reviewed (p=.001) and the number of patients reviewed (p=.002). These results indicate that the desired goal of increasing patient safety with regard to medication errors has been achieved but ongoing study is required to ensure the sustainability of the process changes.
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Biron, Alain. "Medication administration complexity, work interruptions, and nurses' workload as predictors of medication administration errors." Thesis, McGill University, 2009. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=66704.
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Background: The evidence to date in support of system related factors to account for medication administration errors (MAE) remains scant and inconclusive. Objective: To examine the predictive power of medication administration complexity (component and coordinative), work interruptions and nurses' workload as potential contributing factors to MAE. Design: A prospective correlational design. Setting: A medical patient care unit in a university teaching hospital Sample: A convenience sample of medication administration rounds performed by registered nurses with at least six months of professional experience. Method: Data were collected using direct observation (MAE and work interruptions), self-report measures (subjective workload, nurses' characteristics) and the Medication Administration Complexity (MAC) coding scale (component and coordinative medication complexity). Results: One hundred and two rounds were observed, during which 965 doses were administered and performed by 18 nurses. When wrong administration time errors were included, MAE rate was 28.4% whereas it decreased to 11.1% when wrong time errors were excluded. An interruption during the medication preparation phase (OR 1.596; 1.044 - 2.441) significantly increased the odds of MAE. Two significant interaction effects were found (patient demand for nursing care X overtime and patient demand for nursing care X professional experience). These interactions pointed to more negative effects of overtime and professional experience among nurses who rated the demand for nursing care as above average. Contrary to expectations, coordinative medication administration complexity significantly decreased the odds of MAE (OR 0.558; .322-.967). Including wrong administration time errors changed the cluster of predictors with component medication administration complexity (1.039; 1.016 - 1.062), and nurses' workload (1.221; 1.061 - 1.405) were significant preIntroduction: Les résultats probants relatifs aux facteurs prédictifs des erreurs d'administration des médicaments (EAM) sont peu nombreux et non-concluants.Objectif: Examiner la complexité de l'administration (composante et coordination), les interruptions dans le processus d'administration des médicaments et la charge de travail infirmière subjective comme facteurs prédictifs des EAM.Devis: Un devis corrélationnel prospectif. Milieu: Une unité de médecine dans un centre hospitalier universitaire.Échantillon: Un échantillon de convenance formé de 102 cycles d'administration des médicaments effectués par 18 infirmières avec un minimum de six mois d'expérience professionnelle.Méthode: Les données ont été colligées par observation directe (EAM et interruptions), mesures auto-rapportées (charge de travail subjective, caractéristiques sociodémographiques) ainsi qu'avec l'échelle de la complexité de l'administration médicamenteuse (MAC coding scale).Résultats: 102 observations ont été effectuées au cours desquelles 965 doses ont été administrées par 18 infirmières. En incluant les erreurs de temps d'administration, le taux d'EAM était de 28.4% et diminua à 11.1% lorsque les erreurs de temps d'administration étaient exclues. Une interruption lors de la préparation des médicaments (OR 1.596; 1.044 - 2.441) augmente significativement le risque d'EAM. Deux interactions significatives ont été trouvées (charge de travail X temps supplémentaire et charge de travail X expérience professionnelle). Ces interactions indiquent un effet plus négatif du temps supplémentaire et de l'expérience professionnelle parmi les infirmières ayant une charge de travail supérieure à la moyenne. La complexité de coordination de l'administration de médicament, contrairement aux attentes, diminue significativement les risques d'EAM (OR 0.558; .322-.967). L'inclusion des erreurs de temp
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Henni, Sanaa. "Drug safety decision support model to reduce medication errors." Thesis, City University London, 2009. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.508007.
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The steps involved in the medication process for instance prescribing, dispensing and administering medicines (the "medication process") have always posed some risk to individual patient health. Such "medication errors" were sufficiently common indeveloped countries by the 1960s to warrant formal research. Moreover, the frequency of errors appears not to have declined with the introduction of electronic systems. Several technological approaches has been used to reduce medication errors such as Computerized Physician Order Entry (CPOE), Electronic Patient Record (EPR), drug record system in Denmark and PRESGUID project in France, based on models and theories of errors in healthcare and electronic systems that were drawn from different countries including the UK. Examples of the systems and their evaluation methodology are examined, some of them have already been implemented and others are still being assessed. Consequently, an addition of Clinical Decision Support Systems in current prescribing systems (CDSSs) is necessary. The research considers the development of a medication management model including all the steps of the medication process that involves a clinical decision support system starting from medication prescribing to administration. A necessary preliminary step is to understand the types and contexts of the risks involved. The design of the model was based on the systematic review and meta-analysis outcomes that analysed journal papers, addressing individual themes from definitions, the source of risks and the consequences of errors to comparisons of the medication errors rates between simple prescribing systems and electronic prescribing systems that include CDSSs. The English National Programme For IT is also given prominence as it is a test case for many developed countries and the context for much of my practical work. The new model demonstrates a notable reduction in the frequency of medication errors and the number of patients with Adverse Drug Events. A system dynamics methodology is used to design the model; the first step is the development of Causal Loop Diagrams (CLDs) which are used as an alternative summary of systematic review finding. They show connections between human and technological factors in the medication process and suggest points for support and intervention potentially addressed by the model that includes CDSSs. The second step is the development of system dynamic models of hospital medication flow in order to detect the effect of CDSSs in reducing the rate of patients with medication errors and application of the effect data of CDSSs to one large hospital to identify the consequence of the model with CDSSs on patient’s rate. An evaluation is performed based on focus groups and discussions with clinical pharmacists to demonstrate how the drug safety model can be used. Furthermore an exploitation of pharmacist’s opinions on CLDs and drugsafety model by using a short survey has been presented to improve the consequences of medication errors
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Crowley, Clare. "Investigating intravenous medication preparation errors in hospital clinical areas." Thesis, Cardiff University, 2006. http://orca.cf.ac.uk/54310/.
