Let's do no harm: Medication errors in nursing: Part 1

Leufer, Thérèse; Cleary‐Holdforth, Joanne

doi:10.1016/j.nepr.2013.01.013

Cited by 47 publications

(37 citation statements)

References 17 publications

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“…Medication administration represents the last chance of checking and preventing errors, which is fundamental to reduce preventable harm to the patient. 1,9 However, a study in psychiatric wards in Denmark identified that the majority (75%) of medication errors that occurred were related to the medication administration step. 9 The lack of hand hygiene was observed in most procedures.…”

Section: Discussionmentioning

confidence: 99%

“…10 Nurses need to understand that medication administration is a complex, dynamic and multifaceted phenomenon, and to be competently and responsibly involved in this process. 1 It is important to analyze and organize the nursing work process in hospital institutions to optimize the quality of the service provided and to establish an institutional and professional culture of safety, promoting responsibility, non-punitive attitudes and patient safety. 30 This study is limited by the cross-sectional model, which does not allow it to establish causal relations for the issues addressed.…”

Section: Discussionmentioning

confidence: 99%

“…This can lead to the occurrence of medication errors 1 at different stages, such as prescription, dispensation, preparation and administration.…”

Section: Introductionmentioning

confidence: 99%

“…Consequently, nursing is fundamental for the reduction and prevention of medication errors. 1,[9][10] Nurses must play an active role in identifying, reporting and analyzing errors in the medication system. Furthermore, their role is essential for monitoring, planning interventions and policies to promote safety, medication administration and maximize benefits of patient-related care.…”

Section: Introductionmentioning

confidence: 99%

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Medication System: Analysis of Actions Taken by Professionals in Psychiatric Units

Souta¹,

Filho

Vedana

et al. 2016

Texto contexto - enferm.

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This study analyzed the medication systems in psychiatric units of a general hospital and a psychiatric hospital in the state of São Paulo, Brazil. It is a quantitative and cross-sectional, exploratory survey study with 144 professionals from the areas of medication, nursing and pharmacy. Data were collected by direct, non-participative observation and by medical records review. Data were analyzed using descriptive statistics. Factors that affect patient safety, such as interruptions during prescription, handwritten changes to electronic prescriptions, limited handling of the electronic prescription system, unavailable clinical pharmacy, mistakes in activities related to the preparation and administration of medications and other factors were identified. The study reveals the susceptible points for the occurrence of medication errors in psychiatric hospitalization departments and discusses recommendations and technological resources that can promote security in the medication system. DESCRITORS: Medication errors. Safety management. Medication system. Mental health. SISTEMA DE MEDICAÇÃO: ANÁLISE DAS AÇÕES DOS PROFISSIONAIS EM UNIDADES DE INTERNAÇÃO PSIQUIÁTRICARESUMO: Este estudo analisou os sistemas de medicação em unidades de psiquiatria de um hospital geral e de um hospital psiquiátrico, do interior de São Paulo, Brasil. Trata-se de estudo quantitativo, transversal, tipo survey exploratório e realizado com 144 profissionais da medicina, enfermagem e farmácia. Os dados foram coletados por observação não participante direta e revisão em prontuários e foram analisados por estatística descritiva. Foram identificados fatores que desfavorecem a segurança do paciente como interrupções, durante a atividade de prescrição, alterações manuscritas em prescrições eletrônicas, restrições no manuseio do sistema eletrônico de prescrição, indisponibilidade de farmácia clínica, falhas nas atividades relacionadas ao preparo e à administração dos medicamentos e outros. Este estudo revela pontos vulneráveis para a ocorrência de erros de medicação em serviços de internação psiquiátrica e discute recomendações e recursos tecnológicos que podem promover a segurança no sistema de medicação. DESCRITORES:Erros de medicação. Gerenciamento de segurança. Sistema de medicação. Saúde mental. SISTEMA DE MEDICACÍON: ANÁLISIS DE LAS ACCIONES PROFESIONALES EN UNIDADES PSIQUIÁTRICAS RESUMEN:Este estudio analizó los sistemas de medicación en unidades psiquiátricas de un hospital general y de un hospital psiquiátrico del interior del estado de Sao Paulo, en Brasil. Estudio cuantitativo, transversal y exploratorio. Participaron de la encuesta 144 profesionales de medicina, enfermería y farmacia. Los datos fueron obtenidos por medio de observación no participante directa y revisión de fichas médicas y se analizaron por estadística descriptiva. Fueron identificados factores que no favorecen la seguridad del paciente como: interrupciones durante la actividad de prescripción; modificaciones escritas en prescripciones electrónicas; restriccion...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…This can lead to the occurrence of medication errors 1 at different stages, such as prescription, dispensation, preparation and administration.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Medication System: Analysis of Actions Taken by Professionals in Psychiatric Units

