Displaying publications 1 - 20 of 53 in total

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  1. Chew KS, Ooi SK, Abdul Rahim NF, Wong SS, Kandasamy V, Teo SS
    BMC Health Serv Res, 2023 Nov 27;23(1):1310.
    PMID: 38012617 DOI: 10.1186/s12913-023-10247-7
    BACKGROUND: Conventional cognitive interventions to reduce medication errors have been found to be less effective as behavioural change does not always follow intention change. Nudge interventions, which subtly steer one's choices, have recently been introduced.

    METHODS: Conducted from February to May 2023, this study aimed to determine the relationships between perceived effectiveness and perceived ease of implementation of six nudge interventions to reduce medication errors, i.e., provider champion, provider's commitment, peer comparison, provider education, patient education and departmental feedback, and the moderating effects of seniority of job positions and clinical experience on nudge acceptability. Partial Least Square Structural Equation Modelling was used for data analysis.

    RESULTS AND DISCUSSION: All six nudge strategies had significant positive relationships between perceived effectiveness and acceptability. In three out of six interventions, perceived ease of implementation was shown to have positive relationships with perceived acceptability. Only seniority of job position had a significant moderating effect on perceived ease of implementation in peer comparison intervention. Interventions that personally involve senior doctors appeared to have higher predictive accuracy than those that do not, indicating that high power-distance culture influence intervention acceptability.

    CONCLUSION: For successful nudge implementations, both intrinsic properties of the interventions and the broader sociocultural context is necessary.

    Matched MeSH terms: Medication Errors/prevention & control
  2. Henry Basil J, Premakumar CM, Mhd Ali A, Mohd Tahir NA, Mohamed Shah N
    Drug Saf, 2022 Dec;45(12):1457-1476.
    PMID: 36192535 DOI: 10.1007/s40264-022-01236-6
    INTRODUCTION: Neonates are at greater risk of preventable adverse drug events as compared to children and adults.

    OBJECTIVE: This study aimed to estimate and critically appraise the evidence on the prevalence, causes and severity of medication administration errors (MAEs) amongst neonates in Neonatal Intensive Care Units (NICUs).

    METHODS: A systematic review and meta-analysis was conducted by searching nine electronic databases and the grey literature for studies, without language and publication date restrictions. The pooled prevalence of MAEs was estimated using a random-effects model. Data on error causation were synthesised using Reason's model of accident causation.

    RESULTS: Twenty unique studies were included. Amongst direct observation studies reporting total opportunity for errors as the denominator for MAEs, the pooled prevalence was 59.3% (95% confidence interval [CI] 35.4-81.3, I2 = 99.5%). Whereas, the non-direct observation studies reporting medication error reports as the denominator yielded a pooled prevalence of 64.8% (95% CI 46.6-81.1, I2 = 98.2%). The common reported causes were error-provoking environments (five studies), while active failures were reported by three studies. Only three studies examined the severity of MAEs, and each utilised a different method of assessment.

    CONCLUSIONS: This is the first comprehensive systematic review and meta-analysis estimating the prevalence, causes and severity of MAEs amongst neonates. There is a need to improve the quality and reporting of studies to produce a better estimate of the prevalence of MAEs amongst neonates. Important targets such as wrong administration-technique, wrong drug-preparation and wrong time errors have been identified to guide the implementation of remedial measures.

    Matched MeSH terms: Medication Errors
  3. Oh AL, Tan AGHK, Chieng IYY
    J Pharm Pract, 2021 Jan 12.
    PMID: 33433248 DOI: 10.1177/0897190020987127
    INTRODUCTION: Medication history assessment during hospital admissions is an important element in the medication reconciliation process. It ensures continuity of care and reduces medication errors.

    OBJECTIVES: This study aimed to determine the incidence of unintentional discrepancies (medication errors), types of medication errors with its potential severity of patient harm and acceptance rate of pharmaceutical care interventions.

    METHODS: A four-month cross-sectional study was conducted in the general medical wards of a tertiary hospital. All newly admitted patients with at least one prescription medication were recruited via purposive sampling. Medication history assessments were done by clinical pharmacists within 24 hours or as soon as possible after admission. Pharmacist-acquired medication histories were then compared with in-patient medication charts to detect discrepancies. Verification of the discrepancies, interventions, and assessment of the potential severity of patient harm resulting from medication errors were collaboratively carried out with the treating doctors.

