Review Article of International Journal of Hospital Pharmacy
Framework for Patient Safety
Assistant Professor, faculty of Pharmacy, World University of Bangladesh
Medication errors are common in general practice and in hospitals. Both errors in the act of writing (prescription/dispensing/administration errors) and prescribing faults due to erroneous medical decisions can result in harm to patients. Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common. Inadequate knowledge or competence and incomplete information about clinical characteristics and previous treatment of individual patients can result in prescribing faults, including the use of potentially inappropriate medications. An unsafe working environment, complex or undefined procedures, and inadequate communication among health-care personnel, particularly between doctors and nurses, have been identified as important underlying factors that contribute to prescription errors and prescribing faults. Active interventions aimed at reducing prescription errors and prescribing faults are strongly recommended. These should be focused on the education and training of prescribers and the use of on-line aids. The complexity of the prescribing procedure should be reduced by introducing automated systems or uniform prescribing charts, in order to avoid transcription and omission errors. Feedback control systems and immediate review of prescriptions, which can be performed with the assistance of a hospital pharmacist, are also helpful. Audits should be performed periodically.
Keywords: Medication; Errors; Risk, Reporting; Health care professionals; Safety; Patient
How to cite this article:
AK MOHIUDDIN,Framework for Patient Safety.International Journal of Hospital Pharmacy, 2019,4:21.
1. Rodziewicz TL, Hipskind JE. Medical Error Prevention. Treasure Island (FL): StatPearls Publishing; 2018 Jan URL: https://www.ncbi.nlm.nih.gov/books/NBK499956/
2. Steinwachs DM; Hughes RG. Chapter 8. Health Services Research: Scope and Significance. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr
3. Smith KE, Enright SM. Providing a Framework for Ensuring Medication Use Safety. Chapter 102. Providing a Framework for Ensuring Medication Use Safety. Remington: The Science And Practice Of Pharmacy. Author: Joseph P Remington; Paul Beringer Publisher: Philadelphia: Lippincott Williams & Wilkins, ©2006.
4. Wolf ZR; Hughes GR. Chapter 35Error Reporting and Disclosure. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.
5. Pietra LL, Calligaris L, Molendini L, Quattrin R, Brusaferro S. Medical errors and clinical risk management: state of the art. Acta Otorhinolaryngol Ital. 2005 Dec; 25(6): 339–346. PMID: 16749601
6. Nelson EC, Batalden PM, Huber TP, et al. Jt Comm J Qual Improv 2002; 28:472.
7. Kohn LT, Corrigan JM, Donaldson MS, editors. Chapter 8. Creating Safety Systems in Health Care Organizations. To Err is Human: Building a Safer Health System. Institute of Medicine (US) Committee on Quality of Health Care in America. Washington (DC): National Academies Press (US); 2000.
8. Hughes RG; Blegen MA. Chapter 37Medication Administration Safety. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.
9. Thomas JE, Petersen LA. Measuring Errors and Adverse Events in Health Care. J Gen Intern Med. 2003 Jan; 18(1): 61–67. doi: [10.1046/j.1525-1497.2003.20147.x] PMID: 12534766
10. Reason JT. Human Error. New York: Cambridge University Press; 1990.
11. Ferner RE, Aronson JK. Clarification of terminology in medication errors: definitions and classification. Drug Saf. 2006; 29(11):1011-22.
12. Norman DA. Categorization of action slips. Psychol Rev. 1981;88:1–15.
13. Runciman WB, Sellen A, Webb RK, Williamson JA, Currie M, Morgan C, Russell WJ. The Australian incident monitoring study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21:506–19
14. Ferner RE, Langford NJ, Anton C, Hutchings A, Bateman DN, Routledge PA. Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. Br J Clin Pharmacol. 2001;52:573–7.
15. Giampaolo P.V., Pietro M. Medication errors: prescribing faults and prescription errors Br J Clin Pharmacol. 2009 Jun; 67(6): 624–628. doi: [10.1111/j.1365-2125.2009.03425.x] PMID: 19594530
16. Aronson J. K. Medication errors: what they are, how they happen, and how to avoid them QJM Volume 102, Issue 8, 1 August 2009, Pages 513–521, https://doi.org/10.1093/qjmed/hcp052
17. Jessica G. Doctors in US incorrectly prescribe antibiotics in nearly a third of cases The Guardian May, 03 2016
18. The Independent NHS medication errors contribute to as many as 22,000 deaths a year, major report shows 23 February 2018
19. Zayed A., Sharon C., Imti C. Medication errors in the Middle East countries: A systematic review of the literature European Journal of Clinical Pharmacology April 2013, Volume 69, Issue 4, pp 995–1008.
