The prosecution of RaDonda Vaught: An ethical and legal mistake.

This paper addresses the ethics of the prosecution of nurse RaDonda Vaught for a medication error that led to the death of her patient. It is argued that the prosecution of Ms. Vaught was wrong; however, in contrast to some commentators, it is argued that the wrongness of Ms. Vaught's prosecution did not stem from its effects on patient safety, but from the fact that the charges, in this case, were legally and ethically unjustified in themselves.

Nuevas perspectivas en la resolución del error médico: National Health Service Resolution y CARe / New perspectives in resolving medical error: National Health Service Resolution and CARe

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A qualitative analysis of student-written law and ethics cases: A snapshot of PY2 student experience.

INTRODUCTION: This study was designed to better understand pharmacy students' experiences and recognition of legal and ethical tensions existing in pharmacy practice as demonstrated in student-written law and ethics cases. METHODS: A qualitative analysis of 132 student-written cases representing the team efforts of 1053 students over a 12-year time period was conducted. Student-written cases were coded and analyzed thematically. RESULTS: Our results demonstrate the types of ethical and legal issues our students have experienced in pharmacy practice during the first five quarters of their professional education. Our data highlight three themes: 1) ethical dilemmas presented when the law is misapplied; 2) ethical dilemmas presented when an institutional policy or law was viewed as insufficient; and 3) ethical dilemmas presented as provider distress. The third theme was further subdivided into five subthemes. CONCLUSION: The themes that emerged from this study represent some of the ethical dilemmas that second professional year students have encountered and how these dilemmas may intersect with legal boundaries. Educators can use cases demonstrating these themes to reinforce law and ethics education in the curriculum, thus helping prepare students for pharmacy practice. This article recommends how and when to use case examples.

Cuidados na administração de medicamentos: as responsabilidades dos profissionais de enfermagem / Care in the administration of medicines: the responsibilities of nursing professionals

Objetivo: avaliar o conhecimento de profissionais de enfermagem atuantes em uma instituição hospitalar pública quanto às responsabilidades jurídicas e éticas envolvidas na administração de medicamentos. Método: estudo avaliativo, exploratório, com abordagem quantitativa e qualitativa. Foram aplicados questionários a162 profissionais de enfermagem. Os dados quantitativos formaram um banco de dados, digitados no software Statistical Package for the Social Sciences – SPSS. As informações qualitativas foram submetidas à análise de conteúdo. Resultados: constatou-se que os profissionais de enfermagem necessitam de maior aprofundamento científico acerca do Código de Ética da Profissão e que o conhecimento dos enfermeiros acerca das responsabilidades perante os erros de medicação foi superior ao dos técnicos e auxiliares de enfermagem. A advertência verbal foi a principal conduta adotada para responsabilizar os profissionais envolvidos após a ocorrência dos erros. Conclusão: constata-se que o conhecimento acerca do direito e da deontologia propiciam um fazer com resultados efetivos.

Development of a Medication Safety and Quality Survey for Small Rural Hospitals.

PURPOSE: We summarize the development and initial implementation of a survey tool to assess medication safety in small rural hospitals. SUMMARY: As part of an ongoing rural hospital medication safety improvement program, we developed a survey tool in all 13 critical access hospitals (CAHs) in Florida. The survey was compiled from existing medication safety assessments and standards, clinical practice guidelines, and published literature. Survey items were selected based on considerations regarding practicality and relevance to the CAH setting.The final survey instrument included 134 items representing 17 medication safety domains. Overall hospital scores ranged from 41% to 95%, with a median of 59%. Most hospitals showed large variation in scores across domains, with 5 hospitals having at least 1 domain with scores less than 10%. Highest scores across all facilities were seen for safety procedures concerning high-alert or look-alike medications and the assembly of emergency carts. The lowest median scores included availability and consistent use of standardized order sets and the effective implementation of medication safety committees. Most hospitals used the survey results to identify and prioritize quality improvement activities. CONCLUSIONS: The survey can be used to conduct a short medication safety assessment specific to a limited number of areas and services in CAHs. It showed good ability to discriminate medication safety levels across participating sites and highlighted opportunities for improvement. It may need modification if case mix or services differ in other states or if the status quo of medication safety in CAHs or related standards advance. The described process of survey development might be helpful to support such modifications.