    RESULTS: There were 990 medication discrepancies detected among 390 patients recruited in this study. One hundred and thirty-five (13.6%) medication errors were detected in 93 (23.8%) patients (1.45 errors per patient). These were mostly contributed by medication omissions (79.3%), followed by dosing errors (9.6%). Among these errors, 88.2% were considered "significant" or "serious" but none were "life-threatening." Most (83%) of the pharmaceutical interventions were accepted by the doctors.

    CONCLUSION: Medication history assessment by pharmacists proved vital in detecting medication errors, mostly medication omissions. Majority of the errors intervened by pharmacists were accepted by the doctors which prevented potential significant or serious patient harm.

    Matched MeSH terms: Medication Errors
  4. Jafarzadeh Ghoushchi S, Dorosti S, Ab Rahman MN, Khakifirooz M, Fathi M
    J Healthc Eng, 2021;2021:5533208.
    PMID: 33868619 DOI: 10.1155/2021/5533208
    Medication Errors (MEs) are still significant challenges, especially in nonautomated health systems. Qualitative studies are mostly used to identify the parameters involved in MEs. Failing to provide accurate information in expert-based decisions can provoke unrealistic results and inappropriate corrective actions eventually. However, mostly, some levels of uncertainty accompany the decisions in real practice. This study tries to present a hybrid decision-making approach to assigning different weights to risk factors and considering the uncertainty in the ranking process in the Failure Modes and Effect Analysis (FMEA) technique. Initially, significant MEs are identified by three groups of qualified experts (doctors, nurses, and pharmacists). Afterward, for assigning weights to the risk factors, Z-number couples with the Stepwise Weight Assessment Ratio Analysis (SWARA) method, named Z-SWARA, to add reliability concept in the decision-making process. Finally, the identified MEs are ranked through the developed Weighted Aggregated Sum Product Assessment (WASPAS) method, namely, Z-WASPAS. To demonstrate the applicability of the proposed approach, the ranking results compare with typical methods, such as fuzzy-WASPAS and FMEA. The findings of the present study highlight improper medication administration as the main failure mode, which can result in a fatality or patient injury. Moreover, the utilization of multiple-criteria decision-making methods in combination with Z-number can be a useful tool in the healthcare management field since it can address the problems by considering reliability and uncertainty simultaneously.
    Matched MeSH terms: Medication Errors/prevention & control
  5. Samsiah A, Othman N, Jamshed S, Hassali MA
    Int J Clin Pharm, 2020 Aug;42(4):1118-1127.
    PMID: 32494990 DOI: 10.1007/s11096-020-01041-0
    Background Medication errors are the most common types of medical errors that occur in health care organisations; however, these errors are largely underreported. Objective This study assessed knowledge on medication error reporting, perceived barriers to reporting medication errors, motivations for reporting medication errors and medication error reporting practices among various health care practitioners working at primary care clinics. Setting This study was conducted in 27 primary care clinics in Malaysia. Methods A self-administered survey was distributed to family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. Main outcome measures Health care practitioners' knowledge, perceived barriers and motivations for reporting medication errors. Results Of all respondents (N = 376), nurses represented 31.9% (n = 120), followed by doctors (n = 87, 23.1%), pharmacists (n = 63, 16.8%), assistant medical officers (n = 53, 14.1%), pharmacist assistants (n = 46, 12.2%) and family medicine specialists (n = 7, 1.9%). Of the survey respondents who had experience reporting medication errors, 56% (n = 62) had submitted medication error reports in the preceding 12 months. Results showed that 41.2% (n = 155) of respondents were classified as having good knowledge on medication error and medication error reporting. The mean score of knowledge was significantly higher among prescribers and pharmacists than nurses, pharmacist assistants and assistant medical officers (p 
    Matched MeSH terms: Medication Errors*
  6. Mohd Yusof M, Takeda T, Mihara N, Matsumura Y
    Stud Health Technol Inform, 2020 Jun 16;270:1036-1040.
    PMID: 32570539 DOI: 10.3233/SHTI200319
    Health information systems (HIS) and clinical workflows generate medication errors that affect the quality of patient care. The rigorous evaluation of the medication process's error risk, control, and impact on clinical practice enable the understanding of latent and active factors that contribute to HIS-induced errors. This paper reports the preliminary findings of an evaluation case study of a 1000-bed Japanese secondary care teaching hospital using observation, interview, and document analysis methods. Findings were analysed from a process perspective by adopting a recently introduced framework known as Human, Organisation, Process, and Technology-fit. Process factors influencing risk in medication errors include template- and calendar-based systems, intuitive design, barcode check, ease of use, alert, policy, systematic task organisation, and safety culture Approaches for managing medication errors also exert an important role on error reduction and clinical workflow.
    Matched MeSH terms: Medication Errors
  7. Olakotan O, Mohd Yusof M, Ezat Wan Puteh S
    Stud Health Technol Inform, 2020 Jun 16;270:906-910.
    PMID: 32570513 DOI: 10.3233/SHTI200293
