Alshammari T.M., Alshakka M., Aljadhey H. Pharmacovigilance system in Saudi Arabia. To examine the literature, a narrative synthesis was performed due to the variety of instruments and reported data. So, here are 10 strategies to reduce medication errors in nursing homes and care homes. information technology) and increase comfort level by considering system design changes. However, patient safety is not developing fast enough to face future challenges in healthcare [19]. Winterstein AG, Johns TE, Rosenberg EI et al.. Corrective actions can prevent an incident recurrence, mitigate prescription errors, and enhance the long-term well-being of patients, thus improving their quality of care [54]. medication errors Examining and adapting the psychometric properties of the Maslach burnout inventory-health services survey (MBI-HSS) among healthcare professionals. Detailing and reporting the issue is subject to the medical nurse in many ways:[117] capacity to perceive a mistake has happened, the conviction that the mistake warrants reporting, the conviction that she/he has submitted the error, and eagerness to beat the humiliation and dread of striking back for having submitted a medication error. Also, errors were related to omission (25.0%), dosage (30.0%), unauthorized drugs, and the wrong time, patient, and administration technique. [50, 51], Errors might provoke in any stage. The response should be visible, useful, and constructive for the health care system change [56]. [38] Thus, differences in rate are due to differences in organizational reporting systems, and the time frame of studies that have been conducted. Initially, there were five rights for administration including the Doing so will create culture of safety to be accommodated at an individual level [61]. This summary can bridge and open gates of awareness on how to deal with and prevent error occurrences. Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems. (Alya Al Mutairi), A.A.R., M.A. The intervention phase is an integral corrective phase as it should consist of training programs for the targeted healthcare providers [51]. Encouraging reporting, monitoring, and open discussion of medication errors is key in establishing a culture of safety. Popay J., Roberts H., Sowden A., Petticrew M., Arai L., Rodgers M., Britten N., Roen K., Duffy S. Guidance on the conduct of narrative synthesis in systematic reviews. [110] Administration of drugs is likely a standout amongst the most basic missions of nurses since the subsequent errors may have unintended, genuine complication for the patient. Thus, understanding what hinders reporting could eventually result in superior patient care [12]. Correspondence: Nasr Alrabadi, Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan. [104], Nurses have a central role in their activities to advance safety and anticipate damage to patients. Here are certain techniques to follow: 1. The Effective Strategies to Avoid Medication Errors and Organizations must adopt a successful reporting environment for the medication use process to evolve into a safer practice. A total of 384 duplicated articles were excluded from the review. There are some occasions where patients forget to state their drug allergies upon initial history taking. Around 1620% of nurses fail to report incidences [22,23,24,25] because they fear being terminated by employers. [10] It is suggested that at whatever point when medication error has occurred it should be reported to the significant manager, and such notice is essential for understanding the reasons for the errors and to enable strides to be taken to lessen such errors later on. Furthermore, we searched citations from relevant papers to select additional studies. Nurses perceptions: when is it a medication error? When creating this new medication label make sure that it is readable. Wakefield BJ, Blegen MA, Uden-Holman T et al.. How can we, as nurses, prevent medication errors? Holding an individual accountable for continuing unsafe practices. [46] Therefore, medication errors might not only intend harm to patients, they additionally deface the notoriety of all medical experts in whom patients place their trust. Gorgich EA, Barfroshan S, Ghoreishi G et al.. Politics latest: Ministers to announce plans to tackle NHS In the past, medical errors were rarely disclosed; nowadays, however, failing to disclose an error in the hospital is considered a violation of the code of ethics and leads to litigation [17,20]. [56] According to the National Patient Safety Agency (2009) in the United Kingdom, it was observed the most prominent kinds of medication errors were 16.0% in prescribing, 18.0% in dispensing, and 50.0% in the drug administration. Sarfati L, Ranchon F, Vantard N et al.. Also read :8 Best Medical Dictionaries for Nurses. Update: RaDonda Vaught Sentenced to 3 Years Supervised Fontan JE, Maneglier V, Nguyen VX et al.. age, long stretches of training, and education) and the number of medication errors. According to an NCCMERP report, medication errors are ranked the sixth cause of mortality in the United States, with 510% of the reported medication errors classified as harmful [3]. You can do this by simply asking the patients full name and date of birth to make sure the information given matches your medication card. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of Medication safety in acute care in Australia: Where are we now? Reviewing and understanding the topic of medication error especially by nurses can help in advancing the medical services to patients. Preventing medication errors requires specific steps to ensure safety at each stage of the pathway (Table). Inclusion in an NLM database does not imply endorsement of, or agreement with, It is noticed that 19% of medication errors in the Intensive Care Units (ICUs) are life-threatening and 42% are considered to be paramount for further maintaining treatment. Indicate the generic and brand name of the drug as well as dosage and expiry date. Prevent Medication Errors [15] A previous examination has exhibited underreporting among nurses. [131], At present, self-revealed medication errors give negligible data to associations since disparities, as far as answered to-actual rates, are across the board. [65] As seen, a sample of 57 nurses in pediatric settings, medication errors were 67.0% compared to 56.0% of a sample of 227 nurses working with adults. made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; and agree to be accountable for all aspects of the work. We looked for studies that reported medication error reporting culture, incident reporting systems, creation of effective reporting methods, analysis of medication error reports, and recommendations to enhance medication error reporting systems. [68] On the other hand, certain variables add to the high rates of prescription errors in pediatric patients. Another issue is the high proportion of underreporting of medication errors (estimated to be 5060%) across healthcare organizations that is attributed to the lack of medical recording systems in many hospitals [2]. There should be a system where blame is not assigned to those experiencing the errors or those that annotate them. In order to realize the development in such an area, cultural changes have to be made; feeling safe to report a medical error and learning from past mistakes are crucial factors that might improve patient safety [19,28]. Nurses must contrast this with the Medication Administration Record (MAR). One key component of the taxonomy, which categorizes an error in accordance with the severity of the outcome on a scale from A to I, is the NCCMERP medication index [52]. Avoid using improper abbreviations and write the medications name legibly. medication errors Besides, it could provide information for the nurses about black box warnings, look alike, sound alike, and warning labels. Fein and others discussed the most effective factors that influence decisions on disclosing a medical error, which fall into four categories; provider elements, patient elements, error elements, and institutional culture [17,18,19,20,21]. The attributes of the therapeutic framework may increase the danger of slip-ups and compound the results of these mix-ups. Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit. She loves to provide tips and fun facts about nursing and healthy living. This will require a number of approaches, including changes to systems practices (e.g. One of the major threats to the well being of patients is medical errors. The aim of this study was to develop the concept of a patientnurse partnership for medication safety activities. To avoid unnecessary adverse drug reactions, always ask the patient about any known drug allergies before giving new medications. To maintain patient safety and avoid medication errors, it is important that pharmacists, nurses, and other healthcare professionals adhere to the standard for safe ELMeneza S., AbuShady M. Anonymous reporting of medical errors from The Egyptian Neonatal Safety Training Network. Finally, implementing a robust medication review and error reporting process can help to reduce the impacts felt by medication errors. 2. It should also emphasize the re-collecting of data and comparing it with the pre-intervention data. Medication errors have been considered a global issue and it is essential to focus on the causes, results, and solutions. Health administrations, all over the world, endeavor to give proper care to individuals when they are ill or to remain healthy. Priorities of an effective medication error reporting system need to target pre-emptive and retroactive actions as opposed to placing blame on an individual. Be careful in crushing or cutting them up as these drugs will produce quick potent effects when taken without the extended-release coating. Thus, it can be seen that including patient education in as many programs as possible (both medical and non-medical) is of the utmost importance [57]. Cheragi MA, Manoocheri H, Mohammadnejad E et al.. Methods: Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. A system for reporting medical errors can lead to future detection of the possibility of a medical error occurring [17,18]. [65], The error might be identified with expert practice, which is related to human services items, to systems, or to correspondence issues including prescribing, ordering, item naming, labeling/packaging, preparation, compounding, dispensing, administration, education, and the best possible utilization of medicines. Karsh B.T., Escoto K.H., Beasley J.W., Holden R.J. Toward a theoretical approach to medical error reporting system research and design. [53, 64], Prescription errors are a standout amongst the most widely recognized therapeutic errors and their occurrence rate in adult ward accounted to be 5.6 cases per 1000 patients and 14.8 cases per 1000 patients in the pediatrics ward. [116, 117], At the point when errors are distinguished, they can cause many disappointments because of the inability of how to deal with