Medication Error Essay Example
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Article 1: Qualitative study
Reported medication events in a paediatric emergency research network: Sharing to improve patient safety by Kathy N Shaw, Kathleen A Lillis, Richard M Ruddy, Prashant V Mahajan, Richard Lichenstein, Cody S Olsen, James M Chamberlain. 2012
This research paper, aimed to explore incidences of pediatric medication events (MEs) in 18 children’s emergency departments (EDs) using voluntary incidence reporting (IR). This research was performed within a pediatric research network. Hence, the paper aimed to create a standardized manner of analyzing and sharing MEs and describe pediatric MEs that have been reported within a national research network (Shaw et al 2012, p.1). Consequently, this information presents a unique opportunity for hospitals to benefit, since it highlights the severity and types of medication error, types of medications involved, as well as systems and human factors that contribute to medication errors.
The sample included eighteen emergency departments that are registered within the PECARN (pediatric emergency care applied research network) (Shaw et al 2012, p. 2). Out of the 18 hospitals that were sampled, 10 of them are freestanding children’s health institutions.
Deidentified, confidential IRs was collected by investigators who proceeded to categorize the MEs. Responses that appeared discordant were resolved through discussion and consensus. The study was carried out in a year between July 2007 and June 2008. The participants sent deidentfied IRs related to emergency departments. These reports were submitted to the PECARN. PECARN collected this information through their data coordinating center. A qualitative study of the incidence reports was carried out. The qualitative study applied in each case was defined in the reporting mechanisms and scope of the standard hospital policy in each of the health institutions (Shaw et al 2012, p. 2). Information from the IRs was processed under the guidance of a comprehensive manual of operation for the IR reviews that included definitions, processes and taxonomy. Since the study was focused on pediatric patients, the exclusion criterion was individuals who were over 18 years of age. In the case of discordant responses, they were discussed over monthly telephone conferences until consensus was reached.
Three thousand one hundred and six incidence reports were submitted, and out of these 19% (597) of them involved medical errors. The availability or presence of pharmacists at the emergency departments had no correlation with higher rates of IRs. All the MEs discovered were as a result of medical error except for 36 of them that were due to adverse reactions and new allergies. Common MEs included incorrect medication, missing or delayed doses and wrong dose (Shaw et al 2012, p. 3). Errors of wrong medication were related to incorrect entries such as entering kilograms instead of pounds, calculation errors, temperature recorded as weight and duplication of errors. Medications most common in these errors include intravenous fluids, analgesics, oral corticosteroids, medications for respiratory conditions and anti-ineffective agents. None of the errors resulted in permanent disability or deaths. Over 50% of the errors had no effect on the patient. Cases of patient harm were most common in cases of allergies, missed and delayed doses, and adverse reactions (Shaw et al 2012, p. 2). The qualitative study shed light on the human factors involved in the incidences. One of the most significant human factors was the failure to comply with established rules and procedures for drug administration. Other issues included failures in communication, calculation and judgment errors and calculation issues. Eleven percent of reports had system issues as the cause of errors included information systems and equipment problems.
Qualitative analysis provided useful information as regards to precursor events, and contextual issues that result in contributing human factors of medication errors. This information can be used in the redesigning of safety protocols and processes, in order to improve key procedures that would improve behavior to enhance future safety. Incidence reports have been used in other contexts so as to improve their systems (Shaw et al 2012, p. 4). However, one of the major obstacles in hospitals being unwilling to share data concerning incidences of medication error, one of the most efficient ways that emergency departments can ensure the safety of their patients enhanced, is to view incidence reporting as a strategy of risk management. This reporting could be kept internal to deal with fears of liability issues that plague most healthcare institutions. Failure to determine the correct dosage is the most common ME, and it is related to errors in calculation.
Reporting medical errors using the IR system has yielded valuable outcome in terms of potential human factors and medication categories. The occurrence of errors that resulted in harm was reported infrequently (Shaw et al 2012, p. 4). Analysis in this study revealed latent issues in the system that suggests areas that should be focused on in future interventions. The success of future interventions is dependent on accurate data that can shed light on the reduction of pediatric medication errors.
