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AIM: This study aimed to systematically review empirical evidence on factors influencing nurses to report medication errors and near misses. BACKGROUND: There is underreporting of medication errors among nurses, in particular among novice and beginner nurses. To improve quality of care, factors influencing the reporting of medication errors and near misses should be documented. METHOD: A systematic mixed methods review was conducted. CINAHL, Cochrane Collaboration, Embase, Medline, PsycINFO and Web of Science databases were explored and analysed from December 1990 to December 2023. Two reviewers independently selected and extracted data using a standardized data extraction grid. Data were analysed using thematic analysis based on the adapted theory of planned behaviour. RESULTS: Forty-two studies met the eligibility criteria. Principal factors influencing the reporting of medication errors and near misses among nurses were associated with perceived behavioural control, subjective norm and attitude. Few studies examined factors influencing reporting medication errors and near misses among novice and beginner nurses, and sociodemographic and professional factors. CONCLUSION: To understand factors influencing reporting of medication errors and near misses, further studies should be conducted to investigate sociodemographic and professional factors.
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Digoxin is a Na-K ATPase inhibitor commonly used to treat heart failure and atrial fibrillation. It is only approved for oral or intravenous (IV) use. There is no approved indication for intrathecal administration. Only four previously reported cases of intrathecal digoxin administration in pregnant patients are in the literature. We present a patient who had an unfortunate case of erroneous intrathecal Digoxin administration following an elective Cesarean section. Post-delivery, the patient's mental status deteriorated. She became unresponsive and remained comatose for 11 days. Brain magnetic resonance imaging (MRI) showed diffuse, patchy hyperintensities involving bilateral frontotemporal lobes and basal ganglia. A spine MRI showed extensive cervical and thoracic cord edema. At discharge, the patient was paraplegic with no sensation or motor response below the level of T10. At the 90-day follow-up, she had intact mental status and minimal improvement in motor strength and sensation below T10 and was reportedly breastfeeding. This is an unfortunate case of severe neurological deficits resulting from a grave medical error, which continues to be a prevalent issue in the United States healthcare system.
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The integration of Computerized Provider Order Entry (CPOE) systems in hospitals has been instrumental in reducing medication errors and enhancing patient safety. This study examines the implications of a software oversight in a CPOE system : Metoclopramide had a concentrated formulation (100 mg) delisted (and then not manufactured) in 2014 due to safety concerns. Despite this, the CPOE system continued to accept prescriptions for this formulation because it was not removed from the medication library by the pharmacist. The objective of our study was to describe this specific prescription error related to an outdated the medication library of the CPOE. We analyzed all metoclopramide prescriptions from 2014, to 2023. Our findings showed that errors involving 100 mg or more dosages were relatively rare, at 2.98 per 1000 prescriptions (34 errors in 11,372 prescriptions). Notably, 47.1% of these errors occurred during on-call shifts, and 68% of these errors led to actual administration. These errors correlated with periods of higher nurse workload. The findings advocate for the integration of dedicated pharmacists into ICU teams to minimize medication errors and enhance patient outcomes, and a proactive medication management in healthcare.
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Sistemas de Registro de Ordens Médicas , Erros de Medicação , Metoclopramida , Metoclopramida/administração & dosagem , Metoclopramida/uso terapêutico , Erros de Medicação/prevenção & controle , Humanos , Sistemas de Registro de Ordens Médicas/organização & administração , Sistemas de Registro de Ordens Médicas/normas , Antieméticos/administração & dosagem , Antieméticos/uso terapêuticoRESUMO
Dispensing errors pose a significant health risk, with drug name similarity being a potential contributory factor. To determine the impact of drug name similarity on dispensing errors within clinical settings, we analyzed 563 dispensing errors at an acute hospital in Japan from April 2015 to June 2018. Drug name similarity between two drugs was classified into Name-Similar and Name-Dissimilar groups using the m2-vwhtfrag index, the value of the drug name similarity. Drug efficacy similarity was categorized into Efficacy-Same, Efficacy-Close, and Efficacy-Far. The drug name similarity and drug efficacy similarity of all possible pair combinations were obtained and similarly classified. The proportion of the number of pairs with dispensing errors per the total number of drug pairs in the hospital's drug formulary in each category was calculated. The highest proportion of the number of pairs with dispensing errors was 36% for the Efficacy-Same and Name-Similar group, and the lowest proportion was 0.022% for the Efficacy-Far and Name-Dissimilar group. The proportion of the number of pairs with dispensing errors was significantly higher in the Name-Similar category than in the Name-Dissimilar category for all drug efficacy categories. Our results indicate that drug name similarity increases the risk of dispensing errors, and that m2-vwhtfrag is a useful indicator to assess dispensing errors in clinical practice. Such drug name and efficacy similarity evaluations can help identify factors causing dispensing errors, and predict the risk of dispensing errors for newly adopted drugs, considering the relationship with the whole drug formulary in the hospital dispensary.