Efecto sobre la salud de un grupo de pacientes crónicos polimedicados en una farmacia comunitaria / Effects of the pharmacotherapeutical follow-up in a community pharmacy on aged patients with multiple medications

Introducción: El seguimiento farmacoterapéutico (SFT) puede suponer importantes beneficios para la salud de los pacientes mayores polimedicados. Objetivos: Valorar la influencia de la implantación del SFT en la salud de nuestros pacientes. Evaluar la efectividad de las intervenciones farmacéuticas (IF). Analizar los resultados negativos asociados a la medicación (RNM) en función del principio activo y problema de salud. Método: Estudio longitudinal, descriptivo y no aleatorizado en mayores de 65 años polimedicados, siguiendo la metodología delprograma ConSIGUE. Los datos, correspondientes a diez pacientes, se recopilaron de estados de situación (ES), cuestionarios de utilización de recursos sanitarios, encuestas de calidad de vida y registros de RNM e IF. Resultados: Hubo reducción apreciable en número de principios activos, problemas de salud (PS), RNM y visitas a urgencias. Se registró un incremento de la percepción subjetiva de la calidad de vida. En la revisión, se retiró algún medicamento al 80% de los pacientes. Registramos 69 IF, siendo aceptadas 61 (~90%). Detectamos 28 RNM: 20 fueron resueltos (70%) y 2 son todavía objeto de seguimiento. Omeprazol, ácido acetilsalicílico y acenocumarol, estuvieron implicados en el 30% de los RNM. La prevención de gastrolesión, junto con patologías como diabetes y anticoagulación, se asociaron con el 60% de los RNM. Conclusiones: La inclusión en el SFT ha supuesto importantes beneficios en salud para nuestros pacientes. El uso extensivo de fármacos considerados seguros puede contribuir a la aparición de RNM en pacientes crónicos y polimedicados

Introduction: The implementation of a pharmacotherapeutical follow-up program can suppose many health benefits for aged patients with multiple medications. Objectives: The main objectives are to evaluate the impact of this program on patients’ health and the effectiveness of the pharmaceutical interventions. On the other hand, to analyze the negative results associated with the medication according to the active ingredient or the health problem involved. Methods: It was carried out a longitudinal, descriptive and non randomized study in aged patients with multiple medications, following ConSIGUE methodology. Data, concerning ten patients, were collected from assessment forms, use questionnaires of healthcare resources, quality of life surveys and negative results associated with medication and pharmaceutical interventions records. Results: There was a reduction in the number of active ingredients, health problems and hospitalization and emergency room visits. In contrast, an increase in the patients’ quality of life was found. At least, one medicine (outdated medicines or non active prescriptions) was withdrawn in 80% of the patients during the medication review. We recorded 69 pharmaceutical interventions from which 61 were accepted. 20 out of 28 negative results associated with medication were solved while 2 are still under study. Omeprazole, acetylsalicylic acid and acenocumarol were found to be responsible for 30% of negative results associated with medication. 60% of the negative outcomes recorded were associated to the prevention of ulcers and pathologies such as diabetes and anticoagulation. Conclusions: The inclusion in a pharmacotherapeutical follow-up program resulted in improved health outcomes of our patients. The extensive use of safe drugs may contribute to negative phamacotherapeutical results in aged patients with multiple medications

Medication Errors in the Southeast Asian Countries: A Systematic Review.

BACKGROUND: Medication error (ME) is a worldwide issue, but most studies on ME have been undertaken in developed countries and very little is known about ME in Southeast Asian countries. This study aimed systematically to identify and review research done on ME in Southeast Asian countries in order to identify common types of ME and estimate its prevalence in this region. METHODS: The literature relating to MEs in Southeast Asian countries was systematically reviewed in December 2014 by using; Embase, Medline, Pubmed, ProQuest Central and the CINAHL. Inclusion criteria were studies (in any languages) that investigated the incidence and the contributing factors of ME in patients of all ages. RESULTS: The 17 included studies reported data from six of the eleven Southeast Asian countries: five studies in Singapore, four in Malaysia, three in Thailand, three in Vietnam, one in the Philippines and one in Indonesia. There was no data on MEs in Brunei, Laos, Cambodia, Myanmar and Timor. Of the seventeen included studies, eleven measured administration errors, four focused on prescribing errors, three were done on preparation errors, three on dispensing errors and two on transcribing errors. There was only one study of reconciliation error. Three studies were interventional. DISCUSSION: The most frequently reported types of administration error were incorrect time, omission error and incorrect dose. Staff shortages, and hence heavy workload for nurses, doctor/nurse distraction, and misinterpretation of the prescription/medication chart, were identified as contributing factors of ME. There is a serious lack of studies on this topic in this region which needs to be addressed if the issue of ME is to be fully understood and addressed.

