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Objective: The study assessed the following medication error indicators: drug education by pharmacists, the clarity of physician prescription forms, patients' and students' drug package insert (PI) reading habits, and the adequacy of information on drug PIs. Design: A cross‐sectional study was carried out. One‐on‐one interviews were conducted with the pharmacists alongside the use of structured questionnaires to assess their involvement in drug education and experience with the clarity of physician prescription forms. A structured questionnaire was used to investigate patients' and students' PI reading habits. Drug PIs were collected from pharmacies, and their components were examined based on the World Health Organization's (WHO) criteria for labeling pharmaceutical products. Setting: The study was conducted at four selected hospital pharmacies, four community pharmacies, and the University of Cape Coast, in the Cape Coast Metropolis, Ghana. Participants: The study included pharmacists working at the pharmacies, patients, and students of the University of Cape Coast, who visited any of these pharmacies. Results: Fifty‐three percent of pharmacists educate their patients on drug dosage, storage, and precautions during each patient visit, 17.6% hardly do, and 29.4% do not educate their patients. A majority of the sampled prescription forms submitted by patients to the pharmacists had illegible handwriting (63.7%) and unconventional prescription notations (78.0%). Of the 138 visiting patients, only a few (41.0%) read the PIs before drug use as compared to students (72.9%). Out of the 88 PIs collected, 90.2% had component deficiencies. Conclusion: Pharmacists' drug education to visiting patients was poor, just as patients' PI reading habits. Most PIs had component deficiencies, and the majority of prescription forms had some medication error‐provoking features. Going forward, pharmacists, physicians, drug manufacturers, and patients must perform their responsibilities toward the collective effort of minimizing medication errors associated with drug use. [ABSTRACT FROM AUTHOR]

Aims Methods Results Conclusions Previous work has identified several limitations in “Summaries of Product Characteristics” (SmPCs), which are associated with risks for patients. The aim of this study was to evaluate pharmacists' and physicians' interpretation of contraindications in SmPCs and reasons for their nonadherence in clinical routine.For 20 commonly missed or ignored absolute contraindications, an anonymous online survey providing 24 clinical example cases (one or two per contraindication) for physicians and pharmacists was developed. Experts in medication safety were asked whether the respective case fulfilled the definition of the contraindication in the SmPC: (a) formally, irrespective of the clinical relevance of the contraindication (17 cases), and (b) whether the contraindication was deemed clinically relevant in each respective case (24 cases).Twenty‐seven pharmacists and 27 physicians completed the survey. For only one case (1/17; 5.8%) did all experts agree on the same answer option regarding the formal fulfilment of a given contraindication statement. Experts gave heterogeneous answers regarding the interpretation of a contraindication. For instance, among 10 predefined answer options for the contraindication “active liver disease” in the SmPC of simvastatin, every option was selected by at least six experts. In 17/24 (70.8%) clinical example cases a majority of experts agreed on the clinical relevance of a given contraindication. Key reasons for nonadherence to contraindications were “patient monitoring possible”, “lack of alternative treatment” and “acute/severe situations”.Experts' disagreement on the interpretation of contraindications in SmPCs using clinical example cases indicates that further efforts are needed to improve their usability in clinical routine. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) is increasingly used in the management of haemorrhage during and after delivery and haemorrhage caused by other medical conditions due to its efficacy and safety. However, increasing report of fatal complications from inadvertent intrathecal TXA injection remains a cause of concern. The aim of this case report is to demonstrate clinical presentation and predictors of accidental intrathecal injection of TXA within the structure and processes of care in a health facility. Case Description: A 37‐year‐old woman, multiparous woman presented with a diagnosis of obstructed labour and, therefore, was scheduled for emergency caesarean section. She was assigned the American Society of Anesthesiology II physical status. Spinal anaesthesia was performed at a sitting position through L4‐L5 interspace using a 25‐G spinal needle gauge. The anaesthetist injected 3 mL of an aesthetic agent that was prepared earlier as hyperbaric bupivacaine 0.5%. About 2 min after receiving the injection, the patient reported gluteal discomfort and itching and severe back pain. She subsequently developed progressive altered mentation followed by generalized tonic–clonic seizures. General anaesthesia was conducted with propofol (100 mg), pethidine (50 mg) and suxamethonium (100 mg). Episodes of tonic–clonic seizures continued despite treatment with multiple doses of diazepam (10 mg), propofol (100 mg) and phenytoin infusion (1 gm). Postoperatively, the patient was transferred to the intensive care unit with persistent tachycardia (125–138 beats per minute), hypertension (157/105–175/118 mmHg) and oxygen saturation of 90%–95%. She died due to cardiac arrest after 21 h of stay. Conclusion: Medication error such as accidental intrathecal injection of TXA continues to jeopardise the safety of surgery under spinal anaesthesia. [ABSTRACT FROM AUTHOR]

Background and Aims: A quality improvement project (‘Safe Anaesthesia for ALL-SEAL’) was implemented to reduce preventable medication errors and drug wastage in the operating theatre (OT) of a tertiary hospital. The primary objective of this quality improvement project was to prevent the incidence of medication errors, and the secondary objective was to reduce the wastage of unused drugs. Methods: A pre-intervention questionnaire and an audit survey were performed, and multidirectional interventions were designed post-survey. A post-intervention survey was conducted to evaluate effectiveness. The incidence of medication errors, including near misses, was assessed for root causes. Unused drugs drawn or diluted in syringes were recorded daily in each OT. The weekly drug orders and mid-week reordering frequency were also monitored. The data were reported as simple means and percentages. Results: Ninety-eight anaesthesia care providers participated in the survey (72.4% doctors and 27.6% anaesthetic nurses). Pre-intervention, 76.1% of respondents had experienced medication errors during their practice. Common errors included misidentification of ampoules or vials (65.2%), miscalculation of dosages (65.2%), improper syringe labelling (56.5%), accidental drug omission (54.3%) and wrong prescriptions (39.1%). The main sources of errors were fatigue/overwork (80.4%) and a hectic OT environment (71.7%). Post-intervention, no incidents of medication errors were reported. In addition, there was a significant reduction in drug wastage. Conclusions: The SEAL project positively prevented medication errors and reduced drug wastage, which should be further validated in other clinical settings.

Das Projekt „Sichere Gabe von Chemotherapeutika“ am Universitätsklinikum Essen zielt darauf ab, die Sicherheit der Chemotherapiebehandlung durch aktive Einbeziehung der Patient:innen zu verbessern. Hierzu wurden Patient:innen zu ihren Erfahrungen und Wünschen im Hinblick auf die Einbeziehung in die Chemotherapiebehandlung befragt. Dabei wurden die häufigsten Fehler bei der Gabe von Chemotherapeutika identifiziert. Es wurde ein patientenadaptierter Therapieplan mit den wichtigsten Informationen zur Chemotherapie entwickelt. Aus dem Projekt konnte gelernt werden, dass die Einbeziehung der Patient:innen in die Chemotherapiebehandlung ein wichtiger Ansatz zur Verbesserung der Patientensicherheit ist, weiter zeigt sich, wie dies erfolgreich umgesetzt werden kann. Weitere Forschung ist notwendig, um die besten Methoden zur Einbeziehung von Patient:innen in die Behandlung zu identifizieren.