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Erros de Medicação , Erros de Medicação/prevenção & controle , Erros de Medicação/classificação , Humanos , Japão , Serviço de Farmácia HospitalarRESUMO
The presence of comorbidities and complex drug regimens makes palliative care patients more susceptible to opioid medication errors. Most of the studies conducted so far have mainly focused on patients admitted to hospitals or hospice facilities. During this study, we examined the frequency of medication errors with opioids and the causes and consequences for patients, followed by home palliative care teams. Errors occurred in 39% of patients (n = 378) and 27% of all prescribed opioids (n = 708). Of the 148 (39%) patients with error/s in the opioid/s prescribed, in 55% the patient and/or the caregiver were involved in the error; in 26% the health care providers were involved. An association was found between the presence of error in the prescribed opioid and the level of patient education, p = .038, and with the number of days of follow-up, p < .001. Considering their formulation, the prescribed opioids were associated with medication error, type of error, and cause of the error. The study demonstrated an association between the route of administration and error p < .004, and type of error p < .001.
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Simethicone is an antiflatulent medication exclusively administered orally, thus its systemic effects remain unknown. We present a case of an inadvertent intravenous administration of simethicone to a 4-year-old patient, precipitating respiratory difficulty, cyanosis, and altered mental status. The patient's condition improved rapidly with appropriate interventions, leading to discharge in a fully recovered state. To date, only one documented instance of intravenous simethicone administration exists in medical literature.
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Abstract: Medication errors pose significant risks to patients' health, representing a relevant social and economic issue for the healthcare system. This study focuses on the life-threatening consequences of an overdose of intravenous lipid emulsion (ILE), used as an antidote for suspected bupivacaine intoxication in a young woman undergoing hip surgery. Shortly after administration of the local anesthetic, the woman experienced cardiac arrest and was admitted to the intensive care unit with severe respiratory failure, metabolic acidosis and deep coma. Despite medical intervention, her condition worsened, leading the medical team to administer ILE for suspected bupivacaine intoxication. The patient's condition did not improve and ultimately resulted in death. The autopsy highlighted a widespread presence of oily material in the vascular system, compatible with an overdose of ILE. At a checking, medical records reported a dose of ILE that was 4-fold higher than the recommended dose in this off-label indication. This case report highlights the important need for healthcare professionals to understand the risks of using ILE as an antidote. Adequate monitoring of these "sentinel events" and their critical evaluation can lead to the implementation of specific clinical risk management protocols to reduce the risk for the patient and contain healthcare costs.
