The extent of medication errors and adverse drug reactions throughout the patient journey in acute care in Australia

Roughead, Elizabeth E.; Semple, Susan J.; Rosenfeld, Ellie

doi:10.1097/xeb.0000000000000075

Cited by 133 publications

(170 citation statements)

References 21 publications

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“…A recent literature review7 supported early studies23 that, on average, there is an omission of one medication for every two patients when medicine reconciliation does not occur. Stowasser23 identified the incidence of omissions (0.5 per patient) and discrepancies (0.3 per patient) within medication histories undertaken and documented by medical officers.…”

Section: Discussionmentioning

confidence: 87%

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Accuracy of best possible medication history documentation by pharmacists at an Australian tertiary referral metropolitan hospital

2017

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AimTo determine the quality of best possible medication history (BPMH) taking activities undertaken by pharmacists. To identify factors which impact upon erroneous documentation. To assess risks associated with erroneous documentation of BPMH by pharmacists.MethodA clinical pharmacist randomly selected patients across a tertiary referral, metropolitan hospital over an 9-day period and documented comparator medication histories (CMHs) using a structured interview. BPMH documented by pharmacists as part of routine care and CMH were compared, and erroneous documentation was classified according to previous definitions in the literature. Erroneous documentation was risk stratified.Results99 BPMH and CMH were compared. There were 14 medication omissions which occurred across 10 patients and 14 discrepancies across 12 patients. There was no association identified between erroneous documentation and pharmacist seniority/experience (p=0.25), where BPMH taken (p=0.7), day of week BPMH documented (p=0.45) or time since admission to when BPMH was documented (p=1). Patient age did not impact erroneous documentation rates (p=0.22). There was an association between the number of sources used to confirm a medication history and erroneous documentation incidence (p=0.035). The number of medications increased the rate of documentation error. While 85.19% (n=115) of erroneous documentation were deemed unlikely to cause patient discomfort or clinical deterioration, 1.48% (n=2) had the potential to result in severe discomfort or clinical deterioration.ConclusionSix out of seven BPMH documented by pharmacists as part of usual clinical practice are accurate. Major influences on accuracy include the number of medications and sources used. There is a low possibility that erroneous documentation by pharmacists will cause harm.

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Section: Discussionmentioning

confidence: 87%

“…Research has shown that there are high levels of error where medication reconciliation does not occur 7. Furthermore, the omission of a medication for a patient during a hospital stay could have consequences such as withdrawal effects (eg, omission of a short-acting antidepressant) or under treatment (eg, omission of an antihypertensive).…”

Section: Introductionmentioning

confidence: 99%

Accuracy of best possible medication history documentation by pharmacists at an Australian tertiary referral metropolitan hospital

2017

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“…1 They can be defined as any preventable event that can cause or lead to inappropriate medication use or patient harm and can occur at any stage in the medication-use process such as prescribing, transcribing, dispensing, administering, and monitoring of medications. 2 Neonates are more prone to medication errors at each stage of the medicine management process due to the increased need for calculations, dilutions, and manipulations of medications.…”

Section: Introductionmentioning

confidence: 99%

Interventions to reduce medication errors in neonatal care: a systematic review

Nguyen

Mosel

Grzeskowiak

2017

Therapeutic Advances in Drug Safety

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Background: Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors. Methods: A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and referencelist checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting. Results: A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50-70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors. Conclusion: While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice.

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“…Research has shown there is a potential for harm in the transition of care from hospital to a patient's primary care provider. Admission and discharge from hospital have been identified as being associated with a higher risk for the occurrence of an adverse drug reaction, error and/or event . It is important a patient's GP receives timely and detailed communication from the prescribing hospital when the patient is discharged.…”

Section: Discussionmentioning

confidence: 89%

Hospital discharge opioid guidelines and policies: a Victorian survey

Downie

Wood

Summers

et al. 2018

Pharmacy Practice and Res

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Background Opioid prescribing has increased over the past two decades in Australia and has been associated with a rise in opioid‐related harm, including hospitalisations. Guidelines for supplying opioids at discharge from hospitals may reduce these associated risks. Examples of these guidelines exist worldwide, but it is unknown what strategies Victorian hospitals are using. Aim The aim of the present study was to discover what strategies, if any, Victorian hospitals are using to decrease risk associated with opioids prescribed on discharge and the perceived barriers to implementing these strategies. Methods An online survey was sent to each Victorian hospital. Participants were asked questions about whether their service was using an opioid discharge guideline, the barriers to using these guidelines and whether they would use industry‐ or peer‐developed guidelines if available. Results Staff from 41 (19.62%) hospitals responded to the survey. Ten hospitals reported having a guideline. Nearly half (41.5%) of the hospitals that did not have a guideline reported that they would consider using an industry‐ or peer‐developed guideline. Time, funding, collaboration between stakeholders and staffing inconsistencies were reported as barriers to development and implementation. Conclusion Only a small number of Victorian hospitals are using opioid discharge prescribing guidelines. Development of industry‐ or peer‐developed guidelines may bypass many of the barriers to development and implementation.

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The extent of medication errors and adverse drug reactions throughout the patient journey in acute care in Australia

Cited by 133 publications

References 21 publications

Accuracy of best possible medication history documentation by pharmacists at an Australian tertiary referral metropolitan hospital

Accuracy of best possible medication history documentation by pharmacists at an Australian tertiary referral metropolitan hospital

Interventions to reduce medication errors in neonatal care: a systematic review

Hospital discharge opioid guidelines and policies: a Victorian survey

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