    Clinical decision support systems (CDSSs) provides vital information for managing patients by advising clinicians through an alert or reminders about adverse events and medication errors. Clinicians receive a high number of alerts, resulting in alert override and workflow disruptions. A systematic review was carried out to identify factors affecting CDSS alert appropriateness in supporting clinical workflows using a recently introduced framework. The review findings identified several influencing factors of CDSS alert appropriateness including: technology (usability, alert presentation, workload and data entry), human (training, knowledge and skills, attitude and behavior), organization (rules and regulation, privacy and security) and process (waste, delay, tuning and optimization). The findings can be used to guide the design of CDSS alert and minimise potential safety hazards associated with CDSS use.
    Matched MeSH terms: Medication Errors
  8. Hon MY, Chua XY, Premakumar CM, Mohamed Shah N
    Int J Clin Pharm, 2020 Jun;42(3):948-955.
    PMID: 32356248 DOI: 10.1007/s11096-020-01045-w
    Background Drug-related problems are relatively common among hospitalised patients and may be detrimental to patients and even increase healthcare costs. Characterising drug-related problems allows remedial actions to be in place to minimise the frequency and ensure higher medication safety for the patients involved. Currently, the incidence of drug-related problems among hospitalised paediatric patients in Malaysia is unknown. Objective To determine the incidence, types and intervention acceptance, as well as the risk factors associated with drug-related problems in a Malaysian general paediatric ward. Setting General paediatric ward in Universiti Kebangsaan Malaysia Medical Centre. Method A cross-sectional observational study was conducted from March to May 2019. Data were collected from patients' medical charts, clinical notes and medical records for problem identification based on the modified Pharmaceutical Care Network Europe (PCNE) classification V 8.02. The incidence, types, causes and intervention acceptance as well as the risk factors were assessed. Main outcome measure Drug-related problems based on the modified PCNE classification V 8.02. Results In total, 225 paediatric patients with a total of 694 prescriptions were included in this study. The incidence of drug-related problems was 52.9% (198 prescriptions with problems in 119 patients). The main types of problems were treatment safety (68 prescriptions, 34.3%), incomplete prescription (56 prescriptions, 28.3%) and un-optimised drug treatment (35 prescriptions, 17.7%). The main causes for the problems were necessary information not provided (n = 63, 30.1%), inappropriate dose selection (n = 47, 22.5%) and medication served without a valid prescription (n = 40, 19.1%). Of the 143 interventions proposed to prescribers by the pharmacist, 117 (81.8%) were accepted. The number of prescriptions was found to be the only risk factor associated with DRPs (odds ratio, 1.91; 95% confidence interval, 1.54-2.38; p 
    Matched MeSH terms: Medication Errors/statistics & numerical data*
  9. Lee JL
    Int J Clin Pharm, 2020 Apr;42(2):604-609.
    PMID: 32095976 DOI: 10.1007/s11096-020-00996-4
    Background Prescribing errors in children are common due to individualization of dosage regimen. It potentially has a great impact especially in this vulnerable population. Objective To determine the prevalence and common types of prescribing errors in a Malaysian pediatric outpatient department and to determine the factors contributing to prescribing errors. Setting Pediatric Outpatient Department and Outpatient Pharmacy at a tertiary care hospital in Malaysia. Method This is a prospective, cross sectional observational study where all new prescriptions received by the outpatient pharmacy from patients attending pediatric out-patient clinic were included for analysis. Descriptive statistics and logistic regression were used to analyze the data. Main outcome measure Frequency, types, potential clinical consequences and contributing factors of prescribing errors. Results Two hundred and fifty new prescriptions with 493 items were analyzed. There were 13 per 100 prescriptions with at least one prescribing error and 7.3% of the total items were prescribed incorrectly. The most common types of prescribing error were, an ambiguous prescription (61.1%) followed by an unrecommended dose regimen (13.9%). Logistic regression analysis showed that the risk of a prescribing error significantly increased when the prescription was written by a house officer (OR 4.72, p = 0.029). Errors were judged to be potentially non-significant (33.3%), significant (36.1%), or serious (30.6%). Conclusion The experience of prescribers is an important factor that contributes to prescribing errors in pediatrics. Many of the errors made were potentially serious and may impact on the patients' well-being.
    Matched MeSH terms: Medication Errors/prevention & control*
  10. Shitu Z, Aung MMT, Tuan Kamauzaman TH, Ab Rahman AF
    BMC Health Serv Res, 2020 Jan 22;20(1):56.
    PMID: 31969138 DOI: 10.1186/s12913-020-4921-4
    BACKGROUND: Medication use process in the emergency department (ED) can be challenging and the risk for medication error (ME) to occur is high. In Malaysia, several studies on ME have been conducted in various hospital settings. However, little is known about the prevalence of ME in emergency department (ED) in these hospitals. The objective of this study was to determine the prevalence and characteristics of ME at an ED of a teaching hospital in Malaysia.