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Antídotos , Bupivacaína , Emulsões Gordurosas Intravenosas , Humanos , Emulsões Gordurosas Intravenosas/uso terapêutico , Emulsões Gordurosas Intravenosas/administração & dosagem , Feminino , Evolução Fatal , Bupivacaína/administração & dosagem , Antídotos/uso terapêutico , Antídotos/administração & dosagem , Adulto , Anestésicos Locais/administração & dosagem , Anestésicos Locais/intoxicação , Overdose de Drogas , Parada Cardíaca/induzido quimicamente , Erros de Medicação , Acidose/induzido quimicamente , Acidose/tratamento farmacológicoRESUMO
OBJECTIVE: This scoping review aims to map the available literature and provide an overview of the published articles discussing the impact of electronic prescribing on medication errors and pharmacy workflow. METHODS: The literature search was conducted using PubMed®, Web of Science®, and the Cochrane Database of Systematic Reviews®, as well as grey literature reports, using the search terms and related components of "pharmacists", "electronic prescribing", "medication errors", and "efficiency". The search included all articles that were published from January 2011 to September 2023. Twenty-two relevant articles were identified and fully reviewed, ten of which were included in this review. RESULTS: Electronic prescribing (e-prescribing) provides a solution for some of the challenges that are associated with handwritten and paper prescriptions. However, the implementation of e-prescribing systems has been recognized as a source of new unforeseen medication errors in all the reviewed articles. Productivity in community pharmacies has been affected with receiving electronic prescriptions (e-prescriptions) and having to deal with the issues that arise from them. The pharmacists' interventions were not eliminated with e-prescriptions compared to other prescription formats. The most frequently reported reason for intervention was related to incomplete instructions in the field of directions of use. Other common challenges with e-prescriptions were related to missing information, quantity, inappropriate dose, dosage form, and drug. DISCUSSION: This review demonstrates the scarcity of research about the impact of electronic prescribing on medication error and efficiency in community pharmacies. In the literature, most of the studies had mainly focused on hospital pharmacies. The literature search demonstrated that there are still some barriers to overcome with e-prescribing systems and that medication errors were not fully eliminated with e-prescriptions. New errors have been identified with e-prescriptions, all of which caused delays in processing, which affected the productivity of the pharmacy staff, and could have negatively impacted patients' safety if not properly resolved. CONCLUSION: e-Prescribing solved some of the challenges associated with illegibility of handwritten prescriptions. However, more time is required to allow e-prescribing systems to mature. Further training for prescribers and pharmacists is also recommended before and after the implementation.
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OBJECTIVE: To design a homogeneous methodology for the registration and analysis of pharmaceutical interventions performed in Spanish critical adults' care units. METHOD: Observational, prospective and multicenter study. In the first stage, a national registry of pharmaceutical interventions will be agreed upon and subsequently all the pharmaceutical interventions performed on adult patients admitted to Spanish CCUs during eight weeks will be recorded. Variables related to the type of CCU, the drug involved in the intervention, type of intervention (indication, effectiveness, safety), recommendation made by the pharmacist and the degree of acceptance will be evaluated. Risk and incidence will be calculated for each of the medication errors detected. The χ2-squared test or Fisher exact test will be used for categorical variables and Mann-Whitney U or Kruskal-Wallis test for continuous variables. All tests will be performed with a significance level αâ¯=â¯0.05 and confidence intervals with confidence 1- α. DISCUSSION: The results obtained from this project will make it possible to obtain a homogeneous classification of the pharmaceutical interventions performed in CCU, a national record and an evaluation of the weak points with the aim of developing strategies for improvement in the pharmaceutical care of the critically ill patient.
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AIMS: To examine the relationship between the second victim distress and outcome variables, specifically: 'turnover intentions, absenteeism and resilience'. Furthermore, this study also assessed how organizational support mediates the relationship between second victim distress and outcome variables. DESIGN: Cross-sectional survey. METHODS: A cross-sectional survey study using regression and mediation analysis with bootstrapping was conducted among (n = 149) healthcare professionals in two university hospitals in Finland from September 2022 to April 2023 during different time periods. The Finnish version of the revised Second Victim Experience and Support Tool (FI-SVEST-R) was used to assess second victim distress, level of organizational support and related outcomes. RESULTS: Psychological distress was the most frequently experienced form of reported second victim distress, and institutional support was the lowest perceived form of support by healthcare professionals. The study found second victim distress to have a significant association with work-related outcomes: turnover intention and absenteeism. However, no significant relationship was found with resilience. Mediation models with organizational support revealed a partially mediated relationship between second victim distress and work-related outcomes. CONCLUSIONS: The findings from this study indicate that second victim experiences if not adequately addressed can lead to negative work-related outcomes such as increased job turnover and absenteeism. Such outcomes not only affect healthcare professionals but can also have a cascading effect on the quality of care. However, the mediating effect of organizational support suggests that if comprehensive support is provided, it is possible to mitigate the negative impact of the second victim phenomenon. IMPACT: Raising awareness regarding the second victim phenomenon, promoting a culture of safety and shifting the paradigm from a blame to just culture helps in identifying the system flaws thus improving both patient and provider safety. REPORTING METHOD: The study adheres to the STROBE reporting guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.
