Dissertations / Theses on the topic 'Medication errors – Prevention'

Introduction This thesis looks at the pharmacist’s contribution to the capture of medication errors and preventing harm reaching patients. It has several components: an analysis of annual surveys of interventions made by pharmacists at a large teaching hospital, a re-coding of these surveys to see how many interventions were the result of prescribing errors, and an experiment in A&E where the pharmacist drafted the first prescription chart. Methods One-week surveys of pharmacist interventions were regularly made at Southampton General Hospital between 1999 and 2009. These were analysed for trends, then recoded to identify the proportion that were caused by prescribing errors. In addition, a controlled trial was conducted to investigate the effects on prescribing error rate, of a pharmacist obtaining an accurate medication history in A&E, then transcribing the data onto the first inpatient prescription. Key findings In the period 1999-2001, the average number of interventions in each week long survey was 575 and during 2005-9 it was 973. This was a statistically significant increase. More interventions were recorded as serious in the latter period. The rate of interventions also increased from between one per every five and seven patients (31 to 45 prescribed items) to one per every one to two patients (8 to 20 items). The severity of interventions also increased, with between one and five deaths avoided each week. Almost three quarters of pharmacists’ interventions (73.9%) were triggered by prescribing errors, giving an error rate of 644 prescribing errors per week, or 6.2 per 100 prescribed items. These data are in contrast to the Trust submitting 918 error reports per year to the NPSA, the majority of which were administration errors reported by nurses. Nearly a half (45.3%) of all prescribing errors occurred during the admission phase of the hospital episode. Two thirds (67.1%) of prescribing errors detected were errors of omission - things that had not been done. Prescribing errors of commission occurred mainly during the inpatient phase and errors of omission during the admission phase. A quarter of prescribing errors were planning errors. These were failures to follow guidelines, failures to review patients’ prescriptions, manage interactions, and adjust dosage in liver or renal failure or in response to TDM results. One fifth (21.7%) of the patients had events or symptoms that contributed to the admission that could be explained by the medicines they were consuming. Over half of these were potentially avoidable by better monitoring or product selection. A pharmacist working in A&E to obtain complete and accurate drug histories, then transcribing the data onto the first prescription, produced a trend to reduction in the generation of errors throughout the whole hospital episode. Conclusions Analysing pharmacist’s interventions is a useful method of investigation prescribing errors and ways to stop them happening. First prescriptions written by pharmacists should provide an effective means of reducing errors which may be promulgated throughout the hospital stay.

The number of deaths due to medical errors in hospitals ranges from 44,000 to 98,000 yearly. More than 7,000 of these deaths have taken place due to medication errors. This project evaluated the implementation of an automated medication dispensing cabinet or PYXIS machine in a 25-bed upper Midwestern critical access hospital. Lewin's stage theory of organizational change and Roger's diffusion of innovations theory supported the project. Nursing staff members were asked to complete an anonymous, qualitative survey approximately 1 month after the implementation of the PYXIS and again 1 year later. Questions were focused on the device and its use in preventing medication errors in the hospital. In addition to the surveys that were completed, interviews were conducted with the pharmacist, the pharmacy techs, and the director of nursing 1 year after implementation to ascertain perceptions of the change from paper-based medication administration to use of the automated medication dispensing cabinet. Medication errors before, during, and after the PYXIS implementation were analyzed. The small sample and the small number of medication errors allowed simple counts and qualitative analysis of the data. The staff members were generally satisfied with the change, although they acknowledged workflow disruption and increased medication errors. The increase in medication errors may be due in part to better documentation of errors during the transition and after implementation. Social change in practice was supported through the patient safety mechanisms and ongoing process changes that were put in place to support the new technology. This project provides direction to other critical access hospitals regarding planning considerations and best practices in implementing a PYXIS machine.

Medication errors cause harm, yet most of them are preventable (Institute of Medicine, 2006). Nurses spend 40% of their time administering medications; therefore they play a key role in the reduction of medication errors. Little empirical evidence has been collected about the effectiveness of nursing education in reducing medication errors committed by nursing students. Traditional educational interventions focus on the five rights of medication administration; however, the literature shows that interventions focused on instilling a culture of safety have a greater impact on reducing medication errors. The purpose of this article is to review educational strategies that have been implemented and tested in pre-licensure nursing programs to reduce medication errors committed by nursing students.

Medication administration constitutes a key element of acute care delivery, while errors in the process threaten patient safety. The purpose of the study is to explore patients’ perceptions, attitudes and beliefs about the safety practices utilized by nurses when administering medications. Specifically, the study addresses patients’ perceptions of nurse behaviours regarding safe medicine administration, patient behaviours, patients’ perceptions and nurse behaviours regarding pain medicine, patients’ perceptions of nursing care, and patients’ perceptions of their participation/accountability in care. The results identify key safety issues from a patients’ perspective to focus change strategies that will improve patient care.<br>x, 125 leaves ; 29 cm