Abstract Background and aim Medication errors (MEs) in hospitals decrease patient satisfaction, increase hospital mortality, lower hospital productivity, and increase in the costs of the health system. This study was conducted to determine the rate of MEs in Iranian hospitals. Method In this meta-analysis, all published articles on ME rates in Iranian hospitals were identified from five databases and Google Scholar and assessed for quality. The heterogeneity of the studies was examined using the I2 index and a meta-regression model was used to evaluate the variables suspected of heterogeneity at the 0.05 significance level. Finally, 17 articles were eligible to be included in this study and were analyzed using the Comprehensive Meta‐Analysis (CMA) software. Findings Based on the estimation of the random-effects model, the ME rate in Iranian hospitals was 10.9% (5.1%-21.7%; 95% CI). The highest rate was observed in Sanandaj in 2006 at 99.5% (92.6%-100.0%; 95% CI) and the lowest rate was observed in Kashan in 2019 at 0.2% (0.1%-0.3%; 95% CI). In addition, sample size and publication year were significantly correlated with ME rate (P

Bleomycin is an antibiotic with cytotoxic properties that is commonly used in combination regimens for the treatment of Hodgkin lymphoma. The inconsistency in the dosage nomenclature of bleomycin appears universally, which increases the risk of medication errors. However, to the best of our knowledge, no such cases have been reported. Herein, we present a rare case report of a medication error caused by a bleomycin overdose. At the third cycle of chemotherapy, a 25‐year‐old patient with stage II Hodgkin lymphoma received a 10 times higher dose of bleomycin (150 USP) than that usually used as part of the doxorubicin, bleomycin, vindesine and dacarbazine protocol (ABVD). After the medication error was discovered, the patient was immediately treated with intravenous rehydration and furosemide to promote drug clearance. Additionally, methylprednisone and acetylcysteine were administered to prevent lung injury. However, the patient developed slight nausea and mild rash, which gradually improved after treatment. After evaluation with positron emission spectrometry‐computed tomography (PET‐CT), the patient received four cycles of AVD chemotherapy. No other obvious abnormalities were observed during the treatment and 1‐year follow‐up period. Hence, the toxicities, clinical management and selection of further chemotherapy after bleomycin overdose in such cases deserved serious attention. More importantly, management measures after this error may be used as a reference in other hospitals. [ABSTRACT FROM AUTHOR]

Objective: To implement and evaluate the impact of a collaborative pharmacist‐medical officer model of planning discharge prescriptions, Partnered Pharmacist Discharge Prescription Planning (PPDPP) on the safe use of medicines on discharge in an ED short stay unit (SSU). Methods: A prospective pre‐ and post‐intervention study measured the proportion of medication errors on discharge prescriptions from the SSU using the Five Rights (5Rs) method. Pharmacists assessed discharge prescriptions generated by the medical officers (MO) during the pre‐intervention phase (standard practice). During the PPDPP phase, pharmacists planned electronic prescriptions in consultation with MO and completed prescriptions were independently assessed by another pharmacist. Results: There were 163 and 147 prescriptions collected during the pre‐ and post‐intervention phases, respectively. There was a significant difference in the proportion of discharge prescriptions that met all 5Rs between the standard practice (47.2%) and PPDPP phase (91.8%) (P < 0.001). There was no statistical difference seen in the mean time taken from discharge decision to prescriptions given to patients or patients leaving the SSU between the two phases. There was a non‐statically significant trend towards a decrease in time taken for patients to obtain prescriptions by 11% (P = 0.16) and for actual departure time by 6% (P = 0.46). Additionally, the proportion of opioids prescribed as one of the high‐risk medication classes reduced from 23.8% to 16.2% (P = 0.023) with the PPDPP model. Conclusion: The PPDPP model improved medications safety on discharge from the ED SSU. The PPDPP did not impact patient flow parameters as measured in this study. [ABSTRACT FROM AUTHOR]

Introduction and objectives: Omission of insulin, a high-alert medication with one of the highest locally reported errors, could lead to severe hyperglycemia, which could result in coma or death if not treated timeously. This study aimed to identify, evaluate, and implement strategies to reduce the occurrence of insulin omission errors in diabetic adult patients requiring insulin. Methods: This project followed the JBI Evidence Implementation Framework and conducted context analysis, strategy implementation, and evaluation of outcomes according to evidence-based quality indicators. The JBI PACES and JBI GRiP situational analysis tools were used to support data collection and implementation planning. There was one evidence-based criterion and five sub-criteria, with a sample size of 22 patients. Results: There was increased compliance with best practices to reduce interruptions and distractions from baseline audit (50%) to follow-up audits 1 (45.4%) and 2 (31.8%), and no insulin omission incidences during the implementation period. In the post-implementation analysis, there were notable improvements in compliance with strategies related to nurses; however, reduced compliance was observed related to patients. Key barriers to implementation included patients still disturbing nurses despite the nurses wearing the medication vests and patients forgetting instructions not to disturb nurses during medication administration. Strategies to improve compliance included ensuring coverage in each cubicle during insulin preparation and administration, tending to patients' needs prior to insulin administration, and use of posters as reminders. Conclusions: There was an overall increase in compliance with best practice to reduce interruptions and distractions and no insulin omission incidences related to interruptions and distractions during the implementation phase. [ABSTRACT FROM AUTHOR]

Introduction: Medication errors during hospital discharge can lead to adverse outcomes, medication‐related readmissions, and increased health care costs. Pharmacist‐led medication reconciliation at discharge is a potential solution to mitigate poor outcomes and optimize medication safety. Objectives: This study aimed to quantify medication errors identified at discharge and characterize the severity of patient harm prevented following pharmacist‐led discharge medication reconciliation. Cost avoidance analysis was conducted to determine its associated financial impact. Methods: Patients, who were discharged from an adult internal medicine service during October 2022, were included in this one‐month pilot prospective quality improvement study. The number of errors at discharge were documented, categorized by type, and adjudicated for severity of potential harm. Error severity was classified based on a modified National Coordinating Council for Medication Error Reporting and Prevention Medication Error Index. Cost avoidance was calculated based on whether each error would have resulted in additional medical encounters and length of stay. Results: Thirty‐one patients were included in the analysis. Forty errors were identified by pharmacist‐led medication reconciliation at discharge, with a mean of 1.3 ± 1.9 errors per patient and 68% of patients having at least one error. The most common errors were duplication of therapy (25%) and medication access barriers at discharge (25%). The severity of errors included low (22.5%), serious (75%), and life‐threatening harm (2.5%). Thirty‐five percent of errors could have led to emergency visits or hospital readmissions. The estimated total cost for errors was $25 600. Pharmacist labor cost for reconciliation was $816. Cost avoidance was $24 784 from the 14 errors at discharge that could have resulted in additional emergency or inpatient visits. Conclusion: Pharmacist‐led medication reconciliation at discharge may prevent harm from reaching patients, decrease cost from unnecessary health encounters, and stop the error from continuing across transitions of care. [ABSTRACT FROM AUTHOR]

OBJECTIVE The purpose of this study was to evaluate the feasibility of a pharmacist-driven discharge medication reconciliation (DMR) service at our children’s hospital by completing a 2-week pilot on a general pediatrics unit. METHODS This was a prospective study and included patients discharged during pilot hours whose DMR was completed by the pharmacist. The primary outcome was evaluation of time required for a pharmacist to complete the DMR. Secondary outcomes included classification of pharmacist interventions made and their associated cost-avoidance, medication-related problems reported within 14 days of discharge, hospital readmission due to medication problems within 30 days of discharge, and medical resident satisfaction assessed via prepilot and postpilot surveys. RESULTS A total of 67 patients had their DMR completed by a pharmacist during the pilot. The pharmacist spent an average of 30 minutes completing each DMR, although this was variable, as evidenced by an SD of 36.4 minutes. Pharmacists documented 89 total interventions during the study period. The most common intervention types were therapeutic optimization (32.6%) and modification of directions (29.2%). Total estimated cost-avoidance during the study pilot was $84,048.01. For the pilot population, 1 medication-related problem was identified within 14 days of discharge. There were no medication-related readmissions identified. Medical residents reported increased confidence that the DMR was completed accurately and satisfaction with the DMR process during the pilot compared with before the pilot. CONCLUSIONS Implementing a pharmacist discharge medication service requires consideration of pharmacist time and salary, which may be offset by cost-avoidance. [ABSTRACT FROM AUTHOR]

