Medication errors: problems and recommendations from a consensus meeting

Agrawal, Akshat; Aronson, Jeffrey K; Britten, Nicky; Ferner, Robin E; Smet, P A de; Fialová, Daniela; Fitzgerald, Richard J.; Likić, Robert; Maxwell, Simon; Meyboom, R.H.B.; Minuz, Pietro; Onder, Graziano; Schächter, Michael; Velo, Giampaolo

doi:10.1111/j.1365-2125.2009.03414.x

Cited by 44 publications

(28 citation statements)

References 36 publications

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“…Now widely implemented, electronic medication administration records (eMARs) are used to support medication management to reduce medication errors, promote patient safety and improve workflow efficiency [1][2][3]. Nurses represent the greatest numbers of eMAR users and are recognized as the "last line of defense" in preventing medication errors in acute care settings [4].…”

Section: Introductionmentioning

confidence: 99%

Usability Evaluation of An Electronic Medication Administration Record (eMAR) Application

Guo¹,

Iribarren²,

Kapsandoy³

et al. 2011

Appl Clin Inform

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SummaryBackground: Electronic medication administration records (eMARs) have been widely used in recent years. However, formal usability evaluations are not yet available for these vendor applications, especially from the perspective of nurses, the largest group of eMAR users. Objective: To conduct a formal usability evaluation of an implemented eMAR. Methods: Four evaluators examined a commercial vendor eMAR using heuristic evaluation techniques. The evaluators defined seven tasks typical of eMAR use and independently evaluated the application. Consensus techniques were used to obtain 100% agreement of identified usability problems and severity ratings. Findings were reviewed with 5 clinical staff nurses and the Director of Clinical Informatics who verified findings with a small group of clinical nurses. Results: Evaluators found 60 usability problems categorized into 233 heuristic violations. Match, Error, and Visibility heuristics were the most frequently violated. Administer Medication and Order and Modify Medications tasks had the highest number of heuristic violations and usability problems rated as major or catastrophic. Conclusion:The high number of usability problems could impact the effectiveness, efficiency and satisfaction of nurses' medication administration activities and may include concerns about patient safety. Usability is a joint responsibility between sites and vendors. We offer a call to action for usability evaluations at all sites and eMAR application redesign as necessary to improve the user experience and promote patient safety.

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Section: Introductionmentioning

confidence: 99%

Usability Evaluation of An Electronic Medication Administration Record (eMAR) Application

Guo¹,

Iribarren²,

Kapsandoy³

et al. 2011

Appl Clin Inform

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“…Are these findings relevant to patient care? Medicationrelated patient safety is currently a hot topic in research, given the increase in the number of reports of the harmful effects of, often preventable, medication errors and particularly in older patients [4,22]. Investigators mention that prescribing knowledge and skills will improve if education and training are improved [4,23].…”

Section: Discussionmentioning

confidence: 99%

“…These changes have improved the clinical performance of students during and after graduation and increased student satisfaction [1,2]. However, there is also ongoing debate about the potential disadvantages of PBL, such as a loss of knowledge of basic sciences [1][2][3], and especially in pharmacology and pharmacotherapy [4]. Studies of drug safety have shown that the number of prescribing errors is high, which could adversely affect patient outcomes, leading to hospitalization or even death [5,6].…”

Section: Introductionmentioning

confidence: 99%

Education on prescribing for older patients in the Netherlands: a curriculum mapping

Keijsers

Wit

Tichelaar

et al. 2015

Eur J Clin Pharmacol

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Purpose Pharmacology and pharmacotherapy education is being increasingly integrated in medical curricula, which might lead to a specific loss of knowledge in these subjects. This, in turn, could lead to harmful prescribing errors, especially in vulnerable older patients. Methods Teachers who coordinated education in Dutch medical schools completed a structured interview on (geriatric) pharmacology and pharmacotherapy education.A list of core learning goals was developed. Pharmacology and pharmacotherapy education in general was compared to geriatric pharmacology and pharmacotherapy education. Results All Dutch medical schools participated. Contact hours for education in pharmacology and pharmacotherapy ranged from 39 to 107 h; ECTSs (representing 28 study hours) ranged from 0 to 3. The various curricula covered, on average, 79 % of all learning goals for these subjects: knowledge 85 %, skills 76 %, and attitudes 66 %; the curricula also covered specific geriatric goals: knowledge 87 % and skills 65 %. All geriatric learning goals were met if a geriatrician was among the coordinators. Half (4 of 8) of the medical schools lacked appropriate assessment procedures. Evaluation was mostly based on students' opinions. Teachers rated students as being moderately well prepared for daily practice. Conclusions There are large differences in the quantity and quality of (geriatric) pharmacology and pharmacotherapy education in Dutch medical schools. In general, more time should be devoted to skills and attitude, and the assessment procedures should be optimized with high priority. Other curricula with a problem-based approach might benefit from the points of improvement described in this article.

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“…The assessment process makes the adoption of this technology less stressful and more efficient as the staff have a better preparation. [11] Pharmacists and other pharmacy personnel also need to be able to do what they can to ensure the success of the organizations. This includes targeting at a specific system's weakness in the medicationuse processes.…”

Section: Medication Safety In Community Pharmacymentioning

confidence: 99%

Medication Safety Beyond the Hospital and Role of Pharmacists in Ambulatory Medication Safety Process

Alshakka¹,

Hassali²,

Ali³

et al. 2017

JPPCM

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Medication safety is one of the challenges which is in focus now-a-days, and various approaches to reduce the incidence of medication related problems and risks are ongoing.Most initiatives have concentrated on medication safety in the hospital setting considering the increased risks of medication errors in hospitals. However, there are various factors and areas to be addressed regarding medication safety beyond the hospital setting. Although, attitudes towards medication use are changing among the public and health providers but, still the use of medicines beyond hospital settings requires more attention. Great efforts are needed in this area, due to diversity in the types of errors, the relationship between the provider and the patient, information transfer, optimization of e-prescribing systems, the lack of adequate training in analyzing the collected data and poor practical strategies for maintaining accurate medication lists in electronic medical records. Recently individuals have started becoming aware of the risks of patients' medication exposure, however, still the area of medication safety beyond the hospital setting needs comunity pharmacy intervention to avoid malpractice claims and misled decisions in solving medication safety-related problems in the outpatient setting . All these approches will help in identify and prompt the detection of errors, open productive discussions, quality control checks, and effective wise system based decisions, and subsequently reduce the harm and risks before patient is exposed to any form of medication

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Medication errors: problems and recommendations from a consensus meeting

Cited by 44 publications

References 36 publications

Usability Evaluation of An Electronic Medication Administration Record (eMAR) Application

Usability Evaluation of An Electronic Medication Administration Record (eMAR) Application

Education on prescribing for older patients in the Netherlands: a curriculum mapping

Medication Safety Beyond the Hospital and Role of Pharmacists in Ambulatory Medication Safety Process

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