Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis

Appelbaum, Nicholas; Clarke, Jonathan; Feather, Calandra; Franklin, Bryony Dean; Sinha, Ruchi; Pratt, Philip J.; Maconochie, Ian; Darzi, Ara

doi:10.1136/bmjopen-2019-032686

Cited by 10 publications

(21 citation statements)

References 29 publications

(35 reference statements)

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“…Advancement of Zileuton pulsatile drug conveyance elective courses of the organization to impact and give deferred arrival of medication. The de inition was set up by direct pressure technique utilizing different polymers [9][10][11]. The detailed press covered tablets were assessed for various boundaries, for example, drug excipient equivalence considers, thickness weight, variety, hardness, content consistency, In vitro drug discharge.…”

Section: Resultsmentioning

confidence: 99%

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Preparation and analysis of human medication tablets in drug delivery system

Soujanya¹,

Purushothaman²,

Jagadeeshwari³

et al. 2020

ijrpp

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Presently days, a significant objective medication conveyance study is twisted to the improvement of robust medication conveyance frameworks with previously existing dynamic fixings in the event of new medication disclosure. A considerable lot of remedial drug operators are generally viable when made accessible at steady rates close to assimilation locales. Much exertion has been proceeding to create advanced medication conveyance frameworks, for example, osmotic gadgets for oral request. Oral medication conveyance framework is more preferred on famous measured medication conveyance framework in innovative drug work (R and D) business because of increment in attention to clinical and drug network about the significance of sheltered and viable utilization of medication. In the current examination work, pulsatile drug conveyance arrangement of Zileuton tablets was planned by utilizing pressure covering innovation. At first, the centre tablets were set up by 30% groupings of wonderful crumbles; the figured centre tablets were covered with the polymers by utilizing pressure covering innovation. All the centre and press covered tablet details were exposed to different corporeal and concoction assessment tests for centre and press covered tablets. The hardness, thickness and weight variety appeared by all the tablet definitions were originate inside the authorized pharmacopoeias bounds. In-vitro arrival of Zileuton of centre tablet details F1 demonstrated quicker medication discharge after 15 min. Quicker medication delivery can be connected with significant deterioration, and friability saw in this examination. The enteric covered plans C1, C3 indicated the most significant medication discharge following 4 hours. Time subordinate pulsatile drug conveyance framework has been accomplished from the tablet of definition C3, C6 and C9 with 95.5%, 94.76% and 97.48% separately.

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Section: Resultsmentioning

confidence: 99%

“…The Danish, Environmental Protection Agency, assessed that eliminating all pesticides would bring about a general yield decrease of about 25%. Natural and wellbeing impacts were accepted yet dif icult to survey [5,11,12].…”

Section: Resultsmentioning

confidence: 99%

Preparation and analysis of human medication tablets in drug delivery system

Soujanya¹,

Purushothaman²,

Jagadeeshwari³

et al. 2020

ijrpp

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“…Observed deviations from expected practice at the level of an individual task (as described by the present study HTA; Figure 1) were defined as discrepancies and coded using a subset of error modes drawn from a generic human error taxonomy. 8 When a participant sought but did not find relevant sections available within the IMG, the relevant process step was assigned the error mode "information not obtained" (error mode R1).…”

Section: Video Analysismentioning

confidence: 99%

“…Video recordings of each of the 42 discrepancies that occurred during the "Check intravenous administration guidance" task of the original study 8 were reanalyzed by a research pharmacist (MDJ). Observed deviations from expected practice at the level of an individual task (as described by the present study HTA; Figure 1) were defined as discrepancies and coded using a subset of error modes drawn from a generic human error taxonomy.…”

Section: Video Analysismentioning

confidence: 99%

“…A recent study examined medication errors during simulated pediatric resuscitations, using human reliability analysis (HRA) to describe how these errors were linked to discrepancies in individual process steps. 8 As is usual in the United Kingdom, intravenous medicines were prepared at the simulated patient's bedside. Ineffective retrieval of preparation and administration instructions from the NHS Injectable Medicines Guide (IMG) was the step that most often made a major contribution to medication errors.…”

Section: Introductionmentioning

confidence: 99%

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Use of Pediatric Injectable Medicines Guidelines and Associated Medication Administration Errors: A Human Reliability Analysis

et al. 2021

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Background: In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs). Objective: The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice ( discrepancies) that contributed to large-magnitude and/or clinically significant MAEs. Methods: Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study. Results: In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs. Conclusion and Relevance: Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.

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Exploring the Role of Guidelines in Contributing to Medication Errors: A Descriptive Analysis of National Patient Safety Incident Data

Jones,

Liu,

Powell

et al. 2024

Drug Saf

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Introduction Clinical guidelines can contribute to medication errors but there is no overall understanding of how and where these occur. Objectives We aimed to identify guideline-related medication errors reported via a national incident reporting system, and describe types of error, stages of medication use, guidelines, drugs, specialties and clinical locations most commonly associated with such errors. Methods Retrospective analysis of reports to the National Reporting and Learning System for England and Wales. A hierarchical task analysis (HTA) was developed, describing expected practice when using guidelines. A free-text search was conducted of medication incident reports (2016–2021) using search terms related to common guidelines. All identified reports linked to moderate-severe harm or death, and a random sample of 5100 no/low-harm reports were coded to describe deviations from the HTA. A random sample of 500 cases were independently double-coded. Results In total, 28,217 reports were identified, with 608 relating to moderate-severe harm or death. Fleiss’ kappa for interrater reliability was 0.46. Of the 5708 reports coded, 642 described an HTA step discrepancy (including four linked to a death), suggesting over 3200 discrepancies in the entire dataset of 28,217 reports. Discrepancies related to finding guidelines ( n = 300 reports), finding information within guidelines ( n = 166) and using information ( n = 176). Discrepancies were most frequently identified for guidelines produced by a local organisation ( n = 405), and most occurred during prescribing ( n = 277) or medication administration ( n = 241). Conclusion Difficulties finding and using information from clinical guidelines contribute to thousands of prescribing and medication administration incidents, some of which are associated with substantial patient harm. Supplementary Information The online version contains supplementary material available at 10.1007/s40264-024-01396-7.

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Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis

Cited by 10 publications

References 29 publications

Preparation and analysis of human medication tablets in drug delivery system

Preparation and analysis of human medication tablets in drug delivery system

Use of Pediatric Injectable Medicines Guidelines and Associated Medication Administration Errors: A Human Reliability Analysis

Exploring the Role of Guidelines in Contributing to Medication Errors: A Descriptive Analysis of National Patient Safety Incident Data

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