Background/Aim: Intravenous therapy is a complex process usually requiring the preparation of the medicine before administration to the patient and it is well known that errors in preparation and administration can cause harm to patient. Systems that use information technology are key components of strategies to prevent medication errors in developed countries. Therefore, aim of study was to investigate nurses’ perspective on medicines database in clinical information system implemented in university hospital. Methods: A convenience sample of 79 nurses at the bedside from four different hospital wards in the 1200-bed university hospital were asked to participate in the study. The questionnaire included twenty-three questions organised in three different sections and it assessed 3 components of the medicines usage: (1) medicines preparation; (2) medicines administration; (3) clinical information system usage. Mean scores were calculated for the 4-item Likert-type scale. Results: Most nurses found information in drug database reliable (Likert scale mean = 1.42 ± 0.778) and believed that using medicines database can decrease drug preparation and drug administration errors (mean: 1.35 ± 0.717) with no significant difference in mean between four different wards. Similarly, most nurses were familiar with the drug database in clinical information system (mean: 1.22 ± 0.613). Conclusion: Pharmacist as a drug expert could introduce medicines database to nurses, train them how to use it in everyday practice and explain how using information technologies can help in decreasing medication errors which leads to increasing patients’ safety during hospitalisation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Medication errors are known to cause adverse drug reactions, hospital admissions and mortality. In most resource-poor settings, medication errors occur but are undocumented. OBJECTIVE: This study sought to investigate medication errors in a diabetic clinic at Komfo Anokye Teaching Hospital (KATH), Ghana. METHODS: The research combined both qualitative and quantitative data collection methods. The quantitative aspect involved retrospectively reviewing patient folders over two years (1st January 2019 to 31st December 2021). Patients' folders were reviewed to identify possible medication errors. The qualitative arm explored underlying factors and experiences related to medication errors through interviews with healthcare workers. Ten healthcare professionals at KATH were interviewed using an interview guide. RESULTS: A total of 264 patients' folders were retrieved. The majority (23.11%) of the patients were between 18 and 25 y.o., and there were more females (52.27%) than males. About 60% of the patients had diabetes and hypertension comorbidity. The overall prevalence of medication errors was 18.18%. The most prevalent type of medication error identified was wrong drug formulation (n = 19, 39.58%). About 47.92% of the medication errors resulted in adverse events and this was predominantly caused by antidiabetic drugs (47.83%) and anti-hypertensive drugs (34.78%). Patients in the age category of 26–35 y.o. [aOR: 0.31, CI: 0.11–0.90] had reduced odds of medication errors whilst patients with comorbidity of diabetes and hypertension [aOR: 5.95, CI: 2.43–14.60] had an increased odds of medication errors. Large patient population, low staff numbers and inadequate knowledge of drugs by healthcare workers were factors that contributed to medication errors. CONCLUSION: Medication errors was moderately high in this diabetic clinic, and the errors led to a number of adverse events. Age, diabetes and hypertension comorbidity, large patient population, low staff numbers, and inadequate knowledge about drugs were identified as factors that influenced medication errors. [ABSTRACT FROM AUTHOR]

Background: Medication errors in health care are prevalent. Nurses play an important role in reporting; however errors remain underreported in incident reporting systems. Understanding the perspective of nurses will inform strategies to improve reporting and build systems to reduce errors. Purpose: The purpose of this study was to explore nurses' perceptions and attitudes of medication error reporting practices. Methods: This qualitative study used direct content analysis to analyze interview sessions with 21 total nurses. Results: Participant's description of medication error reporting practices fell into 2 themes. Internal factors described circumstances within nurses themselves that affect reporting. External factors described outside influences from processes or places. Conclusions: Medication error reporting is a multidimensional phenomenon with internal and external factors impacting nurses' attitudes and willingness to report errors. Nurses need support from leadership to understand that reporting medication errors can improve practice and impact patient outcomes. [ABSTRACT FROM AUTHOR]

Particularities in psychiatry care can increase the risk of medication errors (MEs). To analyze the MEs that occurred in a psychiatric hospital and to quantify relationships between the use of certain types of medication and the type of MEs. We conducted a retrospective register based cross-sectional study in a French psychiatric hospital (2014–2021). All MEs were analyzed using ALARM method to identify type, stage of occurring and interception (defenses), consequences, drug involved and root causes. The prevalence-odds ratio (POR) was calculated to estimate relationships between five selected medication situations (long-acting injectable antipsychotics (LAIA), oral liquid dosage forms in a multiple-unit-container (OLDS-MC), psychotropic drugs (PD), controlled medicines (CM) or high-alert drugs) and the type of MEs occurred. Among the 609 MEs reported, wrong dose (32.2%), wrong drug (30.3%), omission (14.2%) and wrong patient (12.9%) were frequently observed. The ME occurrence stage were prescribing (55.3%) and administration (30.2%). Medication order review intercepted 77.9% of MEs. CM or LAIA increased the risk of medication omission (POR: 3.9, 95%CI: 1.8–8.4 and 2.5, 95%CI; 1.2–5.1, respectively) while the use of high-alert medications decreased it (0.2, 95%CI: 0.1–0.8). OLDS-MC and PD were more likely to be administered to the wrong patient (6.1, 95%CI: 3.3–11.4 and 16.1, 95%CI: 7.2–35.8). LAIA were associated with an increased risk of wrong dose (3.4, 95%CI: 1.8–6.3). Actual errors risk was lower with high-alert drugs (0.5, 95%CI: 0.3–09), but higher with CM (3.5, 95%CI: 1.5–8.0), OLDS-MC (2.1, 95%CI: 1.2–3.8) and PD (2.5, 95%CI: 1.8–3.5). Patients exposed to high-alert drugs were likely to have a serious error (3.5, 95%CI: 1.2–10.4). This study sheds an innovative approach to analyze MEs by demonstrating that certain medication situations were more likely to lead to certain types of error. This enables the most appropriate prevention barriers to be put in place to intercept ME. • In psychiatry, certain medication situations were associated with certain errors. • Long-acting injectable antipsychotics are associated with a higher risk of wrong dose. • Liquid medicines in psychiatry are associated with a higher risk of wrong patient. • Restrictive regulation induced a higher risk of omission with controlled medicines. [ABSTRACT FROM AUTHOR]

Medication errors pose significant risks to patients’ health, representing a relevant social and economic issue for the healthcare system. This study focuses on the life-threatening consequences of an overdose of intravenous lipid emulsion (ILE), used as an antidote for suspected bupivacaine intoxication in a young woman undergoing hip surgery. Shortly after administration of the local anesthetic, the woman experienced cardiac arrest and was admitted to the intensive care unit with severe respiratory failure, metabolic acidosis and deep coma. Despite medical intervention, her condition worsened, leading the medical team to administer ILE for suspected bupivacaine intoxication. The patient’s condition did not improve and ultimately resulted in death. The autopsy highlighted a widespread presence of oily material in the vascular system, compatible with an overdose of ILE. At a checking, medical records reported a dose of ILE that was 4-fold higher than the recommended dose in this off-label indication. This case report highlights the important need for healthcare professionals to understand the risks of using ILE as an antidote. Adequate monitoring of these “sentinel events” and their critical evaluation can lead to the implementation of specific clinical risk management protocols to reduce the risk for the patient and contain healthcare costs. [ABSTRACT FROM AUTHOR]

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Objective: This scoping review aims to map the available literature and provide an overview of the published articles discussing the impact of electronic prescribing on medication errors and pharmacy workflow. Methods: The literature search was conducted using PubMed®, Web of Science®, and the Cochrane Database of Systematic Reviews®, as well as grey literature reports, using the search terms and related components of "pharmacists", "electronic prescribing", "medication errors", and "efficiency". The search included all articles that were published from January 2011 to September 2023. Twenty-two relevant articles were identified and fully reviewed, ten of which were included in this review. Results: Electronic prescribing (e-prescribing) provides a solution for some of the challenges that are associated with handwritten and paper prescriptions. However, the implementation of e-prescribing systems has been recognized as a source of new unforeseen medication errors in all the reviewed articles. Productivity in community pharmacies has been affected with receiving electronic prescriptions (e-prescriptions) and having to deal with the issues that arise from them. The pharmacists' interventions were not eliminated with e-prescriptions compared to other prescription formats. The most frequently reported reason for intervention was related to incomplete instructions in the field of directions of use. Other common challenges with e-prescriptions were related to missing information, quantity, inappropriate dose, dosage form, and drug. Discussion: This review demonstrates the scarcity of research about the impact of electronic prescribing on medication error and efficiency in community pharmacies. In the literature, most of the studies had mainly focused on hospital pharmacies. The literature search demonstrated that there are still some barriers to overcome with e-prescribing systems and that medication errors were not fully eliminated with e-prescriptions. New errors have been identified with e-prescriptions, all of which caused delays in processing, which affected the productivity of the pharmacy staff, and could have negatively impacted patients' safety if not properly resolved. Conclusion: e-Prescribing solved some of the challenges associated with illegibility of handwritten prescriptions. However, more time is required to allow e-prescribing systems to mature. Further training for prescribers and pharmacists is also recommended before and after the implementation. [ABSTRACT FROM AUTHOR]

