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The purpose of this paper is to study a medication distribution technology's (MDT) impact on medication errors reported in public nursing homes in Québec Province.

The work was carried out in six nursing homes (800 patients). Medication error data were collected from nursing staff through a voluntary reporting process before and after MDT was implemented. The errors were analysed using: totals errors; medication error type; severity and patient consequences. A statistical analysis verified whether there was a significant difference between the variables before and after introducing MDT.

The results show that the MDT detected medication errors. The authors' analysis also indicates that errors are detected more rapidly resulting in less severe consequences for patients.

MDT is a step towards safer and more efficient medication processes. Our findings should convince healthcare administrators to implement technology such as electronic prescriber or bar code medication administration systems to improve medication processes and to provide better healthcare to patients.

Few studies have been carried out in long-term healthcare facilities such as nursing homes. The authors' study extends what is known about MDT's impact on medication errors in nursing homes.

Medication errors are a significant cause of injury in Norwegian hospitals. The purpose of this study is to explore how Lean Six Sigma (LSS) has been used in the Norwegian public health-care context to reduce medication errors.

A mixed method approach was used to gather data from participants working in the four regions served by the Norway health authorities. A survey questionnaire was distributed to 38 health-care practitioners and semi-structured interviews were conducted with 12 health-care practitioners.

The study finds that the implementation of LSS in the Norwegian public health-care context is still in its infancy. This is amidst several challenges faced by Norwegian hospitals such as the lack of top-management support, lack of LSS training and coaching and a lack of awareness around the benefits of LSS in health care.

Because of the large geographical area, it was difficult to reach participants from all health regions in Norway. However, the study managed to assess the current status of LSS implementation through the participants’ perspectives. This is a fruitful area for future research whereby an action research methodology could be used.

To the best of the authors’ knowledge, this is the first empirical study into the use of LSS methodology in reducing medication errors. In addition, this study is valuable for health-care practitioners and professionals as a guideline to achieve the optimal benefit of LSS implementation to reduce medication errors.

The purpose of this paper is to illustrate the use of Lean Six Sigma (LSS) and its associated tools to reduce dispensing errors in an inpatient pharmacy of a teaching hospital in Thailand.

The action research methodology was used to illustrate the implementation of Lean Six Sigma through the collaboration between the researcher and participants. The project team followed the Lean Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) methodology and applied its tools in various phases of the methodology.

The number of dispensing errors decreased from 6 to 2 incidents per 20,000 inpatient days per month between April 2018 and August 2019 representing a 66.66% reduction. The project has improved the dispensing process performance resulting in dispensing error reduction and improved patient safety. The communication channels between the hospital pharmacy and the pharmacy technicians have also been improved.

This study was conducted in an inpatient pharmacy of a teaching hospital in Thailand. Therefore, the findings from this study cannot be generalized beyond the specific setting. However, the findings are applicable in the case of similar contexts and/or situations.

This is the first study that employs a continuous improvement methodology for the purpose of improving the dispensing process and the quality of care in a hospital. This study contributes to an understanding of how the application of action research can save patients' lives, improve patient safety and increase work satisfaction in the pharmacy service.

The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study.

In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility.

Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013).

Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

Few studies examine physical environmental factors and their effects on staff health, effectiveness, work errors and job satisfaction. To address this gap, this study aims to examine environmental features and their role in medication and nursing errors in long‐term care facilities.

A mixed methodological strategy was used. Data were collected via focus groups, observing medication preparation and administration, and a nursing staff survey in four facilities.

The paper reveals that, during the medication preparation phase, physical design, such as medication room layout, is a major source of potential errors. During medication administration, social environment is more likely to contribute to errors. Interruptions, noise and staff shortages were particular problems.

The survey's relatively small sample size needs to be considered when interpreting the findings. Also, actual error data could not be included as existing records were incomplete.

The study offers several relatively low‐cost recommendations to help staff reduce medication errors. Physical environmental factors are important when addressing measures to reduce errors.

The findings of this study underscore the fact that the physical environment's influence on the possibility of medication errors is often neglected. This study contributes to the scarce empirical literature examining the relationship between physical design and patient safety.

The purpose of this paper is to present the implementation of Lean Six Sigma (LSS) to reduce medication errors, by using four case examples. The paper will also suggest appropriate Lean and Sigma tools to improve the medication process.

The authors critically analyze four case examples that used LSS projects, to demonstrate the approach, benefits, success factors and lessons learnt.

LSS is a powerful process improvement methodology that could be applied by health-care sectors to reduce medication errors, increase patient safety and reduce operational costs. Common Lean and Six Sigma tools play a significant role in improving and sustaining the medication process.

It is necessary for the project team to select the most appropriate LSS tools to address medication process problems. Adoption of a LSS roadmap could help health-care organizations in the successful implementation of LSS.

The paper is valuable for health-care professionals seeking to reduce errors in the medication process or other processes that need to be improved.

The developing generic market has huge advantages of availability and affordability of therapy. The question of whether a therapeutic equivalent substitute under an unfamiliar name may cause confusion that leads to medical errors has not been sufficiently studied. This paper seeks to answer this question.

The study was triggered following sporadic reports according to which patients mistakenly consider therapeutic equivalents as unrelated medications rather than substitutes. Family physicians and pharmacists in one of eight districts of Clalit, Israel's largest healthcare provider were surveyed. The survey's questions recall episodes of medication uncertainty, confusion, misidentification, and medication mistakes associated with switching from one therapeutic equivalent to another. A total of 66 physicians and 63 pharmacists responded to the surveys (61 percent and 45 percent, respectively).

The results recall uncertainty, confusion, misidentification, and mainly cases of medication mistakes in which patients consumed both therapeutic equivalents simultaneously as was reported by 81 percent of physicians and 70 percent of pharmacists.

