Abordaje interdisciplinar de la conciliación de la medicación crónica al ingreso en un hospital / An interdisciplinary approach to reconciling chronic medications on admission to Mora d’Ebre local hospital

Objetivos. Reducir los errores de medicación y evitar las interacciones y duplicidades mediante un programa de conciliación de la medicación crónica al ingreso. Crear una lista actualizada de medicamentos conciliados resolviendo las discrepancias antes de 24h del ingreso en planta. Garantizar la medicación necesaria a la dosis, vía e intervalos correctos según la situación clínica del paciente. Material, pacientes y métodos. Estudio observacional, prospectivo, no aleatorizado y no controlado durante el periodo de octubre 2008 a marzo 2009 (ambos incluidos) en un hospital comarcal de primer nivel, donde se concilió la medicación crónica con la del ingreso hospitalario a todos los pacientes ingresados que cumplían los criterios de inclusión. Resultados. Se incluyeron 469 pacientes, conciliándose 3.609 medicamentos de los cuales 2.466 (68,3%) tenían discrepancias: 667 (27,1%) no justificadas y 1.799 (72,9%) justificadas; no tenían discrepancias 1.143 (31,7%). Las discrepancias no justificadas mayoritarias fueron las omisiones de prescripción 662 (26,8%) y las duplicidades 5 (0,2%). En 640 (25,9%) ocasiones el error llegó al paciente sin ocasionar daños y solo en 4 (0,16%) fue precisa su monitorización. Discusión. Mediante el abordaje interdisciplinario del proceso de conciliación de la medicación crónica se han detectado y neutralizado muchos errores de medicación, se han resuelto las discrepancias, neutralizando omisiones, interacciones, duplicidades y se han eliminado los fármacos de bajo valor intrínseco farmacológico, registrándose en la historia clínica informatizada el listado de medicamentos conciliados(AU)

Objectives. To reduce medication errors and prevent interactions and duplications using a Chronic Medication Reconciliation Program on patient admission. To create an updated reconciled medications by resolving discrepancies within 24 hours of admission to the ward. To ensure the necessary medication is given at the dose, route and at the correct intervals depending on the clinical situation of the patient. Material, Patients and Methods. Prospective observational, non-randomised and uncontrolled study during the period from October 2008 to March 2009 (both included) in a primary level local hospital, in which all patients admitted to the hospital who met the inclusion criteria had their chronic medication reconciled on hospital admission. Results. A total of 469 patients were included, with 3609 medications being reconciled, of which 2466 (68.33%) had discrepancies: 667 (27.0%) unjustified and 1799 (72.9%) justified. There were no discrepancies in 1143 (31.6%). The majority of unjustified discrepancies were prescription omissions in 662 (26.8%) and duplications in 5 (0.2%). On 640 (25.9%) occasions the error reached the patient without causing any harm, and only 4 (0.16%) required monitoring. Discussion. Using an interdisciplinary approach in the reconciliation of chronic medication, many medication errors have been detected and neutralised. Discrepancies have been resolved, neutralising omissions, interactions and duplications. Drugs with a low intrinsic pharmacological value were withdrawn, and the list of reconciled medications recorded in the clinical notes(AU)

Work interruptions and their contribution to medication administration errors: an evidence review.

BACKGROUND: In many surveys, nurses cite work interruptions as a significant contributor to medication administration errors. OBJECTIVES: To review the evidence on (1) nurses' interruption rates, (2) characteristics of such work interruptions, and (3) contribution of work interruptions to medication administration errors. SEARCH STRATEGY: CINHAL (1982-2008), MEDLINE (1980-2008), EMBASE (1980-2008), and PSYCINFO (1980-2008) were searched using a combination of keywords and reference lists. SELECTION CRITERIA: Original studies published in English using nurses as participants and for which work interruption frequencies are reported. DATA COLLECTION AND ANALYSIS: Studies were identified and selected by two reviewers. Once selected, a single reviewer extracted data and assessed quality based on established criteria. Data on nurses' work interruption rates were synthesized to produce a pooled estimate. RESULTS: Twenty-three studies were considered for analysis. A rate of 6.7 work interruptions per hour was obtained, based on 14 studies that reported both an observation time and work interruption frequency. Work interruptions are mostly initiated by nurses themselves through face-to-face interactions and are of short duration. A lower proportion of interruptions resulted from work system failures such as missing medication. One nonexperimental study documented the contribution of work interruptions to medication administration errors with evidence of a significant association (p = 0.01) when errors related to time of administration are excluded from the analysis. Conceptual shortcomings were noted in a majority of reviewed studies, which included the absence of theoretical underpinnings and a diversity of definitions of work interruptions. CONCLUSIONS: Future studies should demonstrate improved methodological rigor through a precise definition of work interruptions and reliability reporting to document work interruption characteristics and their potential contribution to medication administration errors, considering the limited evidence found. Meanwhile, efforts should be made to reduce the number of work interruptions experienced by nurses.