Aims Design Methods Results Conclusions Implications for the Profession Impact Reporting Method Patient or Public Contribution To identify the contributing factors behind the second victim phenomenon, describe the emotional responses of nurses after medication errors, assess the support received by them after errors and recognize the need for a suitable support program for second victims.Qualitative descriptive design.Eleven in‐depth semi‐structured interviews were conducted among registered nurses studying advanced degrees at a University in Finland during November 2021–April 2022. Data were analysed using thematic analysis.The study results revealed four themes with various sub‐themes which included: contributing factors behind the second victim phenomenon; emotional responses of nurses after error; support received by nurses; and the desired need for a support program for second victims. The severity of the error and the negative work environment acted as catalysts for the second victim phenomenon among nurses. A “bitter aftermath” of emotions and a sense of insufficient support added further risk to already stressed and anxious nurses.This study identifies the early exploratory and enduring impact of memories associated with medication errors, some of them haunting nurses for long periods of time. Further, the need for support at different levels is highlighted to reduce the impact of negative emotions generated among nurses after medication errors.Through the lens of this study, it has been possible to identify contributing factors behind the second‐victim phenomenon and enduring symptoms that make nurses vulnerable to becoming second victims of medication incidents.This study addresses the aftermath effect of medication errors from the perspective of nurses involved with such incidents. It provides valuable insights for healthcare managers and nurse leaders to establish a just and blame‐free culture in healthcare organizations and help emotionally traumatized nurses cope effectively after error.The research adheres to Consolidated criteria for reporting qualitative research (COREQ) guidelines.No patient or public contribution. [ABSTRACT FROM AUTHOR]

Aims Design Methods Results Conclusions Impact Reporting Method Patient or Public Contribution To examine the relationship between the second victim distress and outcome variables, specifically: ‘turnover intentions, absenteeism and resilience’. Furthermore, this study also assessed how organizational support mediates the relationship between second victim distress and outcome variables.Cross‐sectional survey.A cross‐sectional survey study using regression and mediation analysis with bootstrapping was conducted among (n = 149) healthcare professionals in two university hospitals in Finland from September 2022 to April 2023 during different time periods. The Finnish version of the revised Second Victim Experience and Support Tool (FI‐SVEST‐R) was used to assess second victim distress, level of organizational support and related outcomes.Psychological distress was the most frequently experienced form of reported second victim distress, and institutional support was the lowest perceived form of support by healthcare professionals. The study found second victim distress to have a significant association with work‐related outcomes: turnover intention and absenteeism. However, no significant relationship was found with resilience. Mediation models with organizational support revealed a partially mediated relationship between second victim distress and work‐related outcomes.The findings from this study indicate that second victim experiences if not adequately addressed can lead to negative work‐related outcomes such as increased job turnover and absenteeism. Such outcomes not only affect healthcare professionals but can also have a cascading effect on the quality of care. However, the mediating effect of organizational support suggests that if comprehensive support is provided, it is possible to mitigate the negative impact of the second victim phenomenon.Raising awareness regarding the second victim phenomenon, promoting a culture of safety and shifting the paradigm from a blame to just culture helps in identifying the system flaws thus improving both patient and provider safety.The study adheres to the STROBE reporting guidelines.No patient or public contribution. [ABSTRACT FROM AUTHOR]

AbstractThe presence of comorbidities and complex drug regimens makes palliative care patients more susceptible to opioid medication errors. Most of the studies conducted so far have mainly focused on patients admitted to hospitals or hospice facilities. During this study, we examined the frequency of medication errors with opioids and the causes and consequences for patients, followed by home palliative care teams. Errors occurred in 39% of patients (n = 378) and 27% of all prescribed opioids (n = 708). Of the 148 (39%) patients with error/s in the opioid/s prescribed, in 55% the patient and/or the caregiver were involved in the error; in 26% the health care providers were involved. An association was found between the presence of error in the prescribed opioid and the level of patient education, p = .038, and with the number of days of follow-up, p < .001. Considering their formulation, the prescribed opioids were associated with medication error, type of error, and cause of the error. The study demonstrated an association between the route of administration and error p < .004, and type of error p < .001. [ABSTRACT FROM AUTHOR]

Background and aim: Medication errors (MEs) in hospitals decrease patient satisfaction, increase hospital mortality, lower hospital productivity, and increase in the costs of the health system. This study was conducted to determine the rate of MEs in Iranian hospitals. Method: In this meta-analysis, all published articles on ME rates in Iranian hospitals were identified from five databases and Google Scholar and assessed for quality. The heterogeneity of the studies was examined using the I2 index and a meta-regression model was used to evaluate the variables suspected of heterogeneity at the 0.05 significance level. Finally, 17 articles were eligible to be included in this study and were analyzed using the Comprehensive Meta‐Analysis (CMA) software. Findings: Based on the estimation of the random-effects model, the ME rate in Iranian hospitals was 10.9% (5.1%-21.7%; 95% CI). The highest rate was observed in Sanandaj in 2006 at 99.5% (92.6%-100.0%; 95% CI) and the lowest rate was observed in Kashan in 2019 at 0.2% (0.1%-0.3%; 95% CI). In addition, sample size and publication year were significantly correlated with ME rate (P < 0.05). Conclusion: According to the results of this study; ME rate in Iran is relatvively high based on the synthesis of the research conducted in Iranian hospitals. In addition to being costly, MEs have negative consequences for patients. Thereofore, it is necessary to emphasize the voluntary nature of medication error reporting in health sytem of Iran. [ABSTRACT FROM AUTHOR]

Aim: Partnered Pharmacist Medication Charting (PPMC) in patients admitted under general medical units has been shown to reduce medication errors. The aim of this study is to evaluate the impact of the PPMC model on medication errors in patients admitted under cancer units in Victorian hospitals. Methods: A prospective cohort study comparing cohorts before and after the introduction of PPMC was conducted. This included a 2-month pre-intervention phase and 3-month intervention phase. PPMC was implemented during the intervention phase as new model of care that enabled credentialed pharmacists to chart all admission medications, including pre-admission or new medications and cancer therapies, in collaboration with the admitting medical officer. The proportion of medication charts with at least one error was the primary outcome measure. Results: Seven health services across Victoria were included in the study. The majority of health services were using paper-based prescribing systems for oncology. Of the 547 patients who received standard medical medication charting, 331 (60.5%) had at least one medication error identified compared to 18 out of 416 patients (4.3%) using the PPMC model (p < 0.001). The median (interquartile range) inpatient length of stay was 5 (2.9–10.6) days in pre-intervention and 4.9 (2.9–11) days in intervention (p = 0.88). In the intervention arm, 42 patients had cancer therapy charted by a pharmacist with no errors. Conclusions: PPMC was successfully scaled into cancer units as a collaborative medication safety strategy. The model was associated with significantly lower rates of medication errors, including cancer therapies. PPMC should be adopted more widely in cancer units in Australia. [ABSTRACT FROM AUTHOR]