There are two limitations in this work, the first is the study type, which is recall survey; the second is the response rate which is not unusual among health care professionals. However, the high face‐validity and the consistency of the findings in both physicians and pharmacists surveyed indicates high validity of the study conclusions.

A practical implication is unique medication error of consuming both therapeutic equivalents simultaneously. The authors wish to raise awareness of the potential of such error, which may be difficult to disclose as each of the therapeutic equivalents is apparently the intended medication but consuming them simultaneously results practically in doubling the intended dose. Given the forecast for generic market growth, awareness is not enough and worldwide regulatory cooperation should be made otherwise these types of medication errors will inevitably emerge.

The study is original as a literature search revealed no studies evaluating potential medication mistakes attributed to a switch between therapeutic equivalents.

Medication errors are an important patient safety issue. Electronic medication reconciliation is a system designed to correct medication discrepancies at transitions in healthcare. The purpose of this paper is to measure types and prevalence of intravenous antibiotic errors at hospital discharge before and after the addition of an electronic discharge medication reconciliation tool (EDMRT).

A retrospective study was conducted at a tertiary hospital where house officers order discharge medications. In total, 100 pre-EDMRT and 100 post-EDMRT subjects were randomly recruited from the study center’s clinical Outpatient Parenteral Antimicrobial Therapy (OPAT) program. Using infectious disease consultant recommendations as gold standard, each antibiotic listed in these consultant notes was compared to the hospital discharge orders to ascertain the primary outcome: presence of an intravenous antibiotic error in the discharge orders. The primary covariate of interest was pre- vs post-EDMRT group. After generating the crude prevalence of antibiotic errors, logistic regression accounted for potential confounding: discharge day (weekend vs weekday), average years of practice by prescribing physician, inpatient service (medicine vs surgery) and number of discharge mediations per patient.

Prevalence of medication errors decreased from 30 percent (30/100) among pre-EDMRT subjects to 15 percent (15/100) errors among post-EDMRT subjects. Dosage errors were the most common type of medication error. The adjusted odds ratio of discharge with intravenous antibiotic error in the post-EDMRT era was 0.39 (0.18, 0.87) compared to the pre-EDMRT era. In the adjusted model, the total number of discharge medications was associated with increased OR of discharge error.

To the authors’ knowledge, no other study has examined the impact of reconciliation on types and prevalence of medication errors at hospital discharge. The focus on intravenous antibiotics as a class of high-stakes medications with serious risks to patient safety during error events highlights the clinical importance of the findings. Electronic medication reconciliation may be an important tool in efforts to improve patient safety.

Medication management is a complex process, at high risk of error with life threatening consequences. The focus should be on devising strategies to avoid errors and make the process self-reliable by ensuring prevention of errors and/or error detection at subsequent stages. The purpose of this paper is to use failure mode effect analysis (FMEA), a systematic proactive tool, to identify the likelihood and the causes for the process to fail at various steps and prioritise them to devise risk reduction strategies to improve patient safety.

The study was designed as an observational analytical study of medication management process in the inpatient area of a multi-speciality hospital in Gurgaon, Haryana, India. A team was made to study the complex process of medication management in the hospital. FMEA tool was used. Corrective actions were developed based on the prioritised failure modes which were implemented and monitored.

The percentage distribution of medication errors as per the observation made by the team was found to be maximum of transcription errors (37 per cent) followed by administration errors (29 per cent) indicating the need to identify the causes and effects of their occurrence. In all, 11 failure modes were identified out of which major five were prioritised based on the risk priority number (RPN). The process was repeated after corrective actions were taken which resulted in about 40 per cent (average) and around 60 per cent reduction in the RPN of prioritised failure modes.

FMEA is a time consuming process and requires a multidisciplinary team which has good understanding of the process being analysed. FMEA only helps in identifying the possibilities of a process to fail, it does not eliminate them, additional efforts are required to develop action plans and implement them. Frank discussion and agreement among the team members is required not only for successfully conducing FMEA but also for implementing the corrective actions.

FMEA is an effective proactive risk-assessment tool and is a continuous process which can be continued in phases. The corrective actions taken resulted in reduction in RPN, subjected to further evaluation and usage by others depending on the facility type.

The application of the tool helped the hospital in identifying failures in medication management process, thereby prioritising and correcting them leading to improvement.

Medication reconciliation is integral to every hospital. Approximately 60 percent of all hospital medication errors occur at admission, intra‐hospital transfer or discharge. Effectively and consistently performing medication reconciliation at care‐interfaces continues to be a challenge. Tan Tock Seng Hospital (TTSH) averages 4,700 admissions monthly. Many patients are elderly (>65 years old) at risk from poly‐pharmacy. As part of a medication safety initiative, pharmacy staff started a medication reconciliation service in 2007, which expanded to include all patients in October 2009. This article aims to describe the TTSH medication reconciliation system and to highlight common medication errors occurring following incomplete medication reconciliation.

Where possible, patients admitted into TTSH are seen by pharmacy staff within 24 hours of admission. A form was created to document their medications, which is filed into the case sheets for referencing purposes. Any discrepancies in medicines are brought to doctors' attention. Patients are also counseled about changes to their medications. Errors picked up were captured in an Excel database.

The most common medication error was prescribers missing out medications. The second commonest was recording different doses and regimens. The reason was mainly due to doctors transcribing medications inaccurately.

This is a descriptive study and no statistical tests were carried out. Data entry was done by different pharmacy staff, and not a dedicated person; hence, data might be under‐reported.

The findings demonstrate the importance of medication reconciliation on admission. Accurate medication reconciliation can help to reduce transcription errors and improve service quality.

The article highlights medication reconciliation's importance and has implications for healthcare professionals in all countries.