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Medication is a leading cause of iatrogenic injury throughout the world and this has spawned a rapidly growing body of patient safety research. Lack of standardisation of terminology and research methods, and international variations in healthcare delivery pose problems when interpreting study findings. Within the UK, intravenous medicines prepared in hospital clinical areas have been identified as an area requiring further investigation. A Delphi consensus technique was used to agree a practical error definition for intravenous medicines assembly and preparation in hospital clinical areas, suitable for multiprofessional and international use. This included a framework of inclusion and exclusion criteria which, if adopted for future research, would reduce variability and allow comparison of results. The definition and framework was translated into an observational data collection tool and validated for observational audit in adult and paediatric ward areas. In depth interviews were used to elucidate nurses' views and opinions regarding problems they experienced with intravenous medicines assembly and preparation and how they resolved them. They suggested that priority should be given to minimising interruptions, to the design and provision of a dedicated workspace, and to use of needle-free devices. Appropriate information on intravenous preparation needed to be readily accessible within clinical areas. Standardisation of the taxonomy, standards applied, and competency required for intravenous medicines preparation is needed. Pharmaceutical manufacturers should improve product design to minimise the number and complexity of manipulations required in the workplace. A human factors approach should be used to analyse and plan medicines safety solutions.
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Abduldaeem, Heshem Arafah. "Medication administration errors studied through the mixed-methods lens." Thesis, University of Reading, 2017. http://centaur.reading.ac.uk/77708/.
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Background: In acute-care settings interruptions and workload increase medication administration errors (MAEs). However, MAEs are studied less within mental-health settings, where nursing staff specialise in psychiatric therapeutics and the mode of administration is different; e.g. in psychiatry, patients are not necessarily resting in hospital beds making bedside administration redundant. Existing research in psychiatry suggests MAEs are linked to morning rounds associated with more interruptions, medicines to administer, activities and staff shortages. An audit at the current Trust in 2014 found 13−52% of patients had at least one ‘blank box’ on their drug chart in the preceding seven days on seven mental-health wards necessitating further research. In addition, the Trust spans mental-health (psychiatric) and community wards (some with patient lockers for medication administration), providing an opportunity to examine differences across therapeutic areas and modes of administration. Aim: The study aims to document the rate of MAEs across all inpatient wards at Berkshire Healthcare NHS Foundation Trust (BHFT) psychiatric and community hospital wards, and to investigate the interrelationship between error rates and a range of possible contributing factors as well as the causes behind the MAEs. The aim eventually is to produce recommendations for improving medication administration practices in this type of setting. Methodology: This research used a mixed-method approach by adopting direct observation and semi-structured interviews to examine in depth the rate and causes of MAEs within mental-health and community hospital wards. The researcher visited all 19 wards (9 community hospital wards, 10 psychiatric wards) between July and October 2015 making 65 separate observations in total. Different modes of administration were noted alongside any interruptions and other potential contributing factors. The different modes of administration observed included administering at the patient ‘bedside’ prepared in clinic room (applied to psychiatric wards only), using patient lockers (applied to community hospital wards only) or a drug trolley (applied to community hospital wards only), or via a ‘queue’ where by patients were called to wait outside the clinic room (applied to psychiatric wards only) or a ‘mixed’ mode whereby medicines were given at the bedside or via a queue with the medication prepared in clinic room (applied to psychiatric wards only). In this research, data were entered into SPSS (v21) and analysed descriptively and using the Poisson Regression Model. These findings were discussed in structured interviews with nurses, pharmacists and compared with the researcher’s own notes to describe the causes of errors using the organisational accident causation model as a theoretical framework, which were then triangulated with the quantitative findings. Findings: In total 2237 opportunities for error were observed with 367 MAEs, resulting in a total error rate of 16.4%, 2.4% of which were wrong time errors. When the number of MAEs was separated to procedural errors versus clinical errors, the clinical error rate was 7.7%. The most frequent type of MAE was expiry errors (32% - a type of procedural error) followed by omissions (23% - a type of clinical error). Two modes of administration (‘bedside-prepared in clinic room’ and using ‘bedside-patient locker’) and the non-psychiatric drug group increased the risk of procedural errors. Two administration times (08:00 and 12:00 only), nurse grade (band-5 nurses) and two modes of administration (using ‘bedside-patient locker’ and ‘mixed’) increased the risk of clinical errors. Twelve interviews were completed with eight nurses and four pharmacists. The main active failure category for clinical errors was understood to be ‘lapses’, the main error-producing condition ‘staff workload’ and the main latent condition ‘safety culture and priorities’. The main active failure category for procedural errors was judged to be ‘situational violations’ by the researcher but this was not the view of nurses and pharmacists who painted a more blameless picture of the workplace. Conclusion: The findings show that expiry errors, a major component of procedural errors, take place across both psychiatric and community hospital ward types specifically when medication is given at the patient bedside and is prepared either in the clinic room or given via patient lockers, and that this is likely because of staff workload and/or lack of staff knowledge. The findings also suggest that omissions, a major component of clinical errors, were associated with the mixed mode of administration on psychiatric wards and the 12:00 administration time, and occurred because of a range of reasons that included workload, miscommunication and staff-related factors. Another type of clinical error was the wrong time error which was associated mainly with the patient lockers and the 08:00 administration time, mainly because of the high staff workload. The results suggest that patient lockers are not as safe as perceived because they are implicated in both clinical and procedural errors. In addition, the distinct contributing factors identified in this study can provide a means through which the occurrence of MAEs can be addressed. This mixed-method study makes a novel contribution to knowledge as the first study to compare mental-health and community hospital wards using the direct observation method, researching different modes of administration, and then comparing and contrasting the perceptions of the researcher with nurse and pharmacist opinions for causes of MAEs.
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Mosley, Teresa. "Effectiveness of Guardrails at Reducing Medication Errors inDrug Administration." ScholarWorks, 2018. https://scholarworks.waldenu.edu/dissertations/5755.