Background: There are numerous publications on inpatient medication errors. However, little focus is given to medication errors that occur at home. Aims: To describe and analyse the types of medication errors among community-dwelling patients following their discharge from an acute care hospital in Singapore. Method: This is a retrospective review of a 'good catch' reporting system from December 2018 to March 2022. Medication-related errors were extracted and analysed. Findings: A total of 73 reported medication-related error incidents were reviewed. The mean age of the patients was 78 years old (SD=9). Most patients managed their medications independently at home (45.2%, n=33). The majority of medications involved were cardiovascular medications (51.5%, n=50). Incorrect dosing (41.1%, n=39) was the most common medication error reported. Poor understanding of medication usage (35.6%, n=26) and lack of awareness of medication changes after discharge (24.7%, n=18) were the primary causes of the errors. Conclusion: This study's findings provide valuable insights into reducing medication errors at home. More attention must be given to post-discharge care, especially to preventable medication errors. Medication administration and management education can be emphasised using teach-back methods. [ABSTRACT FROM AUTHOR]

Background: Methotrexate (MTX) at a dose of ≤25 mg/week is one of the most prescribed disease-modifying anti-rheumatic drugs (DMARDs) in a variety of rheumatic diseases. It can potentially cause life-threatening neutropenic sepsis, and acute renal and hepatotoxicity when taken inadvertently at high doses. We aim to analyse the clinical profile and risk factors of patients who presented with acute MTX toxicity. Methods: All patients presenting to the Rheumatology department with a history of inadvertent consumption of higher doses of MTX (>25 mg/week), from July 2021 to May 2023 were included. Additional data was extracted from hospital electronic medical health records. The clinical profile, risk factors, and outcome of patients with MTX toxicity were analysed. Results: The median age of the patients in our cohort was 52 IQR (40–62.5) years, with 80% females. The median cumulative dose of MTX was 120 mg (IQR 95–150). The reason for overdose in our cohort was medication error in comprehending once-weekly dosing. The most common major adverse event was neutropenia (80%). All our patients had stomatitis, with half of them having oral bleeding. Gastrointestinal adverse events like vomiting and diarrhoea were seen in 60% and 13% of the patients, respectively. Our cohort had two patients who succumbed to the complications due to neutropenic sepsis. The dose of MTX did not correlate with the severity of the disease or duration of hospital stay; however, the latter was significantly influenced by lower absolute neutrophil count (ANC). Conclusion: Acute MTX toxicity is one of the severe rheumatological emergencies and the toxicity profile includes haematological, gastrointestinal, hepatic, and renal adverse events. Severe neutropenia leading to sepsis can be fatal if not intervened early. [ABSTRACT FROM AUTHOR]

Background: Medication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient's medication use at home. Aim: In preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients, and data collection to reduce medication discrepancies at discharge and improve medication adherence, and (2) to explore the outcomes of the interventions. Method: Participants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed. Results: Of 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores. Conclusion: Based on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs. [ABSTRACT FROM AUTHOR]

ObjectivesTo investigate the factors influencing medication errors made by informal caregivers while providing care at home.MethodsA cross-sectional study based on an online survey, which included both structured and open-ended questions, was conducted in Spain. The survey comprised 49 questions to collect self-reported avoidable medication errors made by caregivers at home.ResultsA total of 685 caregivers participated in the survey, with 346 considered qualified (having received >20 h of training). On average, 13.5 (SD 38.2, 95% CI 10.5–16.5) errors per caregiver per year were self-reported. Errors were more prevalent among non-qualified caregivers, males, direct relatives of the care recipient, those with external occupations, or those who used external aids.ConclusionErrors made by informal caregivers occur more frequently than expected, and recognizing these errors remains a challenge. Training is essential for creating safer care environments by increasing awareness of error sources and the risks associated with medication. Recipients’ direct relatives should receive appropriate training, considering differences between male and female caregivers. Associations and companies within the care economy sector should prioritize the creation of safer home care environments as a key objective.

Purpose: To demonstrate the effective integration of pharmacometrics and pharmacovigilance in managing medication errors, highlighted by a case involving secukinumab in a patient with hidradenitis suppurativa. Methods: We present the case of a 41-year-old male with progressive hidradenitis suppurativa, unresponsive to multiple antibiotic regimens and infliximab treatment. Due to a medication error, the patient received 300 mg of secukinumab daily for 4 days instead of weekly, totaling 1200 mg. The regional pharmacovigilance center assessed potential toxicity, and a pharmacometric analysis using a population pharmacokinetic model was performed to inform dosing adjustments. Results: Clinical data indicated that the received doses were within a non-toxic range. No adverse effects were observed. Pharmacometric simulations revealed a risk of underexposure due to the dosing error. Based on these simulations, it was recommended to restart monthly secukinumab injections on day 35 after the initial dose. Measured plasma concentrations before re-administration confirmed the model's accuracy. Conclusion: This case highlights the crucial collaboration between clinical services, pharmacovigilance, and pharmacometrics in managing medication errors. Such interdisciplinary efforts ensure therapeutic efficacy and patient safety by maintaining appropriate drug exposure levels. [ABSTRACT FROM AUTHOR]

Medication error is the second most common patient safety incident worldwide. Medication errors can be defined as unintentional failures in medication services that have the potential to cause harm to patients. Maintaining safe health services is highly dependent on the ability of service providers to proactively conduct patient safety risk analysis, one of which is using the Healthcare Failure Mode and Effect Analysis (HFMEA) method. This study was aimed at obtaining the HFMEA design as an effort to prevent medication errors at Company X Clinical Pharmacy Installation. The research method used is qualitative research with a specific type of Operations Research. Data collected by in-depth interviews, observation, secondary data analysis, and focus group discussion. The results of this study found factors that cause medication errors to occur from organizational factors and staff factors. These results then analyzed for the HFMEA design which obtained 11 risks that required attention and then 14 action plans are made to overcome them. This study successfully developed HFMEA design to prevent medication error in Company X Clinical Pharmacy Installation.

Abstract Background Community pharmacies are responsible for dispensing of medicines and related counselling in outpatient care. Dispensing practices have remarkably changed over time, but little is known about how the changes have influenced medication safety. This national study investigated trends in dispensing errors (DEs) related to prescribed medicines, which were reported in Finnish community pharmacies within a 6-year period. Methods This national retrospective register study included all DEs reported to a nationally coordinated voluntary DE reporting system by Finnish community pharmacies during 2015–2020. DE rates, DE types, prescription types, individuals who detected DEs and contributing factors to DEs were quantified as frequencies and percentages. Poisson regression was used to assess the statistical significance of the changes in annual DE rates by type. Results During the study period, altogether 19 550 DEs were reported, and the annual number of error reports showed a decreasing trend (n = 3 913 in 2015 vs. n = 2 117 in 2020, RR 0.54, p