Souta¹,

Filho

Vedana

et al. 2016

Texto contexto - enferm.

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“…Errors are of the most frequent causes of death and preventable complications in hospitals (8). Although nurses do not work apart from the whole system, and are the last part of the chain of care (9), more than 40% of their working time is directly involved in the implementation of health instructions (10). Therefore, committing errors when they are performing their tasks is typical (11).…”

Section: Introductionmentioning

confidence: 99%

SHERPA Technique as an Approach to Healthcare Error Management and Patient Safety Improvement: A Case Study among Nurses

et al. 2016

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Background: Overcoming the challenge of human error occurrence in the healthcare section and patient safety improvement is impossible without understanding the nature of human error and without considering the fundamentals of human factors and ergonomics in designing and implementing sociotechnical systems. Therefore, the first step is to identify medical errors and their causes, using standard methods. Objectives: The aim of this study was to identify and evaluate human errors among nurses in the women's infectious diseases ward in an educational hospital in the city of Qom in 2015. Methods: This cross-sectional study was performed to identify the medical errors among sixteen female nurses working in the women's infectious diseases ward, using SHERPA. Hierarchical task analysis (HTA) was performed; errors were identified by checklist and risk assessment was then carried out. Results: One hundred fifty-nine errors were identified and evaluated in 89 tasks. Most of the detected errors were of the action type (74.21%) and the least errors were of the selection type (0.63%). The least number of the errors' risk level was placed in the undesirable, and the highest was in the unacceptable level. Conclusions: Since the majority of the errors were of the action type, proper measures should be taken to prioritize them in disease control. In addition, designing a treatment process based on human factors and ergonomic principles is highly recommended to enhance the quality of services, improve patient safety and reduce errors. With respect to task analysis, the SHERPA is a good technique to evaluate and monitor medical errors.

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Lean Methodology in the Process of Prescribing and Administering Therapeutics in the Intensive Care Unit

Marques

Sousa

Cortes³

et al. 2021

Lecture Notes in Bioengineering

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Objective: This study was conducted to explore and to describe the causes of medication errors in Intensive Care Units (ICUs) from the perspective of physicians, nurses, and clinical pharmacists. Methods: The study was conducted using a descriptive qualitative method in 2016. We included 16 ICUs of seven educational hospitals affiliated to Isfahan University of Medical Sciences. Participants included 19 members of the healthcare team (physician, nurse, and clinical pharmacist) with at least 1 year of work experience in the ICUs. Participants were selected using purposeful sampling method. Data were collected through semi-structured individual interviews and were used for qualitative content analysis. Findings: The four main categories and ten subcategories were extracted from interviews. The four categories were as follows: "low attention of healthcare professionals to medication safety," "lack of professional communication and collaboration," "environmental determinants," and "management determinants." Conclusion: Incorrect prescribing of physicians, unsafe drug administration of nurses, the lack of pharmaceutical knowledge of the healthcare team, and the weak professional collaboration lead to medication errors. To improve patient safety in the ICUs, healthcare center managers need to promote interprofessional collaboration and participation of clinical pharmacists in the ICUs. Furthermore, interprofessional programs to prevent and reduce medication errors should be developed and implemented.

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Let's do no harm: Medication errors in nursing: Part 1

Cited by 47 publications

References 17 publications

Medication System: Analysis of Actions Taken by Professionals in Psychiatric Units

Medication System: Analysis of Actions Taken by Professionals in Psychiatric Units

SHERPA Technique as an Approach to Healthcare Error Management and Patient Safety Improvement: A Case Study among Nurses

Lean Methodology in the Process of Prescribing and Administering Therapeutics in the Intensive Care Unit

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