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Medication errors during drug administration are an issue in the nursing profession. The errors that occur due to intravenous vein infusions pose threats to patients due to the mode of administration and the risk of occurrence. Strategies such as guardrails have been implemented to reduce the rate of such errors. Despite these guardrails, facilities record mixed results on the effectiveness of infusion pumps in reducing medication errors. The project was designed as a quantitative study to evaluate the effectiveness of guardrails in reducing medication errors at the facility. Data analysis included error reports from the facility before and after the implementation of the guardrails, as well as reports from the software used to monitor the effectiveness of the infusion pumps. Descriptive statistics was used to determine the frequency distribution, percentages, and mean, while t-tests were conducted on the two paired samples. Results showed errors reduced to 7% after the intervention, with a steady decline over the years. The p-value of 0.001 showed that there was a significant difference (α -?¤ 0.05) after the use of guardrails and prior to their usage, indicating that the intervention was effective in reducing the occurrence of medication errors. These findings can be used to promote positive social change at the facility to reduce the occurrence of medication errors during drug administration. The data will be useful to hospital administrators, nursing managers, and nursing staff to encourage compliance in the use of guardrails to help reduce medication errors.
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Gonzales, Kelly. "Safe medication administration." Diss., University of Iowa, 2011. https://ir.uiowa.edu/etd/2877.
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The purpose of this body of work was to address medication errors and safe medication administration practices in relation to practicing nurses and nursing students via several different approaches. These different approaches will be presented as three separate papers but interrelated themes. The specific purpose for each paper and the corresponding research questions were addressed individually in each chapter. The approach used in the first paper was a systematic literature search of medication administration errors and the pediatric population; five themes emerged including the incidence rate of medication administration errors, specific medications involved in medication administration errors and classification of the errors, why medication administration errors occur, medication error reporting, and interventions to reduce medication errors. The approach used in the second paper included a systematic literature review and implementation of a survey, both focusing on the assessment strategies for safe medication administration with practicing nurses and nursing students. Results of both the review and the survey indicated a lack of a comprehensive assessment of safe medication administration. The approach used in the third paper was a research study to conduct a psychometric evaluation of the Safe Medication Administration (SAM) Scale with baccalaureate nursing students. Results provided evidence of the validity and reliability of the SAM Scale. This body of work exposed a gap in nursing and demonstrates the importance of having a standardized assessment of safe medication administration with evidence of validity and reliability to demonstrate competency in this area.
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Carlton, Gaya. "Nurses' perceptions of factors leading to the discovery of potential medication administration errors /." Connect to full text via ProQuest. Limited to UCD Anschutz Medical Campus, 2007.
Find full textAbstract:
Thesis (Ph.D. in Nursing) -- University of Colorado Denver, 2007.Typescript. Includes bibliographical references (leaves 190-197). Free to UCD affiliates. Online version available via ProQuest Digital Dissertations;
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Chen, Y.-F. "Prescribing problems in primary care : focusing on potentially hazardous/contradicted drug combinations." Thesis, University of Nottingham, 2003. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.289070.
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Lim, Rosemary Hwee Mei. "A systems approach to medication safety in care homes: Understanding the medication system, investigating medication errors and identifying the requirements of a safe medication system." Thesis, University of Surrey, 2008. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.493045.
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In the year 2000, the United Kingdom government produced a report called "Organisation With a Memory" in response to the problem of safety in the healthcare sector and committed to reduce the number of serious medication errors. Whilst patient safety research in other healthcare settings such as the primary and secondary care has been under way for the past two decades, patient safety research in care homes has largely been neglected. This thesis presents the findings of the first large-scale epidemiological study of the prevalence and types of medication errors in England that was conducted as part of a wider study.
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McNally, Karen M. "The study of medication errors at a teaching hospital using failure mode and effects analysis." Thesis, Curtin University, 1998. http://hdl.handle.net/20.500.11937/1212.
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The prevalence of medication errors in a major teaching hospital was investigated using several methodologies. The existing ward stock drug distribution system was assessed and a new system designed based on a novel use of failure mode and effects analysis. The existing system was compared to the new unit supply individual patient dispensing system on two wards in terms of medication errors, nursing time, pharmacy time, drug costs, drug security and nurses' opinion. A review of a one year sample of reports submitted under the existing incident reporting scheme was also undertaken. Errors were categorised according to drug group, error type, reason cited for the error, and probability ranking (probability of occurrence, detection and harm). In addition, a "no-blame" medication error reporting scheme was implemented and assessed.Results of the study showed that in the newly designed individual patient dispensing system there was a reduction in nursing time associated with medication activities of approximately 29%, an increase in pharmacy staff time of 64%, a reduction in drug costs and an increase in drug security. Using the disguised observer methodology a reduction in medication errors by 23.5% (including timing errors) and 7.3% (excluding timing errors) was seen on Ward A. Similarly a reduction of 21.1% (including timing errors) and 9.8% (excluding timing errors) was observed on Ward B. Significant support for the individual patient dispensing system was given by nursing staff. Of the errors self-reported under the existing incident/accident reporting scheme the most common type of error was omissions (32.2%), the most common drug group was cardiovascular drugs (19.8%), and the most common cause of the error cited was a faulty check (42.3%). The probability ranking showed that 75% of errors reported scored between 12 and 17 points (from a possible 30 points). In the no-blame error reporting system, an error rate of 2.1% was detected in the existing system and 1.7% in the failure mode analysis designed phase.
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Jafri, Tabassum Fatima. "A stakeholder-led systems approach to medication safety." Thesis, University of Cambridge, 2010. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.608948.
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Miller, Valerie L. "Nurses' attitudes of using a medication error reduction system." Muncie, Ind. : Ball State University, 2009. http://cardinalscholar.bsu.edu/625.
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Dean, Bryony Sandra. "Hospital medication administration errors - their simulation, observation and severity assessment." Thesis, University College London (University of London), 1999. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.322040.
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Williams, Kylie Anne. "Pharmacoepidemiology of nonprescription drugs." Thesis, The University of Sydney, 1998. https://hdl.handle.net/2123/27671.
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Background: In recent years there have been trends towards increased use of. nonprescription medicines and a greater number of products being switched from prescription-only to nonprescription status. When used properly nonprescription products can be safe and effective treatments, however it is not clear that patients do actually use these products in an appropriate
manner. Despite this, there is currently only low level monitoring of nonprescription medicines to assess their use, efficacy and safety under actual clinical conditions of use.
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Johnson, Kathy F. "U. S. Nursing Students' Perceptions of Safe Medication Administration." ScholarWorks, 2016. https://scholarworks.waldenu.edu/dissertations/3228.
