Exploratory Evaluation of Medication Classes Most Commonly Involved in Nursing Home Errors

Desai, Rishi; Williams, Charlotte; Greene, Sheila; Pierson, Stephanie; Caprio, Anthony J.; Hansen, Richard A.

doi:10.1016/j.jamda.2012.11.006

Cited by 28 publications

(48 citation statements)

References 19 publications

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“…Dentre os tipos de erros na AM encontrados nesta revisão, o principal deles diz respeito à dosagem medicamentosa, presente em 27 estudos (67,5%) (8,(10)(11)(13)(14)(16)(17)(19)(20)(23)(24)(25)(26)(27)(28)(30)(31)(32)34,36,(42)(43)(44)(45)(46)(47)(48)(49) . Corroborando com tal achado, uma pesquisa (50) que teve como um dos objetivos identificar o perfil dos erros cometidos durante o preparo, encontrou que 67,7% dos erros estavam associados a doses preparadas erroneamente.…”

Section: Discussionunclassified

“…Esta realidade também foi encontrada na presente pesquisa, em que a administração da medicação errada foi o segundo erro mais comum entre os estudos analisados e esteve presente em 62,5% (n=25) (8)(9)(10)(11)13,16,(20)(21)(23)(24)(25)(26)(28)(29)(30)(31)(36)(37)(42)(43)(45)(46)(48)(49)53) da amostra, seguido pelo medicamento administrado ao paciente errado (n=21;52,5%) (8)(9)(10)(11)16,18,22,(23)(24)(25)(26)(27)(28)(30)(31)(33)(34)(36)(37)(46)(47) .…”

Section: Discussionunclassified

See 1 more Smart Citation

Erros Na Administração De Medicamentos: Evidências E Implicações Na Segurança Do Paciente

Gomes¹,

Assis²,

Silva³

et al. 2016

Cogitare Enferm.

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RESUMO: O estudo objetiva identificar as evidências e as implicações dos erros na administração de medicamentos na segurança do paciente. Trate-se de uma revisão integrativa, com busca dos estudos em quatro bases de dados, em maio de 2015. Obteve-se uma amostra de 40 artigos e foram submetidos à estatística descritiva. Houve predomínio de estudos descritivos -nível de evidência 4 (n=28; 70%), publicados no Brasil (n=17; 42,5%). Quanto aos erros, destacaram-se: erro de dosagem (n=27; 67,5%), medicação errada (n=25; 62,5%); troca de paciente (n=21; 52,5%); erro de horário (n=20;5 0%); via errada (n=17;42,5%), além de erro documental, omissão de justificativas quando necessário e outras. Este tipo de evento é responsável por deixar sequelas irreparáveis nos pacientes ou até levar à morte. MEDICATION ADMINISTRATION ERRORS: EVIDENCES AND IMPLICATIONS FOR PATIENT SAFETY ABSTRACT:The objective is to identify the evidences and implications of medication administration errors for patient safety. An integrative review was undertaken through a search in four databases in May 2015. A sample of 40 articles was obtained, submitted to descriptive statistics. Descriptive studies of evidence level 4 were predominant (n=28; 70%), published in Brazil (n=17; 42.5%). The following errors stood out: dose errors (n=27; 67.5%), wrong drug (n=25; 62.5%); wrong patient (n=21; 52.5%); wrong time (n=20;50%); wrong route (n=17;42.5%), besides documentation errors, omission of justifications when necessary and others. This type of event is responsible for causing irreparable damage to the patient or even death. DESCRIPTORS: Medication errors; Patient safety; Nursing. ERRORES EN LA ADMINISTRACIÓN DE MEDICAMENTOS: EVIDENCIAS Y IMPLICACIONES EN LA SEGURIDAD DEL PACIENTERESUMEN: La finalidad del estudio es identificar las evidencias y las implicaciones de los errores en la administración de medicamentos en la seguridad del paciente. Se trata de una revisión integradora con búsqueda de estudios en cuatro bases de datos en mayo del 2015. Fue encontrada una muestra de 40 artículos, sometidos a la estadística descriptiva. Predominaron estudios descriptivos -nivel de evidencia 4 (n=28; 70%), publicados en Brasil (n=17; 42,5%). Entre los errores se destacaron: error de dosificación (n=27; 67,5%), medicación equivocada (n=25; 62,5%); cambio de paciente (n=21; 52,5%); error de horario (n=20;5 0%); vía equivocada (n=17;42,5%), además de error documental, omisión de justificativas cuando necesario y otras. Este tipo de evento es responsable por dejar secuelas irreparables en los pacientes o incluso llevar a la muerte. DESCRIPTORES: Errores de medicación; Seguridad del paciente; Enfermería.