Syfte: Syftet med studien var att beskriva vilka faktorer som kan orsaka risk för fel i samband med sjuksköterskans läkemedelshantering samt vad sjuksköterskan kan göra för att förebygga att fel uppstår inom den somatiska slutenvården. Syftet var också att granska artiklarnas kvalité utifrån urval och bortfall. Metod: En beskrivande litteraturstudie som baseras på 13 vetenskapliga artiklar med både kvalitativ och kvantitativ ansats. Litteratursökningen genomfördes i databaserna PubMed, Cinahl och Academic Search Elite. Resultat: Faktorer som orsakade att sjuksköterskan begick fel i läkemedelshanteringen var hög arbetsbelastning, bristande kunskaper inom farmakologi, mindre erfarenhet av sjuksköterskeyrket och avbrott i arbetet. Förebyggande åtgärder för att minimera risken att ett fel uppstod i samband med läkemedelshanteringen var att sjuksköterskan ökade sina kunskaper i farmakologi, bidrog till förbättrad arbetsmiljö och kommunikation med annan vårdpersonal samt var nogrannare vid kontroller. Slutsats: Flera förekommande faktorer som orsakade fel i samband med sjuksköterskans läkemedelshantering som hög arbetsbelastning och bristande kunskaper inom farmakologi borde inte vara svåra att förebygga. Det stora förebyggande arbetet bör ske inom verksamheten för att förbättra arbetsmiljön för sjuksköterskorna och på så vis minska att fel uppstår i samband med läkemedelshanteringen.<br>Aim: The purpose of this study was to describe the factors that could cause errors associated with the nurse's medication and what the nurse can do to prevent errors from occurring in somatic inpatient care. The aim was also to examine the quality of the articles in relation to sample size and disappearance. Method: A descriptive literature study based on 13 scientific articles with both qualitative and quantitative approach. The literature research was made in the databases PubMed, Cinahl and Academic Search Elite. Results: Factors that caused the nurse to made ​​errors in the handling of drugs was high workload, lack of knowledge in pharmacology, less experience in the nursing profession and working interruptions. Preventive measures to minimize the risk that an error occurred during the drug treatment were that the nurse increased her knowledge of pharmacology, contributed to a better working environment and the communication with other healthcare professionals and was accurate at the controls. Conclusion: Several common factors that caused the errors associated with the nurse's medication as high workload and insufficient of knowledge in pharmacology should not be difficult to prevent. The major preventive measures should be done within the hospital management to improve the working environment for nurses and prevent the error associated with medication management.

L’iatrogénie induite par les erreurs médicamenteuses est un problème majeur de santé publique. Ce travail a pour objectif de développer une approche systémique visant à réduire leur occurrence en cancérologie. L’étude est menée aux Hospices Civils de Lyon au sein du Groupement Hospitalier Sud. L’analyse des erreurs médicamenteuses interceptées, sur une période de 5 ans, révèle que 4 prescriptions de chimiothérapie sur 100 présentent au moins une erreur médicamenteuse, dont plus de la moitié sont des erreurs de dose. Les facteurs de risque d’erreurs de prescription identifiés sont la prescription par un interne, l’hospitalisation conventionnelle, le patient ayant une surface corporelle supérieure à 2 m², les protocoles de plus de trois médicaments anticancéreux, comprenant du carboplatine ou nécessitant une modification par le prescripteur. L’évaluation de la gravité clinique potentielle des erreurs médicamenteuses montre que 13,4% d’entre elles auraient causé un préjudice temporaire et 2,6% un préjudice permanent. Le pronostic vital aurait été engagé dans 2,6% des cas conduisant au décès pour 6 patients sur une période d’un an. L’évaluation médico-économique permet d’estimer le coût pour l’assurance maladie d’une erreur médicamenteuse en cancérologie avec conséquences cliniques à 1 523€ associé à 3,5 journées d’hospitalisation supplémentaires. Cette approche systémique conduit au développement de revues d’erreurs médicamenteuses et de morbi-mortalité, socle de l’analyse collective indispensable à la prévention du risque médicamenteux en cancérologie<br>Medication errors are a major public health problem. This work aims to develop a systemic approach to reduce their occurrence in oncology. The study was conducted in Groupement Hospitalier Sud (Hospices Civils de Lyon). The analysis of intercepted medication errors, over a period of five years, reveals that four out of 100 prescriptions of chemotherapy include at least one medication error, which over half are dose errors. Risk factors of prescribing errors identified are prescription by a resident physician, inpatient care, patient with a body surface area greater than 2 m², protocol with more that three anticancer drugs, protocol involving carboplatin or protocol requiring at least one modification by the physician. 13.4% of avoided errors would have resulted in temporary injury and 2.6% in permanent damage. The vital prognosis of the patient would have been compromised in 2.6% of cases leading to death for six patients over a period of one year. The cost of one medication error with clinical consequences was estimated at € 1 523 associated to 3.5 additional days of hospitalisation. This approach led to the development of systematic medication errors reviews and morbi-mortality conferences that allow a collective and multidisciplinary analysis to enhance the patient’s safety