Nursing student medication errors involving tubing and catheters: a descriptive study.

This retrospective case study examined reports (N=27) of medication errors made by nursing students involving tubing and catheter misconnections. Characteristics of misconnection errors included attributes of events recorded on MEDMARX error reports of the United States Pharmacopeia. Two near miss errors or Category B errors (medication error occurred, did not reach patient) were identified, with 21 Category C medication errors (occurred, with no resulting patient harm), and four Category D errors (need for increased patient monitoring, no patient harm) reported. Reported intravenous tubing errors were more frequent than other type of tubing errors and problems with clamps were present in 12 error reports. Registered nurses discovered most of the errors; some were implicated in the mistakes along with the students.

Medication errors resulting from computer entry by nonprescribers.

PURPOSE: The characteristics of medication errors associated with the use of computer order-entry systems by nonprescribers are discussed. METHODS: A retrospective analysis of records submitted to MEDMARX was conducted for the period from July 1, 2001, to December 31, 2005, to identify all computer-related medication errors made by nonprescribers. Quantitative analysis of the records included the severity of each error, the origin within the medication-use process, the type of error, principal causes, the location within the facility where the error was made, and the therapeutic drug classes frequently involved. Similar data from the University of Pittsburgh Medical Center (UPMC) were also analyzed and compared with the national data set. RESULTS: During the 4.5 years, 693 unique facilities submitted 90,001 medication error records that were the result of computer entry by nonprescribers. The national data set and the UPMC data had similar findings for error severity, error origin, and type of error but showed some differences in the rank ordering of error causes, location where the error occurred, and drug classes frequently associated with such errors. The percentage of harm associated with computer-entry errors was small for both the national data set and UPMC data (0.99% and 0.80%, respectively). Both data sets cited performance deficit as the leading cause of computer-entry errors, but large percentage differences were seen with other causes, including inaccurate or omitted transcription (30% versus 12.6%, respectively), documentation (19.5% versus 10.6%, respectively), and procedure or protocol not followed (21.7% versus 30.3%, respectively). Both data sets implicated the inpatient pharmacy department as the location where most computer-entry errors occurred (49.3% versus 69.0%, respectively). CONCLUSION: Analysis of the characteristics of medication errors associated with the use of computer-entry systems by non-prescribers from both MEDMARX and an individual health system database demonstrated that computer systems create new opportunities for errors to occur. Working closely with information technology personnel dedicated to assisting pharmacy departments and vendors, adequate training of pharmacy staff, and development of national standards for drug information displays in computer order-entry systems may help minimize such errors.

A near miss involving cyclophosphamide.

Reports of near miss incidents offer valuable learning opportunities. In this article, the authors highlight a near miss incident that occurred in an intensive care unit with the cytotoxic medication cyclophosphamide, for a non-oncology indication. The learning from this incident, including recommendations, is shared.

Medication reconciliation in hospice: a pilot study.

BACKGROUND: The Joint Commission required implementation of medication reconciliation processes by January 2006. Medication reconciliation is the practice of acquiring an accurate medication history at each transitional point of care. Potential for errors increases with inaccurate medication histories. This study determined the extent of medication reconciliation errors in hospice. METHODS: Patients were enrolled from 2 hospices in Maryland (January 2007). An initial medication history was completed by the nurse on hospice admission. The pharmacist did another medication history within 5 days of admission and compared the medication histories. All differences were reported as medication discrepancies. RESULTS: There were 504 medication discrepancies. Medication omissions occurred most commonly. All patients had at least 1 medication discrepancy (average 8.7 per patient). Overall, 190 drug interactions were identified; most were moderately severe. CONCLUSION: Terminal patients often use numerous medications increasing the risk of medication errors. Accurate medication histories reduce errors and potential for harm.

Validação da prescrição oncológica: o papel do farmacêutico na prevenção de erros de medicação / Validation of the oncology prescription: the pharmacist's role in preventing medication errors

Erros de medicação são constantemente relatados na literatura médico-científica. Há casos clínicos em que a administração inadequada de doses altas de alguns citostáticos tem como consequência a toxicidade grave e a morte do paciente. As não conformidades presentes nas prescrições aos pacientes oncológicos podem ser catastróficas em função da estreita margem terapêutica dos medicamentos antineoplásicos. Prevenir erros de medicação torna-se uma prioridade na melhora do processo farmacoterapêutico em pacientes da oncologia. A multidisciplinaridade é um fator essencial de alerta aos erros de medicação de antineoplásicos e às maneiras de preveni-los. Os farmacêuticos e todos os profissionais que constituem uma equipe multidisciplinar de saúde contribuem para garantia do uso seguro dos medicamentos, o que auxilia no aprimoramento de uma assistência qualificada. Para isso, além das atividades já bem estabelecidas, esses profissionais devem (i) implantar um sistema de validação farmacêutica bem como (ii) estabelecer um sistema de verificação da prescrição médica, o qual consiste em diferentes etapas. O objetivo dessa revisão é relatar a validação da prescrição médica, considerando-se os erros de medicação na quimioterapia e o papel do farmacêutico na prevenção desses erros. São medidas que visam a melhorar a qualidade da assistência prestada aos pacientes oncológicos.