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AIMS: To identify the contributing factors behind the second victim phenomenon, describe the emotional responses of nurses after medication errors, assess the support received by them after errors and recognize the need for a suitable support program for second victims. DESIGN: Qualitative descriptive design. METHODS: Eleven in-depth semi-structured interviews were conducted among registered nurses studying advanced degrees at a University in Finland during November 2021-April 2022. Data were analysed using thematic analysis. RESULTS: The study results revealed four themes with various sub-themes which included: contributing factors behind the second victim phenomenon; emotional responses of nurses after error; support received by nurses; and the desired need for a support program for second victims. The severity of the error and the negative work environment acted as catalysts for the second victim phenomenon among nurses. A "bitter aftermath" of emotions and a sense of insufficient support added further risk to already stressed and anxious nurses. CONCLUSIONS: This study identifies the early exploratory and enduring impact of memories associated with medication errors, some of them haunting nurses for long periods of time. Further, the need for support at different levels is highlighted to reduce the impact of negative emotions generated among nurses after medication errors. IMPLICATIONS FOR THE PROFESSION: Through the lens of this study, it has been possible to identify contributing factors behind the second-victim phenomenon and enduring symptoms that make nurses vulnerable to becoming second victims of medication incidents. IMPACT: This study addresses the aftermath effect of medication errors from the perspective of nurses involved with such incidents. It provides valuable insights for healthcare managers and nurse leaders to establish a just and blame-free culture in healthcare organizations and help emotionally traumatized nurses cope effectively after error. REPORTING METHOD: The research adheres to Consolidated criteria for reporting qualitative research (COREQ) guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.
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BACKGROUND AND AIM: Medication errors (MEs) in hospitals decrease patient satisfaction, increase hospital mortality, lower hospital productivity, and increase in the costs of the health system. This study was conducted to determine the rate of MEs in Iranian hospitals. METHOD: In this meta-analysis, all published articles on ME rates in Iranian hospitals were identified from five databases and Google Scholar and assessed for quality. The heterogeneity of the studies was examined using the I2 index and a meta-regression model was used to evaluate the variables suspected of heterogeneity at the 0.05 significance level. Finally, 17 articles were eligible to be included in this study and were analyzed using the Comprehensive Meta-Analysis (CMA) software. FINDINGS: Based on the estimation of the random-effects model, the ME rate in Iranian hospitals was 10.9% (5.1%-21.7%; 95% CI). The highest rate was observed in Sanandaj in 2006 at 99.5% (92.6%-100.0%; 95% CI) and the lowest rate was observed in Kashan in 2019 at 0.2% (0.1%-0.3%; 95% CI). In addition, sample size and publication year were significantly correlated with ME rate (P < 0.05). CONCLUSION: According to the results of this study; ME rate in Iran is relatvively high based on the synthesis of the research conducted in Iranian hospitals. In addition to being costly, MEs have negative consequences for patients. Thereofore, it is necessary to emphasize the voluntary nature of medication error reporting in health sytem of Iran.