    METHODS: A cross-sectional study was conducted over the period of 9 weeks in patients who visited the ED of Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia. Data on patient medication orders and demographic information was collected from the doctor's clerking sheet. Observations were made on nursing activities and these were documented in the data collection form. Other information related to the administration of medications were obtained from the nursing care records.

    RESULTS: Observations and data collections were made for 547 patients who fulfilled the study criteria. From these, 311 patient data were randomly selected for analysis. Ninety-five patients had at least one ME. The prevalence of ME was calculated to be 30.5%. The most common types of ME were wrong time error (46.9%), unauthorized drug error (25.4%), omission error (18.5%) and dose error (9.2%). The most frequently drug associated with ME was analgesics. No adverse event was observed.

    CONCLUSIONS: The prevalence of ME in our ED setting was moderately high. However, the majority of them did not result in any adverse event. Intervention measures are needed to prevent further occurrence.

    Matched MeSH terms: Medication Errors/statistics & numerical data*
  11. Chin JG, Tan M, Francis SY, Idris SR, Padtong M, Lotupas K, et al.
    MyJurnal
    Introduction: Medication error is a global issue. Despite, the various impacts on health and non-health, continuous monitoring, assessment and intervention are required to reduce the number of medication error. Precise information on the root cause of medication error in Hospital Queen Elizabeth II, Kota Kinabalu will aid in the preventative measures to reduce medication error among nurses. Thus, this study aims to describe the incident of medication errors among nurses.
    Methods: A retrospective cross-sectional study was conducted to review medication error incidents Reports between 2015 to 2018. Data were analysed according to the type of error, day and shift of medication error occurred, causes and month of services. The collected data were analysed using descriptive statistics in SPSS 22.
    Results: A total of 54 reports was reviewed. The mean (SD) month of services among nurses involved in the medication error is 41.3 (24.9) months. The most common type of medication error is the wrong frequency with 23 (42.6%) cases. Majority cases of medication error occurred in weekdays with 41 (75.9%) cases and 24 (44.4%) cases happen during the night shift. Poor communication among healthcare workers was the most commonly reported human error with 42 (77.8%) reports, followed by36 (66.7%) reports of failure to comply standard of procedure in medication administration.
    Conclusion: Though this study found team factor is the recurrent causes, poorly designed work systems and individual factor should be imperious as well. A qualitative study is required to understand more on nurse behaviour practice towards medication administration. The high authority plays an important role to monitor this matter to improve medication safety practice.
    Matched MeSH terms: Medication Errors
  12. Li Tsu Chong, Josephine Magdeline Joseph, Nur Atikah Binti Mohd Taib, Nurfirna Suzleyna Binti Mohd Salleh, Jennefer Henry
    MyJurnal
    Introduction: Medication error always happens among the nurses either the trained out staffs nor in nursing students. These errors may harm any patient that is involved and it may lead tolegislation issue. Therefore, this study aims to identify nursing students knowledge and assurance in medication administration. Methods: This study using a cross-sectional survey design using a convenience sampling method. Ethical approval was obtained from The Fac- ulty of Medicine and Health Sciences Ethical Committee. Adapted questionnaire divided into three sections with 14 multi-choice questions for each section (pharmacology, drug management and drug calculation) score (0-14) and Self perceived certainty on their correct answer were scored (1-high certainty, 2-moderate and 3-low certainty). Questionnaires were distributed through the online google form to Diploma of Nursing students of year two and three of Faculty Medicine and Health Science of University Malaysia Sabah. Result reported in mean (+SD). Results: Total of71 students volunteered responded to the survey. 42.3% of respondents (n=30) are the Year Two students and 57.7% (n=41) are the Year Three students.In knowledge about pharmacology mean score was 9.33 (2.37) and their certainty mean score was 1.9 (0.55), Drug management mean score was 8.42 (2.55) and their certainty mean score was 1.90 (0.45), While for their drug calculation mean score was 8.04 (3.03) and certainty mean score was
    2.13 (0.51). Conclusion: Knowledge in drug management and drug calculation both were below the appropriate score (less than 9) respectively. These indicate that more practices and training on the medication administration should be done to the students in order familiar with the context of medication administration. Their certainty level found moderate indicate that their confidence level on medication administration should be reinforced. Nursing educators need to facilitate the students in their learning process and training periods to gain their confidence before their graduation.