Aspectos éticos y legales sobre la seguridad del paciente / No disponible

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Els errors en les relacions assistencials: una aproximació des de la bioética / No disponible

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Errors de prescripció a urgències: un problema deseguretat del pacient / Errores de prescripción en urgencias: un problema de seguridad del paciente / Prescription errors in emergencies: a problem of patient safety

Fonament: els errors de prescripció farmacològica són unacausa important i prevenible de morbimortalitat, especialment en infants. Objectiu: per minimitzar aquests errors és necessari co-nèixer quins són i quins factors els provoquen. Mètode: revisió bibliogràfica mitjançant PubMed, Cochrane Library i Embase fins al juliol del 2013. Es revisen elsarticles en què es reporten errors de prescripció, especialment en infants i als serveis d'urgències, factors associatsa errors i estratègies per prevenir-los. Resultats: els fàrmacs que s'han associat amb més errors són els broncodilatadors, els corticoides i els antiinflamatoris. Entre els errors de medicació, els de prescripció sónels més comuns i entre aquests, els de dosi i indicació. Lamajoria són lleus. S'han descrit factors que afavoreixen laproducció d'errors, com el grau baix d'experiència del facultatiu, la urgència més gran de les prescripcions, els diesfestius i les nits i la poca edat del pacient. Algunes estratègies han demostrat reduir errors, com latecnologia (introducció informatitzada de dades, alarmes, dispensadors automatitzats de fàrmacs), la formació i el reciclatge del personal (sobretot el primer any), la cultura deseguretat, la incorporació d'un farmacèutic, les taules estandarditzades per pes per als fàrmacs de reanimació, elssistemes de torns i una bona comunicació a l'equip i ambels pacients. Conclusions: els errors més freqüents són els de dosi i enels fàrmacs de més ús. Una cultura de seguretat que fomenti expressar els errors i busqui estratègies preventivesés fonamental per reduir-los

Fundamento. Los errores de prescripción farmacológica son una causa importante y prevenible de morbimortalidad, especialmente en niños. Objetivo. Para minimizar estos errores es necesario conocer cuáles son y qué factores los provocan. Método. Revisión bibliográfica a través de PubMed, Cochrane Library y Embase hasta julio de 2013. Se revisan los artículos donde se reportan errores de prescripción, especialmente en niños y en los servicios de urgencias, los factores asociados a éstos y estrategias para prevenirlos. Resultados. Los fármacos que se han asociado con más errores son los broncodilatadores, corticoides y antiinflamatorios. Dentro de los errores de medicación, los de prescripción son los más comunes y entre éstos, los de dosis e indicación. La mayoría son leves. Se han descrito factores que favorecen la producción de errores, como la menor experiencia del facultativo, mayor urgencia de las prescripciones, días festivos y noches y menor edad del paciente. Algunas estrategias han demostrado reducir errores, como la tecnología (introducción informatizada de datos, alarmas, dispensadores automatizados de fármacos), la formación y reciclaje del personal (sobre todo durante el primer año), la cultura de seguridad, la incorporación de un farmacéutico, las tablas estandarizadas por peso para los fármacos de reanimación, los sistemas de turnos y una buena comunicación en el equipo y con los pacientes. Conclusiones. Los errores más frecuentes son los de dosis y en los fármacos de más uso. Una cultura de seguridad que fomente expresar los errores y busque estrategias preventivas es fundamental para reducirlos (AU)

Background. Prescription errors are an important and preventable cause of morbidity, especially for children. Objective. The first step towards reducing prescription errors involves knowing the most common errors and their risk factors. Method. Literature review of manuscripts published until July 2013 using the PubMed, Chochrane Library, and EMBASE databases. Articles reporting prescription errors, especially in children and in the emergency departments, factors associated to those, and strategies to prevent them, were reviewed. Results. The drugs most commonly involved in errors are bronchodilators, systemic steroids, and anti-inflammatory agents. The most common medication errors are related to prescription, particularly in dosing and indication. The majority of errors are of low impact. Factors associated with errors include urgency, physician’s experience, holidays and nights, and younger patient’s age. Some strategies have shown to reduce drug errors, such as technology innovations (computerized data entry, alarms, and automated drug dispensers), training and education (especially during the first year of practice), existence of patient safety culture, incorporation of a pharmacist, weight-adjusted dose tables for resuscitation drugs, well-regulated shifts, and good communication within staff members and with families. Conclusions. The most frequent medication errors are related to dosing and involve the most common drugs. A safety culture that fosters reporting errors and looks for preventive strategies is fundamental to reduce them (AU)

