AIM: To conduct a systematic literature review on the existing literature on the prevalence of medication errors across the medicines management system in primary care; To explore the systems of error management in primary care; to investigate the prevalence and nature of medication errors in children, 0-12 years, and in older patients, ≥65 years, in primary care; and to explore community pharmacists' interventions on medicines-related problems. METHODS: 1) Systematic literature review; 2) Questionnaire survey of Primary Care Trusts (PCTs), Clinical Commissioning Groups (CCGs) and NHS Area Teams; 3) Retrospective review of the electronic medical records of a random sample of older patients, ≥65 years old, and children 0-12 years old, from 2 general practices in Luton and Bedford CCGs, England; 4) Prospective observation of community pharmacists' interventions on medicines-related problems and prescribing errors from 3 community pharmacies in Luton and Bedford CCGs in England. DATA ANALYSIS: Quantitative data from records review were analysed using Microsoft Excel on data extracted from an Access database. Statistical tests of significance were performed as necessary. Descriptive statistics were conducted on quantitative data from the studies and inductive qualitative analyses were conducted on aspects of the questionnaire survey. RESULTS: • The systematic literature review demonstrated that medication errors are common, and occur at every stage of the medication management system in primary care, with error rates between ≤1% and ≥90%, depending on the part of the system studied and the definitions and methods used. There is some evidence that the prescribing stage is the most susceptible, and that the elderly (over 65 years) and children (under 18 years) are more likely to experience significant errors, although very little research has focussed on these age groups. • The questionnaire survey of PCTS, CCGs and NHSE demonstrated that national and local systems for managing medication errors appeared chaotic, and need to be better integrated to improve error learning and prevention in general practice. • The retrospective review of patients' medical records in general practices demonstrated that prescribing and monitoring errors are common in older patients and in children. 2739 unique prescription items for 364 older patients ≥65 years old were reviewed, with prescribing and monitoring errors detected for 1 in 3 patients involving about 1 in 12 prescriptions. The factors associated with increased risk of errors were: number of unique medications prescribed, being ≥75 years old, being prescribed medications requiring monitoring, and medications from these therapeutic areas: corticosteroid, NSAID, diuretic, thyroid and antithyroid hormones, statins and ACE-I/ARB. 755 unique prescription items for 524 younger patients 0-12 years old were examined, with approximately 1 in 10 prescriptions and 1 in 5 patients being exposed to a prescribing error. Factors associated with increased risk of prescribing errors in younger patients were: being aged ≤10 years old, being prescribed three or more medications, and from similar therapeutic areas as above. Majority of the errors were of mild to moderate severity. • Community pharmacists performed critical interventions as the last healthcare professional defense within the medicines management system in primary care. However, this role is challenged by other dispensary duties including the physical aspects of dispensing and other administrative roles. CONCLUSION Prescribing and monitoring errors in general practice, and older patients and children may be more at risk compared to the rest of the population, though most errors detected were less severe. Factors associated with increased risk for errors in these age groups were multifaceted. The systems for periodic laboratory monitoring for routinely prescribed drugs, particularly in older patients, need to be reviewed and strengthened to reduce preventable hospital admissions. Antibiotic dosing in children in general practice needs to be regularly reviewed through continued professional developments and other avenues. As guidance on local arrangements for error reporting and learning systems are less standardised across primary care organisations, pertinent data from adverse prescribing events and near misses may be lost. Interventions for reducing errors should therefore explore how to strengthen local arrangements for error learning and clinical governance. Community pharmacists and/or primary care pharmacists provide an important defence within the medicines management system in primary care. Policy discussions and review around the role of the pharmacist in primary care are necessary to strengthen this defence, and harness the potential thereof.