Parkinson' Disease (PD) is a motor disorder characterized by rigidity, tremor, and hypokinesia with secondary manifestations like defective posture and gait, mask like face and dementia. Over the years it may lead to inability to move, breath and ultimately patient may succumb to chest infection and embolism. Prevalence studies show that more than six million people around the world suffer from PD. At present, there is no cure for PD but there are effective treatments that can slow the progression of the disease and regulate its affects. PD results from a deficiency of dopamine so most drugs that produce a salutary effect in PD either potentiate dopamine or work as dopamine agonists. Hence, to keep the symptoms of PD to a minimum it is very important that the medications be consumed regularly, so that the dopamine level is maintained in the body of the subject. Electronic pillbox logger is a device that has been designed to ensure this very much required medication adherence in PD subjects, which can also be used to measure the response to oral medication. This work describes the design and implementation of an electronic pillbox logger for use by people suffering from Parkinson's disease (PD). The pillbox logger is designed to track medication adherence and prompt the user to take medication on time. It is pocket-sized, portable, and compartmented. It has a variety of alarm systems to remind the user to take the correct dose of their medication at the correct time. Most importantly, it keeps an electronic log of the time of dosage consumption by detecting the presence/absence of pills in the pillbox. This overcomes major limitations of other pillboxes with a logging function that are often too large to carry, contain a single compartment, or only record the time the container was opened rather than the presence or absence of pills. The proposed pillbox logger complements a wearable device under development for people with Parkinson's disease that continuously monitors impaired movement. The combination of the pillbox logger with the wearable sensor will permit clinicians to determine the response to oral therapies, which can be used to optimize therapy. People with PD consume similar pills throughout the day hence the pillbox logger has been designed to detect the presence/absence of pills in general in the pillbox rather than which specific pills are absent or present in the pillbox logger. This feature of the current design that the device records knowledge about pills in general in the pillbox logger and not about any specific pills is a major reason why the current design is specific to PD subjects only. However, though the current design of the pillbox logger is designed for people with Parkinson's Disease, the pillbox is suitable for other maladies in which the timing of the medication is critical. The described pillbox logger was built and the design was validated after running a number of tests. The battery powered pillbox logger is able to accurately store the information about the actual presence/absence of pills in each compartment of the pillbox. It is capable of sending out reminder alarms at the right time of the day and can be connected to a host computer using a USB cable to read the stored information from it. The proper functional working of the pillbox logger after thorough testing proves that the design of pillbox logger was successful.