Influencia de un programa de conciliación terapéutica en la tasa de reingreso de pacientes ancianos / Influence of a medication reconciliation program in elderly patients on readmission rate

Objetivo: Principal: medir el impacto en la tasa de reingreso a los 30 días de un programa de conciliación terapéutica al ingreso y al alta en pacientes mayores de 65 años. Secundarios: detectar, clasificar y analizar las discrepancias, errores de conciliación (EC) y prescripción de medicamentos potencialmente inadecuados (MPI). Material y Método: Estudio observacional prospectivo, no controlado, no aleatorizado, unicéntrico, con pacientes mayores de 65 años, ingresados en Medicina Interna y Geriatría. Se realizó conciliación terapéutica al ingreso y al alta, registrando medicación habitual, discrepancias justificadas, no justificadas, EC, MPI y medicamentos de alto riesgo (MAR). Se calculó la tasa de reingreso y se comparó con la tasa del año 2013 para cada servicio médico. Resultados: 91 pacientes con una media de 86 (71-99) años, el 47% con MAR y 8,9 medicamentos crónicos por paciente. Se conciliaron 1113 medicamentos, con 836 discrepancias justificadas, 56 EC y 36 MPI. Los EC se produjeron por omisión (n=34), diferente dosis o vía (n=16), prescripción incompleta (n=1), medicamento equivocado (n=1) y comisión (n=19). Por gravedad se detectaron en las categorías B (n=16), C (n=30), D (n=9) y E (n=1). El 31,9% de los pacientes tuvo un EC. Las tasas de reingreso para Medicina Interna y Geriatría fueron respectivamente de 12,2% y 14,3% frente a las globales de 2013 de 17,9% (RR=0,652; IC95% 0,279-1,521; p=0,322) y 16,3% (RR=0,895; IC95% 0,443-1,812; p=0,758). Conclusiones: Las tasas de reingreso a los 30 días en los pacientes conciliados fueron inferiores a las globales de 2013, aunque no estadísticamente significativas

Objective: To measure the impact of a pharmacist-based medication reconciliation program on readmission rates 30 days after its implementation, at admission and discharge, in patients aged 65 years and older. Secondary objectives were to detect and classify medication discrepancies, reconciliation errors (RE) and the prescription of potentially inappropriate medications in elderly patients (PIM). Methods: Prospective observational, uncontrolled, nonrandomized, single-center study performed in patients aged 65 years and older, hospitalized in the Internal Medicine and Geriatrics units. Medication reconciliation was performed by a pharmacist at admission and discharge. The pharmacist recorded chronic medication, justified and unjustified discrepancies, RE, PIM and high-risk medications (HRM). 30-day readmission rate was calculated and then compared with the 2013 rate for each medical unit. Results: A total of 91 patients were included, with an average age of 86 (71-99) years, 47% with HRM and 8.9 chronic medications per patient. 1113 medications were reconciled, of which 836 had justified discrepancies, 56 RE and 36 PIM. The RE were caused by omission (n=34), discrepancies in via or dose (n=16), incomplete prescription (n=1), wrong drug (n=1) and commission (n=19). Regarding its seriousness, RE were classified as B (n=16), C (n=30), D (n=9) and E (n=1). 31.9% of the patients had a RE. 30-day readmission rates for Internal Medicine and Geriatrics units were respectively 12,2% and 14,3%, compared with 2013 overall rate of 17,9% (RR=0,652; IC95% 0,279-1,521; p=0,322) and 16,3% (RR=0,895; IC95% 0,443-1,812; p=0,758). Conclusions: 30-day readmission rates were lower than 2013 overall rate with the medication reconciliation program. However, this is not statistically significant

Errores de medicación en el ejercicio de la enfermería: una revisión integrativa / Erro de medicação no exercício da enfermagem: uma revisão integrativa / Medication error in the exercise of nursing: an integrative review