    Matched MeSH terms: Medication Errors
  13. Rasool MF, Rehman AU, Imran I, Abbas S, Shah S, Abbas G, et al.
    Front Public Health, 2020;8:531038.
    PMID: 33330300 DOI: 10.3389/fpubh.2020.531038
    Introduction: Medication error is unintentional and can be reduced by reducing the risk factors. Patients suffering from chronic diseases are at an increased risk of medication errors. Objective: This work aims to assess the risk factors associated with medication errors among patients suffering from chronic disorders in hospitals of South Punjab, Pakistan. Methodology: Multiple logistic regression analysis was used to assess the impact of different risk factors on the prevalence of medication errors in patients suffering from chronic diseases. Results: A greater risk for the occurrence of medication errors was associated with age ≥60 years (odds ratio, OR = 1.9; 95% CI = 1.3-3.1; p = 0.001), overburdened healthcare system (OR = 2.2; 95% CI = 1.64-3.56; p < 0.000), number of prescribed drugs ≥5 (OR = 1.74; 95% CI = 1.02-2.64; p < 0.000), comorbidities (OR = 2.6; 95% CI = 1.72-3.6; p = 0.003), Charlson comorbidity index (OR = 1.31; 95% CI = 0.49-1.84; p = 0.004), and multiple prescribers to one patient (OR = 1.12; 95% CI = 0.64-1.76; p = 0.001). Conclusion: Older age, overburdened healthcare system, number of prescribed drugs, comorbidities, Charlson comorbidity index, and multiple prescribers to one patient are significant risk factors for the occurrence of medication errors.
    Matched MeSH terms: Medication Errors*
  14. Fatokun O
    Curr Drug Saf, 2020;15(3):181-189.
    PMID: 32538733 DOI: 10.2174/1573403X16666200615144946
    BACKGROUND: While off-label drug use is common and sometimes necessary, it also presents considerable risks. Therefore, measures intended to prevent or reduce the potential exposure to off-label risks have been recommended. However, little is known about community pharmacists' beliefs regarding these measures in Malaysia.

    OBJECTIVES: This study examined community pharmacists' beliefs towards risk minimization measures in off-label drug use in Malaysia and assessed the relationship between perceived risk of off-label drug use and beliefs towards risk minimization measures.

    METHODS: A cross-sectional survey was conducted among 154 pharmacists practicing in randomly selected community pharmacies in Kuala Lumpur and the State of Selangor, Malaysia.

    RESULTS: The majority agreed or strongly agreed that adverse drug events from the off-label drug should be reported to the regulatory authority (90.9%) and the off-label drug should only be used when the benefit outweighs potential risks (88.3%). Less than half (48.1%) agreed or strongly agreed that written informed consent should be obtained before dispensing off-label drugs and a majority (63.7%) agreed or strongly agreed that the informed consent process will be burdensome to healthcare professionals. Beliefs towards risk minimization measures were significantly associated with perceived risk of off-label drug use regarding efficacy (p = 0. 033), safety (p = 0.001), adverse drug rection (p = 0.001) and medication errors (p = 0.002).