Submitted by Fabíola Silva (fabiola.silva@famerp.br) on 2017-05-19T13:23:49Z No. of bitstreams: 1 renatapradobvilela_dissert.pdf: 4967278 bytes, checksum: 7bd89c0f78df57cc9c83d2e2b2dd976d (MD5)<br>Made available in DSpace on 2017-05-19T13:23:49Z (GMT). No. of bitstreams: 1 renatapradobvilela_dissert.pdf: 4967278 bytes, checksum: 7bd89c0f78df57cc9c83d2e2b2dd976d (MD5) Previous issue date: 2016-09-16<br>Introduction: Medication error is a frequent event in health and it may have consequences for the patient, professional, institution, and health system. Currently, many technologies can prevent it. However, it requires financial and professional investment to break down the barrier to make these technologies effective. Objectives: Analyze the scientific production related to the cost of medication errors in the stages of the medication therapy chain; Investigate the occurrence of medication errors; Map and validate the use of established technologies that prevent medication errors; Characterize the training related to medication error prevention and to verify the nursing staff compliance to such training; and analyze the costs of the technologies employed to prevent medication error and its impact on a teaching hospital. Methods: Initially, we performed an integrative literature review (2005-2015). A case study was carried out to calculate the incidence indicator of medication error from the equation proposed by the Commitment to Hospital Quality and document analysis from 2007 to 2015. We used as a data source to map and validate preventive technologies, document analysis and interviews. Subsequently, we drew up flowcharts of the medication process in the medication therapy chain, including preventative technologies at every stage. The validation of these flowcharts occurred through interviews with 26 professionals. We carried out a document analysis of practices performed at the integrated center of permanent education in health, as well as the adherence of the nursing staff to practice through the ratio of professionals working in the respective years. We calculated the direct costs of each technology in the medication therapy chain by multiplying the estimated time spent by the personnel in each activity by its cost, adding to the unit cost of inputs multiplied by the amount of the technology acquisition. The impact of technologies was verified from the historical series associated to the incidence indicator of medication error in relation to the time of implementation of technologies in the field of study. Results: We analyzed 14 articles, with a predominance of evidence level 6, through both the hierarchical system (78.5%) and economic evaluations (50%). Among the articles, five were related to drug prescription, one to medication therapy management, one to drug prescription and medication therapy management, and seven included all stages of the medication therapy chain. There was a great mismatch of values presented in the estimation of avoidable cost/medication error, ranging from US$ 9, 041.76 to US$ 5,095,640,000.00. The incidence of medication error was 1.4%. The main type of mistake was “omission” (31.2%). Inpatient units were the most ones that notified the error (53.3%). The main cause-related error was “inattention” (93.3%). The work process cause-related error has not been notified (80%). The decision-making after the error was “individual counseling” (71.1%). The process of the medication therapy chain was divided into three sub-processes (prescription, dispensing, and management) including 50 nursing activities. One of the technologies for the prevention of medication errors was mentioned during the practice training. One hundred and twelve practice trainings were offered from 2011 to 2013. These practice trainings were related to medication errors. Most of the participants were nursing auxiliaries/licensed practical nurses (6.804; 69.3%, respectively). However, the adhesion of nurses (7.5%) was higher than that of technical personnel. The main thematic axis addressed axis and that with greater adherence of the nursing staff was “medication process” (19; 17%; 49.6%). We could identify 13 technologies established to prevent medication errors. The average cost/year of these technologies per patient was R$ 55,75 (US$ 13.94) with an annual projection of R$ 10.259.505,10 (US$ 2, 598, 361.55). The average investment per patient in preventive technologies related to the stage of drug prescription was R$ 17,67 (US$ 4.42). Regarding dispensation, the investments reached R$ 16,19 (US$ 4.05), and related to medication therapy management it was R$ 21,89 (US$ 5.47 ). The incidence indicator of medication error showed a gradual decreased from 2007 to 2013 ranging from 2.4% to 0.4%. Conclusion: Medication Errors can be costly at all stages of the medication therapy chain. However, the literature lacks research with a best level of evidence. Medication error indicator is feasible, and it serves as a tool to the manager in the decision-making process. It also helps to establish preventive strategies. The management of the error is still focused on the human error and not to the process failure. This may be the reason for the underreporting of the problem. The process of the medication therapy chain is complex and several professional categories are involved in it. There are several technologies for medication error prevention. However, these require financial investment for the acquisition and awareness/commitment of the nursing personnel to use it. Thus, it can be inferred that there was an improvement in patient safety, once there was a positive impact of the investment in preventive technology in relation to the decrease in medication error indicator as displayed in time series studies.<br>Introdução: O erro de medicação é um evento frequente na área da saúde e pode ter consequências para o paciente, profissional, instituição e sistema de saúde. Atualmente, existem muitas tecnologias que podem preveni-lo, no entanto, demandam investimento financeiro e profissional para que a barreira seja efetiva. Objetivos: Analisar a produção científica relacionada ao custo dos erros de medicação nas etapas da cadeia medicamentosa; investigar a ocorrência de erros de medicação; mapear e validar a utilização das tecnologias implantadas que previnem o erro de medicação; caracterizar os treinamentos relacionados à prevenção do erro de medicação e verificar a adesão da equipe de enfermagem a esses treinamentos e; analisar os custos das tecnologias empregadas para a prevenção do erro de medicação e o seu impacto em uma instituição hospitalar de ensino. Método: Inicialmente foi realizada uma revisão integrativa (2005 a 2015), depois, um de estudo de caso em um hospital escola de nível quaternário, porte extra, do interior de São Paulo, para o cálculo do indicador de incidência de erro de medicação a partir da equação proposta pelo Compromisso com a Qualidade Hospitalar e análise documental no período de 2007 a 2015. Para mapear e validar as tecnologias preventivas foram utilizados como fonte de dados a análise documental e entrevista. Posteriormente, desenharam-se os fluxogramas do processo de medicação na cadeia medicamentosa, incluindo as tecnologias preventivas em cada etapa. A validação desses fluxogramas ocorreu por meio de entrevista com 26 profissionais. Foi realizada a análise documental dos treinamentos realizados pelo centro integrado de educação permanente em saúde, bem como a adesão da equipe de enfermagem aos treinamentos por meio da proporção de profissionais atuantes nos respectivos anos. Calculou-se o custo direto de cada tecnologia na cadeia medicamentosa, multiplicando-se o tempo estimado despendido da mão de obra em cada atividade pelo seu custo, somando-se o custo unitário dos insumos multiplicado pela quantidade da aquisição da tecnologia. O impacto das tecnologias foi verificado a partir da série histórica do indicador de incidência de erro de medicação em relação aos momentos de implantação das tecnologias no campo de estudo. Resultados: Foram analisados 14 artigos, com predomínio do nível 6 de evidência, tanto pelo sistema hierárquico (78,5%) quanto para avaliações econômicas (50%). Dentre os estudos, cinco estavam relacionados à prescrição, um à administração, um à prescrição e administração e sete contemplavam todas as etapas da cadeia medicamentosa. Houve grande assimetria de valores apresentada na estimação de custo evitável/erro de medicação, variando de US$9, 041.76 a US$5,095,640,000.00. A incidência de erro de medicação foi de 1,4%. O principal tipo de erro foi “omissão” (31,2%). As unidades de internação foram as que mais notificaram (53,3%). A principal causa relacionada ao erro foi “desatenção” (93,3%) e ao processo de trabalho não foi notificada (80%). A ação realizada após o erro foi “aconselhamento individual” (71,1%). O processo da cadeia medicamentosa foi dividido em três subprocessos (prescrição, dispensação e administração) contemplando 50 atividades. Uma das tecnologias para a prevenção do erro de medicação citada foi os treinamentos, no período de 2011 a 2013 foram ministrados 112 treinamentos relacionados ao erro de medicação, a maior parte dos participantes eram auxiliares/ técnicos de enfermagem (6.804; 69,3%), no entanto, a adesão dos enfermeiros (7,5%) foi superior à de nível técnico. O principal eixo temático abordado e com maior adesão da equipe de enfermagem foi “processo de medicação” (19; 17%; 49,6%). Para prevenção do erro de medicação foram identificadas 13 tecnologias implantadas. O custo médio/ano dessas tecnologias por paciente foi de R$ 55,75 (US$ 13.94), com projeção anual de R$ 10.259.505,10 (US$ 2,598,361.55). O investimento médio por paciente em tecnologias preventivas para a etapa da prescrição foi de R$ 17,67 (US$ 4.42), na dispensação R$ 16,19 (US$ 4.05) e na administração R$ 21,89 (US$ 5.47). O indicador de incidência de erro de medicação apresentou queda gradual entre os anos de 2007 a 2013 variando de 2,4% a 0,4%. Conclusão: Erros medicação podem ser custosos em todas as etapas da cadeia medicamentosa, no entanto a literatura carece de pesquisas com melhor nível de evidência. O indicador de erro de medicação é exequível e instrumentaliza o gestor na tomada de decisão e estabelecimento de estratégias preventivas. A gestão do erro ainda está voltada para a falha humana e não do processo, podendo ser este o motivo da subnotificação deste problema. O processo da cadeia medicamentosa é complexo e há participação de várias categorias profissionais. Existem várias tecnologias para prevenção do erro de medicação, no entanto demanda investimento financeiro para sua aquisição e conscientização/comprometimento profissional na utilização. Assim, pode-se inferir que houve melhoria da segurança do paciente, uma vez que o impacto positivo do investimento em tecnologias preventivas em relação à diminuição do indicador de erros de medicação na série histórica apresentada.