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Medication errors are a global concern that may affect patients' hospital stays, patients' lives after discharge, treatment costs, and mortality rates. Understanding medication errors among nursing students may help in preventing these errors as nurses are responsible for safe medication administration. The purpose of this descriptive phenomenological study was to examine upper-level nursing students' understanding of and experiences with medication administration and patient safety. Benner's nursing theory of novice to expert and Dreyfus's model of skill acquisition comprised the conceptual framework. Research questions focused on students' perceptions of safe medication administration. Face-to-face interviews were conducted with 7 upper-level nursing students from a baccalaureate nursing program in the Southeastern U.S. utilizing convenience sampling. Colaizzi's analysis strategy was followed in determining themes and clustering data into categories. Three major themes emerged from the data that included learning curve referring to the rigor of the pharmacology course, gaining self-confidence, and reliance on preceptor. Two sub-themes were identified from the theme learning curve, which included fear of making a mistake causing harm to a patient, and appreciating the complexity of the working environment and the intricacy of the patients. Using study findings, a hybrid pharmacology and medication administration course for nursing students was developed. The course may improve nursing students' confidence in their skills and knowledge and enable them to provide a safer environment for patients. Implications for positive social change include a potential reduction in medication errors and related adverse outcomes experienced by patients and their families and by health care organization.
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Ameer, Ahmed. "Safety measures to reduce medication administration errors in Paediatric Intensive Care Unit." Thesis, University of Hertfordshire, 2015. http://hdl.handle.net/2299/16352.
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Objective: Medicine administration is the last process of the medication cycle. However, errors can happen during this process. Children are at an increased risk from these errors. This has been extensively investigated but evidence is lacking on effective interventions. Therefore, the aim of this research is to propose safety measures to reduce medication administration errors (MAE) in the Paediatric Intensive Care Unit (PICU). Method: The research was carried out over five studies; 1) systematic literature review, 2) national survey of PICU medication error interventions, 3) retrospective analysis of medication error incidents, 4) prospective observation of the administration practice, and 5) survey of PICU healthcare professionals' opinions on MAE contributory factors and safety measures. Results: Hospital MAE in children found in literature accounted for a mean of 50% of all reported medication error reports (n= 12552). It was also identified in a mean of 29% of doses observed (n= 8894). This study found MAE retrospectively in 43% of all medication incidents (n= 412). Additionally, a total of 269 MAEs were observed (32% per dose observation). The characteristics of the interventions used to reduce MAE are diverse but it illustrated that a single approach is not enough. Also for an intervention to be a success it is fundamental to build a safety culture. This is achieved by developing a culture of collaborative learning from errors without assigning blame. Furthermore, MAE contributing factors were found to include; interruptions, inadequate resources, working conditions and no pre-prepared infusions. The following safety measures were proposed to reduce MAE; 1) dose banding, 2) improved lighting conditions, 3) decision support tool with calculation aid, 4) use of pre-prepared infusions, 5) enhance the double-checking process, 6) medicine administration checklist, and 7) an intolerant culture to interruption. Conclusion: This is one of the first comprehensive study of to explore MAE in PICU from different perspectives. The aim and objectives of the research were fulfilled. Future research includes the need to implement the proposed safety measures and evaluate them in practice.
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Kunac, Desirée L., and n/a. "Adverse drug events and medication errors in a paediatric inpatient population." University of Otago. Dunedin School of Medicine, 2005. http://adt.otago.ac.nz./public/adt-NZDU20060707.161220.
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Background. Medication-related patient injuries (adverse drug events, ADEs) are an important problem in all hospitalised populations; however, the potential for injury is reported to be greater in children than adults. Many ADEs are due to error and therefore could be prevented. Data regarding the risk factors (or predictors) for these events in paediatric inpatients is limited. It was hypothesised that "identification of risk factors for ADEs and medication errors in the paediatric inpatient setting will inform likely prevention strategies".
Aims. To determine the frequency, nature and risk factors for ADEs and potential ADEs occurring in a paediatric inpatient population; to assess the vulnerable processes in the neonatal intensive care unit (NICU) medication use process; and to provide recommendations for the targeting of likely prevention strategies.
Setting. A general paediatric ward (PW), postnatal ward (PNW) and NICU of a University- affiliated urban general hospital.
Design. There were two study components: the medEVENT study which involved identification of actual ADEs and potential ADEs over a twelve week period, through prospective review of medical records, medication charts and administration records along with voluntary and solicited staff report and parent interview; and the FMEA study which used a proactive risk assessment technique, Failure Mode and Effect Analysis (FMEA), to rank all potential failures in the NICU medication use process according to risk.
Results. In the MedEVENT study 3160 prescription episodes were reviewed (which represented 520 admissions, 3037 patient-days) and revealed a total of 67 ADEs and 77 potential ADEs. The greatest number of events occurred in NICU with very few events in the PNW. However, paediatric surgical admissions experienced the highest rate of ADEs per 1000 patient-days (80) as compared to medical (65) then NICU admissions (19). Over half of the ADEs were deemed preventable, 38 (57%), with the �more serious� ADEs more likely to be preventable than �not serious� ADEs. The impact on hospital resources was considerable with the cost attributed to extra bed days due to ADEs to be $NZD 50,000. Dosing errors were the most common type of error, particularly when prescribing and administering medications. Antibacterial and narcotic analgesics were commonly implicated, as was the intravenous route of administration. Few events were related to unlicensed use of medications.
For ADEs, the major risk factors when analysed by admission, were greater medication exposure and increasing age; by prescription, were increasing age, oral route and narcotics and antibacterial agents; for paediatric ward admission, were increasing age and increased length of stay; and for NICU admission, no major risk factors emerged. For potential ADEs, the major risk factors when analysed by admission were greater medication exposure; by prescription, were junior prescriber, intravenous route, narcotics and antibacterials; for paediatric ward admission, were junior prescriber and narcotics; and for NICU admission were antibacterials, electrolytes and umbilical venous catheter administration. Neither ADEs nor potential ADEs were associated with unlicensed use of medicines or high alert status drugs.