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Hospitais , Erros de Medicação , Irã (Geográfico) , Erros de Medicação/estatística & dados numéricos , Humanos , Hospitais/estatística & dados numéricosRESUMO
PURPOSE: To demonstrate the effective integration of pharmacometrics and pharmacovigilance in managing medication errors, highlighted by a case involving secukinumab in a patient with hidradenitis suppurativa. METHODS: We present the case of a 41-year-old male with progressive hidradenitis suppurativa, unresponsive to multiple antibiotic regimens and infliximab treatment. Due to a medication error, the patient received 300 mg of secukinumab daily for 4 days instead of weekly, totaling 1200 mg. The regional pharmacovigilance center assessed potential toxicity, and a pharmacometric analysis using a population pharmacokinetic model was performed to inform dosing adjustments. RESULTS: Clinical data indicated that the received doses were within a non-toxic range. No adverse effects were observed. Pharmacometric simulations revealed a risk of underexposure due to the dosing error. Based on these simulations, it was recommended to restart monthly secukinumab injections on day 35 after the initial dose. Measured plasma concentrations before re-administration confirmed the model's accuracy. CONCLUSION: This case highlights the crucial collaboration between clinical services, pharmacovigilance, and pharmacometrics in managing medication errors. Such interdisciplinary efforts ensure therapeutic efficacy and patient safety by maintaining appropriate drug exposure levels.
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Anticorpos Monoclonais Humanizados , Erros de Medicação , Farmacovigilância , Humanos , Masculino , Adulto , Anticorpos Monoclonais Humanizados/efeitos adversos , Anticorpos Monoclonais Humanizados/farmacocinética , Anticorpos Monoclonais Humanizados/administração & dosagem , Anticorpos Monoclonais Humanizados/uso terapêutico , Erros de Medicação/prevenção & controle , Modelos BiológicosRESUMO
BACKGROUND: Community pharmacies are responsible for dispensing of medicines and related counselling in outpatient care. Dispensing practices have remarkably changed over time, but little is known about how the changes have influenced medication safety. This national study investigated trends in dispensing errors (DEs) related to prescribed medicines, which were reported in Finnish community pharmacies within a 6-year period. METHODS: This national retrospective register study included all DEs reported to a nationally coordinated voluntary DE reporting system by Finnish community pharmacies during 2015-2020. DE rates, DE types, prescription types, individuals who detected DEs and contributing factors to DEs were quantified as frequencies and percentages. Poisson regression was used to assess the statistical significance of the changes in annual DE rates by type. RESULTS: During the study period, altogether 19 550 DEs were reported, and the annual number of error reports showed a decreasing trend (n = 3 913 in 2015 vs. n = 2 117 in 2020, RR 0.54, p < 0.001). The greatest decrease in reported DEs occurred in 2019 after the national implementation of the Medicines Verification System (MVS) and the additional safety feature integrated into the MVS process. The most common error type was wrong dispensed strength (50% of all DEs), followed by wrong quantity or pack size (13%). The annual number of almost all DE types decreased, of which wrong strength errors decreased the most (n = 2121 in 2015 vs. n = 926 in 2020). Throughout the study period, DEs were most commonly detected by patients (50% of all DEs) and pharmacy personnel (30%). The most reported contributing factors were factors related to employees (36% of all DEs), similar packaging (26%) and similar names (21%) of medicinal products. CONCLUSIONS: An overall decreasing trend was identified in the reported DEs and almost all DE types. These changes seem to be associated with digitalisation and new technologies implemented in the dispensing process in Finnish community pharmacies, particularly, the implementation of the MVS and the safety feature integrated into the MVS process. The role of patients and pharmacy personnel in detecting DEs has remained central regardless of changes in dispensing practices.