Article 2: Quantitative study
Prescribing medication errors in hospitalized patients: A prospective study By Vesna et al, 2005
The study sought to determine the rate of medication errors and highlight ways of preventing them from occurring. The paper aspired to identify the different types of medication errors that occur in health institutions. Specifically, the paper aimed to identify particular prescribing errors so as to improve the system of drug distribution. The current system is the floor stock system which the paper aimed to change to the Unit Drug Distribution System (UDDS). This change will ensure that clinical pharmacists are directly involved in controlling prescription therapy so that they can promptly identify prescription errors, eliminate and prevent them from reaching patients
The sample included the clinic of internal medicine where 4951 prescriptions were collected over 25 weeks. The occurrence of errors in medication was analyzed in this prospective study using quantitative methodologies. The patient records were selected randomly which resulted in 1303 patient between the ages of 20 and 78. Of this sample, 33% were female while 67% were male.
Following the collection of 4951 prescriptions over the period of 25 weeks, medical records were analyzed, and this was used to compare prescription with AHFS first web version 2 and Croatian drug data. The selection and evaluation of patent records happened using a blind process that involved a pharmacist and a physician. The patients in the sample were hospitalized for 10.4 days as an average with an average of 3.8 drugs prescribed for each of them. Data used in monitoring medication errors was adopted from the database of drugs AHFS first web Version 2. The listed prescribed therapy is according to generic names, which allows one to carry out rapid screening to identify possible significant interactions that are categorized into severe interaction, contraindicated and moderate interaction.
There were 168 cases (3.4%) of incorrect doses. Out of the incorrectly prescribed drugs, 29% of them were overdoses while 71% involved underdosing. Half of the errors related to dosage issues are related to antibiotics, which are the most commonly underdosed. Incorrect dosing intervals occurred in 134 cases (2.7%). In 14% of the cases, the dosing interval was not recorded in the first place. Simultaneous drug prescription often occurred in calcium channel blockers such as verapamil and nifedipine. Duplication of steroid anti-inflammatory drugs such as NSAIDs was also frequent.
Results of the study served to concur with literature that indicates the significance of systematic control on the reduction of medication errors as related to prescribed therapy. Since the study focused on Croatia, it was also a milestone in medical research. The study helped rid the health industry of the assumption that medication error is an inevitable byproduct of patient care. Before this research, little had been done to add up the numbers of medication errors and categorize them. Systematic control over prescriptions can be effected using UDDS implementation in hospitals since the system us widely used and is easily available in healthcare institutions in Croatia. Computerized prescribing should be implemented with UDDS in order to enable review, which raises the chances of early intervention. In addition, it also offers an opportunity to engage in teamwork, which is essential in the development and maintenance of an effective system of medication error prevention.
The realistic differences between theoretically possible incidences and clinically relevant drug interactions are large. Hence, there is a high necessity to develop a critical attitude when dealing with the evaluation of information in drug interactions. Using databases can result in rapid error identification, and the development of relevant interventions. The rapid screening enabled by databases also facilitates prevention in the daily practices of clinical pharmacists. UDDs implementation in the hospital is essential to the systematic control of prescription.
Article 3: Mixed Methods (qualitative and quantitative)
Quantitative and qualitative analysis of medication errors: The New York experience by Elizabeth Duthie, Barbara Favreau, Angelo Ruperto, Janet Mannion, Ellen Flink and Ruth Leslie, 2005
The New York state Department of Health (NYSDOH) carried out this study in an effort to expand its mandatory occurrence reporting and tracking system so that it includes the reporting of medication errors (Duthie et al 2005, p. 131). The errors included were those that had an outcome of patient harm. Using this data, the study aimed to use it in carrying out root cause analysis for future prevention of medication errors.
The sample included reports submitted to the NYSDOH by 249 hospitals. Reports of 24 months were sampled from hospitals in New York State through electronic means (Duthie et al 2005, 133).