Medication errors have been frequently reported in the literature. There have been several clinical cases in which the improper administration of high doses of some cytostatics resulted in serious toxicity and patient’s death. Nonconformities in oncology patients’ prescriptions can lead to serious problems due to the narrow therapeutic range of antineoplastic drugs. Preventing medication errors has become a priority on improving the pharmacotherapeutic process in oncology patients. The presence of a multidisciplinary staff is an important instrument to improve awareness of medication errors and to prevent them. Pharmacists and other health providers that participate in the multidisciplinary team contribute to ensure the safe use of medications and to improve the delivery of quality care. In addition to their well established activities these professionals should: (i) set up a pharmaceutical validation system and (ii) establish a prescription verification system including several checkpoints. The objective of this review of the literature is to report on prescription validation, considering some chemotherapy medication errors and the pharmacist’s role in preventing them. These measures are aimed at improving the quality of the care provided to oncology patients.

Medication reconciliation matters.

Medication reconciliation is a powerful and effective tool in the fight against preventable ADEs. Consequently, it is a focus of national patient safety and health care organization initiatives. Nurses need to understand the requirements and actively support the process as the right thing to do for their patients.

Interruptions during drug rounds: an observational study.

Drug administration errors are a common problem; they contribute to unintended patient harm and may in part be due to distractions during the drug administration round. In this study, a prospective sample of 38 drug rounds on an acute surgical ward were observed, and their duration, time spent dealing with interruptions and nature of the interruptions were recorded. On average, 11% of each drug round was spent dealing with interruptions. There were one or more interruptions in two-thirds of the rounds studied (average 2.61 interruptions per round), with a mean duration of 1 minute per interruption. The interruptions came from doctors (21%), other nurses (17%), patients (11%), telephone enquiries (8%), relatives (3%) or were initiated by the nurse conducting the round (21%). This pattern contradicts the subjective impressions of nurses in previous questionnaire studies, but it was notable that the longest individual interruptions were from conversations with patients (mean 249 seconds) and phone calls (mean 212 seconds). The data confirm the frequency of interruptions, and their potential as a safety hazard. Objective information from direct observation will prove valuable in designing possible solutions to the problem. These will require local knowledge and frontline staff involvement to be sustainable.

Nursing peer review: developing a framework for patient safety.

Patient safety is of great concern to healthcare leaders and is a top priority in all healthcare organizations. It is essential to promote an organizational commitment that values a culture of safety through reporting of medical error and analysis of untoward events. Nursing peer review facilitates the establishment of a culture of safety, as it seeks to analyze medical errors and eliminate the reoccurrence of untoward events.

Desmopressin (dDAVP) incident signals the need for enhanced monitoring protocols.

In this article, the authors highlight the circumstances surrounding the death of a young adult neurosurgical patient, recently reported to ISMP Canada. The incident signals the need for enhanced safeguards for patients receiving desmopressin (also known as dDAVP) and intravenous therapy. The authors present information from a recent ISMP Canada Safety Bulletin relevant to critical care, including an outline of potential contributing factors and suggested recommendations.

Errors in medicine administration: how can they be minimised?

Errors in medicine administration often go unnoticed and unreported. This article describes three medicine-related errors and provides recommendations to reduce risk. All medicine-related errors should be reported locally and to the National Patient Safety Agency (NPSA) so that they can be collated and trends identified. Electronic prescribing and patient/medicine identification by bar codes, double checking and using colour coded syringes for intravenous and enteral administration, employing more clinical pharmacists and regular education may reduce medicine-related errors.

Setting up and priming an intravenous infusion.

The setting up and priming of an intravenous infusion is a common nursing procedure. However, it is associated with certain complications, for example infection. This article describes a step-by-step guide to the equipment required, correct preparation of the patient and the procedure. It also provides readers with calculation of drip-rate formulae.

Inadvertent discogram during epidural steroid injection: a case report.

The obligatory use of fluoroscopy for placement of epidural steroids is controversial. Proponents of the use of fluoroscopy cite studies that report up to 35% rates of inaccurate placement of epidural needles without the aid of fluoroscopic imaging. This case study presents a situation in which a loss-of-resistance technique resulted in an inadvertent discogram.