Medication error trends and effects of person‐related, environment‐related and communication‐related factors on medication errors in a paediatric hospital

Abstract

Encouraging child and family involvement, facilitating hospital redesign and improving communication could help to reduce the harm associated with medication errors.

Communication issues contributing to medication incidents: Mixed‐method analysis of hospitals’ incident reports using indicator phrases based on literature

“…However, most of them were preventing incidents. The number of reports in which patients or family members alerted about an error was higher (8%–15%) in previous studies (Manias, Kinney, Cranswick & Williams 2014; Manias, Cranswick, et al, 2019). Our findings mirror previous evidence (Braaf, Riley, & Manias, 2015b; Keers et al, 2018; Manias, Braaf, et al, 2019; Tobiano et al, 2018, Tobiano et al, 2019) in which patients and family members are vigilant co‐operators and should be further encouraged to communicate.…”

“…Medication incidents are among the major issues jeopardising patient safety (Härkänen, Vehviläinen‐Julkunen, Murrells, Rafferty, & Franklin, 2018;Keers et al, 2018;Manias, Cranswick, et al, 2019;WHO, 2017), accruing the equivalent of 42 billion USD in global costs annually, based on estimations of World Health Organization (WHO, 2017). Communication is one of the most common (46%‐60%) contributing factors of medication incidents (Keers, Williams, Cooke, & Ashcroft, 2013;Lawton, Carruthers, Gardner, Wright, & McEachan, 2012a;Parry, Barriball, & While, 2015).…”

“…In the PuBMed database, a search using the keywords medication incident OR medication error AND communication yielded 11 hits in the year 2000, 97 hits in 2010 and 127 hits in 2018. Errors in medication communication being linked with medication incidents have been studied from specific viewpoints, such as within diverse care‐provider settings or between them (Petersen, Foged, Madsen, Andersen, & Nørholm, 2018), in speciality practices (Keers et al, 2018;Liu, Manias, & Gerdtz, 2014;Manias, Cranswick, et al, 2019;Tobiano, Chaboyer, Teasdale, Raleigh, & Manias, 2019) or among specific patient age group settings (Borrott et al, 2017). Evidence of medication communication exists for a variety of care process situations (Braaf, Rixon, Williams, Liew, & Manias, 2015a;Liu, Manias, & Gerdtz, 2012;Manias, Braaf, et al, 2019;Yu, Li, Gao, Liu, & Lin, 2018), and concerning a diverse range of communication methods (Foged, Nørholm, Andersen, & Petersen, 2017;Redley & Botti, 2013).…”

“…Medication communication has been assessed ethnographically from the interplay viewpoint between nurses, patients, physicians and students (Liu, Gerdtz, & Manias, 2015, 2016;Rutledge, Retrosi, & Ostrowski, 2018;Schoenthaler, Allegrante, Chaplin, & Ogedegbe, 2012;Tobiano et al, 2019), but also concerning professionals’ tendency to follow communicated guidelines (Karttunen et al, 2020). Studies of medication communication have been conducted on emergency situations concerning language barriers (Pun, Chan, Murray, Slade, & Matthiessen, 2016), racial issues affecting medication communication (Schoenthaler et al, 2012) and environmental issues of communication (Liu et al, 2014;Manias, Cranswick, et al, 2019;Yu et al, 2018). Nevertheless, the relative frequency of a wide variety of specific communication issues has not been measured using incident reports submitted in acute care.…”

Ludic strategy for promoting engagement of parents and caregivers in the safety of pediatric patients

“…Patient safety is becoming increasingly relevant in the world scenario as one of the pillars of health care quality, being related to a set of actions that aims to reduce unnecessary harms associated with health care to an acceptable minimum (12) . Potential risks for the patient are intrinsic to care complexity, especially for children in critical conditions, due to physical and psychological characteristics, which can considerably influence patient safety (1)(2) .…”