Analysis of medication incident for improvement of medication process

Sano, Mizuka; Munechika, Masahiko; Jin, Haizhe; Kajihara, Chisato; Hamada, Chikuma

doi:10.1080/14783363.2013.791116

Cited by 10 publications

(11 citation statements)

References 3 publications

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“…The system elements were selected from the perspective of specificity and ease of improvement. 15,57 ''Specificity'' means that the classification of system elements should be specific and reflect the characteristics of medical work. The nine types of workloads used in this study in Table 3 can be systematically divided in terms of time, physical and cognitive, and each type of these workloads was characteristic of medical treatment practice.…”

Section: Discussionmentioning

confidence: 99%

Effects of workload on medication administration errors in nursing: an analysis based on system dynamics modeling

et al. 2023

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Medication administration errors account for a relatively high proportion of medical errors, with more than 50% occurring at the nursing administration stage. Nursing is characterized by a large amount of work, rigid working hours, high information cognitive intensity, and frequent information updates. The high workload of nurses is a significant cause of medication administration errors. In this study, a literature analysis was used to determine the elements of the system dynamics model, and the causal loop diagram was used to draw the relationship framework among the elements. Vensim personal learning edition and interview surveys were then used for model validation and simulation. First, 302 case analyses of medication administration errors collected from the three metropolitan area hospitals were used to construct the causal loop diagram, the stock and flow map of the medication administration error system, and the dynamics model; second, the model was tested from theoretical and historical data simulation perspectives; finally, the system dynamics model proposed in this study was used to simulate a medical institution from overtime and policy perspectives. Through system dynamics modeling, the inducing mechanism of workload on medication administration errors in nursing operations was elucidated, and corresponding suggestions for prevention were provided. In addition, ideas and basis for optimizing the medication administration process, improving workload, and preventing medication administration errors considering workload were provided.

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Section: Discussionmentioning

confidence: 99%

Effects of workload on medication administration errors in nursing: an analysis based on system dynamics modeling

et al. 2023

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“…The importance of assessing and managing risks in public health, including the risk of adverse events (AEs) has been recognized for several years and is one of the main topic while talking about health care quality [6]. This is highly desirable and reasonable, because, as confirmed by the results of studies in different countries, the rate of adverse events ranges from 3-17% [7] and is not decreasing [8]. It is also desirable and reasonable to implement a proactive approach in adverse events risk assessment, as recommended by the Joint Commission on the Accreditation of Healthcare Organization (JCAHO) in the United States (US).…”

Section: Introductionmentioning

confidence: 86%

The Risk Assessment of Adverse Events of Nursing Activities as the Element of Quality Management in Healhcare

Wiśniewska¹,

Grudowski²,

Konieczyńska³

2015

Management and Production Engineering Review

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Accepted: 12 January 2015The purpose of the paper is to present MedCARVER+Shock method and Pareto analysis and its usability for the risk assessment of adverse events of nursing activities. 888 activities carried out by all 190 nurses working at the District Hospital X located in Poland were taken into account. During the research the qualitative approach was used. As the result sixteen groups of nursing activities causing the highest risk of adverse events were selected. Special attention required in: admission of a patient to the ward, sterilization, verbal communication with the patient, using of intravenous cannulas, needles, syringes, devices for transfusion of infusion liquids, servicing of hospital rooms, first aid in life-threatening situations, using medical devices and equipment. Ten basic causes of the risk of adverse events were identified, among others: lack of trainings, of modern equipment, of staff, failure to comply with procedures, lack of staff supervision, poor quality of ancillary materials, lack of management commitment. Finally MedCARVER+Shock method and Pareto analysis usability has been confirmed but it appeared that it is time-consuming and requires support from skilled professionals. Several suggestions have been put forward to improve the utility of MedCARVER+Shock.

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“…The quality of these processes can be effectively enhanced through analysis of medical errors, assessment of error mechanisms, and establishment of countermeasures to improve medical operational processes (Habraken, Vander, & Leistikow, 2009;Sano, Munechika, Jin, Kajihara, & Hamada, 2013;Xie & Carayon, 2015). The performance of medical devices is constantly advancing together with the advancement of medical techniques.…”

Section: Introductionmentioning

confidence: 99%

Operational process improvement in medical TQM: a case study of human error in using devices

Jin

Munechika

Sano

et al. 2016

Total Quality Management & Business Excellence

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Preventing human error in healthcare is a difficult challenge, with multiple approaches to developing prevention methods and tools. The purpose of this article was to construct a method for preventing human error in medical device use from the perspective of Total Quality Management (TQM). Drawing on cases of errors made when using medical devices, error mechanisms were identified. Considering aspects of humans, medical devices, and interactions between these, we investigated error behaviours, as well as their inducing factors and situations. The methods of eliminating those factors causing medical error behaviours were proposed based on the behavioural mechanism of the error. The findings indicate that TQM is an effective way to reduce medical errors.

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Analysis of medication incident for improvement of medication process

Cited by 10 publications

References 3 publications

Effects of workload on medication administration errors in nursing: an analysis based on system dynamics modeling

Effects of workload on medication administration errors in nursing: an analysis based on system dynamics modeling

The Risk Assessment of Adverse Events of Nursing Activities as the Element of Quality Management in Healhcare

Operational process improvement in medical TQM: a case study of human error in using devices

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