Calculating the cost of medication errors: A systematic review of approaches and cost variables.

INTRODUCTION: Medication errors are an unnecessary cost to a healthcare system and patients of a country. This review aimed to systematically identify published cost variables used to calculate the cost of medication errors and to explore any updates on findings already known on calculating the cost of medication errors during the past 10 years. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases, PubMed, Scopus, Emerald and JSTOR were searched, using keywords "medication error" AND "cost" and predetermined inclusion criteria. Duplicate articles were removed. Quality check was done using 10 criteria. Cost variables used in calculating the cost of medication errors were extracted from each article. RESULTS: Among 3088 articles, 33 articles were selected for review. Most studies were conducted in Western countries. Cost variables used (types and number) by different studies varied widely. Most studies (N=29) had used direct costs only. A few studies (N=4) had used both direct and indirect costs for the purpose. Perspectives considered when calculating cost of medication errors also varied widely. A total of 35 variables used to calculate medication error costs were extracted from selected articles. CONCLUSION: Variables used to calculate the cost of medication errors were not uniform across studies. Almost a decade after systematic reviews previously reporting on this area, a validated methodology to calculate the cost of medication errors has still not been reported to date and highlights the still pending necessity of a standard method to be established.

Quality of measuring devices enclosed with paediatric oral liquid dosage forms of medicines registered in Sri Lanka.

INTRODUCTION: Oral liquid dosage forms remain popular in several middle income countries. The accuracy of liquid dosage form dosing depends on the accuracy and availability of measuring devices. Lack of quality oral liquid measuring devices will lead to medication errors. Hence there is an urgent need to describe the quality of manufacturer supplied measuring devices enclosed with paediatric oral liquid dosage forms currently registered in Sri Lanka. METHODOLOGY: Standards for measuring devices were developed after a detailed literature search. Multidisciplinary panel rated each standard for the necessity criteria on a 9 point Likert scale. Standards with overall panel median score of ≥ 7 with agreement were selected. A cross-sectional study was done. All the measuring devices, labels and instructions enclosed with the registered products were assessed against the standards developed. Three volumes of liquid antibacterials were measured using the enclosed measuring device. Accuracy of the volumes was measured. RESULTS: Of the total products (n = 202) only 126 were packed with a dosing device. Around quarter of the oral liquid dosage forms (n = 36) did not have a measuring device. More than half of the measuring devices aligned with all the standards developed. Out of 44 oral liquid paediatric antimicrobials measuring cups (n = 25, 56.8%, 95% CI: 41%-72%) were enclosed more and less error was seen with measuring cups. CONCLUSION: The quality of oral liquid measuring devices were not satisfactory. Quality could be further improved if the regulatory body request the manufactures/importers to adhere to the standards developed. Correct volumes were not measured using the measuring devices provided with the liquid antimicrobial agents.

Administration of oral dosage forms of medicines to children in a resource limited setting.

BACKGROUND: There are many paediatric specific challenges such as lack of age-appropriate dosage forms, inability of young children to swallow tablets and capsules and poor acceptability, during administration of oral dosage forms of medications to children. Parents adopt various methods which they consider best to circumvent this problem. The objective of this study was to describe the administration practice by parents when giving oral dosage forms of medications to children. METHODS: A descriptive cross-sectional study was conducted to assess the administration practice of 1800 oral dosage forms of medications administered to children under the age of 12 years using validated indicators. A pre-tested interviewer-administered questionnaire given to parents or caregivers was used to collect the necessary data. The data were analysed using descriptive statistics. RESULTS: Data from 1800 oral dosage forms was obtained from 663 children. Of the 1287 solid dosage forms, almost one-third were manipulated by parents at the time of giving the medications to children. They were crushed and dissolved in water given to children. In about 17% of instances safety of water was questionable. In 92% of instances, measuring device was found to be inappropriate. CONCLUSION: Administration of oral dosage forms of medications to children is far from ideal and hinders successful use of medications in children.

Rational dispensing of oral dosage forms of medicines to children at a teaching hospital in Sri Lanka.

BACKGROUND: Good dispensing practice is vital for rational use of medicines. There are many paediatric specific challenges when maintaining good dispensing practices to children. Lack of age appropriate dosage forms, lack of medicines in strengths suitable for children, lack of palatable medicines, lack of expertise in paediatric pharmacy are few challenges faced when maintaining good dispensing practices to children. These challenges contribute to poor dispensing practices. Hence there is an urgent need to investigate whether oral dosage forms of medicines are dispensed rationally to children. The objective of this study was to describe the rational dispensing practice of oral dosage forms of medicines to children in a Teaching Hospital in Sri Lanka. METHODS: A descriptive cross sectional study was conducted to assess the dispensing practice of 1800 oral dosage forms of medicines dispensed to children under the age of 12 years in two outdoor pharmacies over a period of 1 year using validated indicators. Required data were extracted from the prescriptions and by observation using a structured pre-tested observation sheet. Descriptive statistics and wherever relevant, chi square test were used in analysing the data. RESULTS: Information on 1800 oral dosage forms was obtained from 1889 medicines dispensed to 727 children. Liquids were 52% [95% CI: 50-55%] of these oral dosage forms. Of the solid dosage forms, about one quarter required manipulation prior to administration such as splitting and dissolving or crushing the adult dosage form. None of the medicine packs or bottles had the patient name on the label. CONCLUSION: Dispensing practice of oral dosage forms of medicines to children has room for improvement.

Prescribing, dispensing and administration indicators to describe rational use of oral dosage forms of medicines given to children.

Background: Owing to lack of indicators, researchers are compelled to use non-specific indicators to assess rational use of medicines in children. Thus, paediatric-specific issues are poorly described. This study aims to develop a set of indicators to describe rational use of oral dosage forms of medicines given to children. Methods: A modified RAND/UCLA Appropriateness Method was used. A comprehensive draft list of 40 indicators was compiled, based on the results of a literature review. Twelve experts rated these indicators in two rounds, using a nine-point Likert scale, first in an online survey, for clarity, necessity and scientific merit, and secondly in a face-to-face meeting, for necessity, feasibility and predictive value. An overall panel median score of ≥7 and agreement within the experts were used in indicators. The indicators were ranked independently by the research team and a final list of indicators was prepared. These indicators were pilot-tested for acceptability and interrater reliability. Results: Nine prescribing indicators, such as weight, appropriate dose and age-appropriate dosage form; five dispensing indicators, such as adequacy of labelling and inappropriate manipulation by pharmacists; and five administration indicators, such as inappropriate manipulation by parents and full completion of dose, were finalized in the second round. Conclusion: This novel approach has provided a set of indicators to describe the use of oral dosage forms of medicines given to children, which can be used by researchers as a supplement to the World Health Organization's drug use indicators when investigating rational use of medicines in children.