Critical Incident Reporting zu Medikationsfehlern mit Masseinheiten und Berechnungen

Kerker-Specker, Carmen; Brühwiler, Lea D.; Paula, Helmut; Schwappach, David

doi:10.1016/j.zefq.2020.10.004

Cited by 4 publications

(3 citation statements)

References 15 publications

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“…Despite detailed preparation and careful execution of an intervention, critical situations or near misses may occur. Among other systems, the legally-required CIRS can be used to document and analyze these events 31 32 . This system can anonymously record critical events or near misses, allowing risk identification and analysis.…”

Section: Intervention Planning and Performancementioning

confidence: 99%

“…Trotz ausführlicher Vorbereitung und sorgfältiger Durchführung einer Intervention kann es zu kritischen Situationen oder Beinahe-Fehlern kommen. Um diese zu dokumentieren und zu analysieren, bestehen Fehlermeldesysteme wie das gesetzlich vorgeschriebene CIRS 31 32 . In diesem System können kritische Ereignisse oder Beinahe-Fehler anonym erfasst werden, wodurch eine Risikoidentifikation und -analyse erfolgen kann.…”

Section: Interventionsplanung Und -Durchführungunclassified

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Complication Management and Prevention in Vascular and non-vascular Interventions

Weiss

Wilms

Ivan

et al. 2022

Rofo

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Purpose This overview summarizes key points of complication management in vascular and non-vascular interventions, particularly focusing on complication prevention and practiced safety culture. Flowcharts for intervention planning and implementation are outlined, and recording systems and conferences are explained in the context of failure analysis. In addition, troubleshooting by interventionalists on patient cases is presented. Material and Methods The patient cases presented are derived from our institute. Literature was researched on PubMed. Results Checklists, structured intervention planning, standard operating procedures, and opportunities for error and complication discussion are important elements of complication management and essential for a practiced safety culture. Conclusion A systematic troubleshooting and a practiced safety culture contribute significantly to patient safety. Primarily, a rational and thorough error analysis is important for quality improvement. Key Points: Citation Format

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Section: Intervention Planning and Performancementioning

confidence: 99%

Section: Interventionsplanung Und -Durchführungunclassified

Complication Management and Prevention in Vascular and non-vascular Interventions

Weiss

Wilms

Ivan

et al. 2022

Rofo

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“…These include changes in body composition, maturation of organs, or age-dependent variation in the activity of metabolising enzymes [13,16]. Not only the dosage itself but also the conversion to the dispensing unit is a well-reported source of errors [17,18]. Thus, the leading causes of preventable errors in paediatric patients are prescribing errors, particularly dosing errors [3,5,19].…”

Section: Introductionmentioning

confidence: 99%

Description of a clinical decision support tool with integrated dose calculator for paediatrics

Higi

Käser²,

Wälti³

et al. 2021

Eur J Pediatr

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Medication errors, especially dosing errors are a leading cause of preventable harm in paediatric patients. The paediatric patient population is particularly vulnerable to dosing errors due to immaturity of metabolising organs and developmental changes. Moreover, the lack of clinical trial data or suitable drug forms, and the need for weight-based dosing, does not simplify drug dosing in paediatric or neonatal patients. Consequently, paediatric pharmacotherapy often requires unlicensed and off-label use including manipulation of adult dosage forms. In practice, this results in the need to calculate individual dosages which in turn increases the likelihood of dosing errors. In the age of digitalisation, clinical decision support (CDS) tools can support healthcare professionals in their daily work. CDS tools are currently amongst the gold standards in reducing preventable errors. In this publication, we describe the development and core functionalities of the CDS tool PEDeDose, a Class IIa medical device software certified according to the European Medical Device Regulation. The CDS tool provides a drug dosing formulary with an integrated calculator to determine individual dosages for paediatric, neonatal, and preterm patients. Even a technical interface is part of the CDS tool to facilitate integration into primary systems. This enables the support of the paediatrician directly during the prescribing process without changing the user interface.Conclusion: PEDeDose is a state-of-the-art CDS tool for individualised paediatric drug dosing that includes a certified calculator. What is Known:• Dosing errors are the most common type of medication errors in paediatric patients.• Clinical decision support tools can reduce medication errors effectively. Integration into the practitioner’s workflow improves usability and user acceptance. What is New:• A clinical decision support tool with a certified integrated dosing calculator for paediatric drug dosing.• The tool was designed to facilitate integration into clinical information systems to directly support the prescribing process. Any clinical information system available can interoperate with the PEDeDose web service.

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Methodological Approaches for Analyzing Medication Error Reports in Patient Safety Reporting Systems: A Scoping Review

Tchijevitch,

Hansen,

Hallas

et al. 2024

The Joint Commission Journal on Quality and Patient Safety

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Critical Incident Reporting zu Medikationsfehlern mit Masseinheiten und Berechnungen

Cited by 4 publications

References 15 publications

Complication Management and Prevention in Vascular and non-vascular Interventions

Complication Management and Prevention in Vascular and non-vascular Interventions

Description of a clinical decision support tool with integrated dose calculator for paediatrics

Methodological Approaches for Analyzing Medication Error Reports in Patient Safety Reporting Systems: A Scoping Review

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