Errors in the medication process: frequency, type, and potential clinical consequences

Lisby, Marianne; Nielsen, Lars Peter; Mainz, Jan

doi:10.1093/intqhc/mzi015

Cited by 295 publications

(293 citation statements)

References 28 publications

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“…There is a need to raise awareness of medical doctors to avoid erasures and, at the same time, health facilities have to take actions to prevent illegible prescriptions, for example, by implementing electronic prescription systems (10)(11) .…”

Section: Influence Of the Writing Of The Medical Orders On The Adminimentioning

confidence: 99%

Influência da redação da prescrição médica na administração de medicamentos em horários diferentes do prescrito

Gimenes

Teixeira²,

Silva

et al. 2009

Acta paul. enferm.

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Original Article ABSTRACTObjective: To evaluate the influence of the writing of medical orders on the administration of medications in medical units from five brazilian hospitals. Methods: This descriptive study used a secondary analysis of data from a multicenter study conducted in 2005. the sample consisted of 1,084 medication orders that had been administered at the wrong schedule time. Results: The great majority of medical orders (96.2%) had acronyms and/or abbreviations, 7.8% of them had incomplete schedules for administration of the medication, and 4.8% had been marked out. in addition, there was no schedule for the administration of the medication in 1.9% of the medical orders. Conclusion: Implementation of electronic prescribing and continuing education of health care providers can minimize the administration of medication at the wrong schedule time. Descriptors: Medication errors; Drug prescriptions; Nursing records; Medical records RESUMO Objetivo: Analisar a influência da redação da prescrição médica na administração de medicamentos em horários diferentes do prescrito ocorridas em unidades de clínica médica de cinco hospitais brasileiros. Métodos: Trata-se de estudo descritivo que utilizou dados secundários obtidos de uma pesquisa multicêntrica realizada em 2005. A amostra foi composta por 1084 doses de medicamentos administradas em horários diferentes do prescrito. Resultados: Do total analisado, 96,2% apresentavam siglas e/ou abreviaturas; 7,8% apresentavam o registro do horário de administração incompleto e 4,8% destes registros estavam rasurados. Ainda, faltou o horário e/ou a freqüência de administração em 1,9% das prescrições. Conclusão: Com a implantação do sistema computadorizado de prescrições, associada à prática da educação permanente será possível minimizar a administração de medicamentos em horários diferentes do prescrito. Descritores: Erros de medicação; Prescrição de medicamentos; Registros de enfermagem; Registros médicos RESUMEN Objetivo: Analizar la influencia de la redacción de la prescripción médica en la administración de medicamentos en horarios diferentes al prescripto ocurridas en unidades de clínica médica de cinco hospitales brasileños. Métodos: Se trata de un estudio descriptivo que utilizó datos secundarios obtenidos de una investigación multicéntrica realizada en el 2005. La muestra estuvo compuesta por 1084 dosis de medicamentos administradas en horarios diferentes al prescripto. Resultados: Del total analizado, el 96,2% presentaba siglas y/o abreviaturas; el 7,8% presentaba el registro del horario de administración incompleto y el 4,8% de estos registros estaban borrados. Aun más, faltó el horario y/o la frecuencia de administración en el 1,9% de las prescripciones. Conclusión: Con la implantación del sistema computarizado de prescripciones, asociada a la práctica de la educación permanente será posible minimizar la administración de medicamentos en horarios diferentes al prescripto. Descriptores: Errores de medicación; Prescripción de medicamentos; Registros de enferm...

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Section: Influence Of the Writing Of The Medical Orders On The Adminimentioning

confidence: 99%

Influência da redação da prescrição médica na administração de medicamentos em horários diferentes do prescrito

Gimenes

Teixeira²,

Silva

et al. 2009

Acta paul. enferm.