    CONCLUSION: The community pharmacists have positive beliefs towards most of the risk minimization measures. However, beliefs towards written informed consent requirements are not encouraging. Enhancing risk perception may help influence positive beliefs towards risk minimization measures.

    Matched MeSH terms: Medication Errors/prevention & control
  15. Liew JES, Abdul Gapar AAB, Shim LT
    PMID: 32537169 DOI: 10.1186/s40545-020-00221-7
    Background: In 2015, the drive-through pharmacy was first introduced in Queen Elizabeth Hospital (QEH), Malaysia as one of the pharmacy value-added services. Therefore, it is imperative to review the service for further amelioration to fulfil patients' needs and expectations.

    Objective: The aim of this study is to evaluate the drive-through pharmacy service in Queen Elizabeth Hospital, Malaysia.

    Methods: A cross-sectional observational study was conducted from July to December 2018. The questionnaire was developed and underwent thorough validation process which yielded a Cronbach's alpha reliability score of 0.9130. Satisfaction was calculated by mean percentage score (0% (dissatisfied) to 100% (satisfied). All data were analysed descriptively and thematic analysis was used in analysing open-ended question.

    Results: Compliance in obtaining medication was at 96.3% with a given two-week grace collection period. Insufficient quantity of medications (33.3%) was the highest near-missed medication errors occurred at the drive-through pharmacy. The mean satisfaction percentage score for all patients were 76.6% ± 8.1. A total of 69.2% (n = 83) were "very satisfied" while 30.8% (n = 37) were "satisfied" with the service. Among the reasons for satisfaction are convenience in getting medication refills (n = 74, 62%), short waiting time (n = 75, 63%) and knowledgeable dispensers (n = 87, 73%). A handful of patients were "dissatisfied" with the opening hours (n = 14, 11.7%) and the location of the drive-through pharmacy service (n = 19, 15.8%).

    Conclusion: Compliance in medication collection is acceptable within stipulated grace period. Despite low occurrence, identification of near-missed medication errors provides useful insights for future improvement of the service. Generally, our patients are satisfied with the service. However, we need to re-evaluate on the opening hours and location of the service.

    Matched MeSH terms: Medication Errors
  16. Mamat R, Awang SA, Ab Rahman AF
    Drug Healthc Patient Saf, 2020;12:95-101.
    PMID: 32523381 DOI: 10.2147/DHPS.S249104
    Purpose: Assessment of medication errors (ME) is crucial to improving the quality of health care. A questionnaire that can be used to explore pharmacists' perspectives regarding ME would be very useful as part of an ongoing process of quality improvement in patient care. The aim of this study was to develop and validate a questionnaire to measure perceived causes of ME and attitude towards ME reporting among pharmacists.

    Methods: The questionnaire was developed from the literature together with outcomes from focus group discussions. It was divided into two domains which are knowledge on ME and attitude towards ME reporting. Content validity index (I-CVI), exploratory factor analysis (EFA), Cronbach alpha and intraclass correlation coefficient (ICC) to assess test-retest reliability were obtained during the validation process.

    Results: Overall Cronbach alpha for internal consistency was good (0.742), where subscale of the questionnaire demonstrated adequate internal consistency, with Cronbach alpha value 0.83 for knowledge and 0.70 for reporting behaviour attitude. The I-CVI showed good scores (knowledge=0.88) and (attitude=0.81), while ICC was moderately accepted with a value of 0.77. Two factors were extracted from the 16 items in EFA.

    Conclusion: The questionnaire to assess knowledge on ME and attitude towards ME reporting among pharmacists is valid and reliable. It demonstrates good psychometric properties.