Qualitative and quantitative analysis was carried out by a panel of 11 professionals. The panel included individuals from multidisciplinary fields. In order to assess the occurrences of medication error, the taxonomy of human error developed using the work of James Reason was used (Duthie et al 2005, p. 133). The submitted root cause analysis were only if there they were represented in each of the professional disciplines including NYSDOH administration, nursing, pharmacy and medicine .108 Reports were reviewed, and 53 of them were submitted with the root cause analysis. Following the extraction of data from the reports, it was then exported to Microsoft Access where cases without medication error code were extracted. Following this, a quantitative analysis was performed, in order to examine the process within which the error occurred. The processes include transcribing, prescribing, administering, monitoring and dispensing. The qualitative analysis also revealed the disciplines involved in medication errors, the medication classes and specific medications involved, as well as the breakdown by patient outcome that has been witnessed. Qualitative data relied on the panel’s expertise, in addition to current literature.
Data analysis found that the most common error was wrong dosage, which is closely followed by wrong drug. Administration processes were responsible for a larger percentage of the medication errors. This finding is not unexpected since most of the errors are related to errors of commission (Duthie et al 2005, 134). Mistaking oral orders accounts for about 15% of errors, nurses were involved 77% of the time, physicians 58% and pharmacists 18% of the time. Older patients above the age of 65 had lower rates of errors compared to those between the ages of 18 and 65. The prevalence in patients below the age of 18 was at 14% (Duthie et al 2005, p. 135). Narcotic analgesic and cardiovascular drugs are the most prevalent at 14% while CNS medications and antibiotics are at 11 and 8 percent respectively.
Finding that nurses are the most involved in errors is not surprising, since they are involved in administering more than other professionals in the healthcare industry administer. In addition, they are the final link that individuals have to the medications. In the absence of technology, there is little to no chance that an error will be intercepted (Duthie et al 2005, p. 137). However, the presence of technology helps in the identification and prevention of medication errors. Although there are fewer incidences of errors in older patients above the age of 65, they also have a higher rate of injuries and harm owing to more drugs being used for the elderly and resilience in younger individuals. Errors can also be reduced by fixing systemic errors
One of the most tragic yet inevitable ways of learning in the health sector is by looking at previous mistakes. Information sharing is essential in making improvements in safety. Additional steps should include educational initiatives that are essential in root cause analysis (Duthie et al 2005, p. 143). Qualitative data analysis needs to be reviewed and customized for particular situations. It is anticipated that additional research initiatives will provide hospitals with skills and knowledge to proactively implement strategies for a safer hospital.
List of References
American Academy of Pediatrics 2007, Patient safety in the pediatric emergency care setting, Pediatrics vol. 120, pp. 1367–75.
Chamberlain, J. M 2012, Reported medication events in a paediatric emergency research network: Sharing to improve patient safety, Emergency Medical Journal, pp. 1-5
Duthie, E., Favreau, B., Ruperto, A., Mannion, J., Flink, E., & Leslie, R 2005, Quantitative and qualitative analysis of medication errors: The New York experience, Advances in Patient Safety, Vol. 1. Pp. 132-143.
Kulstad, E. B., Sikka, R., & Sweis, R. T 2010, ED overcrowding is associated with an increased frequency of medication errors, Am J Emerg Med, vol. 28, pp. 304–9.
National Coordinating Council for Medication Error Reporting and Prevention 2010, Taxomony of Medication Errors, viewed from http://www.nccmerp.org/medErrorTaxonomy.html
Rinke, M. L., Moon, M., Clark, J.S 2008, Prescribing errors in a pediatric emergency department, Pediatr Emerg Care, vol. 24, pp. 1–8.
Sard, B. E., Walsh, K. E., & Doros, G 2008, Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department, Pediatrics, vol. 122, pp. 782–7.
Shaw, K. N., Lillis, K. A., Ruddy, R. M., Mahajan, P. V., Lichenstein, R., Olsen, C. S., &
Shaw, K.N., Ruddy, R. M., Olsen, C. S 2009, Pediatric patient safety in emergency departments: unit characteristics and staff perceptions, Pediatrics, vol. 124, pp. 485–93.
Vesna et al, 2005, Prescribing medication errors in hospitalized patients: A prospective study, Acta Pharm,. Vol. 55, pp. 157–167.
Westbrook, J. I., Woods, A., & Rob, M. I 2010, Association of interruptions with an increased risk and severity of medication administration errors, Arch Intern Med, vol. 170, pp. 683–90.
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