Det övergripande syftet med den här avhandlingen har varit att, inom området läkemedelsinformatik, studera utvecklingen av elektroniska stöd inom läkemedelsförskrivning; för klinisk praxis, uppföljning och forskning. Under århundraden har det handskrivna receptet varit det sätt, med vilket läkare förmedlat sina läkemedelsordinationer till apotekare, vilket också för patienten blivit en informationskälla för hur läkemedel ska användas för att göra bästa nytta. Nu genomgår receptet en förändring från pappersbaserat till elektroniskt meddelande och att anpassa en traditionell process till en ny elektronisk era innebär både möjligheter och utmaningar. Studierna som ingår i avhandlingen har visat att exponeringen av förskrivna läkemedel i en allmän befolkning har ökat under de senaste tre decennierna. Risken för potentiella interaktioner mellan läkemedel, varmed avses den risk som finns att olika läkemedel kan påverka varandras effekter och biverkningar, har också visat sig öka starkt desto fler läkemedel som används av en individ. Denna ökade samtidiga användning av flera olika läkemedel, så kallad polyfarmaci, medför att det finns en större anledning för förskrivare och farmacevter att uppmärksamma risken för potentiella interaktioner mellan läkemedel. De nyinrättade nationella receptregistren över uthämtad receptförskriven medicin bör användas bland annat för att upptäcka potentiella läkemedelsinteraktioner, såväl i vårdens utövning som inom läkemedelsepidemiologisk forskning. Den svenska läkemedelsförteckningen, som omfattar information om uthämtade receptförskrivna läkemedel för huvuddelen av den svenska befolkningen, bedöms ha en stor klinisk potential. Den enskilde individens historiska information om uthämtade läkemedel är tillgänglig för individen på Internet med hjälp av e-legitimation; även förskrivare och farmacevter på apotek kan ta del av informationen med den enskildes samtycke. Brist på tillgång till enhetliga och säkra autenticeringsmetoder inom hälso- och sjukvården kan dock fördröja tillgången på individuell läkemedelsinformation för förskrivare. I och med att de flesta recepten i Sverige nu skrivs och överförs elektroniskt är det viktigt att kvalitetsmässiga aspekter tas tillvara så att en iakttagen ökad risk för receptförskrivningsfel inte överförs i informationskedjan. Avhandlingens slutsats är att e-förskrivning, med kommunikation och användning av lagrad information om receptexpeditioner, möjliggör att läkemedelsbehandling som process kan följas och studeras på ett helt nytt<br>The thesis aimed to study the developments, in the area of pharmacoinformatics, of the electronic prescribing and dispensing processes of drugs - in medical praxis, follow-up, and research. For hundreds of years, the written prescription has been the method of choice for physicians to communicate decisions on drug therapy and for pharmacists to dispense medication. Successively the prescription has also become a source of information for the patient about how to use the medication to maximize its benefit. Currently, the medical prescription is at a transitional stage between paper and web, and to adapt a traditional process to the new electronic era offers both opportunities and challenges The studies in the thesis have shown that the exposure of prescribed drugs in the general population has increased considerably over three decades. The risk of receiving potentially interacting drugs was also strongly correlated to the concomitant use of multiple drugs, polypharmacy. The pronounced increase in polypharmacy over time constitutes a growing reason for prescribers and pharmacists to be aware of drug interactions. Still, there were relatively few severe potential drug interactions. Recently established national prescription registers should be evaluated for drug interaction vigilance, both clinically and epidemiologically. The Swedish National Pharmacy Register provides prescription dispensing information for the majority of the population. The medication history in the register may be accessed online to improve drug utilization, by registered individuals, prescribers, and pharmacists in a safe and secure way. Lack of widespread secure digital signatures in healthcare may delay general availability. With a relatively high prevalence of dispensed drugs in the population, the National Pharmacy Register seems justified in evaluating individual medication history. With a majority of prescriptions transferred as ePrescriptions, the detected increased risk for prescription errors warrants quality improvement, if the full potential of ePrescriptions is to be fulfilled. The main conclusion of the studies was that ePrescribing with communication of prescribed drug information, storing and retrieving dispensed drug information, offers new opportunities for clinical and scientific

Thesis (M.S.)--State University of New York at Binghamton, Thomas J. Watson School of Engineering and Applied Science, Department of Systems Science and Industrial Engineering, 2009.<br>Includes bibliographical references.

