Voluntary and anonymous reporting of medication errors in patients admitted to the Department of Pediatrics

Cernadas, José M. Ceriani; Bogado, Luz; Rolón, Fidencia Espínola; Galletti, María F

doi:10.5546/aap.2019.eng.e592

Cited by 6 publications

(6 citation statements)

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“…35 However, at the international level, the most frequent AEs in Pediatrics are those related to medication. 10,15,30,32,38 In this study, they present high percentages of occurrence, with product or drug prescription errors, product or drug administration errors and incorrectly filled or illegible prescriptions standing out. On the other hand, according to the nurses' perception, the AEs that occur more frequently are those with the highest percentage of recording.…”

Section: Discussionmentioning

confidence: 76%

“…[12][13] Thus, it contributes to build a Safety Culture in the institution, based on trust and shared experiences, without fear of punishment, bearing in mind Patient Safety guidelines during their stay. 10,[15][16] Although health professionals are progressively more aware of the need to Report, it still falls below expectations. [17][18] Several reasons have been given to justify this low adherence, including fear of blame, of administrative and legal sanctions, resistance to bureaucracy, the perception that reports have no impact on the quality of care, the lack of organizational support, late or inadequate feedback, and the lack of knowledge about the Adverse Events Reporting System (AERS).…”

Section: Introductionmentioning

confidence: 99%

“…29 Medication errors are the most prevalent and reported in the different care settings. 10,15,[30][31][32] In association with AE Report, several measures have been taken to prevent the occurrence of Errors in this population, which deserve attention: the adaptation of clinical guidelines, use of the double-check method, 33 trigger tools, 9 barcode systems, [30][31] among others. In this sense it was elaborated a study which objective was to describe Nurses' Adherence to Adverse Events Reporting and the Factors associated with it in a Pediatric setting.…”

Section: Introductionmentioning

confidence: 99%

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Nurses adverse events report adding safety to pediatric nursing

Carvalho¹,

Aguiar²

2023

Pensar Enf

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Introduction: Adverse Events remain a current challenge in healthcare, being defined as incidents that resulted in unnecessary harm to the patient. The choice of the pediatric population the object of this study is based on certain characteristics making it the most susceptible to Adverse Events. Reporting them is a key action of the strategy to reduce its occurrence, while Nurses remain essential elements to the process. The ultimate goal is Patient Safety, the reduction of the risk of unnecessary healthcare-related harm to an acceptable minimum. Objective: Describe Nurses’ Adherence to Adverse Events Reporting and the Factors associated with it in a Pediatric setting. Methods: A Cross-sectional Observational Study is presented, based on a survey conducted in the Pediatrics Department of a hospital. The study included 88 categorical variables, related to respondents' perception of Adverse Events, Errors, Incidents and Patient Safety. Univariable, bivariable, and correlation analysis were used. Results: A total of 69% of nurses did not report any Adverse Event in 2019. The events more frequently reported were those with the most serious consequences for the patients (54%) and those related to organizational dysfunctions of the institution (74-90%). Factors which facilitate the occurrence of Adverse Events include the lack of human resources (19%), communication failures and overtime (17%), and the main barrier to Reporting is forgetting to do so when there is a greater workload (63%). Conclusion: A low percentage of reporting related to nurses’ adherence to adverse events was found in this investigation. This highlighted the need to invest in the institution’s Safety Culture by enhancing healthcare professionals’ awareness of the importance of their role in improving Patient Safety. Integrating notification into the daily practice of professionals, using continuous awareness enhancement, strengthening multidisciplinary teams, investing in communication and down grading workload is essential and can facilitate improvement.

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Section: Discussionmentioning

confidence: 76%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Nurses adverse events report adding safety to pediatric nursing

Carvalho¹,

Aguiar²

2023

Pensar Enf

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“…Additionally, 88.0% (353/401) of these errors reached the patient and 33.4% (118/353) of the dose-related errors were related to administration. Moreover, 13.2% (53/401) of errors were of omission [11].…”

Section: Introductionmentioning

confidence: 99%

Twelve-Month Review of Infusion Pump Near-Miss Medication and Dose Selection Errors and User-Initiated “Good Save” Corrections: Retrospective Study (Preprint)