Este estudio tiene como objetivo analizar las publicaciones nacionales sobre errores de medicación en el ejercicio de la enfermería. Es una revisión integradora, realizada en las bases de datos BDEnf, SciELO y LILACS. Del análisis se seleccionaron cuatro temas: el conocimiento de los criterios que caracterizan a los errores de medicación,causas que originan el error; punición cuando se produce un error, y educación continua como herramienta para reducir los errores de medicación. Se encontró que responsabilizar al profesional por el error es una cultura que persiste en Brasil (AU)

Estudo com objetivo de analisar as publicações nacionais sobre erro de medicação no exercício de enfermagem. Trata-se de uma revisão integrativa, realizada por meio das bases de dados BDEnf, SciELO e LILACS. Da análise foram elencados quatro temas: conhecimento dos critérios que caracterizam o erro de medicação; causas que originam o erro; punição na ocorrência de erro; e educação continuada como ferramenta para redução do erro de medicação. Observou-se que responsabilizar o profissional pelo erro é uma cultura que persiste no Brasil

This study is aimed at analyzing the national publications about medication error in the exercise of nursing. This is an integrative review, conducted by searching the databases BDEnf, SciELO and LILACS. Four topics emerged from the analysis: knowledge of the criteria that characterize the medication error, the error causes; punishment when an error occurs and continuing education as a tool to reduce medication errors. We found that the professional responsibility for the mistake is a culture that persists in Brazil (AU)

Administración de dosis equivocada de fenilefrina en Reanimación. Caso del trimestre / Phenylephrine dosing error in Intensive Care Unit. Case of the trimester

Presentamos un caso real comunicado en SENSAR. Se trataba de un paciente ingresado en una unidad de Reanimación tras una resección pulmonar y que presentaba hipotensión arterial. Se pidió a la enfermera responsable del paciente que le administrara 1 ml de fenilefrina. Unos segundos después, el paciente presentó una crisis hipertensiva autolimitada, que cedió espontáneamente sin producir ningún daño. Se preguntó a la enfermera sobre la medicación administrada y se constató que se había producido un error de dosificación, habiéndose administrado 1 mg (1 ml) de fenilefrina en lugar de 100 mcg (1 ml de la dilución habitual de 1 mg en 10 ml, 100 mcg/ml). Al analizar el incidente hallamos factores latentes (favorecedores del incidente) relacionados con la falta de protocolos y sistemática de trabajo, error en la comunicación entre profesionales (médico-enfermero), problemas en la política de formación y fallo en la cultura de seguridad. Para prevenir este tipo de incidentes se elaboró un protocolo en la Unidad de Reanimación para la administración de fármacos en bolo e infusiones inferiores a 30 min, y se instauraron técnicas para mejorar la comunicación entre profesionales. El protocolo sistematiza el uso de fármacos identificados como de riesgo para generar errores de administración y ha sido desarrollado entre médicos y personal de enfermería de Reanimación. Para mejorar el proceso de comunicación se propone realizar comprobaciones repetidas de lo dicho y entendido, para cerrar el bucle de comunicación (closed loop). También se recomienda el etiquetado de jeringas especificando la dilución del fármaco(AU)

A real clinical case reported to SENSAR is presented. A patient admitted to the surgical intensive care unit following a lung resection, suffered arterial hypotension. The nurse was asked to give the patient 1 mL of phenylephrine. A few seconds afterwards, the patient experienced a hypertensive crisis, which resolved spontaneously without damage. Thereafter, the nurse was interviewed and a dosing error was identified: she had mistakenly given the patient 1 mg of phenylephrine (1 mL) instead of 100 mcg (1 mL of the standard dilution, 1 mg in 10 mL). The incident analysis revealed latent factors (event triggers) due to the lack of protocols and standard operating procedures, communication errors among team members (physician-nurse), suboptimal training, and underdeveloped safety culture. In order to preempt similar incidents in the future, the following actions were implemented in the surgical intensive care unit: a protocol for bolus and short lived infusions (< 30 min) was developed and to close the communication gap through the adoption of communication techniques. The protocol was designed by physicians and nurses to standardize the administration of drugs with high potential for errors. To close the communication gap, repeated checks about saying and understanding was proposed («closed loop»). Labeling syringes with the drug dilution was also recommended(AU)