Analysis of 3 Serious Medication Errors in Provincial Hospital

Ning  Hou; Hui  Tang

doi:10.4236/pp.2014.54049

Ning Hou^*, Hui Tang

Abstract: Background: Medication errors are a common problem in Chinese hospital, with potentially harmful consequences for patients. The objective of this study was to analyze the cause of typical serious medication errors in some first-class provincial hospital to prevent medication error and improve rational use of drug and ensure patients administration security. Medication errors were collected between September 1, 2012 and August 31, 2013. 332 cases’ medication errors were categorized as harmful or not according to NCC MERP’s Index and other indexes such as type of error and causes of error. We focus on analyzing the 3 serious cases (0.9%, n = 3) among the all MEs that may have contributed to or resulted in temporary harm to the patient and required intervention, including the process and the cause and the background of the errors. The case analysis reminds us to pay more attention to prevent medication errors. The preventive medication error’s measures are explored through the analysis of the causes, such as forcing functions and constraints, automation and standardization, double-checking systems, rules and policies, information and more careful working. Conclusion: This analytical study demonstrates that medication error is an objective existent in hospital. It is especially important to ensure patient medication safety for reporting and analyzing medication error in order to explore measures preventing medication error.

Keywords: Medication Error; Cause Analysis; Medication Safety; Prevent Measure

Cite this paper: Hou, N. and Tang, H. (2014) Analysis of 3 Serious Medication Errors in Provincial Hospital. Pharmacology & Pharmacy, 5, 408-412. doi: 10.4236/pp.2014.54049.

References

[1] Kohn, L.T., Corrigan, J.M. and Donaldson, M.S., Eds. (1999) To Err Is Human: Building a Safer Health System. National Academy Press, Institute of Medicine, Washington DC.

[2] Dutton, K., Hedger, N., Wills, S., Brown, D. and Davies, P. (2003) Prevent Medication Errors on Admission. Clinical Governance: An International Journal, 8, 128-137.
http://dx.doi.org/10.1108/14777270310471612

[3] Teinilä, T., Kaunisvesi, K. and Airaksinen, M. (2011) Primary Care Physicians’ Perceptions of Medication Errors and Error Prevention in Cooperation with Community Pharmacists. Research in Social and Administrative Pharmacy, 7, 162-179. http://dx.doi.org/10.1016/j.sapharm.2010.03.007

[4] Aronson, J.K. (2009) Medication Errors: Definitions and Classification. British Journal of Clinical Pharmacology, 67, 599-604. http://dx.doi.org/10.1111/j.1365-2125.2009.03415.x

[5] Peth, H.A. (2003) Medication Errors in the Emergency Department: A Systems Approach to Minimizing Risk. Emergency Medical Clinics of North America, 21, 141-158. http://dx.doi.org/10.1016/S0733-8627(02)00085-8

[6] Hayley, M.V., Lauren, E.W., Jennifer, A.P., Sharon, J.G. and Manya, T.A. (2009) The Effect on Medication Errors of Pharmacists Charting Medication in an Emergency Department. Pharmacy World and Science, 31, 373-379.
http://dx.doi.org/10.1007/s11096-008-9271-y

[7] Leape, L.L. (1994) Error in Medicine. JAMA, 272, 1851-1857.
http://dx.doi.org/10.1001/jama.1994.03520230061039

[8] Reason, J. (2000) Human Error: Models and Management. BMJ, 320, 768-770.
http://dx.doi.org/10.1136/bmj.320.7237.768

[9] Hartwig, S.C., Denger, S.D. and Schneider, P.J. (1991) Severity-Indexed, Incident Report-Based Medication Error-Reporting Program. American Journal of Hospital Pharmacy, 48, 2611-2616.