Advanced prescription of injectable anticancer drugs: Safety assessment in a European Comprehensive Cancer Centre using the risk matrix approach.

AIMS: The purpose of this work was to assess failures in the advanced prescription of parenteral anticancer agents in an adult day oncology care unit with more than 100 patients per day. METHODS: An a priori descriptive analysis was carried out by using the risk matrix approach. After defining the scope in a multidisciplinary meeting, we determined at each step the failure modes (FMs), their effects (E) and their associated causes (C). A severity score (S) was assigned to all effects and a probability of occurrence (O) to all causes. These S and O indicators, were used to obtain a criticality index (CI) matrix. We assessed the risk control (RC) of each failure in order to define a residual criticality index (rCI) matrix. RESULTS: During risk analysis, 14 FMs were detected, and 61 scenarios were identified considering all possible effects and causes. Nine situations (15%) were highlighted with the maximum CI, 18 (30%) with a medium CI, and 34 (55%) with a negligible CI. Nevertheless, among all these critical situations, only three (5%) had an rCI to process (i.e., missed dose adjustment, multiple prescriptions and abnormal biology data); the others required monitoring only. Clinicians' and pharmacists' knowledge of these critical situations enables them to manage the associated risks. CONCLUSIONS: Advanced prescription of injectable anticancer drugs appears to be a safe practice for patients when combined with risk management. The major risks identified concerned missed dose adjustment, prescription duplication and lack of consideration for abnormal biology data.

Standardization of the Verification Nurse Role in the Delivery of Chemotherapy and Biotherapy.

After a chemotherapy overdose in 1994 resulted in the death of one patient and the permanent injury of another, the role of the verification nurse was created at a National Cancer Institute-designated comprehensive cancer c.

Prevalence and factors predisposing to potential drug-drug interactions in a Polish community-dwelling geriatric population: An observational, cross-sectional study.

BACKGROUND: Due to advanced age, multimorbidity and polypharmacotherapy, older patients are predisposed to drug interactions and the adverse effects of inappropriate drug combinations. OBJECTIVES: To provide up-to-date data on predisposing factors and the prevalence of possible drug interactions in the Polish geriatric population and to promote automated analysis programs as part of safe pharmacotherapy. MATERIAL AND METHODS: We used the Lexicomp® Drug Interactions database to assess pharmacological interactions between active substances included in all types of preparations (prescription drugs, over-the-counter drugs, vitamins, nutritional preparations, and dietary supplements) used at least once in the 2 weeks preceding the study, among 2633 home-dwelling people aged >65 years. The variables measured included age, sex, place of residence, level of education, and multimorbidity. Post-stratification was used to weigh the sample structure against the Polish population in 2017. RESULTS: Drug interactions were identified in 81.2% of all individuals. The mean number (with 95% confidence interval (95% CI)) of all drug interactions was 4.24 (4.02-4.46), and the median value (with 1st and 3rd quartiles (Q1-Q3)) was 3 (1-6). At least 1 category C interaction was observed in 75.8% of all study participants, 24.3% had 1 or more category D interaction, and 4.3% had 1 or more category X interaction. The most important predisposing factor to drug interactions was multimorbidity. CONCLUSIONS: This study identified a high prevalence of potential drug interactions in the Polish geriatric population. Automated analysis systems deliver useful information on pharmacological interactions and should be promoted in the Polish healthcare community as tools to support pharmacotherapy.

Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study.