Awatif M Alrasheeday,1 Sameer A Alkubati,2,3 Gamil G Alrubaiee,4,5 Talal A Alqalah,2 Bushra Alshammari,2 Saleh O Abdullah,3 Ahmed Loutfy6,7 1Nursing Administration Department, University of Hail, Hail, Saudi Arabia; 2Department of Medical Surgical Nursing, University of Hail, Hail, Saudi Arabia; 3Department of Nursing, Hodeidah University, Hodeida, Yemen; 4Department of Community Health, University of Hail, Hail, Saudi Arabia; 5Department of Community Health, Al Razi University, Sanaa, Yemen; 6Maternal and Child Nursing Department, College of Nursing, University of Hail, Hail, 2440, Saudi Arabia; 7Department of Nursing, College of Health Sciences, University of Fujairah, Fujairah, 1207, United Arab EmiratesCorrespondence: Sameer A Alkubati, Department of Medical Surgical Nursing, University of Hail, Hail, Saudi Arabia, Tel +966506575284, Email alkubatisa@yahoo.comBackground: Determining the proportion of nurses reporting medication errors (MEs) and identifying the barriers they perceive in ME reporting are crucial to encourage nurses to actively report MEs.Objective: This study aimed to determine the proportion of nurses experiencing and reporting MEs, perceived barriers to reporting MEs and their association with nurses’ sociodemographic and work-related characteristics.Methods: A cross-sectional study was conducted among 350 nurses from June to November 2023. Data about sociodemographic and work-related characteristics, and ME reporting, were collected using a validated self-administered questionnaire.Results: The study found that 34.3% of nurses reported MEs, while 11.1% reported experiencing MEs during their practice. ME reporting was higher proportion among nurses who were older than 40 years (52.1%), males (41.4%), held a master’s degree (58.7%), Saudi nationals (37.8%), experienced for more than 10 years (43.1%), working in intensive care units (44.3%), working for 48 hours or more per week (39.7%), working in hospitals with a nurse-to-patient ratio of 1:3 (44.9%) and having a system for incident reporting (37.7%) and with no training on patient safety (44.6%) compared to their counterparts. The rate of experiencing MEs was higher proportion among nurses who were older than 40 years (16.7%), males (17.3%), married (14.8%), Saudi nationals (13.4%), experienced for more than 10 years (15.6%) and with no training on patient safety (15.3%) compared to their counterparts. Lack of knowledge of the person responsible for reporting MEs was the most frequent perceived barrier to ME reporting (66.6%), followed by fears of blame (65.4%).Conclusion: In this study, nurses reported and experienced MEs during their practice. Most nurses perceive the lack of knowledge and fear of blame or disciplinary actions as barriers to reporting. Healthcare administrators should implement educational programs and workshops to increase nurses’ awareness of ME reporting.Keywords: nurse, medication error, reporting, barrier, patient safety, Saudi Arabia

Abstract Background Medication errors related to the pre-admission medication history obtained on admission are a major cause of medication error during hospitalization. Medication reconciliation (MR) improves patient safety through the detection of inadvertent medication discrepancies at transitions of care. The aim of this study was to evaluate the effect of MR by pharmacists for patients prior to hospital admission on the incidence of medication errors in the early post-admission period. Patients and methods Patients admitted to the orthopedic ward for surgery between April 2012 and March 2020 were included. Pharmacist-led MR for pre-admission patients was started on April 1, 2017. The incidence of medication errors related to pre-admission medications that occurred during hospitalization were compared between the pre- and post-initiation of pharmacist-led MR (pre-initiation: April 1, 2012 to March 31, 2015, post-initiation: April 1, 2017 to March 31, 2020). Result In the post-initiation group, 94.2% (1245/1321) of patients who were taking medications on admission had a pharmacist-led MR before admission. The proportion of patients whose physicians ordered the prescription of their pre-admission medications at the time before hospitalization to continue from admission was significantly higher in the post-initiation group than in the pre-initiation group (47.4% vs. 1.0%, p

Background: Community pharmacies are responsible for dispensing of medicines and related counselling in outpatient care. Dispensing practices have remarkably changed over time, but little is known about how the changes have influenced medication safety. This national study investigated trends in dispensing errors (DEs) related to prescribed medicines, which were reported in Finnish community pharmacies within a 6-year period. Methods: This national retrospective register study included all DEs reported to a nationally coordinated voluntary DE reporting system by Finnish community pharmacies during 2015–2020. DE rates, DE types, prescription types, individuals who detected DEs and contributing factors to DEs were quantified as frequencies and percentages. Poisson regression was used to assess the statistical significance of the changes in annual DE rates by type. Results: During the study period, altogether 19 550 DEs were reported, and the annual number of error reports showed a decreasing trend (n = 3 913 in 2015 vs. n = 2 117 in 2020, RR 0.54, p < 0.001). The greatest decrease in reported DEs occurred in 2019 after the national implementation of the Medicines Verification System (MVS) and the additional safety feature integrated into the MVS process. The most common error type was wrong dispensed strength (50% of all DEs), followed by wrong quantity or pack size (13%). The annual number of almost all DE types decreased, of which wrong strength errors decreased the most (n = 2121 in 2015 vs. n = 926 in 2020). Throughout the study period, DEs were most commonly detected by patients (50% of all DEs) and pharmacy personnel (30%). The most reported contributing factors were factors related to employees (36% of all DEs), similar packaging (26%) and similar names (21%) of medicinal products. Conclusions: An overall decreasing trend was identified in the reported DEs and almost all DE types. These changes seem to be associated with digitalisation and new technologies implemented in the dispensing process in Finnish community pharmacies, particularly, the implementation of the MVS and the safety feature integrated into the MVS process. The role of patients and pharmacy personnel in detecting DEs has remained central regardless of changes in dispensing practices. [ABSTRACT FROM AUTHOR]

Background: Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF) by significantly reducing the risk of stroke. Direct oral anticoagulants (DOAC) became preferred over warfarin due to their superior safety and efficacy profile. Assessing adherence to anticoagulation therapy is necessary in clinical practice for optimising patient outcomes and treatment efficacy, thus emphasising its significance. Methods: A retrospective study utilised the Latvian National Health Service reimbursement prescriptions database, covering prescriptions for AF and flutter from January 2012 to December 2022. The proportion of days covered method was selected for adherence assessment, categorising it into three groups: (1) below 80%, (2) between 80% and 90%, and (3) above 90%. Results: A total of 1,646,648 prescriptions were analysed. Dabigatran prescriptions started declining after 2020, coinciding with a decrease in warfarin prescriptions since 2018. The total adherence levels to DOAC therapy were 69.4%. Only 44.2% of users achieved an adherence level exceeding 80%. The rate of paper prescriptions decreased from 98.5% in 2017 to 1.3% in 2022. Additionally, the utilisation of international non-proprietary names reached 79.7% in 2022. Specifically, 16.7% of patients selected a single pharmacy, whereas 27.7% visited one or two pharmacies. Meanwhile, other patients obtained medicines from multiple pharmacies. Conclusions: The total adherence level to DOAC therapy is evaluated as low and there was no significant difference in age, gender, or "switcher" status among adherence groups. Physicians' prescribing habits have changed over a decade. [ABSTRACT FROM AUTHOR]

Anaesthetic drug administration is complex, and typical clinical environments can entail significant cognitive load. Colour-coded anaesthetic drug trays have shown promising results for error identification and reducing cognitive load. We used experimental psychology methods to test the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a simulated visual search task. Effects of cognitive load were also explored through an accompanying working memory-based task. We hypothesised that colour-coded compartmentalised trays would improve drug-detection error, reduce search time, and reduce cognitive load. This comprised a cognitive load memory task presented alongside a visual search task to detect drug errors. All 53 participants completed 36 trials, which were counterbalanced across the two tray types and 18 different vignettes. There were 16 error-present and 20 error-absent trials, with 18 trials presented for each preloaded tray type. Syringe errors were detected more often in the colour-coded trays than in the conventional trays (91% vs 83%, respectively; P =0.006). In signal detection analysis, colour-coded trays resulted in more sensitivity to the error signal (2.28 vs 1.50, respectively; P <0.001). Confidence in response accuracy correlated more strongly with task performance for the colour-coded tray condition, indicating improved metacognitive sensitivity to task performance (r =0.696 vs r =0.447). Colour coding and compartmentalisation enhanced visual search efficacy of drug trays. This is further evidence that introducing standardised colour-coded trays into operating theatres and procedural suites would add an additional layer of safety for anaesthetic procedures. [ABSTRACT FROM AUTHOR]

Medication errors are regarded as a significant contributor to the morbidity and mortality rates among patients. These errors encompass any mistake made during the prescription, dispensing, administration, or consumption of medication, as well as the monitoring of therapy. Such errors often stem from factors such as insufficient knowledge, limited staff and resources, issues with medication naming and labeling, and inadequate communication among patients, physicians, and pharmacists. Nonetheless, it is crucial to detect these errors, as shortcomings in healthcare systems can lead to seemingly minor mistakes like misuse and abuse, which may ultimately result in more serious errors. The act of reporting a medication error holds great importance in enhancing the quality of life for patients and reducing the financial burden of re-hospitalization. The primary responsibility of a clinical pharmacist is to identify and assess medication errors with the aim of enhancing patient safety and therapeutic results. By closely monitoring the drug therapy administered to patients in a hospital setting and promptly informing healthcare providers of any inconsistencies discovered, the likelihood of medication errors occurring in hospitalized patients can be minimized. [ABSTRACT FROM AUTHOR]