the resulting error, and they might cause potential harm to patients with disabilities. sharing sensitive information, make sure youre on a federal Essentially it is being able to show and employ ones self without fear of negative consequences of self-image, status, or career [62]. Al Mutair A., Al Mutairi A., Chagla H., Alawam K., Alsalman K., Ali A. 1. Medication Errors (b) Nursing errors; as in wrong rate (34.0%), wrong time administration (28.6%), wrong dose (25.3%), medication omitted (24.0%), wrong fluid (22.4%), wrong drug (21.1%), wrong route (19.9%), and wrong patient (19.7%). Reducing the number of errors associated with medication administration has become an important issue when improving nurse service quality (Vrbnjak et Email: Search for other works by this author on: Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Department of Maternal and Child Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Department of Nursing, King Abdullah University Hospital, Jordan University of Science and Technology, Department of Pharmacology and Pharmacotherapy, Applied Science Private University, Faculty of Pharmacy, Philadelphia University, Design for patient safety: a systems-based risk identification framework, Conceptual framework for the international classification for patient safety version 1.1: final technical report January 2009, Drug administration errors and their determinants in pediatric in-patients, To Err is Human: Building a Safer Health System, Medication errors among registered nurses in Jordan, National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors, Paediatric nurses adherence to the double-checking process during medication administration in a childrens hospital: an observational study, Prevention of medication errors in the pediatric inpatient setting, A comparison of two methods of assessing the potential clinical importance of medication errors, Clinical review: medication errors in critical care, Nurses perceptions of medication errors in Jordan, Proportion of medication error reporting and associated factors among nurses: a cross sectional study, Rates and types of events reported to established incident reporting systems in two US hospitals, Relationship between medication errors and adverse drug events, Medication errors in the Middle East countries: a systematic review of the literature. An organizational reporting system should be made user-friendly and accessible to all employees, students, and teaching staff (if not employees) [58]. Ensure the 5 Rs of Medication Are Being Followed. The following (Table 1) depicts a list of necessary factors that should be considered based on the findings explored by other academics [53,54,55,56,57,58,59,60,61,62,63]. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). Stavropoulou C., Doherty C., Tosey P. How effective are incident-reporting systems for improving patient safety? A responsive medication error reporting system stimulates internal reporting within a health organization significantly [56]. [67] The most frequent types of prescribing errors might be related to the inability to manage the medication and mistaken medication writing. They should be mindful of recognition significance of organized prescription to dodge potential dangers and conceivable complexities coming about because of medicine errors. Minimize and address confusion, inexperience, fatigue and other factors that affect performance. Our role is critical as we are the last line of defense against medication errors. FOIA Most medication errors happen when nurses think they know their patients medications well that they dont bother verifying the patients name first. Initiating the idea of the manuscript: Nasr Alrabadi and Razan Haddad. Root factors that contribute to prescription errors that have caused or have had the possibility to cause harm near miss to the patient can thus be realized [50]. [78, 89] However, interruptions play a big impact on causing medication errors especially during administration. Medical Error Reduction and Prevention - StatPearls Health departments endeavor to give care to individuals to remain in healthy conditions. Avoiding Medication Errors A drug handbook is a wealth ofimportant information about different drugs like adverse reactions, drug incompatibilities, precautions and many more. The taxonomy is useful for developing a medication error database and designing an error reporting or data collection form. [133] Their uncommon position is regularly fortified by their continuous learning concerning the medications in addition to their strategies regarding planning and controlling the medicines and for checking the impacts of the treatment. Upon clarification, the ordered medication is actually primidone. A consistent organizational framework is needed to monitor and measure medication safety. To reduce errors, we must follow the rights of medication administration, which includes involving the patient and their family in the process, among other rights. official website and that any information you provide is encrypted Journal of Nursing Care Quality, Reducing Medication Error Through a Collaborative Committee Structure: An Effort to Implement Change in a Community-Based Health System For patients with problems stating their names, you can just look at their name band to check if you are dealing with the right patient. Patient safety is the responsibility of everyone in the healthcare organization. Thus, these medication errors along with the systems in place that allow