Analyzing the Impact of Drug Name Similarity on Dispensing Errors: An Examination Using a Drug Name Similarity Index.

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.

Construction and analysis of a database for medication errors in a pharmacovigilance centre-the Moroccan experience.

PURPOSE: The study aimed to describe the epidemiological profile of medication errors (MEs) reported to the Moroccan Pharmacovigilance Center (MPVC), to determine factors associated with serious MEs, and to describe signals related to them. METHODS: We carried out a retrospective descriptive analysis of MEs reported to the MPVC from 2006 to 2016 and a secondary analysis of the seriousness of MEs with adverse drug reactions (ADRs). The reports were sorted by demographic profile and by ME and ADR characteristics. For signal detection, a quantitative approach was adopted, and the root cause analysis was completed. Epi info 7 software was used to perform descriptive and analytical statistics. The statistical significance level was set at p < 0.05. RESULTS: A total of 1618 ME reports were retrieved. The proportion of MEs associated with serious ADRs was 23.9%. The factors statistically associated with serious MEs were as follows: (i) the age group 16 years old and less (p < 0.001), (ii) the gender (p = 0.01), (iii) the administration and the prescription stages (p < 0.001), and (iv) the ME types related to inappropriate schedule of drug administration, drug prescribing error (p < 0.001), and incorrect drug administration dosage form (p = 0.04). Fourteen signals related to MEs were detected, for which risk minimization actions were implemented. CONCLUSION: The establishment of a ME unit within the MPVC was an opportunity to further improve the pharmacovigilance centre performance and consequently its contribution to medication safety. The lessons learned from MEs should be shared through pharmacovigilance networks and with institutions involved in medication safety for synergistic results to achieve patient safety worldwide.

[Descriptive analysis of medication errors notified by Primary Health Care: Learning from errors]. / Análisis descriptivo de los errores de medicación notificados en atención primaria: aprendiendo de nuestros errores.

INTRODUCTION AND OBJECTIVES: Aim of this study is to determine the setting, causes, and the harm of medication errors (ME) which are notified by Primary Health Care. MATERIAL AND METHODS: Setting: Primary Care Regional Health Service of Madrid. 2016. DESIGN: Descriptive and cross-sectional study. PARTICIPANTS: All ME (1,839) which were notified by Primary Care Centres by notification system of safety incidents between January 1st 2016 and November 17th 2016. MAIN MEASUREMENTS: Setting, real harm, potential harm, and cause of error. These items were classified by one researcher. Concordance was checked with another researcher. RESULTS: Just under half (47%) (95% CI: 44.8%-49.3%) of ME occurred in Primary Care Centre, 26.5% (95% CI: 24.5%-28.6%) of ME were patient medication errors, and 27.5% (95% CI: 24.1%-30.8%) of ME were potential severe harm errors. Prescribing errors were the cause of most ME in Primary Care Centre [27.4% (95% CI: 24.4%-30.4%)]. Communication between patients and doctors were the cause of most patient medication errors [66% (95% CI: 61.8%-70.2%)]. Patient mistakes and forgetfulness were also causes of patient medication errors. CONCLUSIONS: Half of all mediation errors hppened at Primary Care Center while one quarter of them were patient medication errors. One quarter of all ME were potential severe harm errors. The main causes were prescribing errors, failure of communication between patients and doctors, and patient mistakes and forgetfulness. Prescribing aid systems, communication improvements and patients aids should be implemented.

Identifying medication errors in neonatal intensive care units: a two-center study.

BACKGROUND: This study aimed to assess the types and frequency of medication errors in our NICUs (neonatal intensive care units). METHODS: This descriptive cross-sectional study was conducted on two neonatal intensive care units of two hospitals over 3 months. Demographic information, drug information and total number of prescriptions for each neonate were extracted from medical records and assessed. RESULTS: A total of 688 prescriptions for 44 types of drugs were checked for the assessment of medical records of 155 neonates. There were 509 medication errors, averaging (SD) 3.38 (+/- 5.49) errors per patient. Collectively, 116 neonates (74.8%) experienced at least one medication error. Term neonates and preterm neonates experienced 125 and 384 medication errors, respectively. The most frequent medication errors were wrong dosage by physicians in prescription phase [WU1] (142 errors; 28%) and not administering medication by nurse in administration phase (146 errors; 29%). Of total 688 prescriptions, 127 errors were recorded. In this regard, lack of time and/or date of order were the most common errors. CONCLUSIONS: The most frequent medication errors were wrong dosage and not administering the medication to patient, and on the quality of prescribing, lack of time and/or date of order was the most frequent one. Medication errors happened more frequently in preterm neonates (P < 0.001). We think that using computerized physician order entry (CPOE) system and increasing the nurse-to-patient ratio can reduce the possibility of medication errors.

