Medication errors: Is it the hidden part of the submerged iceberg in our health-care system?

Ambwani, Sneha; Misra, Arup Kumar; Kumar, Rajesh

doi:10.4103/ijabmr.ijabmr_96_19

Cited by 21 publications

(15 citation statements)

References 37 publications

(33 reference statements)

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“…The other one is psychological classification that consists of knowledge-based error, rule-based error, action-based, error and memory-based error. 2 , 3 …”

Section: Introductionmentioning

confidence: 99%

“…The reported medical erroris a tip of an iceberg of actual incidences occurring in a healthcare system. 3 Most of the medication errors do not cause any harm to the patient, but there are some that cause unwarranted results, including temporary or permanent harm to the patient's health and well-being, increased length of hospitalization, increase in cost of treatment, people losing faith in healthcare delivery system, and even deaths. 6 , 7 …”

Section: Introductionmentioning

confidence: 99%

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Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand?

Zirpe

Seta

Gholap

et al. 2020

Indian Journal of Critical Care Medicine

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A bstract Background Medication error in developed countries is of primary concern when there is a question of adversity to a patient's health, but in developing countries like India, it is just a term and its significance is undervalued. The incidence of medication error is essential to estimate the proper medical care provided in the healthcare system. Objective The main objective of the study is to determine the incidences of medication error in critical care unit and to evaluate its risk outcomes. Materials and methods This is a prospective observational study conducted over a period of 6 months in a critical care unit of a tertiary care hospital. Medication chart review method was opted for data collection. The medication errors were mainly classified as prescription, transcription, indenting, dispensing, and administration error. A total of 6,705 charts were reviewed. The NCCMERP risk index was used to evaluate the outcome of errors. Results Of the total 6,705 charts, 410 medication errors were found, i.e., 6.11%. The most common error is transcription error that constitutes 44.1% of the total errors, followed by prescription error 40%, and administration error 14%. The frequency of indenting and dispensing errors is negligible with 1.5% and 0.5%, respectively. The main causes of medication errors are due to incomplete prescription 50.2% and wrong doses 22.9%. In drug class, antibiotics and antihypertensive agents are most prone to medication error. About 87.1% errors belonged to the Category B of National Coordinating Council for Medication Error Reporting and Prevention risk index. Conclusion Majority of the errors are transcription errors followed by prescription and administration errors. Consultant doctors have to be more vigilant during prescribing and verifying the medication charts. Clinical pharmacists should act as a checkpoint at each step of medication process to identify and prevent medication errors. How to cite this article Zirpe KG, Seta B, Gholap S, Aurangabadi K, Gurav SK, Deshmukh AM, et al. Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand? Indian J Crit Care Med 2020;24(9):799–803.

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“…The other one is psychological classification that consists of knowledge-based error, rule-based error, action-based, error and memory-based error. 2 , 3 …”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand?

Zirpe

Seta

Gholap

et al. 2020

Indian Journal of Critical Care Medicine

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“…The methodology of full RCA 2 has been described previously. [8,10] A mini-RCA 2 is essentially an informal, abbreviated RCA 2 . The differences between a full RCA 2 and a mini-RCA 2 conducted in our organization are described in Table 1.…”

Section: Interventionmentioning

confidence: 99%

“…[2][3][4][5][6] Alarmingly, the profligate trajectory of medication use is likely to dramatically increase the incidence of ADEs and the risk to patients. [8] Yet, neither the definitions of ADEs and harm outcomes, nor the methods used to detect them, are standardized. [5] So, the true incidence and cost of medication errors are indeterminable.…”

Section: Introduction Problem Descriptionmentioning

confidence: 99%

Reducing Nonsentinel Harm Events due to Medication Errors by Using Mini–Root Cause Analysis and Action

