Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough?

Yu, K H

doi:10.1136/qshc.2005.014159

Cited by 83 publications

(70 citation statements)

References 22 publications

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“…Variables found to be significantly related to a near miss or adverse event by bivariable analysis were used as potential predictors. To adjust the effects of hospitals, the generalized estimating Depression, mean (SD) 4) 6.0 (3.5) 6.8 (3.9) 8.4 (3.9) <0.001 7.3 (4.0) 7.6 (4.4) 7.9 (4.1) 0.08 ER, emergency room; ICU, intensive care unity; SD, standard deviation. 1) Assessed using the Stanford Sleepiness Scale.…”

Section: Resultsmentioning

confidence: 99%

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Similarity in Predictors between Near Miss and Adverse Event among Japanese Nurses Working at Teaching Hospitals

et al. 2010

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Near miss-based analysis has been recently suggested to be more important in the medical field than focusing on adverse events, as in the industrial field. To validate the utility of near miss-based analysis in the medical fields, we investigated whether or not predictors of near misses and adverse events were similar among nurses at teaching hospitals. Of the 1,860 nurses approached, 1,737 (93.4%) were included in the final analysis. Potential predictors provided for analysis included gender, age, years of nursing experience, frequency of alcohol consumption, work place, ward rotation, frequency of night shifts, sleepiness during work, frequency of feeling unskilled, nurses' job stressors, working conditions, and depression. Variables for multivariate analysis were determined by bivariable analysis. Ordinal logistic analysis showed that predictors of near misses and adverse events were markedly similar. Parameters that were significantly related to both near misses and adverse events were years of experience, frequency of night shifts, internal ward, and time pressure (p<0.05 for all). The present study suggested that there was a negligible difference between choosing near miss-or adverse eventbased analysis when identifying possible causes of adverse events in the medical field.

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Section: Resultsmentioning

confidence: 99%

“…Several terms have been brought into use to define outcomes occurring due to error in the medical field, with the two primary categories being "near misses" (also called as close misses or potential adverse events) and "adverse events" (also known as accidents or harmful events) 4) .…”

Section: Introductionmentioning

confidence: 99%

Similarity in Predictors between Near Miss and Adverse Event among Japanese Nurses Working at Teaching Hospitals

et al. 2010

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“…Nurses expressed a much higher expectation of disciplinary action for all types of medication errors, whereas doctors and pharmacists believed they would receive disciplinary action only for serious errors. Accurate reporting of individual medication errors is essential for identifying system faults that can contribute to the likelihood of future errors [14]. Therefore, error reporting helps improve medication safety by addressing systems failures and helps to prevent future errors by allowing appropriate staff training [11].…”

Section: Discussionmentioning

confidence: 99%

Attitudes to reporting medication error among differing healthcare professionals

Sarvadikar

Prescott

Williams

2010

Eur J Clin Pharmacol

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Aims Medication error reporting is an important measure to prevent medication error incidents in a healthcare system and can serve as an important tool for improving patient safety. This study aimed to investigate attitudes of healthcare professionals (doctors, nurses, and pharmacists) in reporting medication errors. Methods Fifty-six healthcare professionals working at a 900-bed tertiary referral hospital were surveyed. A questionnaire using two different clinical scenarios (involving oral and intravenous administration of a drug) and four questions with an ascending order of worsening patient outcome was used. A Likert scale ranging from 1 (unlikely) to 5 (likely) was used to describe the likelihood of reporting a medication error. Results The overall response rate was 57% (43% for doctors, 68% for nurses, and 64% for pharmacists). Results showed that doctors were unlikely to report less-serious medication errors (median value of 2 on the Likert scale). Nurses and pharmacists (median value of 5) were likely to report less-serious as well as serious medication errors despite their fears of receiving disciplinary action. All healthcare professionals were more likely to report an error as the clinical scenarios had a progressively worsening outcome for the patient. Conclusions These results suggest that among healthcare professionals, there are differing attitudes to reporting medication errors. Differing approaches are therefore required to encourage medication error reporting among different healthcare professionals. Future study is required to further investigate these findings and improve reporting rates.

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“…Esta situação prejudica a comparação entre os estudos sobre o tema e retarda o conhecimento epidemiológico sobre o assunto. 24 Embora a maioria dos medicamentos possua uma margem terapêutica segura, alguns fármacos têm risco inerente de lesar o paciente quando existe falha no processo de utilização. Esses fármacos são chamados de high-alert medications ou medicamentos de alto risco, aqui denominados de medicamentos potencialmente perigosos (MPP).…”

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Erros na prescrição hospitalar de medicamentos potencialmente perigosos

et al. 2009

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Erros na prescrição hospitalar de medicamentos potencialmente perigososErrors in hospital prescriptions of high-alert medications RESUMO OBJETIVO: Os erros de medicação são atualmente um problema mundial de saúde pública, sendo os mais sérios os de prescrição. O objetivo do estudo foi analisar a prática da prescrição de medicamentos de alto risco e sua relação com a prevalência de erros de medicação em ambiente hospitalar. MÉTODOS:Estudo transversal retrospectivo abrangendo 4.026 prescrições com medicamentos potencialmente perigosos. Durante 30 dias de 2001, foram analisadas todas as prescrições recebidas na farmácia de um hospital de referência de Minas Gerais. As prescrições foram analisadas quanto a: legibilidade, nome do paciente, tipo de prescrição, data, caligrafi a ou grafi a, identifi cação do prescritor, análise do medicamento e uso de abreviaturas. Os erros de prescrição foram classifi cados como de redação ou decisão, sendo avaliada a infl uência do tipo de prescrição na ocorrência de erros. RESULTADOS:Houve predomínio da prescrição escrita à mão (45,7%). Em 47,0% das prescrições escritas à mão, mistas e pré-digitadas ocorreram erros no nome do paciente, em 33,7% houve difi culdades na identifi cação do prescritor e 19,3% estavam pouco legíveis ou ilegíveis. No total de 7.148 medicamentos de alto risco prescritos, foram observados 3.177 erros, sendo mais freqüente a omissão de informação (86,5%). Os erros se concentraram principalmente nos medicamentos heparina, fentanil e midazolam; e os setores de tratamento intensivo e a neurologia apresentaram maior número de erros por prescrição. Observou-se o uso intensivo e sem padronização de abreviaturas. Quando computados todos os tipos de erros, verifi cou-se 3,3 por prescrição. A prescrição pré-digitada apresentou menor chance de erros do que as mistas ou escritas à mão. CONCLUSÕES:Os resultados sugerem a necessidade da padronização no processo de prescrição e a eliminação daquelas feitas à mão. O uso de prescrições pré-digitadas ou editadas poderá diminuir os erros relacionados aos medicamentos potencialmente perigosos.

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Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough?

Cited by 83 publications

References 22 publications

Similarity in Predictors between Near Miss and Adverse Event among Japanese Nurses Working at Teaching Hospitals

Similarity in Predictors between Near Miss and Adverse Event among Japanese Nurses Working at Teaching Hospitals

Attitudes to reporting medication error among differing healthcare professionals

Erros na prescrição hospitalar de medicamentos potencialmente perigosos

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