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Erros de Medicação , Sistema de Registros , Finlândia , Humanos , Erros de Medicação/estatística & dados numéricos , Erros de Medicação/tendências , Estudos Retrospectivos , Serviços Comunitários de Farmácia/tendências , Serviços Comunitários de Farmácia/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-Idade , Farmácias/estatística & dados numéricos , Farmácias/tendências , Adulto , Idoso , AdolescenteRESUMO
BACKGROUND: Medication errors are known to cause adverse drug reactions, hospital admissions and mortality. In most resource-poor settings, medication errors occur but are undocumented. OBJECTIVE: This study sought to investigate medication errors in a diabetic clinic at Komfo Anokye Teaching Hospital (KATH), Ghana. METHODS: The research combined both qualitative and quantitative data collection methods. The quantitative aspect involved retrospectively reviewing patient folders over two years (1st January 2019 to 31st December 2021). Patients' folders were reviewed to identify possible medication errors. The qualitative arm explored underlying factors and experiences related to medication errors through interviews with healthcare workers. Ten healthcare professionals at KATH were interviewed using an interview guide. RESULTS: A total of 264 patients' folders were retrieved. The majority (23.11%) of the patients were between 18 and 25 y.o., and there were more females (52.27%) than males. About 60% of the patients had diabetes and hypertension comorbidity. The overall prevalence of medication errors was 18.18%. The most prevalent type of medication error identified was wrong drug formulation (n = 19, 39.58%). About 47.92% of the medication errors resulted in adverse events and this was predominantly caused by antidiabetic drugs (47.83%) and anti-hypertensive drugs (34.78%). Patients in the age category of 26-35 y.o. [aOR: 0.31, CI: 0.11-0.90] had reduced odds of medication errors whilst patients with comorbidity of diabetes and hypertension [aOR: 5.95, CI: 2.43-14.60] had an increased odds of medication errors. Large patient population, low staff numbers and inadequate knowledge of drugs by healthcare workers were factors that contributed to medication errors. CONCLUSION: Medication errors was moderately high in this diabetic clinic, and the errors led to a number of adverse events. Age, diabetes and hypertension comorbidity, large patient population, low staff numbers, and inadequate knowledge about drugs were identified as factors that influenced medication errors.
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Diabetes Mellitus , Erros de Medicação , Humanos , Erros de Medicação/estatística & dados numéricos , Masculino , Feminino , Gana , Adulto , Diabetes Mellitus/tratamento farmacológico , Diabetes Mellitus/epidemiologia , Estudos Retrospectivos , Adolescente , Pessoa de Meia-Idade , Hipoglicemiantes/efeitos adversos , Hipoglicemiantes/uso terapêutico , Adulto Jovem , Hospitais de Ensino/estatística & dados numéricosRESUMO
BACKGROUND: Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF) by significantly reducing the risk of stroke. Direct oral anticoagulants (DOAC) became preferred over warfarin due to their superior safety and efficacy profile. Assessing adherence to anticoagulation therapy is necessary in clinical practice for optimising patient outcomes and treatment efficacy, thus emphasising its significance. METHODS: A retrospective study utilised the Latvian National Health Service reimbursement prescriptions database, covering prescriptions for AF and flutter from January 2012 to December 2022. The proportion of days covered method was selected for adherence assessment, categorising it into three groups: (1) below 80%, (2) between 80% and 90%, and (3) above 90%. RESULTS: A total of 1,646,648 prescriptions were analysed. Dabigatran prescriptions started declining after 2020, coinciding with a decrease in warfarin prescriptions since 2018. The total adherence levels to DOAC therapy were 69.4%. Only 44.2% of users achieved an adherence level exceeding 80%. The rate of paper prescriptions decreased from 98.5% in 2017 to 1.3% in 2022. Additionally, the utilisation of international non-proprietary names reached 79.7% in 2022. Specifically, 16.7% of patients selected a single pharmacy, whereas 27.7% visited one or two pharmacies. Meanwhile, other patients obtained medicines from multiple pharmacies. CONCLUSIONS: The total adherence level to DOAC therapy is evaluated as low and there was no significant difference in age, gender, or "switcher" status among adherence groups. Physicians' prescribing habits have changed over a decade.