The FMEA study identified 72 potential failures in the NICU medication use process with 193 associated causes and effects. Multiple failures were possible in the process of �prescribing medication� and in the process of �preparation of medication for administration�. The highest ranking issues were found to occur at the administration stage. Common potential failures related to errors in the dose, timing of administration, infusion pump settings and route of administration.
Conclusions. Analysis of the risk factors of ADEs and potential ADEs found that the most vulnerable processes were when prescribing and when preparing a medicine for administration; especially when involving narcotic and antibacterial agents and for children with greater medication exposure Strategies that selectively target these high risk areas are therefore likely to have the greatest impact on preventing drug-related injuries in hospitalised children.
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Lemer, Claire. "An Examination of the Role of Communication in Paediatric Medication Errors." Thesis, University College London (University of London), 2007. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.498727.
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Taxis, Katja. "The incidence, severity and causes of intravenous medication errors in hospitals." Thesis, University College London (University of London), 2001. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.251691.
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Alsenani, Ahmed. "Medication errors in paediatric patients : the role of the clinical pharmacist." Thesis, University of Nottingham, 2015. http://eprints.nottingham.ac.uk/27946/.
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Six electronic databases were searched and 153 studies which identified the number or the rate of paediatric medication errors were identified; mainly from the US. These studies were compared to identify factors responsible for the great variations seen in reported error rates (Chapter 2). The most important factors were the use of different denominators, different definitions of medication errors, and the use of different methods of data collection. To explore further the reasons for the wide ranges of error rate identified in Chapter 2, the studies that used the same denominators, methods, and error types were compared, yet showed a difference between the highest and lowest error rate of more than 50% (Chapter 3). Factors identified for the variation in error rates included differences in setting, drugs studied, participants, study design details and countries involved. To try to clarify the relationship between the method of data collection and results obtained (Chapter 3), the rates of specific types of medication errors reported by studies using different methods but the same denominator were compared. Conclusions were difficult to draw due to the heterogeneity of the current literature. Prescription errors are probably best studied using chart review and administration errors by direct observation. The relationship between the clarity of definitions and results was investigated in Chapter 3, in terms of how clearly the studies had defined errors and the degree to which the definition(s) used matched each study’s aim. Studies were too heterogeneous and unfortunately could not adequately be compared. Chapter 3 also explores the interventional tools reported. Of all studies, 59 used interventional tools and assessed their benefit. These included dosing supporting tools, electronic prescribing, education, health and safety strategies, clinical pharmacist services and pre-printed forms among others. Most studies reported that their interventions effectively reduced or prevented medication errors, despite in some cases not measuring errors before and after interventions and even in some studies where error rates increased. Chapter 3 also explores the UK studies. Very few studies occurred in the same setting and used both the same methodology and denominators to identify the rate of the same types of medication errors. It was difficult to draw firm conclusions but prescribing and administration errors seem to happen more often in paediatric units in general hospitals than in specialist children’s hospitals. Most studies were of prescribing errors with other types of error rarely studied in the UK. Four studies identified the time of day most associated with errors; three the time of day and days of the week most associated with errors; and one the days of the week most associated with errors (Chapter 3). However, given the diversity of definitions of times of day, shifts, and weekdays, it was impossible to draw conclusions regarding the temporal aspect of medication errors from these studies. A second systematic review was conducted to explore the current literature that examines the role of paediatric clinical pharmacists in reducing the rate of medication errors (Chapter 4). Twenty-five studies published until the end of July 2013 were identified that reported pharmacists’ activities in reducing or preventing medication errors. The most commonly intercepted types of errors were wrong dose, wrong drug and wrong route of administration. The most common types of pharmacists’ contributions were reactive information giving in response to other healthcare professionals’ queries, education of healthcare professionals and cost saving. Based on knowledge gained from the second systematic review, an observational study of the role of paediatric clinical pharmacists was conducted in two NHS Trusts in the UK (Chapter 5). By shadowing pharmacists, they were observed during their day-to-day work and their contributions to health care were documented, as well as the errors that they identified and addressed. Having ultimately shadowed 14 pharmacists over the course of 197 ward visits, clinical pharmacists were found to play an important role in improving the health care services provided to paediatric patients and are effective in averting different types of medication errors. Pharmacists intercepted errors in 8.4% of all prescriptions and the overall contribution rate of all prescriptions was 54.8%. The most common types of errors intercepted by pharmacists were omission errors (27.9%), wrong dose (24%) and illegible prescribing (19.2%). The most common types of contributions were annotating prescriptions with information (e.g. administration instructions) (19.2% of all prescriptions), drug history check (97% of all new patients) and allergy status checked (100% of all new patients). The acceptance rate of pharmacists’ recommendations by doctors was very high (99.5%).
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Obua, Uche Gerard. "Strategies for Reducing Medication Errors in an Outpatient Internal Medicine Clinic." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/6638.
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Medication errors are among the most common causes of unintended harm to patients and have led to many deaths. Some categories of medication errors include; medications administered to the wrong person; medications administered at the wrong time, through the wrong route; administration of the wrong medication and/or dose; and the omission of medications. Guided by the logic model, the just culture model, and the Knowles theory of andragogy, the purpose of the project was to determine if providing information related to evidence-based strategies to reduce medication errors would result in safer medication administration practices and improved patient outcomes A survey was administered to 11 medical and nursing staff at an outpatient internal medical clinic to determine their knowledge about medications errors prior to providing evidence-based information on strategies to reduce medication errors. After the educational session, a survey was conducted to determine staff members' retention of knowledge. A significant increase in the percent of correct responses to the survey from 68% to 100% after the educational session (t = -3.9; p = 0.001)) shows that the educational in-service had a positive outcome in increasing staff members' knowledge about reducing medication errors in an out-patient internal medicine clinic. Improving clinic staff knowledge and behaviors regarding medication administration has the potential to bring about social change by decreasing medication errors, improving patient safety, and improving health outcomes.
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Tingling, Louis Gilbert. "Root Cause of Medication Errors In a Pediatric Intensive Care Unit." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7201.