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“…severe consequences for the patient, and 20-30% of medication errors have been assessed as potential adverse drug events [2]. A review article reports that of the medication errors identified, 11-59% were thought to be of clinical importance [3].…”

mentioning

confidence: 99%

Improved quality in the hospital discharge summary reduces medication errors—LIMM: Landskrona Integrated Medicines Management

Bergkvist

Midlöv

Höglund

et al. 2009

Eur J Clin Pharmacol

104

114

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Purpose We have developed a model for integrated medicines management, including tools and activities for medication reconciliation and medication review. In this study, we focus on improving the quality of the discharge summary including the medication report to reduce medication errors in the transition from hospital to primary and community care. Methods This study is a longitudinal study with an intervention group and a control group. The intervention group comprised 52 patients, who were included from 1 March 2006 until 31 December 2006, with a break during summer. Inclusion in the control group was performed in the same wards during the period 1 September 2005 until 20 December 2005, and 63 patients were included in the control group. In order to improve the quality of the medication report, clinical pharmacists reviewed and gave feedback to the physician on the discharge summary before patient discharge, using a structured checklist. Medication errors were then identified by comparing the medication list in the discharge summary with the first medication list used in the community health care after the patient had returned home.Results By improving the quality of the discharge summary, patients had on average 45% fewer medication errors per patient (P=0.012). The proportion of patients without medication errors was 63.5% in the control group and 73.1% in the intervention group. However, this increase was not significant (P=0.319). Patients who used a specific medication dispensing system (ApoDos) had a 5.9-fold higher risk of suffering from medication errors than those without this medication dispensing system (P<0.001). Conclusion Review and feedback on errors in the discharge summary, including the medication report and a correct medication list, reduced medication errors during the transfer of information from hospital to primary and community care.Keywords Elderly . Hospital discharge . Inpatients . Medication errors . Medication reconciliation . Medication report IntroductionIn the elderly, the risk of medication errors increases with the number of home medications when admitted to or discharged from hospital [1]. Medication errors can lead to Eur J Clin Pharmacol (2009) severe consequences for the patient, and 20-30% of medication errors have been assessed as potential adverse drug events [2]. A review article reports that of the medication errors identified, 11-59% were thought to be of clinical importance [3]. Various types of medication errors are frequent in hospitals [4,5] and in the interface between care levels [6][7][8][9][10][11][12][13][14][15][16]. Insufficient quality in the transfer of information on a patient's medications has recently been highlighted as one of the most important problems in health care, and international and national programs have been developed for information and help [16]. According to the Institute for Healthcare Improvement, poor communication of medical information at transition points is responsible for as many as 50% of all medication errors and 20...

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“…Although this system can avoid transcription errors, the copy handled by the pharmacy is not always legible. According to the literature, this practice causes serious risks of dose errors, route and dosage form, for example, as illegible handwriting may, in the worse case scenario, lead to a patient's death 22,28 . In almost all cases, errors caused by illegible handwritten prescriptions could be preventable, thus, efforts from universities and ANVISA are necessary to qualify prescribers and eliminate this problem from the Sentinel Hospitals Network.…”

Section: Discussionmentioning

confidence: 99%

“…Data was collected in close proximity to the nursing staff and always at the end of the afternoon, during seven consecutive days 17,20,21 through a structured instrument developed by the group of researchers, based on the literature 22 , with items about the type of medication prescription (electronic or handwritten), legibility (legible, illegible or partially printing), completeness of prescriptions (complete or not complete), abbreviations (present or not present) and existence of changes and erasures. It is important to highlight that illegible prescriptions or unmarked items were not included in the other analysis.…”

Section: Data Collection Proceduresmentioning

confidence: 99%

Prescription errors in Brazilian hospitals: a multi-centre exploratory survey

et al. 2009

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Errors in the medication process: frequency, type, and potential clinical consequences

Cited by 295 publications

References 28 publications

Influência da redação da prescrição médica na administração de medicamentos em horários diferentes do prescrito

Influência da redação da prescrição médica na administração de medicamentos em horários diferentes do prescrito

Improved quality in the hospital discharge summary reduces medication errors—LIMM: Landskrona Integrated Medicines Management

Prescription errors in Brazilian hospitals: a multi-centre exploratory survey

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