Open Journal Systems
Effective methods to detect medication administration and its related errors in surgical wards by clinical pharmacist at a tertiary care hospital - a single blinded study
Abstract
Objectives:
The goal of this study was to investigate the feasibility method between “direct observation” and “medication chart review” in detection of medication errors.
Methods:
This single-blind observational study was focused to explore the suitable method to capture the error that occurs during drug administration. Direct observation was used to detect medication errors on each day upon directly observing the nurses while administering the medications. In the medication chart review process, all available case information sheets were thoroughly investigated to identify any associated errors in the case. Then, the observer analyzed the collected data and finally reported the errors for the concerned clinicians.
Key Findings:
Total doses of 12572 in 558 patients were observed over a period of six months. The rate of errors detected by direct observation was 22.5% while medication chart review was 20 %. Bedside storage without prescription were the most common frequent error (n=526, 50.9%). Unauthorized drug use errors were frequent administration errors (n=61, 21%), followed by the wrong time (n=56, 19.3%). Documentation error were the most frequent error (n=406, 29.6 %) and followed by inappropriate abbreviations (n=350, 25.52%) used.
Conclusion:
Both of the methods were proved to be efficient and reliable. The direct observation method was able to capture a higher number of medication errors primarily related to administration errors compared to the medication chart review. The medication chart review method was able to capture the superficial information related to a medication error. Finally, the direct observation method was more effective to detect medication errors.
Keywords
References
-Haftay B et al. Prevalance of medication prescribing errors in the elderly. Int. J. Pharm. Sci. Res 2015; 5(2): 981-985.
-Buck ML et al. Medication rates in infants and children, improving pediatric medication safety part. Paediatr Pharm 2008; 14: 1-5.
-Grober E, Bohnen J. Defining medical error. Can J Surg 2005; 48(1): 39-44.
-Phillips J et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001; 58 (19): 1835-1841)
-Flynn EA, Barker KN. Medication error research. In: Cohen MR, ed. Medication Errors. Washington, DC: American Pharmaceutical Association; 1999:6.1-6.30. 9. Barker KN, Felkey BG, Flynn EA, Carper JL. White paper on automation in pharmacy. Consult Pharm. 1998;13:256-293.
-Karna K et al. Study and evaluation of medication errors in tertiary care teaching hospital-A baseline study. Int J Pharm Pharm Sci 2012; 4(5): 587-593.
-Majid AK et al. The roles of clinical pharmacy in reducing medication errors. Asian J Pharm Clin Res 2012;3(9):76-83.
-Barker KN et al. Medication Errors Observed in 36 Health Care Facilities. Arch Intern Med. 2002;162(16):1897-1903. doi:10.1001/archinte.162.16.1897
-Allard J. Medication errors: causes, prevention and reduction. British J Haematol 2002; 116, 255-265. https://doi.org/10.1046/j.1365-2141.2002.03272.x
-Flynn EA et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002; 59: 436-446.
-Ehsani SR et al. Medication errors of nurses in the emergency department. J Med Ethics Hist Med 2013; 6: 11. PMID: 24427488
-Webster CS, Anderson DJ. A practical guide to the implementation of an effective incident reporting scheme to reduce medication error on the hospital ward. Int J Nurs Pract 2002; 8(4): 176-83.
-Penjvini S. Investigation of the rate and type of medication errors of nurses in Sanandaj hospital. Iran J Nurs Res 2006; 1(1): 59-64. [In Persian]
-Karna et al. STUDY AND EVALUATION OF MEDICATION ERRORS IN A TERTIARY CARE TEACHING HOSPITAL – A BASELINE STUDYInt J Pharm Pharm Sci, Vol 4, Suppl 5, 587-593
-Lisby M et al. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care 2005; 17(1):15-22.
-ASHP, 1982, Dean, 1999, Greengold et al., 2003, Williams, 2007
-Patanwala AE et al. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med 2010; 55(6):522-6.
-Mohammadi A et al .Medication errors and their relationship with job and demographic characteristics. Jentashapir J Health Res 2014; 5(3):141-151.
-Karna K et al. The impact of educational intervention strategies in reducing medication errors. IRJP 2012; 3 (11).
-Karthikeyan M et al. A systematic review on medication errors. Int J Drug Dev. Res 2015; 7:4.
-Sravya et al. Medication errors as a major concern to health care A Case Report. Int. J. Pharm. Biol. Sci 2013;4 (10): 3057-3059
-Berdot S et al. Evaluation of drug administration errors in a teaching hospital. BMC Health Serv. Res 2012;12:60.