Le système de santé actuel fait face à une augmentation du vieillissement et des maladies chroniques. Les professionnels de la santé doivent prodiguer des soins de plus en plus complexes. Il est ainsi nécessaire de disposer de personnel en quantité suffisante, utilisant toute l’étendue de leur pratique et opérant dans un environnement de travail favorable. Le but de cette étude est de décrire l’organisation des services (dotation, étendue de pratique et travail d’équipe) dans trois centres hospitaliers de réadaptation de la région de Montréal et d’examiner l’association entre l’organisation des services et la sécurité des patients. Un devis descriptif corrélationnel a été utilisé. En total, cinq unités de réadaptation ont participé à cette étude pour une période de 93 jours. L’unité d’analyse est le quart de travail pour un total de 1 395 quarts analysés. Cette étude originale indique que les unités de réadaptation examinées sont caractérisées par une dotation d’intensité modérée, un niveau relativement faible de soins manquants et une perception moyennement favorable du travail d’équipe. Une association directe et positive a été trouvée entre la sécurité des patients et l’intensité de la dotation, de la proportion d’infirmières bachelières et d’une façon inattendue, du personnel de la main d’œuvre indépendante. Par ailleurs, cette étude montre le rôle clé de la dotation en personnel (la quantité de ressources mesurée par le nombre d’heures de personnel par quart-patient et la composition de l’équipe mesurée par la prédominance d’infirmières bachelières par quart) dans la réduction du risque de survenue d’événements indésirables. / The current healthcare system is experiencing a growth of the aging population and the complexity of chronic diseases. Healthcare professionals must provide increasingly complex care. Therefore, it is necessary to have enough staff, using the full scope of their practice and operating in a favorable working environment. The aim of this study is to describe the organization of nursing services (staffing, scope of practice and teamwork) in three rehabilitation hospitals in the Montreal region and the association between the organization of services and patient safety. A correlational descriptive study was conducted. In total, five rehabilitation units participated in this study for a period of 93 days. The unit of analysis was the working shift for a total of 1 395 shifts analyzed. This original study indicates that the rehabilitation units examined are characterized by a moderate staffing intensity, a moderate favorable perception of teamwork score and a relatively low score of missed care. A positive and direct association was found between the staffing intensity, the proportion of nurses with bachelor’s degrees, and unexpectedly the proportion of agency staff and patient outcomes. It indicated the key role of the staffing (the quantity of resources measured by the staff hours per patient shift, and the team composition measured by the predominance of bachelor nurses per shift) in reducing the risk of occurrence of adverse events in rehabilitation.

Background: The acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of medication error jeopardizing patient safety are LASA as well as high workload. Case presentation: A critical incident report of medication errors of opioids for postoperative analgesia by lookalike packaging highlights the LASA aspects in everyday scenarios. A change to a generic brand of medication saved costs of up to 16% per annum. Consequently, confusion of medication incidents occurred due to the similar appearance of the newly introduced generic opioid. Due to consecutive underdosing no life-threatening situation arose out of this LASA based medication error. Conclusion: Current recommendations for the prevention of LASA are quite extensive; still, in a system with a lump sum payment per case not all of these security measures may be feasible. This issue remains to be approached on an individual basis, taking into consideration local set ups as well as financial issues.

Regardless of the setting, medication errors are of great concern when associated with an individual’s health outcomes, along with the increased costs to society, healthcare institutions, and providers. Current research focuses on medication error data primarily in acute and extended care facilities. However, there is a paucity of research examining the causes of medication errors that occur post hospital discharge when individuals transition to the home. The purpose of this integrative literature review is to examine risk factors for medication errors outside of these settings, specifically in the home. A systematic literature search was conducted using multiple databases for relevant articles in the English language between 2006 to 2017, including CINAHL, MEDLINE, PubMed, and PsycINFO. Search terms included ‘medication errors’, ‘home care’, ‘post-discharge’, ‘hospital readmission’, and ‘medication error risks in the home’. Exclusion criteria included medication errors in acute and extended care settings. The integrative review involved reading, analyzing and selecting articles, and summarizing on a matrix. Findings on occurrences of medication errors in the home included impaired client mental status, confusion related to medication names, limited understanding of medication purpose in the care plan and its side effects, level of health literacy, and client-provider miscommunication in discharge planning. Consistent and conflicting findings are discussed along with gaps in the literature. Limitations and implications for nursing practice, policy, research, and education are also noted.

L’iatrogénie induite par les erreurs médicamenteuses est un problème majeur de santé publique. Ce travail a pour objectif de développer une approche systémique visant à réduire leur occurrence en cancérologie. L’étude est menée aux Hospices Civils de Lyon au sein du Groupement Hospitalier Sud. L’analyse des erreurs médicamenteuses interceptées, sur une période de 5 ans, révèle que 4 prescriptions de chimiothérapie sur 100 présentent au moins une erreur médicamenteuse, dont plus de la moitié sont des erreurs de dose. Les facteurs de risque d’erreurs de prescription identifiés sont la prescription par un interne, l’hospitalisation conventionnelle, le patient ayant une surface corporelle supérieure à 2 m², les protocoles de plus de trois médicaments anticancéreux, comprenant du carboplatine ou nécessitant une modification par le prescripteur. L’évaluation de la gravité clinique potentielle des erreurs médicamenteuses montre que 13,4% d’entre elles auraient causé un préjudice temporaire et 2,6% un préjudice permanent. Le pronostic vital aurait été engagé dans 2,6% des cas conduisant au décès pour 6 patients sur une période d’un an. L’évaluation médico-économique permet d’estimer le coût pour l’assurance maladie d’une erreur médicamenteuse en cancérologie avec conséquences cliniques à 1 523€ associé à 3,5 journées d’hospitalisation supplémentaires. Cette approche systémique conduit au développement de revues d’erreurs médicamenteuses et de morbi-mortalité, socle de l’analyse collective indispensable à la prévention du risque médicamenteux en cancérologie / Medication errors are a major public health problem. This work aims to develop a systemic approach to reduce their occurrence in oncology. The study was conducted in Groupement Hospitalier Sud (Hospices Civils de Lyon). The analysis of intercepted medication errors, over a period of five years, reveals that four out of 100 prescriptions of chemotherapy include at least one medication error, which over half are dose errors. Risk factors of prescribing errors identified are prescription by a resident physician, inpatient care, patient with a body surface area greater than 2 m², protocol with more that three anticancer drugs, protocol involving carboplatin or protocol requiring at least one modification by the physician. 13.4% of avoided errors would have resulted in temporary injury and 2.6% in permanent damage. The vital prognosis of the patient would have been compromised in 2.6% of cases leading to death for six patients over a period of one year. The cost of one medication error with clinical consequences was estimated at € 1 523 associated to 3.5 additional days of hospitalisation. This approach led to the development of systematic medication errors reviews and morbi-mortality conferences that allow a collective and multidisciplinary analysis to enhance the patient’s safety

Background: In paediatrics, the limited documentation to guide medication, the lack of suitable dosage forms, and the continuous development in childhood present a scenario where safety of medication is a particular challenge. Aim: To explore reported adverse drug reactions (ADRs) and the challenges in prescribing and administering medicines in paediatrics, in order to identify and suggest areas needing international surveillance within medication safety and improvement in the clinical setting. Methods: Four exploratory studies were conducted. Worldwide reporting of suspected ADRs (individual case safety reports, ICSR) with ages 0-17 years were examined overall. Twenty published case reports and ICSRs for adolescents, who developed a rare and incompletely documented ADR (rhabdomyolysis) during antipsychotic medicine use, were analysed in-depth. Prescribed doses of anti-inflammatory medicines were studied in a UK electronic health record database. Transcribed focus group interviews with 20 registered nurses from four paediatric wards in Sweden were analysed for factors that may promote or hinder safe medication practices. Descriptive statistics, multiple regression, and content analyses were used. Results: Although, skin reactions and anti-infective medicines were most frequently reported, and more reported in paediatric patients than in adults, medication errors and adverse reactions related to psychostimulant medicines were reported with increased frequency during 2005 to February 2010. The in-depth case analysis emphasised the need for increased vigilance following changes in patients’ medicine regimens, and indicated that ICSRs could contribute with clinically valuable information. Prescribed dose variations were associated with type of dosage form. Tablets and capsules were prescribed with a higher dose than liquid dosage forms. Six themes emerged from the interviews: preparation and administration was complex; medication errors caused considerable psychological burden; support from nurse colleagues was highly valued; unfamiliar medication was challenging; clear dose instructions were important; nurses handling medications needed to be accorded higher priority. Conclusions: Age-specific screening of ICSRs and the use of ICSRs to enhance knowledge of ADRs and medication errors need to be developed. Access to age-appropriate dosage forms is important when prescribing medicines to children. To improve medication safety practices in paediatric care, interdisciplinary collaborations across hospitals on national or even global levels are needed.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / INTRODUCTION: Although patient safety institutions define High-Alert Medications (MAVs) as those that are at increased risk of causing significant harm to patients as a result of a failure to use, there are few scientific studies to prove the prevalence of harm due to MAVs. OBJECTIVES: To determine the prevalence of harm to patients involving MAVs due to medications errors (MEs) in hospitals. Make recommendations for conducting studies that identify harm caused by MEs and for the preparation of lists of MAVs. METHODOLOGY: Chapter 1 was carried out through a systematic review of the PubMed, Scopus, Web of Science and Lilacs databases, considering the studies published until April 2017, using descriptors and their synonyms in different combinations. Then, titles, abstracts and full texts were evaluated by two authors independently, according to the previously established inclusion criteria. In case of discrepancies, a third evaluator was consulted. The articles were included when they determined or allowed the determination of the rates of harm caused by MAVs as a result of MEs in hospitals. Chapter 2 comprised recommendations for patient safety from the studies found in chapter one. RESULTS: In the systematic review, five articles met the inclusion criteria. The overall prevalence of harm resulting from MEs involving MAVs was 16.3%. Less than 0.01% of MEs involving MAVs resulted in death. Hypotension, hypoglycemia, hyperglycemia, hemorrhage, cardiac arrest, stroke, prolonged hospitalization, coma, permanent injury, death have been reported. The drugs most related to the damages were 15% potassium chloride, insulin, anticoagulants, epoprostenol, anesthetics. The recommendations proposed in chapter two include methods for conducting studies that identify MEs harm and emphasize the importance of hospital units to create their own lists of MAVs. CONCLUSION: Two-thirds of the medications on the ISMP list of MEs from the United States and Brazil did not provide evidence of potential harm. In general, few studies - characterized by methodological and conceptual heterogeneity - were performed to determine the prevalence of harm resulting from errors involving these drugs. / INTRODUÇÃO: Embora instituições de segurança do paciente definam os Medicamentos Alta Vigilância (MAVs) como aqueles que apresentam risco aumentado de provocar danos significativos aos pacientes em decorrência de falha no processo de utilização, há poucos estudos científicos que comprovem a prevalência dos danos devidos erros com MAVs. OBJETIVOS: Determinar a prevalência dos danos aos pacientes envolvendo MAVs em decorrência de erros de medicação (EMs) em hospitais. Realizar recomendações para realização de estudos que identifiquem danos causados por EM e para elaboração das listas de MAVs. METODOLOGIA: O Capítulo 1 foi realizado através de uma revisão sistemática nas bases PubMed, Scopus, Web of Science e Lilacs, sendo considerados os estudos publicados até abril de 2017, usando descritores e seus sinônimos em diferentes combinações. Em seguida foram avaliados títulos, resumos e textos completos por dois autores de forma independente, de acordo com os critérios de inclusão previamente estabelecidos. Em caso de discrepâncias, um terceiro avaliador foi consultado. Os artigos foram incluídos quando determinaram ou possibilitaram a determinação das taxas de danos causados por medicamentos de alta vigilância em decorrência de erros de medicação em hospitais. O Capítulo 2 compreendeu recomendações para segurança do paciente apartir dos estudos encontrados no capítulo um. RESULTADOS: Na revisão sistemática, cinco artigos atenderam os critérios de inclusão. A prevalência geral de danos decorrentes de EMs envolvendo MAVs foi de 16,3%. Menos de 0,01% dos EMs envolvendo MAVs resultaram em morte. Foram reportados danos como hipotensão, hipoglicemia, hiperglicemia, hemorragia, parada cardíaca, acidente vascular cerebral, hospitalização prolongada, coma, lesão permanente, morte. Os medicamentos mais relacionados aos danos foram cloreto de potássio a 15%, insulina, anticoagulantes, epoprostenol, anestésicos. As recomendações propostas no capítulo dois incluem métodos para realização de estudos que identifiquem danos provocados por EMs e refoça a importância das unidades hospitalares criarem suas próprias listas de MAVs. CONCLUSÃO: Dois terços do medicamentos presentes na lista de MAVs do ISMP dos Estados Unidos e do Brasil não apresentaram evidências quanto ao potencial de provocar danos. Em geral, poucos estudos - caracterizados por heterogeneidade metodológica e conceitual - foram realizados para determinar a prevalência de danos decorrentes de erros envolvendo esses medicamentos. / São Cristóvão, SE

La transition du patient entre les secteurs de soins est une période à haut risque de discontinuité de la prise en charge médicamenteuse. Les problèmes liés aux médicaments spécifiquement rencontrés résultent principalement de différences non expliquées entre les traitements médicamenteux documentés aux niveaux des différents sites de soins et/ou des différents professionnels de la santé, également appelés discordances médicamenteuses médicalement non justifiées. Leur survenue peut entrainer des préjudices pour le patient mais aussi une utilisation accrue des services de soins de santé et par conséquent une augmentation des coûts. <p><p>Dans ce contexte, la première partie de ce travail est consacrée à la mise au point d’un instrument valide et fiable permettant de caractériser les discordances médicamenteuses médicalement non justifiées lors de la sortie de l’hôpital. Il s’avère particulièrement bien approprié pour la recherche ou pour la familiarisation à la problématique. La deuxième partie de ce travail a permis de mettre en œuvre cet outil dans une situation clinique réelle. Une étude prospective d’observation incluant des patients recevant les soins usuels (groupe contrôle) et des patients pris en charge par des pharmaciens cliniciens (groupe intervention) a été réalisée. L’intervention des pharmaciens cliniciens comportait la réalisation d’une conciliation médicamenteuse à l’admission et à la sortie de l’hôpital. La conciliation médicamenteuse est un processus structuré pendant lequel le professionnel de santé collabore avec le patient, la famille et les proches pour s’assurer qu’une information correcte et exhaustive sur les médicaments est communiquée lors de la transition du patient entre les secteurs de soins. Elle consiste en la vérification (collecte d’un historique médicamenteux correct et l’identification des discordances médicamenteuses), la clarification (s’assurer que les médicaments et la posologie sont appropriés), la conciliation (documentation de chaque changement de médicament et éducation du patient à ce sujet) et finalement le transfert d’information aux autres professionnels de santé. Les résultats montrent que l’intervention des pharmaciens cliniciens diminue le risque de discordances médicamenteuses médicalement non justifiées après la sortie de l’hôpital. De plus, la satisfaction des patients vis à vis de l’information sur les médicaments prescrits à la sortie est significativement plus élevée dans le groupe pris en charge par le pharmacien clinicien. Cependant, aucun impact n’a été montré sur l’utilisation des services de soins (visites aux urgences et réadmission à l’hôpital) dans le mois après la sortie. Finalement, la dernière partie de ce travail a permis de développer une information sur les médicaments destinée aux pharmaciens d’officine à la sortie de l’hôpital du patient. Une étude prospective a évalué l’effet de la remise de cette information, dénommée feuille de transfert, par le pharmacien clinicien au patient. Une enquête en ligne ouverte à tous les pharmaciens d’officine a par ailleurs évalué leurs besoins en information. Il a été observé que la communication d’une feuille de transfert contenant des informations sur le traitement médicamenteux à la sortie de l’hôpital présente un réel intérêt pour le pharmacien d’officine. Ces informations vont en effet au-delà des informations retrouvées sur une prescription médicale. Néanmoins, la feuille de transfert devrait inclure davantage d'informations nécessaires pour la réalisation des soins pharmaceutiques. <p><p>En conclusion, ce travail a permis de développer, d’une part, un nouvel outil de détection et de classification des discordances médicamenteuses médicalement non justifiées et d’autre part, un modèle de pratique qui a montré son efficacité sur la continuité des traitements médicamenteux lors de la sortie des patients de l’hôpital à leur domicile, en maison de repos et en revalidation. Toutefois, des perspectives d’amélioration de ce modèle ont été mises en évidence et mériteraient une attention particulière dans le futur. / Doctorat en Sciences biomédicales et pharmaceutiques / info:eu-repo/semantics/nonPublished

Every year, millions of medical errors are committed, costing not only patient health and satisfaction, but thousands of lives and billions of dollars. Errors occur in many areas of the healthcare environment, including the profession of nursing. Nurses provide and delegate patient care and consequently, standard nursing responsibilities such as medication administration, charting, patient education, and basic life support protocol may be incorrect, inadequate, or omitted. Although there is much literature about errors among the general nurse population and there is indication that new nurses commit more errors than experienced nurses, not much literature asks the following question: What are the factors contributing to the commission of errors, including the omission of standard nursing care, among new nurses? Ten studies (quantitative, qualitative, and mixed-mode) were examined to identify these factors. From the 10 studies, the researcher identified the three themes of lack of experience, stressful working conditions, and interpersonal and intrapersonal factors. New nurses may not have had enough clinical time, may develop poor habits, may not turn to more experienced nurses and other professionals, may be fatigued from working too many hours with not enough staffing, may not be able to concentrate at work, and may not give or receive adequate communication. Based on these findings and discussion, suggested implications for nursing practice include extended clinical experience, skills practice, adherence to the nursing process, adherence to medications standards such as the five rights and independent double verification, shorter working hours, adequate staffing, no-interruption and no-phone zones, creating a culture of support, electronically entered orders, translation phones, read-backs, and standardized handoff reports.