Kan, Ka Lai Carrie.<br>"May 2008."<br>Thesis (M.Phil.)--Chinese University of Hong Kong, 2008.<br>Includes bibliographical references (leaves 118-125).<br>Abstracts in English and Chinese, some text in appendix also in Chinese.<br>Chapter CHAPTER 1: --- INTRODUCTION --- p.1<br>Chapter CHAPTER 2: --- LITERATURE REVIEW<br>Introduction --- p.3<br>Medication error --- p.4<br>Definition of medication error --- p.4<br>Incidents of medication error --- p.6<br>The issues of defining medication error --- p.7<br>The issue of medication error reporting --- p.8<br>Near miss --- p.9<br>Factors associated with medication error --- p.10<br>System factors --- p.10<br>Environmental factors --- p.12<br>Human factors --- p.13<br>Slips and lapses and medication error --- p.14<br>"Distraction, slips and lapses and medication error" --- p.15<br>Distraction --- p.15<br>Definition of distraction --- p.15<br>Consequences of distraction --- p.16<br>Factors associated with distraction --- p.16<br>Cognitive factors --- p.17<br>Personality factors --- p.18<br>Environmental factors --- p.18<br>Studies on distraction during medication administration --- p.19<br>Distraction and medication error --- p.21<br>Strategies to reduce distraction --- p.22<br>Visual Sign --- p.23<br>Definition of visual sign --- p.23<br>Nature of visual sign --- p.24<br>Studies on visual sign to reduce distraction --- p.25<br>Summary of literature review --- p.25<br>Chapter CHAPTER 3: --- METHODOLOGY<br>Introduction --- p.27<br>Aims and objectives --- p.27<br>Operational definitions --- p.28<br>Research design --- p.28<br>Setting --- p.31<br>Stage one --- p.32<br>Setting --- p.32<br>Sampling --- p.33<br>Instrument --- p.35<br>Data collection method --- p.36<br>Data analysis --- p.37<br>Stage two --- p.38<br>Stage three --- p.40<br>Pilot study --- p.40<br>Validity and reliability of methodology --- p.41<br>Interview --- p.41<br>Observation --- p.42<br>Ethical considerations --- p.43<br>Chapter CHAPTER 4: --- FINDINGS<br>Introduction --- p.44<br>Stage one --- p.44<br>Baseline interview --- p.44<br>Informants' characteristics --- p.44<br>Categories and sub-categories --- p.45<br>Feelings of medication error --- p.46<br>Causes of medication error --- p.47<br>Causes of distraction --- p.49<br>Perception of distraction --- p.50<br>Feelings about distraction --- p.52<br>Strategies to reduce distraction --- p.53<br>Strategies to reduce medication error --- p.54<br>Baseline observation --- p.56<br>Findings of stage one --- p.59<br>Stage two --- p.60<br>One week after implementation observation --- p.60<br>Findings of stage two --- p.63<br>Stage three<br>Three months after implementation observation --- p.63<br>Follow-up interview --- p.66<br>Informants' characteristics --- p.66<br>Categories and sub-categories --- p.67<br>Conflicting feelings --- p.68<br>Different effects on nursing service --- p.69<br>Feelings about wearing the red vest --- p.70<br>Enhanced a non-distractive culture --- p.72<br>Improved cognitive process --- p.73<br>Improved performance --- p.75<br>Findings of stage three --- p.76<br>Comparison of the three stages of quantitative observational data --- p.77<br>"Lapse time, items given, and number of patients" --- p.77<br>Comparison of lapse time and total distraction --- p.78<br>Comparison of the ten items on distraction --- p.78<br>Comparison of total distraction --- p.79<br>Comparison of near misses --- p.80<br>Overall Summary of the findings --- p.80<br>Chapter CHAPTER 5: --- DISCUSSION<br>Introduction --- p.82<br>Characteristics of informants and observational data --- p.82<br>Nurseśة perception of distraction as a cause of medication administration error --- p.83<br>Causes of distraction during medication administration --- p.87<br>Evaluation outcome --- p.91<br>Evaluation process --- p.98<br>Chapter CHAPTER 6: --- "LIMITATIONS, IMPLICATIONS AND RECOMMEDATIONS"<br>Limitations --- p.111<br>Setting --- p.111<br>Population and sampling --- p.111<br>Observer's influence --- p.112<br>Interviewer's influence --- p.112<br>Implications for nursing practice --- p.113<br>Recommendations for future studies --- p.114<br>Conclusion --- p.116<br>REFERENCES --- p.118<br>APPENDICES<br>Chapter 1: --- Literature search --- p.126<br>Chapter 2: --- Medication Administration Distraction Observation Sheet (MADOS) --- p.127<br>Chapter 3: --- Adapted MADOS --- p.128<br>Chapter 4: --- Baseline interview guide --- p.129<br>Chapter 5: --- Interview consent form --- p.130<br>Chapter 6: --- Observation consent form --- p.136<br>Chapter 7: --- Informal letter to nursing staff --- p.142<br>Chapter 8: --- Follow-up interview guide --- p.144<br>Chapter 9: --- Rationale for pilot study --- p.145<br>Chapter 10: --- Ethical approval (CUHK) --- p.147<br>Chapter 11: --- Ethical approval ( Hospital Administrative Council) --- p.148<br>Chapter 12: --- Baseline interview (1) --- p.149<br>Chapter 13: --- Baseline observation (MAC 4) --- p.154<br>Chapter 14: --- One week after observation (MAC 01) --- p.155<br>Chapter 15: --- Three months after observation (MAC 005) --- p.156<br>Chapter 16: --- Follow-up interview (08) --- p.157<br>TABLES<br>Chapter 1: --- Different units and the approximate numbers of nurses --- p.30<br>Chapter 2: --- Proposed sample size for baseline interview --- p.33<br>Chapter 3. --- Medication administration at different scheduled time --- p.35<br>Chapter 4. --- Informantśة characteristics at baseline interview --- p.45<br>Chapter 5: --- Categories and subcategories: baseline interview --- p.46<br>Chapter 6: --- "Elapse time, items given, number of patients, distractions and near misses at baseline observation" --- p.57<br>Chapter 7: --- Frequency of the ten items of distraction at baseline observation --- p.57<br>Chapter 8: --- Ranking of the ten items on distraction at baseline observation --- p.58

Indiana University-Purdue University Indianapolis (IUPUI)<br>Medication administration error remains a leading cause of preventable death. A gap exists in understanding attentional dynamics, such as nurse situation awareness (SA) while managing interruptions during medication administration. The aim was to describe SA during medication administration and interruption handling strategies. A crosssectional, descriptive design was used. Cognitive task analysis (CTA) methods informed analysis of 230 interruptions. Themes were analyzed by SA level. The nature of the stimuli noticed emerged as a Level 1 theme, in contrast to themes of uncertainty, relevance, and expectations (Level 2 themes). Projected or anticipated interventions (Level 3 themes) reflected workload balance between team and patient foregrounds. The prevalence of cognitive time-sharing during the medication administration process was significant or may be remarkable. Findings substantiated the importance of the concept of SA within nursing as well as the contribution of CTA in understanding the cognitive work of nursing during medication administration.