AIMS AND OBJECTIVES: To identify the prevalence and determinants of medication administration errors (MAEs). BACKGROUND: Insight into determinants of MAEs is necessary to identify interventions to prevent MAEs. DESIGN: A prospective observational study in two Dutch hospitals, a university and teaching hospital. METHODS: Data were collected by observation. The primary outcome was the proportion of administrations with one or more MAEs. Secondary outcomes were the type, severity and determinants of MAEs. Multivariable mixed-effects logistic regression analyses were used for determinant analysis. Reporting adheres to the STROBE guideline. RESULTS: MAEs occurred in 352 of 2576 medication administrations (13.7%). Of all MAEs (n = 380), the most prevalent types were omission (n = 87) and wrong medication handling (n = 75). Forty-five MAEs (11.8%) were potentially harmful. The pharmaceutical forms oral liquid (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43-7.25), infusion (OR 1.73, CI 1.02-2.94), injection (OR 3.52, CI 2.00-6.21), ointment (OR 10.78, CI 2.10-55.26), suppository/enema (OR 6.39, CI 1.13-36.03) and miscellaneous (OR 6.17, CI 1.90-20.04) were more prone to MAEs compared to oral solid. MAEs were more likely to occur when medication was administered between 10 a.m.-2 p.m. (OR 1.91, CI 1.06-3.46) and 6 p.m.-7 a.m. (OR 1.88, CI 1.00-3.52) compared to 7 a.m.-10 a.m. and when administered by staff with higher professional education compared to staff with secondary vocational education (OR 1.68, CI 1.03-2.74). MAEs were less likely to occur in the teaching hospital (OR 0.17, CI 0.08-0.33). Day of the week, patient-to-nurse ratio, interruptions and other nurse characteristics (degree, experience, employment type) were not associated with MAEs. CONCLUSIONS: This study identified a high MAE prevalence. Identified determinants suggest that focusing interventions on complex pharmaceutical forms and error-prone administration times may contribute to MAE reduction. RELEVANCE TO CLINICAL PRACTICE: The findings of this study can be used to develop targeted interventions to improve patient safety.

Impact of a standardized order set and medication-use process on medication error rates in sexual assault patients presenting to the emergency department for HIV nonoccupational postexposure prophylaxis.

PURPOSE: To evaluate the impact of a standardized order set and medication-use process on antiretroviral medication errors in sexual assault (SA) patients presenting to the emergency department (ED) for nonoccupational postexposure prophylaxis (nPEP). METHODS: In November 2019, a multidisciplinary group collaborated on an initiative to improve the nPEP medication-use process for SA patients presenting to the EDs within a large integrated health system. Electronic medical records of patients 13 years of age or older who presented for SA examination and were prescribed nPEP during the pre- (February 2018-August 2019) and poststandardization (February 2020-August 2021) periods were included. The primary objective was to compare the proportion of patients experiencing a medication error before and after SA/nPEP process standardization. Data regarding the following medication errors were evaluated: incomplete regimen; inappropriate/duplicative regimen; dosing, frequency, or quantity prescribed error; and initiation of nPEP without an HIV test. RESULTS: Two hundred six patients met criteria for inclusion. A higher proportion of patients experienced medication errors in the prestandardization group relative to the poststandardization group (46.5% vs 11.9%, P < 0.001). Fifty-five errors were observed in the prestandardization group, compared to 16 errors in the poststandardization group. The majority of errors in the prestandardization group were directly related to antiretroviral regimens, while the majority of errors in the poststandardization group involved initiation of nPEP without an HIV test. CONCLUSION: The standardization of the SA/nPEP process was associated with significantly lower medication error rates. Optimization of medication-use technology is an effective strategy in reducing medication errors.

An umbrella review of systematic reviews on contributory factors to medication errors in health-care settings.

INTRODUCTION: Medication errors are common events that compromise patient safety and are prevalent in all health-care settings. This umbrella review aims to systematically evaluate the evidence on contributory factors to medication errors in health-care settings in terms of the nature of these factors, methodologies and theories used to identify and classify them, and the terminologies and definitions used to describe them. AREAS COVERED: Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and Google Scholar were searched from inception to March 2022. The data extraction form was derived from the Joanna Briggs Institute (JBI) Reviewers' Manual, and critical appraisal was conducted using the JBI quality assessment tool. A narrative approach to data synthesis was adopted. EXPERT OPINION: Twenty-seven systematic reviews were included, most of which focused on a specific health-care setting or clinical area. Decision-making mistakes such as non-consideration of patient risk factors most commonly led to error, followed by organizational and environmental factors (e.g. understaffing and distractions). Only 10 studies had a pre-specified methodology to classify contributory factors, among which the use of theory, specifically Reason's theory was commonly used. None of the reviews evaluated the effectiveness of interventions in preventing errors. The collated contributory factors identified in this umbrella review can inform holistic theory-based intervention development.

Modelling and assessing one- and two-drug dose titrations.

In health-care, there is a need to quantify medical errors. Among these errors, we observe wrong dose prescriptions. Drug dose titration (DT) is the process by which dosage is progressively adjusted to the patient till a steady dose is reached. Depending on the clinical disease, drug, and patient condition, dose titration can follow different procedures. Once modeled, these procedures can serve for clinical homogenization, standardization, decision support and retrospective analysis. Here, we propose a language to model dose titration procedures. The language was used to formalize one- and two-drug titration of chronic and acute cases, and to perform retrospective analysis of the drug titration processes on 253 patients diagnosed of diabetes mellitus type 2 and treated with metformin, 321 patients treated of chonic heart failure with furosemide, 155 patients with hyperuricemia treated with allopurinol as initial drug and febuxostat as alternative drug, and 187 hyperuricemia patients with primary drug allopurinol and supplementary drug probenecid, in order to identify different types of drug titration deviations from standard DT methods.

