Harm Prevalence Due to Medication Errors Involving High-Alert Medications: A Systematic Review

Abstract

Objective The aim of the study was to determine the prevalence and main types of harm caused by high-alert medication after medication errors (MEs) in hospitals. Method A literature systematic review was conducted on PubMed, Scopus, Web of Science, and Lilacs. Eligible studies published until June 2017 were included. Result Of 6244 studies identified through searching four electronic databases, five studies meeting the selection criteria of this study were analyzed. There was wide variation in the overall prevalence of harm due to MEs involving HAM, from 3.8% to 100%, whereas the pooled prevalence was 16.3%. Overall, 0.01% of harm caused by MEs involving HAM resulted in death. The severity of errors ranged from 0.1% to 19.2% for moderate errors, 0.2% to 15.4% for serious errors, and 1.9% lethal to the patients. The highest prevalences of harm occurred after errors involving potassium chloride 15%, insulin, and epoprostenol. The lowest prevalence of harm was related to errors of anticoagulants administration. The methodological heterogeneity limited direct comparisons among the studies. Conclusions Of the 15 drugs on the list of Institute for Safe Medication Practices HAMs in the United States and Brazil, nine did not present scientific evidence of the potential for harm. In general, few studies, characterized by methodological and conceptual heterogeneity, were performed to determine the harm prevalence resulting from errors involving these drugs.

Prevalence and predictors of medication-related emergency department visit in older adults: A multicenter study linking national claim database and hospital medical records

“…A significant proportion of MRED-ADE consequences were falls or fractures (156 cases, 26.8%), bleeding (118 cases, 20.2%), and hypoglycemia (34 cases, 5.8%), and these were mostly wellknown high-alert medication-related outcomes (Sodré Alves et al, 2021;Virnes et al, 2022). Multivariate results identified high-alert medication and some potentially inappropriate medications in older adults as predictors of MRED.…”

Effect of Educational Guidelines on Nurses’ Performance regarding Safe Use of High Alert Medications at Pediatric Intensive Care Units

“…Also, children in pediatric intensive care units have three times more risk for medication errors. (Alves et al,2021).…”

Errors in diabetic insulin therapy and the vitality of proper precautions in Bangladesh: Real-life insights from the developing world

“…Insulin is considered a high-alert medication (HAM), which means that mistakes with this medication, either in preparation or administration, can have very serious consequences. [ 3 4 ] Hospitalized patients are particularly at risk of medication errors with insulin, which can lead to longer hospital stays. [ 4 ] About 31% of patients with diabetes are treated with insulin, and a significant proportion of medication errors resulting in death within 48 h involve insulin therapy.…”

“…[ 9 ] Such errors can occur at every stage of the process, from the initial prescription to administration, and can have serious consequences including low or high blood sugar. [ 3 4 ] The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines medication error as “any preventable event that can cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health-care professional, patient, or consumer,” and avoiding such errors in insulin-treated patients is critical to the therapeutic success. [ 10 ] Given the high prevalence of diabetes in Bangladesh, it is important to identify the types of errors that occur in insulin therapy and develop strategies to minimize them.…”