1 ABSTRACT Background The annual drug overdose rates have been increasing exponentially since the 90's worldwide. Toxicological information centre (TIC) represents a valuable source of information for evaluating the trends in the drug poisonings in Czech Republic. Aim of the study The purpose was to analyze the number and trends in the calls concerning poisonings due to central nervous system (CNS) affecting drugs, identify the reasons of medication errors caused by laymen, frequency and consequences of these errors across all age groups and also to analyze the numbers, causes, symptoms and severity of the paracetamol intoxications. Methods During the reference period the data from the enquiries were extracted from the TIC electronic database, discharge reports from the hospital were studied or phone call follow-ups with the patients were carried out to be able to evaluate the outcome of the poisonings. Results In the years 1997-2002 the number of calls caused by poisoning with tricyclic antidepressants and barbiturates decreased (by 366.7 % and 340,0 %, respectively) whereas the calls due to selective serotonin reuptake inhibitors and benzodiazepines overdose increased (by 1347.4 % and 359.8 %). The 0-5 years old children are at the highest risk of experiencing medication errors or accidental poisonings...

碩士<br>元智大學<br>資訊管理學系<br>99<br>Recent studies indicated that the major medication errors result from the procedural flaws while the healthcare is delivered but not a nurse’s recklessness while medication administration is conducted. The major reason why medication errors are reported in a hospital is that patients’ medical treatments are constantly changed and the nurse is not always to get the latest medical treatment lists in the administration procedures. Therefore, it is vital to provide the latest medical treatment lists to the nurses when they are doing the administration procedures. In this study, we proposed a mobile system using radio frequency identification (RFID) and personal digital assistant (PDA), which are integrated with the Hospital Information System (HIS), to provide nurses with real-time patients’ medical treatment lists. The proposed system is consisted of HIS, Drug Identification System (DIS), Patient Safety Event Reporting System (PSERS), Middle-Gateway (MG) and PDA. HIS contains inpatients’ medical treatment plans and relative information. DIS contains the drug picture and relative information. PSERS is used by nurses to upload inpatients’ pictures, maintain inpatients’ safety events and print inpatients’ medical treatment records. MG synchronizes and transforms the relative data from HIS and DIS. PDA provides nurses with abilities to indentify patients’ status, to access medical treatment plans in real time and to record inpatients’ medical treatments in database. This mobile system helps nurses to reduce workload and enhance patient safety while nurses are performing medication administration.

碩士<br>南開科技大學<br>福祉科技與服務管理所<br>98<br>This study is to investigate the drug usage problems among aged. Through analyzing the current pill-boxes, often used for solving elderly drug usage problems, we find that the design of the commonly used pill-boxes can help patients overcome problems like forgetting to take medicine or repetitive medicine taking. However, it doesn’t solve problems like mis-taking medicine. Therefore, this study considers the problem of medication error. The survey data was collected from chronic disease patients’ questionnaires. It helps us preliminary understand the need of pill-box design for aged. Then, we discuss if the current pill-boxes provide prevention of drug taking. Finally, we use the common design method to devise medication error prevention device for elderly. The designed medication error prevention device is to help patients not to touch medicine that shouldn’t be taken in the particular drug taking period. About the products interface of current design, we interview elderly individually and find that this system does prevent the medication error problems. Except previous dispense prescription and medication reminder functions, for caring patients, the taking-medicine-on-time monitoring mechanism can be added in. If the patients didn’t take medicine on time, the medication system would send a message to the assigned cell-phone. Thus, the family members of the patient, health care workers, nursing or medical staff, and those who have special relations to the patients can know the medicine taking situation and help to reduce the medication error problems.

碩士<br>國立虎尾科技大學<br>資訊管理研究所<br>100<br>The incident of medication errors emerges in an endless stream. It has been a most worried medical mistreatment at all time. Medicines with names that sound and/or look alike tend to lead to medication errors, and continue to threaten patients’ health. Cloud computing brings a series of innovation and challenges for contemporary information technology. It makes use of technology such as virtualization and automation to provide the efficient way to access database, thus meaningful medical information is able to make exchange on internet. The purpose of this research is to develop a prevention system based on Google App Engine. Through the discussion of related references, and drug product specifications in the Department of Health, a drug-information system is developed by taking advantage of cloud computing capacity. Hopefully the medications safety is improved. The patients get the best medication treatment. People make quick access to the drug information. The suggestion collected from this research is offered to the medicine department of hospital for future practical reference.