Disseminated cryptococcosis by biological therapy: We must manage the risk / Criptococosis diseminada por terapia biológica, se debe gestionar el riesgo

Introduction: Multiple adverse effects have been described for the biological therapy in autoimmune diseases including many secondary to immunosuppression producing bacterial, fungal, or viral infections. Clinical case: We present the case of a 64-year-old female patient with proven disseminated cryptococcosis secondary to the use of tofacitinib. Other possible causes of immunosuppression such as the human immunodeficiency virus (HIV) were ruled out. The patient had been in treatment for rheumatoid arthritis diagnosed three years before. This drug is a biological agent that inhibits JAK enzymes. Very few cases of pulmonary and meningeal cryptococcosis in this type of patient have been described in the literature. Conclusion: This case report should be useful for other clinicians to bear in mind the possibility of this type of invasive fungal infection associated with biological therapy and to take a risk-management approach.

Introducción. Se han descrito múltiples efectos adversos con el uso de la terapia biológica para enfermedades autoinmunitarias, muchos de ellos secundarios al estado de inmunosupresión, como las infecciones bacterianas, fúngicas o virales. Caso clínico. Se presenta el caso de una mujer de 64 años con diagnóstico comprobado de criptococosis diseminada secundaria al uso de tofacitinib. Se descartaron otras causas de inmunosupresión, como infección por el virus de la inmunodeficiencia humana (HIV). Tres años antes se le había diagnosticado artritis reumatoide y se encontraba en tratamiento farmacológico con un agente biológico que inhibe las enzimas JAK. Se han descrito muy pocos casos de criptococosis pulmonar y meníngea en este tipo de pacientes. Conclusión. Este reporte de caso es útil para que otros médicos tratantes tengan presente la posibilidad de este tipo de infección fúngica invasora asociada con la terapia biológica y el enfoque de gestión de riesgo.

A Survey of Prescription Errors in Paediatric Outpatients in Multi-Primary Care Settings: The Implementation of an Electronic Pre-Prescription System.

Background: Prescription errors impact the safety and efficacy of therapy and are considered to have a higher impact on paediatric populations. Nevertheless, information in paediatrics is still lacking, particularly in primary care settings. There exists a need to investigate the prevalence and characteristics of prescription errors in paediatric outpatients to prevent such errors during the prescription stage. Methods: A cross-sectional study to evaluate paediatric prescription errors in multi-primary care settings was conducted between August 2019 and July 2021. Prescriptions documented within the electronic pre-prescription system were automatically reviewed by the system and then, potentially inappropriate prescriptions would be reconciled by remote pharmacists via a regional pharmacy information exchange network. The demographics of paediatric patients, prescription details, and types/rates of errors were assessed and used to identify associated factors for prescription using logistic regression. Results: A total of 39,754 outpatient paediatric prescriptions in 13 community health care centres were reviewed, among which 1,724 prescriptions (4.3%) were enrolled in the study as they met the inclusion criteria. Dose errors were the most prevalent (27%), with the predominance of underdosing (69%). They were followed by errors in selection without specified indications (24.5%), incompatibility (12.4%), and frequency errors (9.9%). Among critical errors were drug duplication (8.7%), contraindication (.9%), and drug interaction (.8%) that directly affect the drug's safety and efficacy. Notably, error rates were highest in medications for respiratory system drugs (50.5%), antibiotics (27.3%), and Chinese traditional medicine (12.3%). Results of logistic regression revealed that specific drug classification (antitussives, expectorants and mucolytic agents, anti-infective agents), patient age (<6 years), and prescriber specialty (paediatrics) related positively to errors. Conclusion: Our study provides the prevalence and characteristics of prescription errors of paediatric outpatients in community settings based on an electronic pre-prescription system. Errors in dose calculations and medications commonly prescribed in primary care settings, such as respiratory system drugs, antibiotics, and Chinese traditional medicine, are certainly to be aware of. These results highlight an essential requirement to update the rules of prescriptions in the pre-prescription system to facilitate the delivery of excellent therapeutic outcomes.

