Contributing factors to outpatient pharmacy near miss errors: a Malaysian prospective multi-center study

Rajah, Retha; Hanif, Atisha Abdul; Tan, Sherene Su Ann; Lim, Phin Phin; Karim, Sarah Abdul; Othman, E; Teoh, Tsyr Fen

doi:10.1007/s11096-018-0762-1

Cited by 10 publications

(10 citation statements)

References 19 publications

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“…This finding reveals that extensive training and continuing education are necessary. Generally in line with previous studies, 6,8,36,37 our study suggests that the wrong medication, wrong quantity and wrong strength were the most common error types and that drugs that LASA, inadequate checks, and high workload were the most common contributing factors. Through detailed discussions on the contributing factors related to MEs, focused prevention strategies were more easily generated.…”

Section: Discussionsupporting

confidence: 91%

“…However, this study is a presentation of the real situation at our hospital. Our study revealed that the outpatient pharmacy was the most error prone, which was the same as previous studies, 5,36 given that the number of patients served and the number of prescriptions filled by the outpatient pharmacy are the largest out of all the pharmacies in the hospital. The main individuals responsible for errors in dispensing were junior pharmacists rather than intern pharmacists, probably because their work is supervised by associate chief pharmacists for the latter.…”

Section: Discussionsupporting

confidence: 87%

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Preventing dispensing errors through the utilization of lean six sigma and failure model and effect analysis: A prospective exploratory study in China

Chen

Liu

et al. 2020

Evaluation Clinical Practice

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Aims To utilize lean six sigma (LSS) and failure model and effect analysis (FMEA) to prevent dispensing errors in a Chinese teaching hospital. Methods Medication errors (MEs) reported to the China Core Group of the international network for the rational use of drugs (INRUD) by pharmacists at the hospital were collected. Following LSS methodology, the data analysis was structured according to define, measure, analyse, improve, and control (DMAIC) phases, and typical LSS tools (Pareto diagrams, brainstorming sessions) were used to determine the risk factors leading to dispensing errors. FMEA was applied to generate the risk priority numbers (RPNs) of MEs events, and key medications targeted for error prevention strategies were identified through quantitative analysis of the impacts of failure. Finally, corrective measures to prevent MEs were implemented and monitored for efficacy. Results Before the implementation of this programme, a total of 603 cases of dispensing errors were reported from the Year 1 to Year 6, reaching an average rate of incidence of 0.33 cases per 10 000 medication orders delivered, and no difference was found between these years (P = .9424). There was also no difference as location, error type, contributing factors, cause classification were considered. We then determined the real cause behind dispensing errors, and a total of 67 medications were targeted for specific error prevention strategies. One year after intervention, progress had been achieved in the following aspects: the incidence rate of dispensing errors was significantly decreased compared with the previous years (0.19, P = .007). Simultaneously, the incidence rate of dispensing errors occurred in outpatient pharmacy (0.04, P = .0008), with junior pharmacists (0.15, P = .0258), with LASA medications (0.06, P = .0319), as well as with memory‐based errors were significantly decreased (0.03, P = .0191). Conclusion The combination of LSS and the FMEA tool can be an efficient approach for helping reduce MEs in pharmacy dispensing.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionsupporting

confidence: 87%

Preventing dispensing errors through the utilization of lean six sigma and failure model and effect analysis: A prospective exploratory study in China

Chen

Liu

et al. 2020

Evaluation Clinical Practice

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“…The results from this study indicated that the top three causes of incorrect medication selection were; non-compliance with the medication selection standard procedure, and technicians reporting that they were too rushed and the workload was imbalanced. These findings are in line with those from Aldhwaihi et al (2016) and Rajah et al (2019). In a study of dispensing errors in an outpatient pharmacy in six Malaysian hospitals, distractions and an interrupted work environment were cited as the leading cause of dispensing error (Rajah et al , 2019).…”

Section: Discussionsupporting

confidence: 81%

Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study

Trakulsunti

Antony

Dempsey

et al. 2020

IJQRM

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PurposeThe purpose of this paper is to illustrate the use of Lean Six Sigma (LSS) and its associated tools to reduce dispensing errors in an inpatient pharmacy of a teaching hospital in Thailand.Design/methodology/approachThe action research methodology was used to illustrate the implementation of Lean Six Sigma through the collaboration between the researcher and participants. The project team followed the Lean Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) methodology and applied its tools in various phases of the methodology.FindingsThe number of dispensing errors decreased from 6 to 2 incidents per 20,000 inpatient days per month between April 2018 and August 2019 representing a 66.66% reduction. The project has improved the dispensing process performance resulting in dispensing error reduction and improved patient safety. The communication channels between the hospital pharmacy and the pharmacy technicians have also been improved.Research limitations/implicationsThis study was conducted in an inpatient pharmacy of a teaching hospital in Thailand. Therefore, the findings from this study cannot be generalized beyond the specific setting. However, the findings are applicable in the case of similar contexts and/or situations.Originality/valueThis is the first study that employs a continuous improvement methodology for the purpose of improving the dispensing process and the quality of care in a hospital. This study contributes to an understanding of how the application of action research can save patients' lives, improve patient safety and increase work satisfaction in the pharmacy service.

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“…6,7 In ambulatory care setting, the types of ME at the dispensing stage include labelling and filling errors. 8 In the inpatient setting, nurses are usually involved in medication administration activities and the most common type of administration error reported was wrong time error. 9 Pharmacists are essential health-care providers who can help ensure patients receive their medications safely.…”

Section: Introductionmentioning

confidence: 99%

<p>Development and Psychometric Validation of a Questionnaire to Evaluate Knowledge and Attitude Towards Medication Error Reporting Among Pharmacists</p>

Mamat¹,

Awang²,

Rahman

2020

DHPS

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Purpose: Assessment of medication errors (ME) is crucial to improving the quality of health care. A questionnaire that can be used to explore pharmacists' perspectives regarding ME would be very useful as part of an ongoing process of quality improvement in patient care. The aim of this study was to develop and validate a questionnaire to measure perceived causes of ME and attitude towards ME reporting among pharmacists. Methods: The questionnaire was developed from the literature together with outcomes from focus group discussions. It was divided into two domains which are knowledge on ME and attitude towards ME reporting. Content validity index (I-CVI), exploratory factor analysis (EFA), Cronbach alpha and intraclass correlation coefficient (ICC) to assess test-retest reliability were obtained during the validation process. Results: Overall Cronbach alpha for internal consistency was good (0.742), where subscale of the questionnaire demonstrated adequate internal consistency, with Cronbach alpha value 0.83 for knowledge and 0.70 for reporting behaviour attitude. The I-CVI showed good scores (knowledge=0.88) and (attitude=0.81), while ICC was moderately accepted with a value of 0.77. Two factors were extracted from the 16 items in EFA. Conclusion: The questionnaire to assess knowledge on ME and attitude towards ME reporting among pharmacists is valid and reliable. It demonstrates good psychometric properties.

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Contributing factors to outpatient pharmacy near miss errors: a Malaysian prospective multi-center study

Cited by 10 publications

References 19 publications

Preventing dispensing errors through the utilization of lean six sigma and failure model and effect analysis: A prospective exploratory study in China

Preventing dispensing errors through the utilization of lean six sigma and failure model and effect analysis: A prospective exploratory study in China

Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study

<p>Development and Psychometric Validation of a Questionnaire to Evaluate Knowledge and Attitude Towards Medication Error Reporting Among Pharmacists</p>

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