What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?

Linden-Lahti, Carita; Takala, Anna; Holmström, Anna-Riia; Airaksinen, Marja

doi:10.1097/pts.0000000000000914

Cited by 15 publications

(16 citation statements)

References 39 publications

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“…In more than half of the cases (52%, n = 30), the ME caused the patient’s death or severe harm. Other characteristics of the data have been published elsewhere [ 17 ].…”

Section: Resultsmentioning

confidence: 99%

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Applicability of drug-related problem (DRP) classification system for classifying severe medication errors

Linden-Lahti

Takala

Holmström

et al. 2023

BMC Health Serv Res

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Background Several classification systems for medication errors (MEs) have been established over time, but none of them apply optimally for classifying severe MEs. In severe MEs, recognizing the causes of the error is essential for error prevention and risk management. Therefore, this study focuses on exploring the applicability of a cause-based DRP classification system for classifying severe MEs and their causes. Methods This was a retrospective document analysis study on medication-related complaints and authoritative statements investigated by the Finnish National Supervisory Authority for Welfare and Health (Valvira) in 2013–2017. The data was classified by applying a previously developed aggregated DRP classification system by Basger et al. Error setting and harm to the patient were identified using qualitative content analysis to describe the characteristics of the MEs in the data. The systems approach to human error, error prevention, and risk management was used as a theoretical framework. Results Fifty-eight of the complaints and authoritative statements concerned MEs, which had occurred in a wide range of social and healthcare settings. More than half of the ME cases (52%, n = 30) had caused the patient’s death or severe harm. In total, 100 MEs were identified from the ME case reports. In 53% (n = 31) of the cases, more than one ME was identified, and the mean number of MEs identified was 1.7 per case. It was possible to classify all MEs according to aggregated DRP system, and only a small proportion (8%, n = 8) were classified in the category “Other,” indicating that the cause of the ME could not be classified to specific cause-based category. MEs in the “Other” category included dispensing errors, documenting errors, prescribing error, and a near miss. Conclusions Our study provides promising preliminary results for using DRP classification system for classifying and analyzing especially severe MEs. With Basger et al.’s aggregated DRP classification system, we were able to categorize both the ME and its cause. More research is encouraged with other ME incident data from different reporting systems to confirm our results.

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“…In more than half of the cases (52%, n = 30), the ME caused the patient’s death or severe harm. Other characteristics of the data have been published elsewhere [ 17 ].…”

Section: Resultsmentioning

confidence: 99%

“…The main researcher made notes of those MEs for detecting possible missing categories in the aggregated DRP classification system. Because severe MEs are often complex processes including several errors [ 16 , 17 , 31 , 32 ], all identified MEs were categorized from description of each case.…”

Section: Methodsmentioning

confidence: 99%

Applicability of drug-related problem (DRP) classification system for classifying severe medication errors

Linden-Lahti

Takala

Holmström

et al. 2023

BMC Health Serv Res

Self Cite

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“…A retrospective study stated that 52% of cases of medication errors reported to the National Monitoring Authority for Welfare and Health in Finland resulted in death or worsening conditions. The study also said that as much as 47% of them occurred in terms of drug prescribing [10] . Medication errors can occur in every step of the treatment process, both in the processes of prescribing, reading prescriptions (transcription), preparing for drug delivery (dispensing), and using drugs (administration) [11] .…”

Section: Introductionmentioning

confidence: 84%

Figure of Potential Medication Error in Medicine Prescription for Outpatient Services of "X" Hospital in Bali

Nuryatama

Jaya

2022

JPSA

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Background: Medication errors (ME) in health services; in this case, hospitals are supposed to have zero accidents. Evaluation of the potential ME, such as doctor's prescription writing, must still be carried out in an effort to maintain service quality, especially in maintaining patient safety or preventing medication errors. Objective: This research aimed to see the figure of potential medication errors that occur in the prescribing process, in this case, is related to the completeness of the prescription seen from the administration and pharmaceutical approach, as well as the legibility of the prescriptions originating from outpatient services at one of the hospitals in Bali. Methods: This research was observational with a qualitative descriptive approach. Data collection was carried out retrospectively through medication prescriptions for patients received by pharmaceutical installations for outpatient services at hospitals from July until October 2022, totaling 110 prescriptions. Results: Results showed that 1.8% of prescriptions still did not write down the patient's name, then 9.1% of prescriptions had not written down the patient's age, 21.8% of prescriptions had not written down the patient's gender, and as many as 93.6% of prescriptions did not include the patient's weight, 2.7 % of prescriptions did not include the name of the doctor, 75.5% of the prescriptions did not include the doctor's SIP number, 1.8% of the prescriptions still did not write down the rules for using the drug, 10.9% of the prescriptions did not write down the strength of the drug dosage and 19.1% of the prescriptions did not provide information about dosage form to be administered to the patient. This study also shows 8.9% of the prescriptions are Illegible prescription. Conclusion: The results of the research found that administratively and pharmaceutically incomplete prescriptions and also Illegible prescription writing were still found. So the results of this study show how important it is to always evaluate the potential of medication errors, especially at the prescribing and transcribing phases, to improve patient safety. Keywords: Medication error; Prescription; Hospital; Retrospective

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“…Many reported medical errors and incidents are related to pharmaceutical products [1][2][3]. Pharmaceutical products come in various dosage forms including infusions, injections, powders, tablets, and patches.…”

Section: Introductionmentioning

confidence: 99%

Investigation of Information Printed on The Blister Pack of Loxoprofen Sodium Tablets

Houchi¹

2023

J Med Healthcare

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Introduction: Loxoprofen sodium was selected as a commonly used medicine. The loxoprofen sodium tablets are marketed by 22 companies in Japan. The 22 different packaging types for this single active ingredient are served. We investigated the specifications printed on the 10-tablet blister pack. Methods: Regarding specifications printing, using the 22 loxoprofen sodium products, the survey items included how many times each of the specific printing was printed on the 10-tablet blister pack. About the questionnaire survey, a question I assessed the desired number of specifications. Question II assessed the direct printing of the drug name on each of the tablets and the size of tablet. The target population of the survey consisted of prescribing doctors, nurses, pharmacists, and non-healthcare workers. Result: The number of instances in which the drug name was listed ranged from 3 to 22 on the 10-tablet blister pack. The tablet identification code was printed ranged 0 - 10. Eleven products had no medical effect information on the pack. The expiration date was printed on two products. The serial number was not printed on one product. On the questionnaire survey, the desired number of instances that the standard dose was printed was significantly higher for nurses and pharmacists than for prescribing doctors and non-healthcare workers. Nurses considered information about medical effects to be important. Pharmacists demanded more barcodes. Several identification codes were requested by health care professionals. Although many of the tablets were 9 mm in size, the respondents desired smaller tablets. Conclusion: There were gaps between the amount of information printed on the pack and that was considered desirable by healthcare professionals and non-healthcare workers. Our findings indicate that multiple items are considered useful for developing packages for oral drugs marketed in the future as well as in ensuring safe and secure pharmacological therapy

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What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?

Cited by 15 publications

References 39 publications

Applicability of drug-related problem (DRP) classification system for classifying severe medication errors

Applicability of drug-related problem (DRP) classification system for classifying severe medication errors

Figure of Potential Medication Error in Medicine Prescription for Outpatient Services of "X" Hospital in Bali

Investigation of Information Printed on The Blister Pack of Loxoprofen Sodium Tablets

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