Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital

Michaelson, Moshe; Walsh, Elaine; Bradley, Colin; McCague, Paul; Owens, Rachelle; Sahm, Laura J.

doi:10.1007/s11845-017-1556-5

Cited by 11 publications

(8 citation statements)

References 11 publications

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“…Approximately 40% of patients who have been discharged from hospital may subsequently experience medicines-related problems, including medicines-related errors. [5][6][7][8][9][10][11][12][13] Findings indicate that patients often lack knowledge about their medications following hospital discharge [14][15][16][17][18] and that many patients report not receiving important medicines-related information. [19][20][21] World Health Organisation policy states that offering information on medicines via Medicines Information Centres, and providing public education about medicines, are two of 12 essential interventions to promote the rational use of medicines.…”

Section: Introductionmentioning

confidence: 99%

A systematic review examining the effectiveness of medicines information services for patients and the general public

Williams

Jordan

Scott

et al. 2019

International Journal of Pharmacy Practice

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Objectives Hospital-based patient medicines helpline services (PMHS) and medicines information services for the general public (MISGP) are available in many countries to support people with their medicines. Our aim was to examine the available evidence regarding the effectiveness of PMHS and MISGP. Methods Searches were conducted using Medline, EMBASE, CINAHL, Scopus and Web of Science, on 11 August 2018. Forward and backward citation searches were conducted, grey literature was searched, and study quality/risk of bias was assessed. Findings were synthesised in a narrative synthesis. Where appropriate, weighted means were calculated. Key findings Thirty-two studies were identified for inclusion (17 published articles, 15 conference abstracts). Eighteen studies were conducted within the United Kingdom. Mean quality assessment was moderate (51%), and risk of bias was high (63%). PMHS and MISGP are both typically perceived as positive (e.g. 94% and 91% of participants were satisfied with using a PMHS and MISGP, respectively). For PMHS, the advice received is reported to be usually followed (94%, and 66% for MISGP). For both services, users report several positive outcomes (e.g. problems resolved/avoided, feeling reassured and improved health). PMHS may also be effective for correcting medicines-related errors (up to 39% of calls may concern such errors) and for potentially avoiding medicines-related harm (48% of enquiries concerned situations that were judged to have the potential to harm patients). Conclusions Findings suggest that both PMHS and MISGP may be beneficial sources of medicines-related support. However, the moderate quality and high risk of bias of studies highlight that more high-quality research is needed.

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Section: Introductionmentioning

confidence: 99%

A systematic review examining the effectiveness of medicines information services for patients and the general public

Williams

Jordan

Scott

et al. 2019

International Journal of Pharmacy Practice

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“…A sample size of 65 patients per arm has been calculated. Previous work in the same clinical setting has indicated a rate of 1.1 medication errors per prescription from a total of 1600 prescriptions written with in a similar timescale to that envisaged in the feasibility study [ 30 ]. A sample size of 65 from a population of 1600 prescriptions would be capable of providing estimates of the difference in medication error rates of 10% with a confidence of 90% [ 31 ].…”

Section: Main Textmentioning

confidence: 98%

The PHARMS (Patient Held Active Record of Medication Status) feasibility study: a research proposal

et al. 2018

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ObjectiveMedication errors are a major source of preventable morbidity, mortality and cost and many occur at the times of hospital admission and discharge. Novel interventions (such as new methods of recording medication information and conducting medication reconciliation) are required to facilitate accurate transfer of medication information. With existing evidence supporting the use of information technology and the patient representing the one constant in the care process, an electronic patient held medication record may provide a solution. This study will assess the feasibility of introducing a patient held electronic medication record in primary and secondary care using the Consolidated Framework for Implementation Research (CFIR).This feasibility study is a mixed method study of community dwelling older adult patients admitted to an urban secondary care facility comprising a non-randomised intervention and qualitative interviews with key stakeholders. Outcomes of interest include clinical outcomes and process evaluation.This study will yield insights pertaining to feasibility, acceptability and participation for a more definitive evaluation of the intervention. The study also has the potential to contribute to knowledge of implementation of technology in a healthcare context and to the broader area of implementation science.Electronic supplementary materialThe online version of this article (10.1186/s13104-017-3118-3) contains supplementary material, which is available to authorized users.

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“…La literatura destaca muchos errores en la fase de prescripción y administración (9)(10)(11) , pero se ha hecho poco énfasis en la fase de preparación y dispensación. El Institute for Safe Drug Use Practices (ISMP) recomienda la aplicación de una herramienta de gestión de riesgos como el Failure Mode and Effects Analysis (FMEA) para minimizar los fallos en todo el proceso de administración del medicamento (12).…”

Section: Introductionunclassified

Análise de falhas e efeitos na preparação e dispensação de quimioterápicos

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Nunes

Pimenta³

et al. 2020

Enf Global

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Objetivo: Realizar un Análisis Multimodal de fallas y efectos para identificar prospectivamente los riesgos relacionados a la fase de la preparación y dispensación de medicamentos quimioterápicos en una unidad ambulatoria de un centro de referencia en oncología. Métodos: Se utilizaron las seis primeras etapas del Análisis Multimodal de fallas y Efectos: identificar las situaciones peligrosas y montar un equipo; definir el proceso a ser analizado describiendo gráficamente; aplicar lluvia de ideas buscando identificar modos de fallas; priorizar los modos de fallas y realizar análisis de riesgos; identificar las causas potenciales de los modos de fallo y volver a dibujar el proceso. Resultados: Se identificaron diecisiete modos de falla, siendo dos clasificados como de alto riesgo: cambiar la ventana de salida del medicamento y cálculo erróneo de la dosis de medicamento intratecal. Conclusiones: Se identificaron los posibles modos de falla que se relacionaban al proceso analizado, además, fue posible definir causas potenciales para la existencia de esos riesgos. Aim: Conduct a Failure Mode and Effect Analysis (FMEA) to prospectively identify the risks related to the preparation and dispensation of chemotherapy drugs at an outpatient unit of a reference center in oncology. Methods: The first six stages of Failure Mode and Effect Analysis were used to identify dangerous situations and assemble a team; define the process to be analyzed and describe it graphically; apply a host of ideas to identify failure modes; prioritize failure modes and conduct risk analysis; identify potential causes of failure modes and redesign the process. Results: Seventeen failure modes were identified, two of which were classified as high risk: changing the output window for the drug and miscalculating the intrathecal drug dose. Conclusions: The possible failure modes related to the process analyzed were identified; in addition, it was possible to define potential causes of these risks.

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Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital

Abstract: The study identified the time of discharge as a point at which prescribing errors are likely to occur. This has implications for patient safety and provider work load in both primary and secondary care.

Cited by 11 publications

References 11 publications

A systematic review examining the effectiveness of medicines information services for patients and the general public

A systematic review examining the effectiveness of medicines information services for patients and the general public

The PHARMS (Patient Held Active Record of Medication Status) feasibility study: a research proposal

Análise de falhas e efeitos na preparação e dispensação de quimioterápicos

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