Background: Medication errors related to the pre-admission medication history obtained on admission are a major cause of medication error during hospitalization. Medication reconciliation (MR) improves patient safety through the detection of inadvertent medication discrepancies at transitions of care. The aim of this study was to evaluate the effect of MR by pharmacists for patients prior to hospital admission on the incidence of medication errors in the early post-admission period. Patients and methods: Patients admitted to the orthopedic ward for surgery between April 2012 and March 2020 were included. Pharmacist-led MR for pre-admission patients was started on April 1, 2017. The incidence of medication errors related to pre-admission medications that occurred during hospitalization were compared between the pre- and post-initiation of pharmacist-led MR (pre-initiation: April 1, 2012 to March 31, 2015, post-initiation: April 1, 2017 to March 31, 2020). Result: In the post-initiation group, 94.2% (1245/1321) of patients who were taking medications on admission had a pharmacist-led MR before admission. The proportion of patients whose physicians ordered the prescription of their pre-admission medications at the time before hospitalization to continue from admission was significantly higher in the post-initiation group than in the pre-initiation group (47.4% vs. 1.0%, p < 0.001). The incidence of medication errors related to pre-admission medications during hospitalization was significantly lower in the post-initiation group than in the pre-initiation group (1.83% vs. 0.85%, p = 0.025). Pharmacist-led MR prior to admission was a significant protective factor against incidents related to pre-admission medication (odds ratio (OR), 0.3810; 95% confidence interval (CI); 0.156–0.9320, p = 0.035). Conclusion: Pharmacist-led MR for patients prior to hospital admission led to a reduction in medication errors related to pre-admission medications during hospitalization. Patient safety during hospitalization can be improved by accurate medication histories provided early by pharmacists. [ABSTRACT FROM AUTHOR]

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with wellestablished clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included--225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. [ABSTRACT FROM AUTHOR]

BACKGROUND: Most research on the impact of medication reconciliation on patient safety focused on the retroactive model, with limited attention given to the proactive model. OBJECTIVE: This study was conducted to compare the proactive and retroactive models in patients hospitalized for acute decompensated heart failure. METHODS: This prospective, quasi-experimental study was conducted over six months, from June to November 2022, at the cardiology unit of an academic hospital in Iran. Eligible patients were those hospitalized for acute decompensated heart failure using a minimum of five regular medications before admission. Medication reconciliation was performed in 81 cases using the proactive model and in 81 using the retroactive model. RESULTS: 556 medications were reconciled using the retroactive model, and 581 were reconciled using the proactive model. In the retroactive cases, 341 discrepancies (both intentional and unintentional) were identified, compared to 231 in the proactive cases. The proportion of patients with at least one unintentional discrepancy was significantly lower in the proactive cases than in the retroactive cases (23.80% versus 74.03%). Moreover, the number of unintentional discrepancies was significantly lower in the proactive cases compared to the retroactive cases (22 out of 231 discrepancies versus 150 out of 341 discrepancies). In the retroactive cases, medication omission was the most frequent type of unintentional discrepancy (44.00). About, 42.70% of reconciliation errors detected in the retroactive cases were judged to have the potential to cause moderate to severe harm. While the average time spent obtaining medication history was similar in both models (00:27 [h: min] versus 00:30), the average time needed to complete the entire process was significantly shorter in the proactive model compared to the retroactive model (00:41 min versus 00:51). CONCLUSION: This study highlighted that the proactive model is a timely and effective method of medication reconciliation, particularly in improving medication safety for high-risk patients. [ABSTRACT FROM AUTHOR]

Objective: To analyze the serious medication errors (MEs) on dabigatran, and their related factors, in order to avoid or reduce the occurrence of adverse events. Methods: Serious MEs related to dabigatran were extracted from the WHO global database of reported potential side effects of medicinal products (VigiBase) by using "Medication errors and other product use errors and issues" High Level Group Term (HLGT) of the international Medical Dictionary for Regulatory Activities (MedDRA). Well-documented reports, vigiGrade completeness score ≥ 0.80, or with an informative narrative were analyzed with a focus on the clinical features of the cases. The PCNE Classification for drug-related problems (DRP) was used to classify medication errors in our analysis of cases. Results: Until January 26, 2020, there were 453 cases with serious MEs related to dabigatran in VigiBase, and 113 were well-documented. Among these, 69 patients (61%) were hospitalized or had prolonged hospitalization, 16 (14%) had life-threatening events, and 12 (11%) died. The MEs occurred in the prescription phase in 77 cases, in administration in 35, and at the dispensing stage in one case. The MEs in prescription were related to a drug selection error in 44 cases (24 concerning contraindications and 20 drug interactions) and to dose error in 33 cases (17 with excessive dose; eight with insufficient frequency; four had an incorrect time; in three, the dose was too low; and in one, too frequent). The MEs in administration were medical-staff-related errors in five cases (three with wrong administration route, one administration omission, and one overdose), patient-related errors in 28 (14 insufficient dose or no administration, seven improper drug storage, four wrong administration method, and three over prescribed dose), and other errors in two (without efficacy monitoring). The dispensing error of a wrong drug strength occurred in a pharmacy. The main adverse events in the 113 patients were haemorrhage in 57 cases (50%) and ischemia in 29 cases (26%). Conclusion: Based on the analysis of reports in VigiBase, serious MEs related to dabigatran mainly occurred during prescription and administration. Although the incidence of MEs with clinical consequences in the use of dabigatran cannot be determined, attention should be paid to selection of the appropriate dose to a right patient in the prescription, and to patient compliance and storage in drug administration. The patient harm mainly manifested itself as bleeding or ischemia including fatal outcome in rare patients. [ABSTRACT FROM AUTHOR]

Background: Working for extended hours in a physically and mentally demanding profession has subjected nurses to occupational fatigue. Limited evidence exists about nurse fatigue and alertness changes throughout shift work and their relationship with medication errors and near misses. Purpose: The purposes of this study were to: (1) assess the relationship between nurses' fatigue and alertness, (2) evaluate nurses' fatigue and alertness changes throughout their shift, and (3) examine the relationship between nurses' fatigue, alertness, and medication errors and near misses. Methods: This prospective study is part of a larger mixed-method study. Fatigue and alertness data from 14 work and non-workdays were collected from a convenience sample of 90 nurses. A wearable actigraph (ReadibandTM) was used to measure alertness, while ecological momentary assessment (EMA) using text messaging was used to measure nurses' fatigue. Results: A 1-unit increase in fatigue was associated with a 1.06-unit reduction in nurses' alertness score (β = –1.06, 95% CI: [–1.33, –0.78], p <.01). Night-shift nurses experienced a 31-point reduction in alertness from the start to the end of the work shift. Nurses' fatigue, but not alertness, was associated with medication errors and near misses (OR = 1.26, 95% CI [1.07, 1.48], p =.01). Conclusion: Initiating fatigue mitigation measures during mid-shift, especially for night-shift nurses, may be a viable option to mitigate fatigue and alertness deterioration among nurses and to maintain patient safety. The multifaceted nature of fatigue, as captured by EMA, is a stronger predictor of medication errors and near misses than device-measured alertness. [ABSTRACT FROM AUTHOR]

