The disadvantages are resistance by nurses to the system, the need for extra staff and pharmacy infrastructure, the need to acquire specific equipment, and a high initial financial investment. Implementation of this system in Brazil is a huge challenge. Only 0. The causes of these errors included poor handwriting quality, errors in transcribing the prescription, the use of non-standard abbreviations, different weights and measures systems adopted within the same hospital, verbal medical order, incomplete or confusing prescriptions, failure in communicating discontinuation of prescribed drugs, lack of knowledge about drug stability, incompatible associations and inadequate storage by nurses, similar trade and generic names, and difficulties for nurses in correlating the generic and trade name nomenclature.
A study in compared the incidence of medication errors in hospitals using different dispensing systems, and the results showed a significant reduction in medication error rates with the unit dose system. Detected errors, comparing drug prescription and delivery, were reduced from The new system increased pharmacist participation in drug control and distribution by The dispensing error rate reported in the unit dose system was 3. Another study conducted during 23 days in compared dispensing error rates in work environments with varying interruption levels, distractions, noise, and work overload, and found that error rates were 3.
A study in a Brazilian hospital based on reports of situations associated with drug delivery errors noted that Failures included delays in the delivery time, drugs with similar labels and packages, many drugs at the same time with resulting delays in drug administration, and drugs sent with the wrong presentation.
One of the reports is a good example of how a dispensation error can lead to a drug administration error: " Concern with determining factors of medication errors is not recent. A study had reported errors by nurses in a teaching hospital, the most common of which was delivery of the wrong drug and drug administration to the wrong patient. Factors most frequently associated with errors were failures when reading the prescription, lack of attention, forgetfulness, and inadequate patient identification.
Today there are many known factors causing dispensing errors. Knowledge about them facilitates operational procedures for efficient and safe practices. The most common causes of these errors are associated with the unsafe and inefficient nature of dispensing systems and other factors directly connected with drug dispensing and delivery Table 2. According to Cohen, 14 these factors may be summarized as communication failures, issues relating to drug labeling and packaging, work overload and the structure of the work area, distractions and interruptions, incorrect or outdated sources of information, and lack of knowledge and education of patients on the drugs delivered to them.
These factors are listed and discussed below:. The prescription is responsible for conveying information about the prescribed drug and its usage in a way that anyone reading it may fully understand the instructions. Ambiguous, incomplete, or confusing prescriptions may lead to poor understanding of fundamental information for correct drug dispensing and delivery.
Prescription readability problems are well known as a cause of medication errors. A prescription should be easily read rather than interpreted. This situation may lead to errors and cause injury or even death for patients. In , the American Medical Association stated that errors resulting from poorly interpreted prescriptions were the second most prevalent complaint and the most expensive in a list containing 90, complaints over 7 years.
Manual writing may complicate the distinction between 2 drugs with similar names. Many drugs have similar names or drug names may sound similar, leading to confusion, particularly when they are delivered through the same route or have similar dosages.
Dispensing of the drug Plendil felodipine in place of Isordil isosorbide due to poor prescription readability in a North-American pharmacy involved the pharmacist, the pharmacy, and the physician in a lawsuit as being responsible for the death of a patient who had an acute myocardial infarction after taking the wrong drug. Confusion may happen with both generic and trade names. This becomes even more critical with injections, where ampoules and flasks may be similar in size, shape, and color, in general containing similarly colored solutions.
Confusion may occur with greater frequency during emergencies and urgencies. An unfavorable working environment tends to increase dispensing error rates.
Safety measures for medication in nursing homes
The designated area for drug dispensing should have adequate space and appropriate lighting, temperature, and humidity for comfortable work. The most significant cause of dispensing errors in community and institutional pharmacies is work overload. Studies have demonstrated a direct relationship between errors and work overload. Stress caused by imposing a maximum time limit for dispensing the prescription is a significant factor.