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Background: Determining the proportion of nurses reporting medication errors (MEs) and identifying the barriers they perceive in ME reporting are crucial to encourage nurses to actively report MEs. Objective: This study aimed to determine the proportion of nurses experiencing and reporting MEs, perceived barriers to reporting MEs and their association with nurses' sociodemographic and work-related characteristics. Methods: A cross-sectional study was conducted among 350 nurses from June to November 2023. Data about sociodemographic and work-related characteristics, and ME reporting, were collected using a validated self-administered questionnaire. Results: The study found that 34.3% of nurses reported MEs, while 11.1% reported experiencing MEs during their practice. ME reporting was higher proportion among nurses who were older than 40 years (52.1%), males (41.4%), held a master's degree (58.7%), Saudi nationals (37.8%), experienced for more than 10 years (43.1%), working in intensive care units (44.3%), working for 48 hours or more per week (39.7%), working in hospitals with a nurse-to-patient ratio of 1:3 (44.9%) and having a system for incident reporting (37.7%) and with no training on patient safety (44.6%) compared to their counterparts. The rate of experiencing MEs was higher proportion among nurses who were older than 40 years (16.7%), males (17.3%), married (14.8%), Saudi nationals (13.4%), experienced for more than 10 years (15.6%) and with no training on patient safety (15.3%) compared to their counterparts. Lack of knowledge of the person responsible for reporting MEs was the most frequent perceived barrier to ME reporting (66.6%), followed by fears of blame (65.4%). Conclusion: In this study, nurses reported and experienced MEs during their practice. Most nurses perceive the lack of knowledge and fear of blame or disciplinary actions as barriers to reporting. Healthcare administrators should implement educational programs and workshops to increase nurses' awareness of ME reporting.
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BACKGROUND: There are numerous publications on inpatient medication errors. However, little focus is given to medication errors that occur at home. AIMS: To describe and analyse the types of medication errors among community-dwelling patients following their discharge from an acute care hospital in Singapore. METHOD: This is a retrospective review of a 'good catch' reporting system from December 2018 to March 2022. Medication-related errors were extracted and analysed. FINDINGS: A total of 73 reported medication-related error incidents were reviewed. The mean age of the patients was 78 years old (SD=9). Most patients managed their medications independently at home (45.2%, n=33). The majority of medications involved were cardiovascular medications (51.5%, n=50). Incorrect dosing (41.1%, n=39) was the most common medication error reported. Poor understanding of medication usage (35.6%, n=26) and lack of awareness of medication changes after discharge (24.7%, n=18) were the primary causes of the errors. CONCLUSION: This study's findings provide valuable insights into reducing medication errors at home. More attention must be given to post-discharge care, especially to preventable medication errors. Medication administration and management education can be emphasised using teach-back methods.
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Erros de Medicação , Segurança do Paciente , Humanos , Erros de Medicação/prevenção & controle , Idoso , Feminino , Estudos Retrospectivos , Masculino , Singapura , Idoso de 80 Anos ou mais , Alta do Paciente , Pessoa de Meia-Idade , Vida IndependenteRESUMO
BACKGROUND: Medication errors significantly impact patient safety and healthcare costs. This study investigates the influence of interprofessional communication on medication error rates, with a focus on identifying actionable strategies to improve communication efficacy among healthcare professionals. METHODS: Utilizing a quantitative approach, this research distributed a detailed online questionnaire to a broad cohort of healthcare workers in various settings within Saudi Arabia. The survey encompassed sections on demographics, the frequency and quality of interprofessional communication, perceived barriers and facilitators to effective communication, and personal experiences with medication errors. Statistical analysis was performed using SPSS to derive descriptive and inferential statistics, alongside thematic analysis for qualitative responses. RESULTS: The survey attracted 1165 respondents, predominantly aged 20-30 (68.58%) and female (65.49%). Pharmacists constituted the largest professional group (40.34%). We identified a notable positive correlation (r = 0.16) between high-quality interprofessional communication and employment in hospital environments or having 5-20 years of experience. In contrast, negative correlations were observed with employment in non-traditional healthcare settings (r = -0.19) and professionals with less than five years of experience (r = -0.13), indicating communication challenges. The analysis also highlighted a concerning frequency of prescription and dispensing errors, with 52.70% of participants reporting prescription errors as the most common issue encountered. CONCLUSION: Effective interprofessional communication is pivotal in mitigating medication errors within healthcare settings. The study illuminates specific areas for improvement, including the need for targeted communication training, particularly for less experienced professionals and those in non-traditional settings. Enhancing communication channels and fostering an environment conducive to open, interdisciplinary dialogue are essential steps towards advancing patient safety and reducing medication errors.