Epidemiology of and Risk Factors for Harmful Anti-Infective Medication Errors in a Pediatric Hospital.

BACKGROUND: Literature is limited on pediatric anti-infective medication errors. There is a pressing need for additional research, as studies suggest high rates of overall pediatric medication errors and known harmful side effect profiles for anti-infective medications with narrow dosing ranges. This study aimed to identify risk factors related to harmful anti-infective medication errors in pediatric patients. METHODS: A retrospective chart review of all voluntary error reports involving anti-infective medication errors and pediatric patients (0 to < 22 years old) reported June 2014-December 2015 was conducted. Error reports were generated using the hospital's general error reporting system and a pharmacy-based patient surveillance reporting system and were stratified based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index. Harmful errors were compared to nonharmful errors using Fisher's exact test. RESULTS: Of 338 anti-infective medication-related error reports, 13.6% of voluntarily reported errors reached the patient and 1.5% resulted in harm to the patient and required additional monitoring, interventions, and/or prolonged hospitalization. Antibacterials comprised 93.8% of all error reports, with beta-lactams (63.0%), macrolides (6.5%) and glycopeptides (6.2%) the most common classes. When using Fisher's exact test to compare harmful and nonharmful medication errors, the risk factor significantly associated with harmful errors was anti-infective class (p = 0.001). CONCLUSION: Voluntarily reported anti-infective medication errors within the pediatric patient population often reached the patient, and specific anti-infective medications are potentially of higher risk. Further investigation and additional quality and patient safety strategies may be needed for these higher-risk profile medications.

Period prevalence and reporting rate of medication errors among nurses in Iran: A systematic review and meta-analysis.

AIMS: To estimate the 1-year period prevalence of medication errors and the reporting rate to nurse managers among nurses working in hospitals in Iran. BACKGROUND: Medication errors are one of the main factors affecting the quality of hospital services and reducing patient safety in health care systems. METHOD: A literature search from Iranian and international scientific databases was developed to find relevant studies. Meta-regression was used to identify which characteristics may have a confounding effect on the pooled prevalence estimates. RESULTS: Based on the final 22 studies with 3556 samples, the overall estimated 1-year period prevalence of medication errors and its reporting rate to nurse managers among nurses were 53% (95% confidence interval, 41%-60%) and 36% (95% confidence interval, 23%-50%), respectively. The meta-regression analyses indicated that the sex (female/male) ratio was a statistically significant predictor of the prevalence of medication errors (p < .05), but not of the prevalence of reporting medication errors to nurse managers. CONCLUSION: The period prevalence of medication errors among nurses working in hospitals was high in Iran, whereas its reporting rate to nurse managers was low. IMPLICATIONS FOR NURSING MANAGEMENT: Continuous training programmes are required to reduce and prevent medication errors among nursing staff and to improve the reporting rate to nurse managers in in Iran.

Investigating health information systems-induced errors.

PURPOSE: The purpose of this paper is to present a review of health information system (HIS)-induced errors and its management. This paper concludes that the occurrence of errors is inevitable but it can be minimised with preventive measures. The review of classifications can be used to evaluate medical errors related to HISs using a socio-technical approach. The evaluation could provide an understanding of errors as a learning process in managing medical errors. DESIGN/METHODOLOGY/APPROACH: A literature review was performed on issues, sources, management and approaches to HISs-induced errors. A critical review of selected models was performed in order to identify medical error dimensions and elements based on human, process, technology and organisation factors. FINDINGS: Various error classifications have resulted in the difficulty to understand the overall error incidents. Most classifications are based on clinical processes and settings. Medical errors are attributed to human, process, technology and organisation factors that influenced and need to be aligned with each other. Although most medical errors are caused by humans, they also originate from other latent factors such as poor system design and training. Existing evaluation models emphasise different aspects of medical errors and could be combined into a comprehensive evaluation model. RESEARCH LIMITATIONS/IMPLICATIONS: Overview of the issues and discourses in HIS-induced errors could divulge its complexity and enable its causal analysis. PRACTICAL IMPLICATIONS: This paper helps in understanding various types of HIS-induced errors and promising prevention and management approaches that call for further studies and improvement leading to good practices that help prevent medical errors. ORIGINALITY/VALUE: Classification of HIS-induced errors and its management, which incorporates a socio-technical and multi-disciplinary approach, could guide researchers and practitioners to conduct a holistic and systematic evaluation.