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Five to 27% of all pediatric medication orders lead to errors and play a significant role in the morbidity and mortality of the pediatric patients admitted to hospitals. The practice problem explored the high rate of medication errors in the pediatric intensive care unit (PICU) of the project site, where the population is particularly vulnerable due to their acute illnesses. The purpose of this project was to analyze the root causes of all cases of medication error in this hospital's PICU during the last 2 years. The literature review was used to categorize secondary data extracted from the hospital's quality assurance database. An analysis of the 41 total medication errors showed that 49% of the medication errors made in the PICU were due to the nurse administering the incorrect dose of medication. Most (60%) occurred on the day shift when the unit was busy and the patient's medication orders were constantly being changed. Missed doses' mostly due to oversight and ineffective follow-up by clinical staff, pharmacy, and providers accounted for 27% of the medication errors. There were instances in which the physician and the pharmacy did not properly order and verify a medication. The summary of the root cause analysis and recommendations from the literature for improved clinical practice will be presented through the hospital's quality assurance structure. Recommendations include implementing computerized physician order entry, regular education of staff, involvement of the pharmacist in new medication orders, updated nursing protocols, and support systems for decision making. The implications of this project for positive social change include the impact of improved practices on decreasing medication errors and improving health outcomes in the PICU population.
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Felix, Francisco, and Nathaniel Mesa. "Identifying the Types and Frequencies of Medication Dispensing Errors in Community Pharmacies and their Potential Causation." The University of Arizona, 2017. http://hdl.handle.net/10150/624174.
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Class of 2017 AbstractObjectives: To explore the available literature for information on the types of medication errors committed in community pharmacies, the rate of occurrence, and potential causation of those errors. Methods: A literature search was conducted in PubMed for articles dating from 1995-present concerning medication errors committed in community pharmacies. A total of eight studies were used in the evaluation. Results: Error types identified in the literature include content errors, labeling errors, near errors, clinically significant errors, and any other deviation from the prescriber's original order. Each study had its own individual error rate. Combining all studies reviewed, the overall average error rate was 2.2% (516 errors out of 23,455 prescriptions total). Proposed causation of medication dispensing errors include low lighting levels, high sound levels, the use of manual prescription inspection alone, pharmacy design, problems with efficiency, the use of drive through pick up windows, errors in communication, high prescription volume, high pharmacist workload, inadequate pharmacy staffing, and the use of dispensing software programs that provide alerts and clinical information. Conclusions: The available literature proposes that medication-dispensing errors in community pharmacies continue to be a frequent issue. Error types include content, labeling, clinically significant, near errors, and any other deviation from the prescriber's original order. Of the observed errors, labeling was most frequent. The data indicated low lighting, amplified noise, and sociotechnical factors could contribute to error frequency. Future studies are required to focus on other potential causes of dispensing errors and how to minimize rate of occurrence.
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Gray, Michael David Thomas Robert Evans. "Data mining medication administration incident data to identify opportunities for improving patient safety." Auburn, Ala., 2009. http://hdl.handle.net/10415/1998.
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Ahmed, Idil. "Medication Errors Involving Geriatric Patients, Perceived Causes and Reporting Behaviours by Nurses." Thesis, Université d'Ottawa / University of Ottawa, 2016. http://hdl.handle.net/10393/34305.
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Background: Drug administration is a main duty of a nurse’s clinical role. It involves great risk
in patients’ lives and can potentially cause great harm. Despite many safeguards, preventable
medication errors still occur. The aim of this descriptive quantitative study is to explore geriatric
nurses’ perceptions of medication errors, perceived causes and their reporting behaviours.
Methods: A self- report standardized survey was used to collect data from a purpose sample of
nurses (n=17) working on geriatric wards at the Montfort hospital located in the province of
Ontario. Data entry and analysis were done by using Statistical Package for the Social Sciences
(SPSS) version 12 and presented using frequencies, number and percentage.
Results: The most frequently identified causes of medication errors were failure to check
patient’s name band with the patient’s medication administration record (MAR), nurses'
tiredness, illegible physician handwriting, and nurses’ miscalculations of medication doses. In
general, nurses were usually sure of constitutes a medication error and when to report it.
However, only 30% of errors were perceived by nurses to be reported to the nurse manager.
More than half (64.7%) of participants perceived that, some errors are not reported because
nurses are afraid of the reaction they will receive from the nurse manager and the majority of
them will notify the physician than to complete an incident report.
Conclusion: Recognizing a medication error is the first step to reduce report and eliminate them,
especially in acute care settings. Finding suggests that nurses need more educational reenforcement
as to various issues related to medication errors, particularly defining and reporting
these errors. Furthermore, the introduction of hospital policies and the development of structured
protocols on drug administration may decrease medication errors. The hospital administration
system needs to stress the importance of reporting errors and adopt a non-punitive approach to
safeguard patient safety.
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Mazur, Lukasz Maciej. "The study of errors, expectations and skills for medication delivery systems improvement." Thesis, Montana State University, 2008. http://etd.lib.montana.edu/etd/2008/mazur/MazurL0508.pdf.
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Medication errors occurring in hospitals are a growing national concern. The enormous gaps in knowledge related to medication errors are often seen as major reasons for increased patient safety risks and increased waste in the hospital setting. However, little research effort in industrial and management engineering has been devoted specifically to medication delivery systems to improve or optimize their operations in terms of patient safety and systems efficiency and productivity. As a result, the current literature does not offer integrated solutions to overcome the workflow and management difficulties with medication delivery. Therefore, a better understanding of workflow and management sources of medication errors is needed to help support decisions about investing in strategies to reduce medication errors. Using qualitative and quantitative research methods the work reported in this dissertation makes several contributions to the existing body of knowledge. First, using healthcare professionals' perceptions of medication delivery system, a set of simple and logical workflow design rules are proposed. If properly implemented, the proposed rules are capable of eliminating the unnecessary variations in the process of medication delivery which cause medication errors and waste. Second, a theoretical model of 'expectations' for effective management of medication error reporting, analysis and improvement is provided. The practical implication of this theoretical model extends to effective management strategies that can increase feelings of competence and help create a culture that values improvement efforts. Third, eight propositions for effective use of a systems engineering method (in this research the "Map-to-Improve" (M2I) method) for medication delivery improvement are offered. Finally, a set of skills needed for future healthcare professionals to effectively use systems engineering methods is provided. The proposed insights into these areas can result in improved pedagogy for professional development of healthcare professionals. The practical implication extends to the development of better methods for healthcare systems analysis. In summary, the author of this research work hopes that the findings and discussions will help healthcare organizations to achieve satisfactory improvement in medication delivery.
