A comparison between Parkinson's medication errors identified through retrospective case note review versus via an incident reporting system during hospital admission.


Journal

The International journal of pharmacy practice
ISSN: 2042-7174
Titre abrégé: Int J Pharm Pract
Pays: England
ID NLM: 9204243

Informations de publication

Date de publication:
Dec 2020
Historique:
received: 19 12 2019
revised: 24 06 2020
accepted: 04 08 2020
pubmed: 28 8 2020
medline: 30 7 2021
entrez: 27 8 2020
Statut: ppublish

Résumé

To compare the frequency and type of inpatient Parkinson's medication errors reported through an incident report system versus those identified through retrospective case note review in a tertiary teaching hospital. A search of inpatient medication-related incident reports identified those pertaining to Parkinson's medication. A discharge diagnoses search identified admissions for patients with Parkinson's disease over the same time period. A retrospective case note and incident report review were performed to describe and quantify medication-related events. Substantially, more medication-related problems were identified via case note review (n = 805) versus incident reporting system (n = 19). A significantly different pattern of error types was identified utilising case note review versus incident reporting, with case note review more likely to identify delayed dosing, and incident reports more likely to identify wrong dose or formulation administered errors. Retrospective incident report and case note review can be used to characterise medication administration errors encountered in an inpatient setting. Incident report review alone is insufficient in estimating error rates, and dual data collection methods should be used.

Identifiants

pubmed: 32844477
doi: 10.1111/ijpp.12668
doi:

Substances chimiques

Antiparkinson Agents 0

Types de publication

Comparative Study Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

663-666

Informations de copyright

© 2020 Royal Pharmaceutical Society.

Références

World Health Organisation (WHO). Patient Safety, The third WHO Global Patient Safety Challenge: Medication Without Harm. https://www.who.int/patientsafety/medication-safety/en/ (cited 26 June 2019).
Gandhi T, Seger D, Bates D. Identifying drug safety issues: from research to practice. Int J Qual Health Care 2000; 12: 69-76.
Myer-Massetti C et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011; 68: 227.
Scott S, Henneman E. Underreporting of medical errors. Medsurg Nurs. 2017; 26: 211-213.
George D, Hss A, Hassali A. Medication error reporting: underreporting and acceptability of smartphone application for reporting among health care professionals in Perak, Malaysia. Cureus. 2018; 10: 05.
Westbrook JI et al. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Int J Qual Health Care 2015; 27: 1-9.
Hartnell N et al. Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. BMJ Qual Saf 2012; 21: 361-368.
Gerlach O, Winogrodzka A, Weber WEJ. Clinical problems in the hospitalized Parkinson's disease patient: systematic review. Mov Disord. 2011; 26: 197-208.
Dyab E et al. Exploration of nurses' knowledge, attitudes, and perceived barriers towards medication error reporting in a tertiary health care facility: a qualitative approach. Pharmacy (Basel) 2018; 6: 05.
Martinez-Ramirez D et al. Missing dosages and neuroleptic usage may prolong length of stay in hospitalized Parkinson's disease patients. PLoS One 2015; 10: e0124356.

Auteurs

Deanna Mill (D)

SALHN, Flinders Medical Centre, SA Pharmacy, Bedford Park, SA, Australia.
School of Allied Health, The University of Western Australia, Crawley, WA, Australia.

Michael Bakker (M)

SALHN, Flinders Medical Centre, SA Pharmacy, Bedford Park, SA, Australia.

Lauren Corre (L)

SALHN, Flinders Medical Centre, SA Pharmacy, Bedford Park, SA, Australia.

Amy Page (A)

Centre for Medicine Use and Safety, Monash University, Melbourne, Vic., Australia.
Pharmacy Department, Alfred Hospital, Melbourne, Vic., Australia.

Jacinta Johnson (J)

SALHN, Flinders Medical Centre, SA Pharmacy, Bedford Park, SA, Australia.
UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia.

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