The impact of a hospital electronic prescribing and medication administration system on medication administration safety: an observational study.

BACKGROUND: The aim of the study was to explore the impact of the implementation of an electronic prescribing and medication administration system (ePA) on the safety of medication administration in an inpatient hospital setting. Objectives were to compare the prevalence and types of: 1) medication administration errors, and 2) documentation discrepancies, between a paper and an ePA system. Additionally, we wanted to describe any observed changes to medication administration practices. METHODS: The study was based on an elderly medicine ward in an English hospital. From December 2014 to June 2015, nurses' medication administration rounds were observed every 5 days before and after ePA implementation using an interrupted time-series approach. Medication administration error and documentation discrepancy rates pre- versus post-ePA were analysed descriptively and chi-squared tests used to test for any difference; segmented regression analysis was used to determine changes in longitudinal trend. RESULTS: Observations were made at 15 pre- and 15 post-ePA implementation time-points. Pre-ePA on paper, there were 18 medication administration errors in 428 opportunities for error (4.2%; 95% confidence interval 2.3-6.1%), and with ePA there were 18 in 528 (3.4%; 95% confidence interval 1.9-5.0%; p = 0.64). Regarding documentation, pre-ePA on paper there were 5 discrepancies in 460 observed documentations (1.1%; 95% confidence interval 0.1-2.0%); with ePA there were 18 in 557 (3.2%; 95% confidence interval 1.8-4.7%; p = 0.04). The most common electronic documentation discrepancy was documentation that a dose had been administered when it had not. Segmented regression analysis was unable to detect any significant longitudinal changes. Changes to working practices post-ePA were observed, such as nurses demonstrating less-consistent self-checking when preparing and administering medications. CONCLUSIONS: Findings suggest no change in medication error rate, although ePA encourages certain types of errors and mitigates others. There was a statistically significant increase in documentation discrepancies which is likely to be due to adoption of new working practices with ePA.

[Errors in prescriptions and their preparation at the outpatient pharmacy of a regional hospital]. / Errores en las recetas médicas y en la preparación de estas en farmacia de pacientes ambulatorios: El caso del Hospital de Nueva Imperial.

BACKGROUND: Adverse effects of medications are an important cause of morbidity and hospital admissions. Errors in prescription or preparation of medications by pharmacy personnel are a factor that may influence these occurrence of the adverse effects Aim: To assess the frequency and type of errors in prescriptions and in their preparation at the pharmacy unit of a regional public hospital. MATERIAL AND METHODS: Prescriptions received by ambulatory patients and those being discharged from the hospital, were reviewed using a 12-item checklist. The preparation of such prescriptions at the pharmacy unit was also reviewed using a seven item checklist. RESULTS: Seventy two percent of prescriptions had at least one error. The most common mistake was the impossibility of determining the concentration of the prescribed drug. Prescriptions for patients being discharged from the hospital had the higher number of errors. When a prescription had more than two drugs, the risk of error increased 2.4 times. Twenty four percent of prescription preparations had at least one error. The most common mistake was the labeling of drugs with incomplete medical indications. When a preparation included more than three drugs, the risk of preparation error increased 1.8 times. CONCLUSIONS: Prescription and preparation of medication delivered to patients had frequent errors. The most important risk factor for errors was the number of drugs prescribed.

Use of failure mode effect analysis (FMEA) to improve medication management process.