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Montague, Diane M. "Medication errors in hospitals : to ERR is human, to report is divine." Honors in the Major Thesis, University of Central Florida, 2001. http://digital.library.ucf.edu/cdm/ref/collection/ETH/id/235.
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This item is only available in print in the UCF Libraries. If this is your Honors Thesis, you can help us make it available online for use by researchers around the world by following the instructions on the distribution consent form at http://library.ucf.edu/Systems/DigitalInitiatives/DigitalCollections/InternetDistributionConsentAgreementForm.pdf You may also contact the project coordinator, Kerri Bottorff, at kerri.bottorff@ucf.edu for more information.Bachelors
Health and Public Affairs
Legal Studies
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McNally, Karen M. "The study of medication errors at a teaching hospital using failure mode and effects analysis." Curtin University of Technology, School of Pharmacy, 1998. http://espace.library.curtin.edu.au:80/R/?func=dbin-jump-full&object_id=12102.
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The prevalence of medication errors in a major teaching hospital was investigated using several methodologies. The existing ward stock drug distribution system was assessed and a new system designed based on a novel use of failure mode and effects analysis. The existing system was compared to the new unit supply individual patient dispensing system on two wards in terms of medication errors, nursing time, pharmacy time, drug costs, drug security and nurses' opinion. A review of a one year sample of reports submitted under the existing incident reporting scheme was also undertaken. Errors were categorised according to drug group, error type, reason cited for the error, and probability ranking (probability of occurrence, detection and harm). In addition, a "no-blame" medication error reporting scheme was implemented and assessed.Results of the study showed that in the newly designed individual patient dispensing system there was a reduction in nursing time associated with medication activities of approximately 29%, an increase in pharmacy staff time of 64%, a reduction in drug costs and an increase in drug security. Using the disguised observer methodology a reduction in medication errors by 23.5% (including timing errors) and 7.3% (excluding timing errors) was seen on Ward A. Similarly a reduction of 21.1% (including timing errors) and 9.8% (excluding timing errors) was observed on Ward B. Significant support for the individual patient dispensing system was given by nursing staff. Of the errors self-reported under the existing incident/accident reporting scheme the most common type of error was omissions (32.2%), the most common drug group was cardiovascular drugs (19.8%), and the most common cause of the error cited was a faulty check (42.3%). The probability ranking showed that 75% of errors reported scored between 12 and 17 points (from a possible 30 points). In ++the no-blame error reporting system, an error rate of 2.1% was detected in the existing system and 1.7% in the failure mode analysis designed phase.
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Dalmolin, Gabriella Rejane dos Santos. "Erros de medicação no ambiente hospitalar : uma abordagem através da bioética complexa." reponame:Biblioteca Digital de Teses e Dissertações da UFRGS, 2012. http://hdl.handle.net/10183/60813.
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Introdução: Erros envolvendo medicamentos ocorrem frequentemente em hospitais, possuem natureza multidisciplinar e podem ocorrer nas várias etapas da terapia medicamentosa. Objetivos: Avaliar a seriedade, o tipo e os medicamentos envolvidos nos erros de medicação notificados no Hospital de Clínicas de Porto Alegre. Verificar a qualidade do conteúdo das notificações obtidas pelos instrumentos de notificação disponíveis na Instituição. Classificar os erros através de árvore de decisão para atos inseguros, quando aplicável. Métodos: Foram analisadas notificações comunicadas por escrito em 2010-2011. A amostra foi composta por 165 notificações. Os erros identificados foram classificados de acordo com a seriedade, o tipo e a classe farmacológica. Foram analisadas 114 notificações, nas quais um erro de fato ocorreu, quanto à qualidade das informações contidas. A qualidade foi avaliada considerando-se os itens preconizados pela ANVISA. A árvore de decisão para atos inseguros foi utilizada para verificar fatores individuais ou sistêmicos nos erros notificados. Resultados: Apesar de um maior número de notificações comunicadas em 2011, comparativamente a 2010, não houve uma alteração significativa no perfil de seriedade destes eventos. Os erros ocorridos ao longo do processo geraram, em algumas situações, novos erros de medicação associados. O tipo de erro mais frequente foi o de prescrição (40%). Nas 114 notificações de erro foram citados 122 medicamentos. O conteúdo das notificações demonstrou que todos itens preconizados pela ANVISA estavam presentes, mas informados em frequências diferentes. A caracterização dos atos inseguros foi realizada com as 30 notificações comunicadas por ficha padronizada pela Instituição. Constatou-se que 19 ações se enquadram como possíveis violações por imprudência e 9 ações, como erros induzidos pelo sistema. Conclusão: A segurança dos pacientes depende do processo de comunicação, do registro adequado das informações e do monitoramento propriamente dito no uso dos medicamentos.Background: Errors involving medications occur frequently in hospitals, they are multidisciplinary and can occur at many stages of drug therapy. Objectives: Assess the seriousness, the type and drugs involved in medication errors reported on Hospital de Clínicas de Porto Alegre. Checking the quality of the reports obtained by the notification tools available in the institution. Classifying errors by decision tree for unsafe acts, when applicable. Methods: The sample consisted of 165 notifications. The errors identified were classified according to the seriousness, type and pharmacological class. We analyzed 114 notifications, in which an error has occurred, as to the quality of information. The quality was evaluated considering the items recommended by ANVISA. The decision tree for unsafe acts was used to identify individual or systemic factors in the errors reported. Results: Although a greater number of notifications reported in 2011 compared to 2010, there was no significant change in the profile of seriousness of these events. The errors occurred during the process, have in some situations, new medication errors associated with it. The most common type of error is the prescription error (40%). In 114 reports, 122 medication errors were cited. The content of notifications showed that all items recommended by ANVISA were present, but reported at different frequencies. The characterization of unsafe acts were performed with 30 notifications from a standardized form by the institution. We verified that 19 actions were classified as potential violations recklessness and 9 actions, such as errors induced by the system. Conclusion: Patient safety depends on the communication process, the suitable recording of information and monitoring the appropiate use of medicines.