Criptococosis diseminada por terapia biológica, se debe gestionar el riesgo / Disseminated cryptococcosis by biological therapy: We must manage the risk

Introducción. Se han descrito múltiples efectos adversos con el uso de la terapia biológica para enfermedades autoinmunitarias, muchos de ellos secundarios al estado de inmunosupresión, como las infecciones bacterianas, fúngicas o virales. Caso clínico. Se presenta el caso de una mujer de 64 años con diagnóstico comprobado de criptococosis diseminada secundaria al uso de tofacitinib. Se descartaron otras causas de inmunosupresión, como infección por el virus de la inmunodeficiencia humana (HIV). Tres años antes se le había diagnosticado artritis reumatoide y se encontraba en tratamiento farmacológico con un agente biológico que inhibe las enzimas JAK. Se han descrito muy pocos casos de criptococosis pulmonar y meníngea en este tipo de pacientes. Conclusión. Este reporte de caso es útil para que otros médicos tratantes tengan presente la posibilidad de este tipo de infección fúngica invasora asociada con la terapia biológica y el enfoque de gestión de riesgo.

Introduction: Multiple adverse effects have been described for the biological therapy in autoimmune diseases including many secondary to immunosuppression producing bacterial, fungal, or viral infections. Clinical case: We present the case of a 64-year-old female patient with proven disseminated cryptococcosis secondary to the use of tofacitinib. Other possible causes of immunosuppression such as the human immunodeficiency virus (HIV) were ruled out. The patient had been in treatment for rheumatoid arthritis diagnosed three years before. This drug is a biological agent that inhibits JAK enzymes. Very few cases of pulmonary and meningeal cryptococcosis in this type of patient have been described in the literature. Conclusion: This case report should be useful for other clinicians to bear in mind the possibility of this type of invasive fungal infection associated with biological therapy and to take a risk-management approach.

A communication procedure between community pharmacists and primary care professionals resolves medication errors and other administrative issues.

OBJECTIVES: The aim of this study was to implement a communication procedure, with agreed-upon protocols, to resolve daily medication errors and other administrative issues that require communication between community pharmacists (CPs) and primary healthcare professionals (PHCPs). METHODS: A 6-month pilot study followed by a year-length principal study was carried out in the Donostialdea Integrated Healthcare Organisation (IHO). Afterwards, the project was extended to other IHOs. The CPs identified medication errors or other administrative issues that required communication with PHCPs, contacting the customer service staff by telephone for urgent problems and by email for non-urgent problems. KEY FINDINGS: In total, 49 community pharmacies participated in the study. A total of 1179 medication errors and other administrative issues were detected, and over 90% of problems were solved in less than 24 h (n = 1079, 91.5%). Email was the more frequently used communication method (n = 874, 74.1%), and the most prevalent problems were due to absent (n = 766, 65.0%) and expired (n = 226, 19.2%) electronic prescriptions. Most of the participants were satisfied with the programme. CONCLUSION: The present communication procedure between CPs and PHCPs is an efficient tool to resolve a variety of challenges that occur in community pharmacies.

Evaluación de una intervención para mejora en la administración segura de medicación en el turno de noche / An Intervention to Improve Safe Administration of Medication in the Night Shift

Introducción: Uno de cada siete pacientes hospitalizados experimenta un evento adverso relacionado con la administración de medicación. Los errores de medicación son una de las causas más importantes de mortalidad y morbilidad prevenible. Objetivo: Evaluar la eficacia de una intervención formativa sobre la población de enfermeras de turno de noche de un hospital de agudos para mejorar el cumplimiento del protocolo de administración segura de medicación. Métodos: Ensayo experimental, pre-post intervención formativa, realizado en Hospital Clínic de Barcelona, durante 2015-2016. Población: 268 enfermeras en dos turnos de noche, muestra: 177 participantes (88 Grupo Control y 89 Grupo Experimental). La intervención consistió en sesiones informativas y acceso a Procedimiento escrito. El instrumento de medida fue el Procedimiento Normalizado de Trabajo de la institución mediante check-list de cumplimiento. Se realzó estudio uni-bivariable, mediante Chi2 y test de Fisher con significancia para p < 0,05. Resultados: Se realizaron 219 observaciones en Grupo Control y 207 en Grupo Experimental. De 17 variables analizadas, solo tres mostraron diferencias significativas: en Grupo Experimental mejoró el conocimiento del Procedimiento; se incrementó el uso del agua y jabón sobre la solución hidroalcohólica; y empeoró la identificación normalizada de fármacos pendientes de administrar. Ninguna de las 14 variables restantes mostró diferencias significativas. De 426 observaciones, solo se produjeron 3 errores de medicación en Grupo control, subsanados antes de su administración, y 0 en Grupo Experimental. Conclusiones: Las intervenciones formativas clásicas con receptores pasivos pueden no ser eficaces para mejorar la práctica enfermera en administración segura de medicación(AU)