Purpose Medication management is a complex process, at high risk of error with life threatening consequences. The focus should be on devising strategies to avoid errors and make the process self-reliable by ensuring prevention of errors and/or error detection at subsequent stages. The purpose of this paper is to use failure mode effect analysis (FMEA), a systematic proactive tool, to identify the likelihood and the causes for the process to fail at various steps and prioritise them to devise risk reduction strategies to improve patient safety. Design/methodology/approach The study was designed as an observational analytical study of medication management process in the inpatient area of a multi-speciality hospital in Gurgaon, Haryana, India. A team was made to study the complex process of medication management in the hospital. FMEA tool was used. Corrective actions were developed based on the prioritised failure modes which were implemented and monitored. Findings The percentage distribution of medication errors as per the observation made by the team was found to be maximum of transcription errors (37 per cent) followed by administration errors (29 per cent) indicating the need to identify the causes and effects of their occurrence. In all, 11 failure modes were identified out of which major five were prioritised based on the risk priority number (RPN). The process was repeated after corrective actions were taken which resulted in about 40 per cent (average) and around 60 per cent reduction in the RPN of prioritised failure modes. Research limitations/implications FMEA is a time consuming process and requires a multidisciplinary team which has good understanding of the process being analysed. FMEA only helps in identifying the possibilities of a process to fail, it does not eliminate them, additional efforts are required to develop action plans and implement them. Frank discussion and agreement among the team members is required not only for successfully conducing FMEA but also for implementing the corrective actions. Practical implications FMEA is an effective proactive risk-assessment tool and is a continuous process which can be continued in phases. The corrective actions taken resulted in reduction in RPN, subjected to further evaluation and usage by others depending on the facility type. Originality/value The application of the tool helped the hospital in identifying failures in medication management process, thereby prioritising and correcting them leading to improvement.

The medication reconciliation process and classification of discrepancies: a systematic review.

AIMS: Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has been conducted and how medication discrepancies have been classified. METHODS: We searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstracts (IPA), and Web of Science (WOS), in accordance with the PRISMA statement up to April 2016. Studies were eligible for inclusion if they evaluated the types of medication discrepancy found through the medication reconciliation process and contained a classification system for discrepancies. Data were extracted by one author based on a predefined table, and 10% of included studies were verified by two authors. RESULTS: Ninety-five studies met the inclusion criteria. Approximately one-third of included studies (n = 35, 36.8%) utilized a 'gold' standard medication list. The majority of studies (n = 57, 60%) used an empirical classification system and the number of classification terms ranged from 2 to 50 terms. Whilst we identified three taxonomies, only eight studies utilized these tools to categorize discrepancies, and 11.6% of included studies used different patient safety related terms rather than discrepancy to describe the disagreement between the medication lists. CONCLUSIONS: We suggest that clear and consistent information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well-designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice.

Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints.

OBJECTIVE: To explore the applicability of a patient complaint taxonomy to data on serious complaint cases. DESIGN: Qualitative descriptive study. SETTING: Complaints made to the New South Wales (NSW) Health Care Complaints Commission, Australia between 2005 and 2010. PARTICIPANTS: All 138 cases of serious complaints by patients about public hospitals and other health facilities investigated in the 5-year period. MAIN OUTCOME MEASURE: A thematic analysis of the complaints was conducted to identify particular complaint issues and the Reader et al. (Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf 2014;23:678-89.) patient complaint taxonomy was then used to classify these issues into categories and sub-categories. RESULTS: The 138 investigated cases revealed 223 complaint issues. Complaint issues were distributed into the three domains of the patient complaint taxonomy: clinical, management and relationships. Complaint issue most commonly related to delayed diagnosis, misdiagnosis, medication errors, inadequate examinations, inadequate/nil treatment and quality of care including nursing care. CONCLUSIONS: The types of complaints from patients about their healthcare investigated by the NSW Commission were similar to those received by other patient complaint entities in Australia and worldwide. The application of a standard taxonomy to large numbers of complaints cases from different sources would enable the creation of aggregated data. Such data would have better statistical capacity to identify common safety and quality healthcare problems and so point to important areas for improvement. Some conceptual challenges in devising and using a taxonomy must be addressed, such as inherent problems in ensuring coding consistency, and giving greater weight to patient concerns about their treatment.

Errors in preparation and administration of parenteral drugs in neonatology: evaluation and corrective actions.