them to propagate can be further explored, giving an informed, better understood wide-scale picture that can then be implemented. Articles were published from 1998 to 2020 with a summit of papers between 2006 and 2014. [138, 139], 6. High alert drugsinclude heparin, dopamine, dobutamine, nicardipine, digoxin and many more. Healthcare organizations should build systems and procedures to accumulate ample information required to inspect and report medication errors at the time the events occur (ideally, all the elements identified in the taxonomy). Medication errors in nursing occur for various reasons and in System design changes should be considered to make it easy and meaningful to report; for example, minimize the number of screens or paper pages required for reporting, balance the need for detail with ease of use, and utilize check-boxes or drop-downs [59]. For instance, infusing diclofenac into the sidelong (lateral) thigh instead of being injected into the butt cheek. Hammam R., Abosrea M., Hagag S. Assessment of physicians communication and job performance during morning and night shifts in emergency hospitals at Zagazig district, Egypt. Interventions to reduce medication errors in adult medical and surgical settings: a systematic review A number of activity types were shown to be successful in reducing prescribing and medication-giving errors. Double-check dosing of medications, especially high-alert medications. Many countries such as Greece [42], Korea [43], Japan [44], and France [45] have adopted similar systems which have shown substantial positive benefits [46,47,48,49]. On the other hand, mandatory reports have shown the effectiveness of participation in reporting medical errors. Electronic error-reporting systems: A case study into the impact on nurse reporting of medical errors. Lengacher CA, Mabe PR, Bowling CD et al.. Jember A, Hailu M, Messele A et al.. [(accessed on 1 April 2021)]. Strategies to Prevent Adverse Drug Events Two reviewers (AA and SA) individually vetted titles with abstracts followed by a full article review, where any doubt remained. Amarasingham R., Plantinga L., Diener-West M., Gaskin D.J., Powe N.R. Vozikis A. Newly qualified nurses often fear making or identifying a clinical error. [30] Karthikeyan et al. Know institution policies, regulations, and guidelines, Nurses should be familiar with the policies and guidelines and how to apply them. when the patient is administered a wrong medicine). [18] The total cost of these errors, including expenses of error, disability, and lost income and productivity, is expected to be between $17 billion and $29 billion per year. [64, 65] The occurrence of prescription errors in pediatrics is three-times higher than adults. Al-Nomay N.S., Ashi A., Al-Hargan A., Alshalhoub A., Masuadi E. Attitudes of dental professional staff and auxiliaries in Riyadh, Saudi Arabia, toward disclosure of medical errors. WebPreventing medication errors in the information age. Edmondson A. Doing so allows the whole mechanism of reporting systems, in its giving and receiving feedback and identification of errors, to be further enriched [62]. Medical Error. It is not advisable to put drugs into another container but if you must do it, label the new container properly. ADE Prevention Study Group, Occurrence and reporting of nurses medication errors in a teaching hospital in Isfahan, Innovative approaches to reducing nurses distractions during medication administration, Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM); Sentinel Events Evaluation (SEE) Study Investigators, Errors in administration of parenteral drugs in intensive care units: multinational prospective study, A systems approach to the reduction of medication error on the hospital ward, Medication errors: the problem and its scope, Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the global trigger tool method, and observations, Medication errors among nurses in intensive care units (ICU), Journal of Mazandaran University of Medical Sciences, The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper, Medication errors among nurses in teaching hospitals in the west of Iran: what we need to know about prevalence, types, and barriers to reporting, Adverse events in drug administration: a literature review, Check the amount and type of medication errors in nursing students at four teaching hospitals of Tehran, Nurse experience and education: effect on quality of care, Using drugs safely: Undergraduates Must be Proficient in Basic Prescribing, Medication administration errors and mortality: incidents reported in England and Wales between 20072016, Ranking factors contributing to medication error incidents in private hospital: a nurses perspective, Executive summary: the State of the Science on Safe Medication Administration symposium, Medication administration errors at Childrens University hospitals: nurses point of view. In: Oxford University Press is a department of the University of Oxford. No punishment for the reporter as a result of error reporting. Staff Educational Program to Prevent Medication Errors The incident is then reported nationally through the organizations system or online electronic-form. Careers, Unable to load your collection due to an error. reviewed the occurrence of errors among healthcare providers. Hrknen M, Turunen H, Vehvilinen-Julkunen K. Cheraghi MA, Nasabadi N, Reza A et al.. [68] Patient safety is esteemed as a critical issue for our social insurance framework and human services providers,[9] and in