Introduction: One in seven hospitalized patients experiences an adverse event related to administration of medication. Medication errors are one of the most important causes of preventable mortality and morbidity. Objective: To assess the efficacy of a training intervention with the population of night shift nurses in an acute care hospital, in order to improve compliance with the protocol for the safe administration of medication. Methods: Experimental trial, pre-post training intervention, carried out at Hospital Clínic of Barcelona, during 2015-2016. The population consisted of 268 nurses in two night shifts. The sample consisted of 177 participants (88 from the control group and 89 from the experimental group). The intervention consisted in information sessions and access to a written procedure. The measurement instrument was the Institution's Standard Work Procedure by means of a compliance check-list. Uni-bivariate study was performed, using chi-square and Fisher's test with a significance of P < 0.05. Results: 219 observations were carried out in the control group and 207, in the experimental group. Of seventeen variables analyzed, only three showed significant differences: in the experimental group, knowledge of the procedure improved, increase in the use of soap and water over hydroalcoholic solution, and worsening of standardized identification of drugs pending from being administered. None of the fourteen remaining variables showed significant differences. Of 426 observations, only three medication errors occurred in the control group, corrected before its administration, and zero occurred in the experimental group. Conclusions: Classic training interventions with passive receptors may not be effective to improve nursing practice in safe administration of medication(AU)

Prescribing patterns and drug-related problems (DRPs) in transfusion-dependent paediatric thalassemia patients: A prospective interventional study from a tertiary care hospital in India.

BACKGROUND: Each year nearly 10,000 children with thalassaemia major are born in India, but among them, very few are optimally managed mainly in urban regions even though the Government of India has incorporated their care and treatment in the 12th Five-Year Plan. Data on prescribing patterns and drug-related problems (DRPs) in paediatric thalassaemia patients in India are limited. METHODS: In this prospective interventional study, the medications prescribed were recorded after reviewing the treatment charts, thalassaemia register, thalassaemia card, nurses' notes, as well as discharge summaries. When DRPs and/or medication errors were identified, the same was discussed with the concerned health care professionals and suitable suggestions were made at the earliest. RESULTS: Out of the enrolled 54 patients, only 94% (n = 51) of the patients received iron chelation therapy with deferasirox and/or deferiprone, Folic acid tablet was prescribed for 100% of the patients (n = 54). Five percent of patients (n = 3) had undergone splenectomy and was prescribed with amoxicillin prophylactically. There were a total of 16 DRPs and 15 medication errors were identified and suitable measurements were taken to solve these problems. CONCLUSIONS: The prescribing patterns, DRPs and medication errors in transfusion-dependent paediatric thalassaemia patients were discussed in this study. Our study was effective in identifying and solving the DRPs and medication problems that occurred in thalassaemia patients.

Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol.

BACKGROUND: Use of direct oral anticoagulants (DOAC) is rapidly growing for treatment of atrial fibrillation and venous thromboembolism. However, incorrect dosing of these medications is common and puts patients at risk of adverse drug events. One way to improve safe prescribing is the use of population health tools, including interactive dashboards built into the electronic health record (EHR). As such tools become more common, exploring ways to understand which aspects are effective in specific settings and how to effectively adapt and implement in existing anticoagulation clinics across different health systems is vital. METHODS: This three-phase project will evaluate a current nation-wide implementation effort of the DOAC Dashboard in the Veterans Health Administration (VHA) using both quantitative and qualitative methods. Informed by this evaluation, the DOAC Dashboard will be implemented in four new health systems using an implementation strategy derived from the VHA experience and interviews with providers in those new health systems. Quantitative evaluation of the VHA and non-VHA implementation will follow the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Qualitative interviews with stakeholders will be analyzed using the Consolidated Framework for Implementation Research and Technology Acceptance Models to identify key determinants of implementation success. DISCUSSION: This study will (1) evaluate the implementation of an EHR-based population health tool for medication management within a large, nation-wide, highly integrated health system; (2) guide the adoption in a set of four different health systems; and (3) evaluation that multi-center implementation effort. These findings will help to inform future EHR-based implementation efforts in a wide variety of health care settings.

