Error recovery in a hospital pharmacy

Kanse, Lisette; Schaaf, van der Tw Tjerk; Vrijland, ND Nanco; Mierlo, van H Heleen

doi:10.1080/00140130600568741

Cited by 49 publications

(42 citation statements)

References 28 publications

(23 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…This notion is further supported by Kanse and colleagues, 12 who found that organizational factors have the greatest impact on the effectiveness of reported QREs and cited management priorities as one of these organizational factors. Kanse et al also stated that one reason that QRE recovery opportunities were missed was because management did not see it as a high enough priority.…”

Section: Discussionsupporting

confidence: 59%

Head Office Commitment to Quality-Related Event Reporting in Community Pharmacy

et al. 2012

View full text Add to dashboard Cite

Community pharmacy is a key area in which to implement patient safety and quality improvement practices, due to the significant volume of prescriptions dispensed in the community. While considerable research exists that looked at medication safety within hospitals, there is a growing body of knowledge regarding safety issues in the community setting. Incidence rates in Britain, Denmark and the United States suggest that between 23 and 26 medication errors and near misses occur for every 10,000 prescriptions dispensed.1-3 In Britain, the primary cause of medication incidents was determined to be misreading the prescription. 1 These findings were echoed in Denmark, with the majority of errors occurring in the transcription phase, including the wrong strength, wrong medicine and wrong dosage.

show abstract

Section: Discussionsupporting

confidence: 59%

Head Office Commitment to Quality-Related Event Reporting in Community Pharmacy

et al. 2012

View full text Add to dashboard Cite

show abstract

“…12 FCRs represent an established venue in which several of the key features of successful error recovery are present. 8,9,13 Specifically, FCRs often include monitoring medication outcomes and review of treatment plans under the watchful eyes of those most knowledgeable about the child's care, such as attending physicians, nurses, pharmacists, and the family. 14,15 The objective of the present study was to further understand the potential for FCRs to foster pediatric medication safety.…”

Section: What This Study Addsmentioning

confidence: 99%

“…6 Error recovery describes this type of process and includes 3 stages: (1) detection; (2) explanation; and (3) correction. 8 Detection involves identifying the error and can be done by the person committing the error or by others familiar with the care plan. Explanation involves understanding how the error occurred.…”

Section: What This Study Addsmentioning

confidence: 99%

Family-Initiated Dialogue About Medications During Family-Centered Rounds

et al. 2015

View full text Add to dashboard Cite

BACKGROUND AND OBJECTIVE: Experts suggest family engagement in care can improve safety for hospitalized children. Family-centered rounds (FCRs) can offer families the opportunity to participate in error recovery related to children's medications. The objective of this study was to describe family-initiated dialogue about medications and health care team responses to this dialogue during FCR to understand the potential for FCR to foster safe medication use.METHODS: FCR were video-recorded daily for 150 hospitalized children. Coders sorted family-initiated medication dialogue into mutually exclusive categories, reflecting place of administration, therapeutic class, topic, and health care team responses. Health care team responses were coded to reflect intent, actions taken by the team, and appropriateness of any changes.RESULTS: Eighty-three (55%) of the 150 families raised 318 medication topics during 347 FCR. Most familyinitiated dialogue focused on inpatient medications (65%), with home medications comprising 35%. Antiinfectives (31%), analgesics (14%), and corticosteroids (11%) were the most commonly discussed medications. The most common medication topics raised by families were scheduling (24%) and adverse drug reactions (11%). Although most health care team responses were provision of information (74%), appropriate changes to the child's medications occurred in response to 8% of family-initiated dialogue, with most changes preventing or addressing adverse drug reactions or scheduling issues.CONCLUSIONS: Most families initiated dialogue regarding medications during FCRs, including both inpatient and home medications. They raised topics that altered treatment and were important for medication safety, adherence, and satisfaction. Study findings suggest specific medication topics that health care teams can anticipate addressing during FCR. WHAT'S KNOWN ON THIS SUBJECT:Family engagement in the care of hospitalized children may improve outcomes, including medication safety. Although family-centered rounds (FCRs) provide a venue for family engagement in care, how families use this venue to influence medication-related topics is unknown. WHAT THIS STUDY ADDS:Most families initiated medication-related dialogue during FCRs, discussing inpatient and home medications. Topics raised were important for medication adherence and safety, even altering treatment plans. Findings suggest specific medication topics that health care team members can anticipate addressing during FCR.

show abstract

“…and (2) What are nurses' experience in clinical practice following a pressure ulcer assessment intervention?…”

mentioning

confidence: 99%

Leveraging Safer Nursing Care by Conceptualizing Near Misses as Recovery Processes

Jeffs

MacMillan

2009

Journal of Nursing Care Quality

View full text Add to dashboard Cite

The purpose of this study was to elicit perceptions and experiences of nurses associated with a recovery process (near miss) intervention (wound care management). From the content analysis of interview data involving 12 registered nurses, 2 key themes emerged. Both themes illuminated the links among pattern recognition, alignment of care processes and practice guidelines, and nurses' accountability for safe pressure ulcer care.

show abstract

Error recovery in a hospital pharmacy

Cited by 49 publications

References 28 publications

Head Office Commitment to Quality-Related Event Reporting in Community Pharmacy

Head Office Commitment to Quality-Related Event Reporting in Community Pharmacy

Family-Initiated Dialogue About Medications During Family-Centered Rounds

Leveraging Safer Nursing Care by Conceptualizing Near Misses as Recovery Processes

Contact Info

Product

Resources

About