The most obvious solution for work overload is to have enough trained staff and to increase the time limit for dispensing the prescription. Lack of adequate training or supervision of pharmacy assistants also contributes to medication errors. Many Brazilian pharmacies have only one pharmacist, which means that the work of the pharmacy assistant goes mostly unsupervised and unchecked.
Also, pharmacy assistants are usually trained in-service. Training courses in this area are recent and restricted to a few cities. Continuous technological development has led to frequent changes in information relating to drug use and safety. These changes have to be monitored by health professionals and applied in order for patients to benefit from them.
It is a dangerous practice to use traditional or virtual books, outdated scientific magazines, Web sites, or other unreliable sources, all of which may yield incorrect information. Users of medical drugs may become allies in preventing medication errors if they are well informed about the drugs being taken and can perceive errors not detected by health professionals, such as a dispensing error or a change in the delivery route.
According to Cohen, 14 patient counseling means additional safety against medication errors. The pharmacy is an important link in the complex process of the use of drugs within a hospital.
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It permeates and interconnects many actions developed in different areas of this process. Its physical structure, human and technological resources, and organization according to state-of-the-art standards for patient safety are essential for preventing and reducing medication errors.
The ever-growing worldwide pressure to overcome drug safety failures requires that health professionals and health institutions acquire elaborate knowledge of a variety of incidents that may occur during the process of drug use. A clear conceptual definition of such incidents allows us to seek knowledge about the true epidemiological force of each of thedetermining factors, which is essential for promoting change in posture and in defining preventive measures.
Although most dispensing errors may be classified as banal, they can reach significant epidemiological levels. Failures in the dispensing process mean that one of the last links in the safe use of drugs has been breached. Even though for the most part they do not cause harm to patients, the existence of dispensing errors reveals failures in the work process and directly points towards a higher risk of severe accidents. Sevalho G. Farm Hosp. Rosenfeld S.
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Manasse HR. Medication use in an imperfect world: drug misadventuring as an issue of public policy, part 1. Am J Hosp Pharm. Medication use in an imperfect world: drug misadventuring as an issue of public policy, part 2. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. To err is human: building a safer health system. Washington: National Academy of the Institute of Medicine; Retrospective analysis of mortalities associated with medication errors.
Am J Health Syst Pharm. Rosa MB, Perini E. Rev Assoc Med Bras. Taxonomy of medication errors, Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reactions, World Health Organization. Requirements for adverse reaction reporting. Geneva: World Health Organization; Cohen MR. Medication errors. Washington: American Pharmaceutical Association; National observational study of prescription dispensing accuracy and safety in 50 pharmacies.
J Am Pharm Assoc. Ribeiro E. Rev Adm Emp. Reducing adverse drug events: lessons from a breakthrough series collaborative. Jt Comm J Qual Improv. The problem of detecting errors in hospitals. A study of medication errors in hospital. Arkansas: University of Arkansas; Barker KN. The effects of an experimental medication systems on medication errors and costs.
Introduction and error study. Comparison of a traditional and unit dose drug distribution system in a nursing home. Drug Intell Clin Pharm. Effect of an automated bedside dispensing machine on medical errors. Research on drug-use-system errors. Faddis MO. Eliminating errors in medication.
Am J Nurs. Rev Baiana Enferm. Madrid: Farmacia Hospitalaria, , p. Received for publication on October 07, Accepted for publication on April 29, All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License. Services on Demand Journal. Collective System The collective system, also known as the traditional system, is the oldest and most obsolete.
In the direct system, the prescription may be forwarded to the pharmacy as follows 17 : a the prescription is written over carbon paper to produce a copy of the original. Poor quality carbon paper or inadequate pens may result in prescription copies that are difficult to read; b photocopy to reproduce the original prescription; c fax from the hospital unit to the pharmacy. Tell us if something is incorrect. Only 5 left! Add to Cart. Free delivery. Arrives by Wednesday, Oct 9. Pickup not available. Medication Safety focuses on promoting safety in the various stages of the medication process.
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