Individual Circadian Preference, Shift Work, and Risk of Medication Errors: A Cross-Sectional Web Survey among Italian Midwives.

BACKGROUND: In order to explore the possible association between chronotype and risk of medication errors and chronotype in Italian midwives, we conducted a web-based survey. The questionnaire comprised three main components: (1) demographic information, previous working experience, actual working schedule; (2) individual chronotype, either calculated by Morningness-Eveningness Questionnaire (MEQ); (3) self-perception of risk of medication error. RESULTS: Midwives (n = 401) responded "yes, at least once" to the question dealing with self-perception of risk of medication error in 48.1% of cases. Cluster analysis showed that perception of risk of medication errors was associated with class of age 31-35 years, shift work schedule, working experience 6-10 years, and Intermediate-type MEQ score. CONCLUSIONS: Perception of the risk of medication errors is present in near one out of two midwives in Italy. In particular, younger midwives with lower working experience, engaged in shift work, and belonging to an Intermediate chronotype, seem to be at higher risk of potential medication error. Since early morning hours seem to represent highest risk frame for female healthcare workers, shift work is not always aligned with individual circadian preference. Assessment of chronotype could represent a method to identify healthcare personnel at higher risk of circadian disruption.

Determination of Antimicrobial Prescribing Practices in an Integrated Health System Emergency Department.

INTRODUCTION: Antibiotic stewardship utilizes interprofessional collaborative practices, including professionals from medicine, pharmacy, nursing, social services, and clinical laboratory science, to identify potential problems proactively. A tertiary care integrated health system's Emergency Department (ED) aimed to identify antimicrobials prescribed to the outpatient community as part of a proactive antimicrobial stewardship project. METHODS: A pilot, prospective, snapshot of a tertiary community hospital's outpatient antimicrobial prescribing habits was conducted. All subjects were identified via a daily report of patients discharged from the ED over 30 days in the summer of 2017 and individually reviewed for prescribed antimicrobial(s). Exclusions were hospital admission, antimicrobial sensitivity, and antimicrobial courses less than five days or more than 14 days. The primary goal was determining the number of antimicrobial oral tablets/capsule prescriptions to adult outpatients within a 5 to 14-day treatment window. Secondary goals were to include the diagnosis, non-capsule/tablet antimicrobial, pediatric patients, and prescriptions outside the treatment window. RESULTS: Total number of antimicrobial prescriptions over the 30-day period was 653 in 5,520 individual visits. Total number of adults prescribed oral antimicrobials was 467 (15.6 daily). Patients were diagnosed with infections including urinary tract, cellulitis, soft tissue injury, abscess, upper respiratory, dental caries, gastrointestinal, sexually transmitted, otitis media/externa, pneumonia, viral, pyelonephritis, tick-borne, fungal, Bell's Palsy, and sepsis. The number of non-adult, non-oral, and outside window treatment antimicrobial prescriptions were 186 (6.2 daily). With an average 184 patients treated in the ED daily, approximately 11.8% received antimicrobial treatment on discharge. CONCLUSION: Important aspects of the project were the evaluation of antimicrobial prescribing habits for a midwest ED and identification of potential complications requiring future interventions for follow-up or preventative measures to assist in patient care and community health. Areas of practice improvement were identified inadvertently as a result of this project. Potential future studies included seasonal variability, whether the patient obtained a prescription and complied with treatment, and differences between inpatient and outpatient antimicrobial prescribing practices.

Comparison of the effects of simulation training and problem-based scenarios on the improvement of graduating nursing students to speak up about medication errors: A quasi-experimental study.