BACKGROUND: The medication iatrogenic risk is quite unevaluated in neonatology Objective: Assessment of errors that occurred during the preparation and administration of injectable medicines in a neonatal unit in order to implement corrective actions to reduce the occurrence of these errors. METHODS: A prospective, observational study was performed in a neonatal unit over a period of one month. The practice of preparing and administering injectable medications were identified through a standardized data collection form. These practices were compared with summaries of the characteristics of each product (RCP) and the bibliography. RESULTS: One hundred preparations were observed of 13 different drugs. 85 errors during preparations and administration steps were detected. These errors were divided into preparation errors in 59% of cases such as changing the dilution protocol (32%), the use of bad solvent (11%) and administration errors in 41% of cases as errors timing of administration (18%) or omission of administration (9%). CONCLUSION: This study showed a high rate of errors during stages of preparation and administration of injectable drugs. In order to optimize the care of newborns and reduce the risk of medication errors, corrective actions have been implemented through the establishment of a quality assurance system which consisted of the development of injectable drugs preparation procedures, the introduction of a labeling system and staff training.

Learning from no-fault treatment injury claims to improve the safety of older patients.

New Zealand's treatment injury compensation claims data set provides an uncommon no-fault perspective of patient safety incidents. Analysis of primary care claims data confirmed medication as the leading threat to the safety of older patients in primary care and drew particular attention to the threat posed by antibiotics. For most injuries there was no suggestion of error. The no-fault perspective reveals the greatest threat to the safety of older patients in primary care to be, not error, but the risk posed by treatment itself. To improve patients' safety, in addition to reducing error, clinicians need to reduce patients' exposure to treatment risk, where appropriate.

Analysis of medication prescribing errors in critically ill children.

UNLABELLED: Medication prescribing errors (MPE) can result in serious consequences for patients. In order to reduce errors, we need to know more about the frequency, the type and the severity of such errors. We therefore performed a prospective observational study to determine the number and type of medication prescribing errors in critically ill children in a paediatric intensive care unit (PICU). Prescribing errors were prospectively identified by a clinical pharmacist. A total of 1129 medication orders were analysed. There were 151 prescribing errors, giving an overall error rate of 14 % (95 % CI 11 to 16). The medication groups with the highest proportion of MPEs were antihypertensives, antimycotics and drugs for nasal preparation with error rates of each 50 %, followed by antiasthmatic drugs (25 %), antibiotics (15 %) and analgesics (14 %). One hundred four errors (70 %) were classified as MPEs which required interventions and/or resulted in patient harm equivalent to 9 % of all medication orders (95 % CI 6.5 to 14.4). Forty-five MPEs (30 %) did not result in patient harm. CONCLUSION: With a view to reduce MPEs and to improve patient safety, our data may help to prevent errors before they occur. WHAT IS KNOWN: • Prescribing errors may be the most frequent medication errors. • In paediatric populations, the incidence of prescribing errors is higher than in adults. What is New: • Several risk factors for medication prescribing errors, such as medication groups, long PICU stay, and mechanical ventilation could be presented. • Analysing the combination of the most frequent prescribing errors and the severity of these errors.

What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system.

OBJECTIVES: To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. DESIGN: Audit of 3291 patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as 'clinically important'. SETTING: Two major academic teaching hospitals in Sydney, Australia. MAIN OUTCOME MEASURES: Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. RESULTS: A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6-1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0-253.8), but only 13.0/1000 (95% CI: 3.4-22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4-28.4%) contained ≥ 1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. CONCLUSIONS: Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

[Developing a terminology in the French language for clinical practice and research in drug safety]. / Iatrogénie médicamenteuse : contribution à l'uniformisation de la terminologie en langue française pour la pratique de soins et la recherche clinique.

While several attempts have been made to clarify the English terminology of drug-related iatrogeny, a consensus has still not been reached in the French language. We set up a multidisciplinary task force to propose a terminology that differs from the one used in pharmacovigilance and risk management. We prefer the term "adverse drug event" (ADE) over "adverse drug reaction", and recommend avoiding the term "adverse event", which is too general. We propose to classify ADEs as "direct drug effect" or "drug involvement in a multifactorial pathological condition", taking into account the close relationship commonly found between drug and non-drug etiologies of a pathology. The consistent association between the notions "error" and "preventability" is also questionable, and we suggest assessing the "ameliorability" of ADEs rather than their "preventability". "Misuse" (i.e., the non-respect by the patient of the drug label) must be distinguished from "off-label use or substance abuse".

Identifying high-risk medication: a systematic literature review.