    Matched MeSH terms: Medication Errors
  17. Mortell M
    Br J Nurs, 2019 Nov 14;28(20):1292-1298.
    PMID: 31714835 DOI: 10.12968/bjon.2019.28.20.1292
    This article employs a paediatric case study, involving a 3-year-old child who had an anaphylactic reaction that occurred as a result of the multidisciplinary team's failure to identify and acknowledge the patient's documented 'known allergy' status. It examines and reconsiders the ongoing healthcare dilemma of medication errors and recommends that known allergy status should be considered the second medication administration 'right' before the prescribing, transcribing, dispensing and administration of any drug. Identifying and documenting drug allergy status is particularly important when caring for paediatric patients, because they cannot speak for themselves and must rely on their parents, guardians or health professionals as patient advocates. The literature states that medication errors can be prevented by employing a 'rights of medication administration' format, whether that be the familiar '5 rights' or a more detailed list. However, none of these formats specify known allergy status as a distinct 'right'. The medication safety literature is also found wanting in respect of the known allergy status of the patient. When health professionals employ a medication administration rights format prior to prescribing, transcribing, dispensing or administering a medication, the 'known allergy status' of the patient should be a transparent inclusion.
    Matched MeSH terms: Medication Errors/adverse effects; Medication Errors/prevention & control*
  18. Ab Rahman AF
    Bull World Health Organ, 2019 Nov 01;97(11):730.
    PMID: 31673185 DOI: 10.2471/BLT.19.245019
    Matched MeSH terms: Medication Errors/statistics & numerical data*
  19. George D, Supramaniam ND, Hamid SQA, Hassali MA, Lim WY, Hss AS
    Pharm Pract (Granada), 2019 08 21;17(3):1501.
    PMID: 31592290 DOI: 10.18549/PharmPract.2019.3.1501
    Background: Patients requiring medications during discharge are at risk of discharge medication errors that potentially cause readmission due to medication-related events.

    Objective: The objective of this study was to develop interventions to reduce percentage of patients with one or more medication errors during discharge.

    Methods: A pharmacist-led quality improvement (QI) program over 6 months was conducted in medical wards at a tertiary public hospital. Percentage of patients discharge with one or more medication errors was reviewed in the pre-intervention and four main improvements were developed: increase the ratio of pharmacist to patient, prioritize discharge prescription order within office hours, complete discharge medication reconciliation by ward pharmacist, set up a Centralized Discharge Medication Pre-packing Unit. Percentage of patients with one or more medication errors in both pre- and post-intervention phase were monitored using process control chart.

    Results: With the implementation of the QI program, the percentage of patients with one or more medication errors during discharge that were corrected by pharmacists significantly increased from 77.6% to 95.9% (p<0.001). Percentage of patients with one or more clinically significant error was similar in both pre and post-QI with an average of 24.8%.

    Conclusions: Increasing ratio of pharmacist to patient to complete discharge medication reconciliation during discharge significantly recorded a reduction in the percentage of patients with one or more medication errors.

    Matched MeSH terms: Medication Errors
  20. Di Simone E, Di Muzio M, Dionisi S, Giannetta N, Di Muzio F, De Gennaro L, et al.
    Eur Rev Med Pharmacol Sci, 2019 Jun;23(12):5522-5529.
    PMID: 31298407 DOI: 10.26355/eurrev_201906_18224
    INTRODUCTION: Western world health care systems have been trying to improve their efficiency and effectiveness in order to respond properly to population aging and non-communicable diseases epidemic. Treatment of the elderly population is becoming complex due to the high number of prescribed drugs because of multimorbidity. Errors in drugs administration in different health care related settings are an actual important issue due to different causes. Aim of this observational study is to measure the online interest in seeking medication errors information related to risk management and shift work.

    MATERIALS AND METHODS: We investigated Google Trends® for popular search relating to medication errors, risk management and shift work. Relative search volumes (RSVs) were evaluated from 2008 to 2018. A comparison between RSV curves related to medication errors, risk management and shift work was carried out. Then, we compared the world to Italian search.

    RESULTS: RSVs were persistently higher for risk management than for medication errors (mean RSVs 069 vs. 48%) and RSVs were stably higher for medication errors than shift work (mean RSVs 48 vs. 22%). In Italy, RSVs were much lower compared to the rest of the world, and RSVs for medication errors during the study period were negligible. Mean RSVs for risk management and shift work were 3 and 25%, respectively. RSVs related to medication errors and clinical risk management were correlated (r=0.520, p<0.0001).

    CONCLUSIONS: Google Trends® search query volumes related to medication errors, risk management and shift work are different. RSVs for risk management are higher, and they are correlated with medication errors. Also, shift work search appears to be lower. These results should be interpreted in order to correctly evaluate how to decrease the number of medication errors in different health care related setting.

    Matched MeSH terms: Medication Errors/prevention & control; Medication Errors/statistics & numerical data*
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