Background: Look-alike/sound-alike (LASA) drugs substantially contribute to global healthcare challenges and patient harm, necessitating a comprehensive understanding of LASA medication errors. Objective: The current study explored the prevalence and characteristics of medication errors related to LASA in a 200-bed general hospital. Methods: A mixed-methods approach was employed. The quantitative component analyzed the LASA drug error data using the hospital database. For the qualitative component, in-depth interviews with pharmacists and pharmacy staff were undertaken to gain insights into stakeholder perceptions and management of LASA-related issues. Results: Quantitative analysis highlighted three types of LASA medication errors: confusion due to similar drug names, appearance, and packaging. Drug name confusion accounted for most errors (64.62%), demonstrating the considerable risk associated with similar medication names. Packaging confusion accounted for 24.61% of errors, indicating the importance of a unique packaging design. Overall, 10.77% of errors were attributed to similar appearance, indicating that the visual resemblance of medications played a considerable role in LASA errors. Forty-six LASA drug pairs were identified, the most frequent being simvastatin 10 mg and simvastatin 20 mg. The errors were divided into two categories: Category A, with two pairs related to name and packaging similarities, and Category B, with 44 pairs involving all types of similarities. The differentiation between these categories underscores the complex nature of LASA errors. Semi-structured interviews revealed that anticipatory errors often occurred during busy periods, which could result in crucial details, such as drug strengths, being overlooked. Proposed solutions for reducing LASA errors included implementing Tall Man lettering, developing movable LASA signage, and improving workforce allocation. Root-cause analysis identified several factors, including drug similarities and staffing issues, as notable contributors to LASA errors, highlighting the need for a multi- pronged approach. Conclusion: LASA medication errors, particularly those attributed to drug name similarities, pose a considerable risk and persist despite existing safeguards. Implementing tailored strategies, such as Tall Man letters, movable LASA signage, and careful management of high-risk medication pairs, could aid in addressing these issues. [ABSTRACT FROM AUTHOR]

Background: The intensive care unit (ICU) brings together high‐risk patients and interventions in a complex environment. Based on this consideration, medication administration error is the most common type of error that occurs in ICUs. Literature confirms that human factors (lack of knowledge, poor practices and negative attitudes) of nurses are the main contributors to the occurrence of medication administration errors in ICUs. Aim: To examine and compare the knowledge, attitudes and behaviour scores on medication administration error according to nurses' sociodemographic and professional variables. Study Design: This is a secondary analysis of data from a cross‐sectional international study based on a survey. Descriptive statistics were computed for all items of the questionnaire. Non‐parametric tests (Kruskal Wallis and Mann Whitney U tests) were used to carry out the comparison between groups. Results: The international sample consisted of 1383 nurses in 12 different countries. Statistically significant changes were seen in knowledge, attitudes and behaviour scores among several subgroups of the international population. Eastern nurses were more likely to show adequate knowledge about medication administration error prevention than Western nurses; concurrently, Western nurses were significantly more likely to show positive attitudes than Eastern nurses. No statistically significant differences in the behaviour scale were found in this study. Conclusions: The findings show a difference between knowledge and attitudes in relation to cultural background. Relevance to Clinical Practice: Decision makers in ICUs should consider cultural background when planning and implementing prevention strategies for medication administration errors. Further research is needed to investigate the effectiveness of educational systems on the decrease of the incidence of medication administration errors in ICU. [ABSTRACT FROM AUTHOR]

Aim: To explore whether sleep deprivation contributes to medication errors in registered nurses (RNs). Background: Sleep deprivation is a potential issue for RNs, particularly those who work shifts. Sleep deprivation has been found to have a negative impact on numerous cognitive processes. Nurses administer several medications to patients a day, potentially while sleep deprived—anecdotal reports suggest that this could result in an increased risk of error occurring. Design: A scoping review was conducted using the Prisma‐ScR extension framework to explore what is known about the effect of RNs' sleep deprivation on medication administration errors. Methods: A search of databases generated 171 results. When inclusion and exclusion criteria were applied, 18 empirical studies were analysed. Studies included retrospective analysis of errors, surveys of perceptions of causes and observational studies. Results: Data indicated that RNs consider fatigue, which may be caused by sleep deprivation, to be a contributing factor to medication errors. The search only identified three observer studies, which provided conflicting results as to whether lack of sleep contributes to the error rate. Of the numerous tools used to measure sleep, the Pittsburgh Sleep Quality Index was the most frequently used. Conclusion: Although RNs anecdotally consider a lack of sleep potentially contributes to medication errors, there is insufficient research to provide robust evidence to confirm this assumption. No Patient or Public Contributions: Patient or public contributions were not required for this scoping review. Relevance to Clinical Practice: Sleep deprivation is a potential issue for nurses, especially those who work shifts. Poor sleep impacts cognitive processes that potentially could increase errors. Nurses should be aware of the impact sleep may have on patient safety. [ABSTRACT FROM AUTHOR]

Effective medication management practice (MMP) improves compliance of chronic conditions management and reduces medication error for better clinical outcomes. This is important for stroke survivors with multiple comorbidities and post-stroke complications. This study aimed to determine appropriateness of home MMP and its associated factors among post stroke patients. This was a cross-sectional, single-centre study involving 120 stroke patients of a primary care medical centre in Kuala Lumpur between January and March 2021. The assessment of MMP appropriateness relied on scores obtained through a set of questions administered via face-to-face, online or telephone interview. The mean age of participants was 65.1 (SD 11.7) years. 55.8% of participants had inappropriate home MMP; where the majority did not update their medication list (86.3%), did not memorise the medication's name (75%), and did not return the leftover medication to the pharmacy (63.3%). Female gender (AOR: 2.74, 95% CI: 1.18-6.35, p-value: 0.019), household income (> RM4850) (AOR: 2.82, 95% CI: 1.03-7.69, p-value: 0.043), and number of clinic appointments (>2) (AOR: 5.27, 95% CI: 1.44-19.24, p-value: 0.012) were significantly correlated with better home MMP. The MMP among post-stroke patients was poor. Better home MMP were associated with female gender, higher socioeconomic status, and more frequent clinic appointments. Concerted health education should be provided, particularly focusing on medication management to improve home MMP in post-stroke patients and ultimately improving their overall health outcomes. [ABSTRACT FROM AUTHOR]

Background: In hospitals, medication errors still occur, especially in developing countries such as Indonesia. However, most incidents can be prevented. Objective: To evaluate medication prescription errors for in and out-patients at hospitals based on pharmacists' reports of medical errors. Methods: A retrospective study was carried out between January and December 2021. Pharmacists analyzed medication error reports based on age, sex, drug name list or quantity recorded, prescription listed in the medication error report, and length of hospital stay.Statistical analysis of drug interaction and the factors affecting potential drug interactions was carried out by using multiple linear regression. Results: Approximately 338 medication errors from 251,491 prescriptions were recorded by pharmacists across hospital departments in 2021. The age of patients with medication errors ranged from newborn babies to 86 years old, with an average of 40.9 years old (±21.03). The most common types of medication errors were prescribing errors (184, 54.4 %). The average length of hospital stay was 11.35 days (±10.36). A total of 557 potential drug interactions were recorded in 182 (53.85 %) prescriptions. The risk for potential drug interaction is increased by the number of medications per prescription (COR = 3.361, P

Background: Chronic kidney disease has emerged as a prominent cause of mortality worldwide in the last two decades. Drug interactions are a significant problem in individuals with chronic kidney disease, as they often receive numerous concurrent treatments. The aim is to examine the frequency of drug-drug interactions in outpatient treatment for chronic renal disease, classified according to their severity and risk level. Furthermore, the study aims to demonstrate the combined effect of the most common drug-drug interactions potency and associated risk factors. Methods: This study is a retrospective cross-sectional analysis of outpatients diagnosed with chronic kidney disease at Ansari Saleh Public Hospital in Banjarmasin, Indonesia. Medical records from 2022 were obtained retrospectively from computerised sources. The evaluation of potential interactions between drugs was conducted using Lexicomp®. The categorical data were displayed as percentages, and the continuous variables were depicted as means. Results: The study found that most drug interactions fell into the moderate severity (77.1%) and category C (75.5%) for the risk assessment. The prevalence of drug-drug interactions was 83.6% and the average number of potential drug interactions per patient was 3.34 ± 3.481. The concurrent use of candesartan and furosemide was the most prevalent drug-drug interaction (5.1%). The number of prescribed medications was a notable determinant for probable drug-drug interactions (p < 0.05). Conclusion: Identifying and averting potential drug-drug interactions is crucial to guarantee patient safety.