Waterson¹,

Al-Jaber²,

Kassab³

et al. 2020

Preprint

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BACKGROUND There is a paucity of quantitative evidence in the current literature on the incidence of wrong-medication and wrong-dose administration of intravenous medications by clinicians. The difficulties of obtaining reliable data in this area are related to the fact that at this stage of the medication administration chain detection of error becomes extremely difficult. Smart pump medication library logs, and their reporting software, record medication and dose selections made by users, as well as cancellations of selections and the time between these actions. Analysis of this data adds quality quantitative data to the detection of these kinds of error. OBJECTIVE To establish, in a reproducible and reliable study, baseline data to show how metrics on the set-up and initial programming phase of intravenous medication administration can be produced from review of medication library near-miss error reports from infusion pumps. METHODS A twelve-month retrospective review of medication library reports from infusion pumps used in 15 disciplines across a facility obtained metrics on the set-up phase of intravenous medication administration. Cancelled infusions and resolutions of all infusion alerts by users were analysed. Decision times of clinicians were calculated from the time-date stamps of the pumps’ logs. RESULTS Incorrect medication selections were 3.45% of all medication library alerts and 22.4% of all cancelled infusions. Of these cancelled medications all high-risk medications, oncology medications, and all IV medications delivered to paediatrics and neonates, would require a two-nurse check according to local policy. Wrong dose selection was responsible for 2.93% of all alarms and 19.08% of infusion cancellations. Average error recognition to cancellation and correction time was 27 seconds (22.25) for medication error correction, and 26.52 seconds (24.71) for dose corrections. The mean average character count of medications corrected from initial lookalike-soundalike selection errors was 13.04, with a heavier distribution towards higher character counts. In terms of the position of the word/phrase error, this was spread between name beginning (69.8%), name middle (21.4%), and name end (8.8%). CONCLUSIONS The study identified a significant number of lookalike-soundalike near miss errors, with cancellations of one medication being rapidly followed by the programming of a second. This phenomenon was found to be largely centred on initial mis-readings of the beginning of the medication name, but also showed some incidences of mis-reading in the middle and end portions of medication nomenclature. The value of an infusion pump having the capability to show the entire medication name, complete with TALLman lettering on the interface matching that of medication labelling is supported by these findings. The study provides a quantitative appraisal of an area that has been resistant to study and measurement; the number of intravenous medication administration errors of wrong medication and wrong dose that occur in clinical areas. CLINICALTRIAL

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“…A compounding workflow software solution that allows for electronic verification and documentation of each preparation from end-to-end with ideally image recognition and capture that can document workarounds, such as “supermarket-style” scanning of the same ampoule several times for multiple vial usage, can give this level of real-world evidence. Equally, rejected patient-medication scans at the bedside could assist us in identifying a little more of the iceberg of this error, as currently the other established methods are very much retrospective because they are based on chart review [ 12 ] or reliant on self-reporting, with all its attendant issues [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

Evaluating An Automated Compounding Workflow Software for Safety and Efficiency: Implementation Study

Meren¹,

Waterson²

2021

JMIR Hum Factors

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Background The forms of automation available to the oncology pharmacy range from compounding robotic solutions through to combination workflow software, which can scale-up to cover the entire workflow from prescribing to administration. A solution that offers entire workflow management for oncology is desirable because (in terms of cytotoxic delivery of a regimen to a patient) the chain that starts with prescription and the assay of the patient’s laboratory results and ends with administration has multiple potential safety gaps and choke points. Objective The aim of this study was to show how incremental change to a core compounding workflow software solution has helped an organization meet goals of improved patient safety; increasing the number of oncology treatments; improving documentation; and improving communication between oncologists, pharmacists, and nurses. We also aimed to illustrate how using this technology flow beyond the pharmacy has extended medication safety to the patient’s bedside through the deployment of a connected solution for confirming and documenting right patient–right medication transactions. Methods A compounding workflow software solution was introduced for both preparation and documentation, with pharmacist verification of the order, gravimetric checks, and step-by-step on-screen instructions displayed in the work area for the technician. The software supported the technician during compounding by proposing the required drug vial size, diluents, and consumables. Out-of-tolerance concentrations were auto-alerted via an integrated gravimetric scale. A patient-medication label was created. Integration was undertaken between a prescribing module and the compounding module to reduce the risk of transcription errors. The deployment of wireless-connected handheld barcode scanners was then made to allow nurses to use the patient-medication label on each compounded product and to scan patient identification bands to ensure right patient–right prescription. Results Despite an increase in compounding, with a growth of 12% per annum and no increase in pharmacy headcount, we doubled our output to 14,000 medications per annum through the application of the compounding solution. The use of a handheld barcode scanning device for nurses reduced the time for medication administration from ≈6 minutes per item to 41 seconds, with a mean average saving of 5 minutes and 19 seconds per item. When calculated against our throughput of 14,000 items per annum (current production rate via pharmacy), this gives a saving of 3 hours and 24 minutes of nursing time per day, equivalent to 0.425 full-time nurses per annum. Conclusions The addition of prescribing, compounding, and administration software solutions to our oncology medication chain has increased detection and decreased the risk of error at each stage of the process. The double-checks that the system has built in by virtue of its own systems and through the flow of control of drugs and dosages from physician to pharmacist to nurse allow it to integrate fully with our human systems of risk management.

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Voluntary and anonymous reporting of medication errors in patients admitted to the Department of Pediatrics

Cited by 6 publications

References 32 publications

Nurses adverse events report adding safety to pediatric nursing

Nurses adverse events report adding safety to pediatric nursing

Twelve-Month Review of Infusion Pump Near-Miss Medication and Dose Selection Errors and User-Initiated “Good Save” Corrections: Retrospective Study (Preprint)

Evaluating An Automated Compounding Workflow Software for Safety and Efficiency: Implementation Study

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