no<br>PURPOSE/OBJECTIVES: To assess and improve the safety of hospital-based adult chemotherapy administration. DESIGN: Prospective, systems-focused clinical risk assessment. SETTING: An adult inpatient and outpatient oncology unit in a large urban hospital in the United Kingdom. SAMPLE: 8-person nurse-led multidisciplinary team, which included managerial staff and patient safety researchers. METHODS: Failure mode and effects analysis (FMEA), a prospective, systems-focused risk assessment methodology, was undertaken in biweekly team meetings and included mapping the chemotherapy administration process, identifying and numerically prioritizing potential errors (failure modes) for each process step, and generating remedial strategies to counteract them. MAIN RESEARCH VARIABLES: The analysis aimed to identify chemotherapy administration failure modes and to generate remedial strategies to address them. User feedback on the FMEA process also was collected. FINDINGS: Several specific chemotherapy failure modes were identified, the majority of which had not previously been recognized, and several novel strategies to counteract them were generated. Many of the strategies were specific, environment-focused actions, which are simple, quick, and inexpensive to implement; however, more substantive, longer-term initiatives also were generated. User feedback generally was very positive, and the process of undertaking the analysis improved multidisciplinary teamwork and communication. CONCLUSIONS: Although time and resource intensive, FMEA is a useful safety improvement tool. IMPLICATIONS FOR NURSING: Nurses should be aware of and informed about FMEA as a tool they can use in partnership with management and other disciplines to proactively and collectively improve the safety of high-risk oncology procedures such as chemotherapy administration.

Current status: Currently, the safety of patients is a key element in the provision of safe and high quality care. The drug administration is the main danger fro the patiens which is neccessery to be mentined. (Buchini and Quattrin, 2012). Each provider of health care services should follow specific internal regulation of medication process. Morover, it is necessary to support employee to report possible misconduct in the adverse event to the reporting system, which is used to create functional corrective measures. However, we have to realize that it is impossible to forget the role of the patient in the prevention of medication errors. Goals: The main aim of the research was to find out whether the nurses know the recommended nursing procedure of medication to patients.Not only, mentioned the most common misconduct during the administration of drugs, but also identify the most common causes of these misconductions. After that to describe preventive mechanisms for reducing the risk of medication errors. In conclusion it was necessary to point out the cooperation of patients in the process of safe medication administration. Methodology: The research was conducted using a qualitative research method. The data were collected the polling method, along with in-depth interview technique. The qualitative data was coded using ,,paper and pencil" and semantically organized into groups along with the categorization schemes. Research file: In order to archieve the highest level of objectivity the research was carried out with a group of nurses and patients only from the Surgical Department of a particular nursing unit. First, the research consisted of six nurses working in the surgical Department at the hospital České Budějovice a.s. and the second research file consisted of six clients admitted to the same Department. Due to the fact that the respondents were genrally reluctant to cooperate the researched sample is limited.

No âmbito o 3.º Curso de Mestrado em Enfermagem de Associação ministrado pela Escola Superior de Saúde (ESS) do Instituto Politécnico de Portalegre (IPP) na área de especialização, Enfermagem médico cirúrgica a Pessoa em Situação Crítica, surge o presente relatório. Este relatório traduz o trabalho desenvolvido e as aprendizagens adquiridas ao longo dos estágios realizados na Unidade de Acidentes Vasculares Cerebrais (UAVC) e na Unidade de Cuidados Intensivos Polivalente (UCIP) do Centro Hospitalar de Setúbal (CHS). A materialização destas atividades e os aportes teóricos obtidos durante a formação teórica, proporcionaram oportunidades de formação e aprendizagem aplicadas na prática diária de prestação de cuidados que contribuíram para o desenvolvimento de competências de Enfermeiro Especialista em Enfermagem Médico-Cirúrgica e Mestre em Enfermagem, visando uma melhoria da qualidade dos cuidados e a excelência no exercício da profissão. Ao longo dos estágios realizados e com base na metodologia de Projeto, foi desenvolvido um Projeto de Intervenção em Serviço (PIS) com a finalidade de promover a qualidade dos cuidados de enfermagem na área da segurança do doente e da medicação look-alike sound alike (LASA), através da implementação de estratégias com o objetivo de prevenir os erros associados aos medicamentos LASA. Paralelamente, este relatório comtempla uma análise e reflexão crítica fundamentada, sobre o processo de aquisição e desenvolvimento de competências de Mestre em Enfermagem, bem como competências comuns e especificas do Enfermeiro Especialista em Enfermagem Médico-cirúrgica a Pessoa em Situação Crítica e de que forma os aportes teóricos e os estágios realizados contribuíram para a sua aquisição<br>This essay relates to the 3rd Association Nursing Masters Course, with Specialization in Medical and Surgical Nursing for people in Critical Condition offered by the Health School of the Polytechnic Institute of Portalegre. This survey analyses the work developed and the lessons learned during the internships carried out at the Stroke Unit (UAVC) and the Multipurpose Intensive Care Unit (UCIP) of na Hospital Center on the south bank of the Tagus River. The daily participation in health care procedures provided training and learning opportunities for the employment of the theoretical knowledge obtained during the Course and contributed for an improvement of skill acquisition and development in the Masters Degree in Nursing, as well as the specific skills of the Specialist Nurse in Medical-Surgical Nursing for People in Critical Condition and Master’s Degree in Nursing, aiming quality of nursing care and excellence in the practice of the profession. Based on the Project methodology, in Service Intervention Project was carried out with strategies to prevent errors associated with look-alike sound-alike (LASA) medications and to promote nursing quality in the area of patient safety during administration of LASA medication. Simultaneously, this essay includes a substantiated analysis and critical reflection on the process of skill acquisition and development in the master’s degree in nursing, as well as the specific skills of the Specialist Nurse in Medical-Surgical Nursing for People in Critical Condition and how theoretical knowledge and internships contributed to its refinement