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Section: Discussionunclassified

Erros Na Administração De Medicamentos: Evidências E Implicações Na Segurança Do Paciente

Gomes¹,

Assis²,

Silva³

et al. 2016

Cogitare Enferm.

View full text Add to dashboard Cite

show abstract

“…[1,6] Approximately 19%-42% of all medication doses administered in nursing facilities are associated with medication errors. [7] In addition, new data among Medicare beneficiaries suggests that 22% of skilled nursing home residents experienced an adverse event (AE) within first 35 days of their stay; of these, 37% were due to medications. [8] By definition, these AEs may have resulted in prolonged stay in a nursing home or hospitalization, permanent harm or death.…”

Section: Introductionmentioning

confidence: 99%

“…[8] In general, evidence indicates that preventable ADEs caused by errors occur at a rate of 1 per 100 resident-months. [7] In addition, ADEs in a nursing home are costly. It is estimated that for every $1 spent on medications, $1.33 is spent on the treatment of harm caused by the medications.…”

Section: Introductionmentioning

confidence: 99%

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Common issues in the medication use processes in nursing homes: a review of medication use quality improvement strategies

Hughes

Freeman

Slaton

2016

JNEP

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Background: A continuous evaluation of safety practices in nursing homes and long-term care (LTC) facilities is needed. Numerous studies have highlighted the deficiencies in safety processes of nursing homes compared with institutional practice despite the fact that many residents in the nursing home setting also suffer from complex medical conditions and are receiving multiple medications to treat the comorbidities. As part of larger grant initiative, an extensive search was conducted to identify common problems in nursing facilities and potential strategies for improvement. This review highlights common problems in the medication use process in nursing facilities and strategies to improve processes and general resident safety based upon pertinent findings from the literature. Findings: There are proven medication safety strategies utilized in institutions that should be a foundational practice in nursing and LTC facilities. These strategies include, but are not limited to, reduction of polypharmacy and increased sensitivity to and prioritization of medication therapy monitoring processes, which will assist in the creation of a culture of safety. Specific goals of this process includes frequent education and encouraged use of best practices surrounding handling of high-alert medications, proper drug administration (e.g., crushing medications), drug interactions and reporting of adverse medication events. Conclusion: Medication use process failures are common in nursing and LTC facilities. However, an integrated approach can be used to mitigate some of the common problems. Pharmacists and nurses should work more closely to implement proven medication safety strategies. Implementing these strategies in concert with improved communication between team members can benefit residents by preventing avoidable events and hospitalizations.

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Registered Nurses' perspective of systemic factors affecting nursing home care quality decline: A qualitative descriptive study

Park

Min

2022

Nursing Open

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Aim A growing number of older people are living in nursing homes worldwide, but their safety and quality of care are not guaranteed. This study explores registered nurses' (RNs) perspectives on systemic factors affecting the quality of care and safety decline of nursing home. Design Qualitative descriptive study. Methods In this study, semi‐structured interviews were conducted with 10 RNs working in six nursing homes, who were chosen through purposive sampling. Data were collected from 1 August–19 September 2019, and analysed using thematic analysis. Results The following five themes were derived: lack of sufficient number of RNs, poor work conditions, unclear job descriptions for RNs, no official position of nursing director and absence of transition care system. Patient or Public Contribution All reports of RNs affecting resident safety and quality of care decline were related to systemic factors. Therefore, improving quality of care in nursing homes should be supported by changes in systemic factors, such as maintaining an appropriate number of RNs and improving their working conditions.

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Exploratory Evaluation of Medication Classes Most Commonly Involved in Nursing Home Errors

Cited by 28 publications

References 19 publications

Erros Na Administração De Medicamentos: Evidências E Implicações Na Segurança Do Paciente

Erros Na Administração De Medicamentos: Evidências E Implicações Na Segurança Do Paciente

Common issues in the medication use processes in nursing homes: a review of medication use quality improvement strategies

Registered Nurses' perspective of systemic factors affecting nursing home care quality decline: A qualitative descriptive study

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