PURPOSE: A medication error (ME) is an error that causes damage or poses a threat of harm to a patient. Several studies have shown that only a minority of MEs actually causes harm, and this might explain why medication reviews at hospital admission reduce the number of MEs without showing an effect on length of hospital stay, readmissions, or death. The purpose of this study was to define drugs that actually cause serious MEs. We conducted a literature search of medication reviews and other preventive efforts. METHODS: A systematic search in PubMed, Embase, Cochrane Reviews, Psycinfo, and SweMed+ was performed. Danish databases containing published patient complaints, patient compensation, and reported medication errors were also searched. Articles and case reports were included if they contained information of an ME causing a serious adverse reaction (AR) in a patient. Information concerning AR seriousness, causality, and preventability was required for inclusion. RESULTS: This systematic literature review revealed that 47 % of all serious MEs were caused by seven drugs or drug classes: methotrexate, warfarin, nonsteroidal anti-inflammatory drugs (NSAIDS), digoxin, opioids, acetylic salicylic acid, and beta-blockers; 30 drugs or drug classes caused 82 % of all serious MEs. The top ten drugs involved in fatal events accounted for 73 % of all drugs identified. CONCLUSION: Increasing focus on seven drugs/drug classes can potentially reduce hospitalizations, extended hospitalizations, disability, life-threatening conditions, and death by almost 50 %.

Frequency, types, and direct related costs of medication errors in an academic nephrology ward in Iran.

Medication errors are ongoing problems among hospitalized patients especially those with multiple co-morbidities and polypharmacy such as patients with renal diseases. This study evaluated the frequency, types and direct related cost of medication errors in nephrology ward and the role played by clinical pharmacists. During this study, clinical pharmacists detected, managed, and recorded the medication errors. Prescribing errors including inappropriate drug, dose, or treatment durations were gathered. To assess transcription errors, the equivalence of nursery charts and physician's orders were evaluated. Administration errors were assessed by observing drugs' preparation, storage, and administration by nurses. The changes in medications costs after implementing clinical pharmacists' interventions were compared with the calculated medications costs if the medication errors were continued up to patients' discharge time. More than 85% of patients experienced medication error. The rate of medication errors was 3.5 errors per patient and 0.18 errors per ordered medication. More than 95% of medication errors occurred at prescription nodes. Most common prescribing errors were omission (26.9%) or unauthorized drugs (18.3%) and low drug dosage or frequency (17.3%). Most of the medication errors happened on cardiovascular drugs (24%) followed by vitamins and electrolytes (22.1%) and antimicrobials (18.5%). The number of medication errors was correlated with the number of ordered medications and length of hospital stay. Clinical pharmacists' interventions decreased patients' direct medication costs by 4.3%. About 22% of medication errors led to patients' harm. In conclusion, clinical pharmacists' contributions in nephrology wards were of value to prevent medication errors and to reduce medications cost.

Immunisation errors reported to a vaccine advice service: intelligence to improve practice.

BACKGROUND: The success of immunisation programmes depends on the quality with which they are administered. The Vaccine Advice for CliniCians Service (VACCSline) is an advice service to support immunisers and promote excellence in immunisation practice, through specialist guidance and local education, covering a catchment population of two million people. All enquiries are recorded onto a database and categorised. Vaccine error is selected when a vaccine has not been prepared or administered according to national recommendations or relevant expert guidance. METHOD: All enquiries from 2009 to 2011, categorised on the VACCSline database as 'vaccine error' were analysed and subjected to a detailed free-text review. RESULTS: Of 4301 enquiries, 158 (3.7%) concerned vaccine errors. The greatest frequency of errors, 145 (92.9%) concerned immunisations delivered in primary care services; 92% of all errors occurred during either vaccine selection and preparation or history checking and scheduling. Administration of the wrong vaccine was the most frequent error recorded in 33.3% of reports. A shared first letter of the vaccine name was noted to occur in 13 error reports in which the incorrect vaccine was inadvertently administered. Consultations involving pairs of siblings were associated with various errors in seven enquiries. Failure to revaccinate after spillage (seven reports) showed a widespread knowledge gap in this area. CONCLUSION: Advice line enquiries provide intelligence to alert immunisers to the errors that are commonly reported and may serve to highlight processes that predispose to errors, thus informing immuniser training and updating.