BACKGROUND: Medication administration errors are common among new nurses. Nursing students might be less willing to speak up about errors because of a lack of knowledge and experience. OBJECTIVES: To examine the effects of simulation training and problem-based scenarios on speaking up about medication errors among graduating nursing students. DESIGN: Prospective, controlled experimental study design. SETTING: A university four-year nursing program in Taiwan. PARTICIPANTS: In total, 93 graduating nursing students in their last semester were recruited. Sixty-six students who received both a problem-based scenario and medication administration simulation training comprised the experimental group, while 27 students who received problem-based scenarios alone comprised the control group. METHODS: Experimental group students underwent 2 h of simulation training. This training class was designed based on Kolb's experiential learning theory for knowledge development and speaking up about errors. Students in both groups administered medications in problem-based scenarios with eight embedded errors. Students' performance in speaking up about medication errors was directly observed and graded using an objective structured checklist. The McNeamer Chi-squared test, paired t-test, Z test, t-test, and Hedges' g effect size were conducted. RESULTS: The number of times participants spoke up about medication errors significantly improved in both the experimental group (pre-test: 2.05 ± 1.12 and post-test 6.14 ± 1.25, t = 22.85, p<0.001) and control group (pretest: 2.04 ± 1.16 and post-test: 4.26 ± 1.63, t = 6.33, p<0.001). However, after the intervention, the mean number of times participants spoke up about medication errors in the experimental group was significantly higher than that in the control group (t = 5.99, p<0.001) in the post-test. CONCLUSIONS: Simulation training exhibited more-significant improvements than problem-based scenarios. Nursing schools and hospitals should incorporate simulation training or at least problem-based scenarios to improve medication safety.

Medication safety challenges in Aboriginal Health Care services.

OBJECTIVE: The aim of this study is to examine the challenges faced by the Aboriginal Health Practitioners in the community assisting their clients to manage medicines. DESIGN: Qualitative, in depth interviews with eight Aboriginal Health Practitioners employed at various Aboriginal Community Controlled Health services in Victoria were undertaken. SETTING: Rural Aboriginal Community Controlled Health Service. PARTICIPANTS: Aboriginal Health Practitioners who are registered with the Aboriginal and Torres Strait Islander Health Practice Board of Australia as an Aboriginal Health Practitioner and who have experience in the planning, provision, management and evaluation of health services within their scope of practice. RESULTS: This study revealed multiples challenges faced by Aboriginal Health Practitioners assisting clients with medication management. These were mainly divided into the attitudes and the culture of the workplace and barriers with medications use faced by the clients. The following subthemes were identified within the attitudes and workplace culture theme. These were reporting of errors, pamphlets not culturally appropriate, lack of education of Aboriginal Health Practitioner role and doctors' understanding of Aboriginal culture. The subthemes identified by the Aboriginal Health Practitioners that were specific to the clients included language barriers, immediacy, sharing medications by family members, medications disposal, self-diagnosis, traditional medicine, not feeling comfortable with doctors, literacy and alcohol use. CONCLUSION: This study has identified many barriers to medication safety in the Aboriginal community, and strategies to improve some of the challenges identified.

A meta-synthesis of how registered nurses make sense of their lived experiences of medication errors.

BACKGROUND: Medication errors are a frequent phenomenon in nursing, as the nurses are primarily responsible for preparation and administration of medications to patients. Little is known about how nurses make sense of their experiences of medication errors as a lived phenomenon. OBJECTIVE: To aggregate, synthesise and interpret the qualitative evidence of studies which explored nurses' lived experiences of medication errors. METHOD: A meta-synthesis is presented with thematic analysis by Thomas & Harden (BMC Medical Research Methodology, 8, 2008, 45). Qualitative studies (January 1980-June 2018) retrieved from PubMed, BNI, CINAHL, EMBASE, AMED, PsycINFO, ProQuest, ScienceDirect and Wiley Online Library. The PRISMA flow chart, CASP tool and COREQ checklist are integrated in the meta-synthesis. FINDINGS: Eight primary research studies were included with the follow themes: "moral impact," "emotional impact," "constructive learning," "impact on professional registration and employment," "nurses' coping strategies with the experience," "patient and family," "identification of contributing factors to medication errors" and "preventive measures for medication errors." CONCLUSION: The moral and emotional impact of medication errors to nurses was devastating for themselves. Yet, they detected strategies to cope with their error and its consequences and even more translated their experience into a constructive lesson and identified ways to prevent future errors. RELEVANCE FOR CLINICAL PRACTICE: The meta-synthesis provides a holistic perspective about how registered nurses made sense of their lived experiences of medication errors. Its findings reveal that the experience has both positive impact and negative impact to the nurses. Its findings should inform mainly the clinical nursing practice, clinical nurses, nurse educators, nurse leaders and policymakers of medication administration.

Quality of care for people with multimorbidity - a case series.

BACKGROUND: Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark. METHODS: To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients' medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records. RESULTS: The review of the patients' records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment. CONCLUSIONS: Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems.