Category: Federal Forum Posters
Purpose: Medication error is a common vital problem in all healthcare systems around the world. They are associated with life threatening complications, rise in patient treatment cost as well as prolong hospitalisation. The purpose of this study was to determine and compare the effective methods that can detect the medication errors. Two methods were included in this study via direct observation method which was done by directly observing the nurses while administering the medications and medication chart review method was done by collecting and analysing the data and finally reporting it to the concerned clinicians.
Methods: The complete study was primarily focused on the errors that occurs during drug administration and its related errors. Direct observation was used to detect medication errors on each day upon observation, the clinical pharmacist as an observer was present at the nursing unit prior to medication administration. The observer witnessed the administration of 100 doses per day by the nurses. During this process, the nurses were blinded and were not aware of the clinical pharmacist observation. The observed data were then cross checked with the medication chart to confirm the errors. The error was further discussed with the clinicians immediately. In medication chart review process, the charts with the same hospital reference number as that observed using direct observation method were being studied. The case sheet, medication profile, lab master, hospital formulary, drug storage and labelling , databases and hospital protocol files were thoroughly investigated to identify for any associated errors in the case. Then, the observer analysed the collected data and finally reported the errors for the concerned clinicians. All the errors were further classified and the effectiveness of the method was demonstrated based on the nature, type and number of the errors reported by respective method. This study included all patients admitted to the surgical ward both adult and geriatric patients irrespective of the diagnosis.
Results: A total doses of 12572 in 558 patients were observed over a period of six months. In the study, the male patients (77 percent) were higher compared to female patients. The direct observation method covered a total of 5820 (46.2 percent) doses and the medication chart review method involved 6752 (53.7percent) doses. Out of 12572 doses, the administration error was documented in 383 (3 percent ) doses, in which direct observation method share was 290 errors (75.7 percent ) and the medication chart review method accounted for 93 errors (24.2 percent). The type of errors observed by both the methods were distinguish. Out of 2713 errors, 1323 errors (48.7 percent) were detected by direct observation method and 1390 errors (51.2 percent) by medication chart review method. Subsequently, the direct observation method detected 22.7 percent of errors compared to 20.5 percent errors by medication chart review. Direct observation method showed effective in observing unauthorised drug (drug not prescribed) storage at patient bedside (29.7 percent) followed by drug duplication (18.2 percent). Whereas the medication chart review demonstrated its effectiveness in identifying use of inappropriate abbreviation (21percent ) as well as drug drug interactions (19.6 percent).
Conclusion: Two detection methods to observe medication errors (observation and medication chart review) proved to be efficient and reliable . The direct observation method was able to capture higher number of medication errors primarily related to administration errors compared to the medication chart review. The medication chart review method was able to capture the superficial information related to medication error. Over all, the direct observation method was more effective method to detect medication errors.
Badr ali Ahmed Gassar– Pharm.D. Intern, Karnataka College of Pharmacy, Bangaluru, Karnataka, India