Mardawi

Rajendram

Alowesie

et al. 2021

Global Journal on Quality and Safety in Healthcare

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Introduction A full root cause analysis (RCA) such as that required following a sentinel event is time-consuming, labor-intensive, and expensive. This quality improvement project used a similar but abbreviated process (mini-RCA and action; mini-RCA2) in response to medication errors that caused less serious harm. Methods In 2018, all medication errors that caused harm due to system failures but were not sentinel events were investigated by mini-RCA2. The incidence of similar medication errors reported in the year before and in the year after the introduction of mini-RCA2 was compared to determine the impact of this intervention. Similar events were identified by searching the safety reporting system database for reported medication errors by drug name (e.g., Humate® P) and/or event type (e.g., prescribing error—omission of a patient's home medications on admission to hospital). The time and labor costs of this intervention were estimated. Results Seven medication errors were investigated by mini-RCA2. More than 48 members of staff from 11 clinical and nonclinical departments contributed to the identification of 39 system failures and made 42 recommendations, of which 22 (52%) were implemented. This reduced the recurrence of reports of similar events from 35 (0.57%) to 21 (0.36%). Although this 0.21% absolute decrease did not achieve statistical significance, recurrence of similar harm events was reduced from 7 (0.11%) to 0 (p = 0.016). Benefits were greatest when the mini-RCA2 recommendations were fully implemented. This reduced the recurrence of similar events from 9 (0.21%) to 0 (p = 0.007). A total of 251 hours (mean ± SD, 35.9 ± 16.6 hours) were required for this intervention. The associated labor cost was Saudi Arabia Riyal (SAR) 34,181 (US $8256; mean SAR ± SD, 4883 ± 1302 [mean US $ ± SD, $2102 ± $561]). Conclusion The use of mini-RCA2 to review medication errors provided a structured process to manage reported events, monitor the implementation of recommendations, and assess the effectiveness of implemented actions. The use of this rapid process to investigate errors that cause harm but are not sentinel events reduced recurrence of similar medication errors. Although the time and cost required for this intervention is not insignificant, the cumulative benefit to patients, healthcare professionals, and the organization are greater.

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“…According to the reports revealed by WHO, states that at least 6.5% of the Indian population suffers from some form of the serious mental disorders. Over the past six decades, antipsychotic drugs have revolutionized the treatment of many psychiatric disorders (Ambwani et al, 2019). Medication error rates may vary from 4.4% to 59.1% worldwide and 5.2 million medication errors have been reported annually in India (Ayani et al, 2016).…”

Section: Introductionmentioning

confidence: 99%

Medication errors and adverse drug reactions in psychiatry department: A prospective observational study

Thomas¹,

Staudinger²,

Venkateswaramurthy³

et al. 2020

ijrps

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The study was aimed to analyse the pattern of medication errors and drug interaction induced adverse drug reactions in the psychiatry department of a tertiary care hospital. A Prospective observational study being conducted in the inpatient and outpatient department of psychiatry in a tertiary care hospital, Erode, Tamil Nadu for over six months. A total of 80 prescriptions with psychiatric illness and 174 medication errors were observed. Of the 174 medication errors observed, 132(75.8%) were incomplete prescriptions making the highest number of medication errors. The highest number of errors occurred due to Prescription error 156(89.0%), followed by administration error 8(4.5%). According to the NCCMERP classification, the majority of medication errors were coming under category B 120(68.9%) but there is no harm. The demographic reports of outpatients in the present study showed a higher incidence of medication errors in patients with the age group of 31-40 years 25(36.7%). Considering the factors contributing to a medication error, refusal of the patient to take the drug 27(39.7%) followed by forgetting 13(19.1%) due to the vulnerable characteristics of the patient was more significant. Although there is a general lack of awareness, many patients and bystanders are unaware of their diagnosis and medications. It is, therefore, a crucial step to educate and make them aware of the correct use of medicine.

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Medication errors: Is it the hidden part of the submerged iceberg in our health-care system?

Cited by 21 publications

References 37 publications

Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand?

Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand?

Reducing Nonsentinel Harm Events due to Medication Errors by Using Mini–Root Cause Analysis and Action

Medication errors and adverse drug reactions in psychiatry department: A prospective observational study

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