20. Khaleej Times UAE bans handwritten medical prescriptions 7,000 deaths worldwide result from illegible handwriting. March 6, 2018
21. Shuvasis S., Tawhid M.H. Evaluation of medicines dispensing pattern of private pharmacies in Rajshahi, Bangladesh. BMC Health Serv Res. 2017; 17: 136. doi: [10.1186/s12913-017-2072-z]. PMID: 28193274
22. Complexity of medication-related verbal orders. Am J Med Qual. 2008 Jan-Feb;23(1):7-17. doi: 10.1177/1062860607310922. PMID: 18187586
23. Dahl FC, Davis NM. A survey of hospital policies on verbal orders. Hosp Pharm. 1990 May;25(5):443-7. PubMed PMID: 10104823.
24. Simonian AI. Medication order communication using fax and document-imaging technologies. Am J Health Syst Pharm. 2008 Mar 15;65(6):570-3. doi: 10.2146/ajhp070461. PubMed PMID: 18319505.
25. Hsu CC, Chou CL, Chen TJ, Ho CC, Lee CY, Chou YC. Physicians Failed to Write Flawless Prescriptions When Computerized Physician Order Entry System Crashed. Clin Ther. 2015 May 1;37(5):1076-1080.e1. doi: 10.1016/j.clinthera.2015.03.003. Epub 2015 Apr 1. PMID: 25841544
26. Timothy S. L. Prescribing Errors Involving Medication Dosage Forms J Gen Intern Med. 2002 Aug; 17(8): 579–587. doi: [10.1046/j.1525-1497.2002. 11056.x] PMID: 12213138
27. SA Health. Pharmacist legal obligations when handling, dispensing and supplying drugs of dependence. © 2012 SA Health (Govt. of South Australia). ABN 97 643 356 590. Last Modified: 23 Nov 2018
28. NABP. Report of the Task Force on Uniform Prescription Labeling Requirements. National Association of Boards of Pharmacy • (P) 847/391-4406 • (F) 847/391-4502
29. Website. Texas State Board of Pharmacy. (Tab 30) Operation Standards. Prescription dispensing and delivery. URL: https://www.pharmacy.texas.gov/files_pdf/BN/Aug13/Tab_30.pdf
30. Cheung K, Marcel LB, De Smet AGMP. Medication errors: the importance of safe dispensing. Br J Clin Pharmacol. 2009 Jun; 67(6): 676–680. doi: [10.1111/j.1365-2125.2009.03428.x] PMID: 19594537
31. Flanagan ME, Ramanujam R, Doebbeling BN. The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance. Implement Sci. 2009;4:71. Published 2009 Oct 29. doi:10.1186/1748-5908-4-71
34. Mendes JR, Lopes MCBT, Vancini-Campanharo CR, Okuno MFP, Batista REA. Types and frequency of errors in the preparation and administration of drugs. Einstein (Sao Paulo). 2018;16(3):eAO4146. Published 2018 Sep 10. doi:10.1590/S1679-45082018AO4146
35. Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med. 2014; 6: 45–55. doi: [10.2147/OAEM.S64174] PMID: 27147879
36. McLeod M, Barber N, Franklin BD. Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses’ Medication Administration Processes and Systems (the MAPS Study). PLoS One. 2015;10(6):e0128958. Published 2015 Jun 22. doi:10.1371/journal.pone.0128958
37. Alduais, A.M., Mogali, S., Shabrain, B.A., Enazi, A.A., & Al-awad, F. (2014). Barriers and strategies of reporting medical errors in public hospitals in Riyadh city : A survey-study. IOSR Journal of Nursing and Health Science (IOSR – JNHS) e – ISSN: 2320 – 1959.p – ISSN: 2320 – 1940 Volume 3, Issue 5 Ver. III (Sep. – Oct. 2014), P P 72 – 85
38. Handler SM, Perera S, Olshansky EF, et al. Identifying modifiable barriers to medication error reporting in the nursing home setting. J Am Med Dir Assoc. 2007;8(9):568-74.
39. Hartnell N, MacKinnon N, Sketris I, et alIdentifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group studyBMJ Qual Saf 2012;21:361-368.
40. Haw C, Stubbs J, Dickens GL. Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital. J Psychiatr Ment Health Nurs. 2014;21(9):797-805. doi: 10.1111/jpm.12143. Epub 2014 Mar 20. PubMed PMID: 24646372.
41. Koohestani, Hamid Reza and Baghcheghi, Nayereh. Barriers to the Reporting of Medication Administration Errors among Nursing Students [online]. Australian Journal of Advanced Nursing, The, Vol. 27, No. 1, Sept/Nov 2009: 66-74.
42. Britten N. Medication errors: the role of the patient. Br J Clin Pharmacol. 2009 Jun; 67(6): 646–650. doi: [10.1111/j.1365-2125.2009.03421.x] PMID: 19594532