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Monzani, Aline Aparecida Silva. ""A ponta do iceberg: o método de notificação de erros de medicação em um hospital geral privado no município de Campinas-SP"." Universidade de São Paulo, 2006. http://www.teses.usp.br/teses/disponiveis/22/22132/tde-16082006-223547/.
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Observações realizadas na prática de enfermagem indicam que erros na administração de medicamentos são passíveis de ocorrer e, de fato ocorrem. Como causas têm-se, entre outras, a sobrecarga de trabalho da equipe de enfermagem, o conhecimento insuficiente sobre os medicamentos, número elevado de medicamentos lançados no mercado anualmente, a qualidade das prescrições médicas, enfim, falhas no sistema de medicação de uma maneira geral. Uma forma de diminuir os erros de medicação é a sua notificação, o que permite o estudo das suas causas, podendo então preveni-los. Desta forma, este estudo foi desenvolvido com os seguintes objetivos: descrever e analisar os erros de medicação notificados em um Hospital Geral Privado no município de Campinas-SP e o relatório de ocorrências utilizado por esta instituição e, propor um relatório de erros de medicação. Trata-se de um estudo descritivo exploratório, retrospectivo e longitudinal, que foi dividido em duas fases: na primeira foi realizada a análise dos erros de medicação ocorridos e na segunda fase a entrevista com os profissionais. Foram analisados 39 erros de medicação no período de janeiro de 1999 a dezembro de 2005, onde 13 (33,3%) estavam relacionados à administração de medicamento não prescrito e 10 (25,6%) a erros de omissão. A entrevista foi realizada com 64 profissionais e destes, 45 (70,3%) não conhecem o relatório de ocorrências utilizado na instituição. Dos 19 (29,7%) profissionais que o conhecem, todos o consideram adequado para o relato dos erros de medicação, além disso, 30 (46,9%) profissionais acreditam que os erros de medicação são notificados na instituição. Entretanto com o número de erros notificados em um período de 6 anos, ficou claro que a subnotificação é uma realidade vivenciada pela instituição. Desta forma, foi proposto um modelo de relatório de notificação de erros, estruturado de acordo com dados da literatura e de órgãos e instituições governamentais. Conclui-se que os profissionais da instituição não têm conhecimento da situação atual vivenciada pela instituição com relação aos erros de medicação e à subnotificação destes erros. Além disso, o relatório de ocorrências da instituição está incompleto, necessita ser revisado e divulgado dentro da instituição a fim de envolver toda a equipe multidisciplinar, aumentar o número de erros relatados e desta forma, implementar estratégias de ação para evitar novos erros e, consequentemente, aumentar a segurança dos pacientes e a qualidade da assistência prestada.Observations made within nursing practice indicate that errors in the ministering of medicaments are liable to occur and in fact they do. As causes, amongst others, there is the workload of the nursing team, the insufficient knowledge of medicaments, the large number of medicaments launched in the market each year, the quality of medical prescriptions, ultimately, failure in the medication system in a general manner. One way to lower medication errors is to notify them, which leads to the study of the causes and enables their prevention. In this way, this study was developed with the following objectives: to describe and analyze the notified medication errors in a General Private Hospital in the city of Campinas-SP and the incident report used by the institution and propose a report on medication errors. This deals with a longitudinal and retrospective study which is exploratory, descriptive and divided into two fases: in the first an analysis of the medication errors was performed and in the second an interview with the professionals. In the period of January 1999 to December 2005, 39 medication errors were analyzed, whereby 13 (33,3%) were related to the ministering of non-prescribed medication and 10 (25,6%) were related to errors of omission. The interview was performed with 64 professionals and of these, 45 (70,3%) did not know about the incident report used at the institution. Of the 19 (29,7%) professional who did know about the report, all considered it to be adequate for reporting medication errors. In addition to this, 30 (46,9%) professionals believe that medication errors are notified to the institution. However with the low number of errors notified in the period of 6 years, it is clear that the true picture at the institution is quite different. Due to this, a model of Error Notification Report, that was structured according to data from literature and from governmental organs and institutions, was proposed. It is concluded that the professionals of this institution have no knowledge of the present situation, which occurs inside their institution. Also, the institutions incident report is incomplete, needs to be revised and disclosed within the institution in order to involve the entire multi-disciplinary team, increase the number of errors reported, thereby implementing action strategies to avoid new errors and consequently increase the safety of patients and the quality of the rendered assistance.
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Abood, Ekhlas. "Identifying Medication History Errors at Iraqi Hospital Admissions Using The Swedish-LIMM model." Thesis, Uppsala universitet, Institutionen för farmaceutisk biovetenskap, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-350150.
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Abstract Background and Objective: An accurate medication history list is an integral part of the patient assessment at hospital admission. The objective of the study was to describe the frequency, type, and predictors of unintentional medication errors and to evaluate the quality of the clinical pharmacy services focusing on the acceptance of the recommendations made by the clinical pharmacist. Setting and methods: A descriptive study was conducted at two internal medicine wards at Baghdad Teaching Hospital in Iraq using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. The study pharmacist conducted medication interviews for patients shortly after hospital admission to obtain the most accurate pre-admission medication history list. This list was compared with the medication list in the patient’s medical chart. Intended addition, withdrawal of a drug, or changes to the dose/ dosage form in the patient’s medical list was considered as medication discrepancies. However, medication discrepancies were considered as medication errors based on no identified clinical reason. Results: A total of 114 patients were included in this study. Over two-thirds of the study patients (73.7%) experienced 215 medication errors identified by a clinical pharmacist conducting medication reconciliation. Most errors were omission (87.9%). Cardiovascular agents followed by NSAID were commonly in error (53%) and (10.2%) respectively. In a logistic regression model, age (odds ratio (OR), 1.055: 95% confidence interval (CI) 1.010 - 1.102), female gender (OR, 3.468: 95% CI 1.232- 9.761) and number of medications at admission (OR, 0.810: 95% CI 0.681-0.963) were predictors for medication history errors at admission. Conclusions: Medication errors at the time of hospital admission are common and undetected. A structured approach like the LIMM-based medication reconciliation at Iraqi hospital is needed to detect these errors.