such manner, medication errors are utilized as a list to survey quiet wellbeing in clinics. A successful strategy to prevent and detect drug-related problems may involve three stages: pre-intervention phase, intervention phase, and post-intervention phase [51]. Factors such as whether the error got to the patient and if the patient was affected by the error and to what level, are considered by the index. Never stop asking for the patients name for each medication you will give even if you do it several times in a shift. Reducing medication errors: Teaching strategies that Lippincott NursingCenter, Safe Medication Use in the ICU [Guideline Summary] These medications are usually antihypertensive and hypoglycemic drugs. Additionally, in Ireland, the National Adverse Event Management System (NAEMS) (formally known as STARS web IRS) was implemented and has been in use since 2004 [31]. [59, 60] There were 192 477 medication errors reported by staff from 482 hospitals through voluntary reporting that could occur at any stage. Santell J.P., Hicks R.W., McMeekin J., Cousins D.D. The National Coordinating Council for Medication Error Reporting and Prevention: Promoting patient safety and quality through innovation and leadership. British Journal of Nursing - Medication errors: a positive safety Perusing the medicine name/label and expiration date of the medicine is additionally another best practice. Nowadays, medical error reporting systems are widely used. Rogers AE, Hwang WT, Scott LD et al.. [62] A previous study showed that (94.0%) out of 430 errors were omissions and only 6.0% of errors caused a major impact on patients life but was not considered as a lifealarming errors. Donaldson M.S., Corrigan J.M., Kohn L.T., editors. Following this rule before giving any prescription, can help nurses keep away from the vast majority of medication errors. A successful medication error reporting program has the following characteristics: safe for the reporter, results in useful recommendations and effective changes, includes everyone, and is supported with required resources. Reporting the medication errors is critical in improving the medication management process, therefore, it is considered a legal and ethical commitment in each health care settings. A search using search engines such as PubMed and Google scholar were used in finding articles related to the review topic. Sutherland A., Canobbio M., Clarke J., Randall M., Skelland T., Weston E. Incidence and prevalence of intravenous medication errors in the UK: A systematic review. Available online: The Academy of Managed Care Pharmacys Concepts in Managed Care Pharmacy, Medication Errors. 9 Simple Steps to Reduce Medication Errors Ensure the Six Rights of Medication Administration Are Followed. Furthermore, in Egypt, neonatal intensive care units (NICUs) utilize the Egyptian Neonatal Safety Training Network (ENSTN), which can be used confidentially and anonymously to report medical errors [40]. Be careful as well with drug packaging as some medicinescome in deceptively similar packaging or canisters. Ulanimo V.M., OLeary-Kelley C., Connolly P.M. Nurses perceptions of causes of medication errors and barriers to reporting. [103, 105] While this of great practice, nurses ought to assess how they work in groups to guarantee that the aggregate frameworks and procedures of training are sheltered and to help and instruct unpracticed partners. For example, in Denmark the reporting rate is 50% compared to 1% in Australia, where the reporting is voluntary [19]. There are two kinds of reporting systems, voluntary and mandatory. Engaging everyone (prescriber, pharmacist, nurse, allied health professionals, patient, and family). [53] On the other hand, no examinations have exhibited solid connections between nurses qualities (i.e. The incident(s) and types of medication error(s) within the healthcare facility will be identified. This procedure can likewise be completed starting with one medical nurse then onto the next whereby a medical nurse peruses back a request deciphered to the doctors structure to another medical nurse as the MAR is checked on to guarantee precision. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Bates DW, Leape LL, Cullen DJ et al.. [36, 37, 39] It is noticed that competence skills in drug calculation are prerequisites to nursing registration and examining their learning abilities rather than follow strict protocol which imped nurses thinking skills. [115] This would appear to show that nurses are conceivably in danger of making a medication error. Clarifying adverse drug events: a clinicians guide to terminology, documentation, and reporting, Errors in the administration of intravenous medication in Brazilian hospitals, A look into the nature and causes of human errors in the intensive care unit, Medication administration errors in an intensive care unit in Ethiopia, Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital, Medication errors at the administration stage in an intensive care unit, Incidence of medication errors and adverse drug events in the ICU: a systematic review, Effect of computerized physician order entry and a team intervention on prevention of serious medication errors, Review - medication errors and strategies for their prevention. In Australia, the Advanced Incident Monitoring System (AIMS) was implemented around 2005 [31], and the National Reporting and Learning System (NRLS) is used since 2003 in the United Kingdom [31].
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