DOI QR코드

DOI QR Code

Development of a Medication Error Prevention System and Its Influence on Patient Safety Culture and Initiatives

투약오류예방 시스템 구축에 따른 환자안전문화와 환자안전행위계획

  • Received : 2014.07.30
  • Accepted : 2015.02.03
  • Published : 2015.02.28

Abstract

Purpose: The objective of this study was to examine patient safety culture (PSC) and patient safety initiatives (PSI) according to IT-based medication errors prevention system which is constructed in this study, and to identify the relationships among system construction, perception to the usage, PSC and PSI. Methods: The subjects were 180 nurses who work at 12 different hospitals with over 300 beds. The questionnaire included the characteristics of participants, a system construction status, the perception to the usage using electric pharmacopoeia (EP), a drug dose calculation system (DDCS), a patient safety reporting system (PSRS) and a bar-code system (BS). The data were collected from July 2011 to August 2011. Descriptive statistics, ANOVA, Pearson correlation and MANOVA were used for data analysis. Results: Systems were constructed in participating hospitals; For EP and PSRS, 83.9%, DDCS, 50%, and BS, 18.3%. The perceptions on the usage of the system were marked highest in BS as 4.54 followed by EP as 3.85. There were significant positive correlations between PSI and EP construction (r=.17, p=.028); PSRS (r=.17, p=.028) and DDCS (r=.23, p=.002). Conclusion: The developed system for improving the user experiences and reducing medication errors was found out well accepted. It is hoped that the system is helpful for PSC and PSI improvement in clinical settings.

Keywords

References

  1. Kim EK, Lee SY, Eom MR. DICS Behavior pattern and medication errors by nurses. Journal of Korean Academy of Nursing Administration. 2013;19(1):28-38. https://doi.org/10.11111/jkana.2013.19.1.28
  2. Ahn SH. Analysis of risk factors for patient safety management. Journal of Korean Academy of Nursing Administration. 2006;12(3):373-84.
  3. Kim MS. Medication error management climate and perception for system use according to construction of medication error prevention system. Journal of Korean Academy of Nursing. 2012;42(4):568-78. https://doi.org/10.4040/jkan.2012.42.4.568
  4. Oh CA, Yoon HS. Perception and experience of medication errors in nurses with tess than one year job experience. Journal of Korean Academy of Fundamentals of Nursing. 2007;14(1):6-17.
  5. Ehsani SR, Cheraghi MA, Nejati A, Salari A, Esmaeilpoor AH, Nejad EM. Medication errors of nurses in the emergency department. Journal of Medical Ethics and History of Medicine. [electronic resource]. 2013;6:11.
  6. Keistinen T, Kinnunen M. Increased patient safety with an Internet-based reporting system. World Hospitals and Health Services: The official journal of the International Hospital Federation. 2008;44(2):37-9.
  7. Pierson S, Hansen R, Greene S, Williams C, Akers R, Jonsson M, et al. Preventing medication errors in long-term care: Results and evaluation of a large scale web-based error reporting system. Quality & Safety in Health Care. 2007;16(4): 297-302. http://dx.doi.org/10.1136/qshc.2007.022483
  8. Jones SW. Reducing medication administration errors in nursing practice. Nursing Standard. 2009;23(50):40-6. https://doi.org/10.7748/ns.23.32.40.s47
  9. Dimberg I, Grzymala-Lubanski B, Hagerfelth A, Rosenqvist M, Svensson P, Sjalander A. Computerized assistance for war farin dosage-effects on treatment quality. European Journal of Internal Medicine. 2012;23(8):742-4. http://dx.doi.org/10.1016/j.ejim.2012.07.011
  10. DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-codeassisted medication administration on medication error rates in an adult medical intensive care unit. American Journal of Health-System Pharmacy. 2009;66(12):1110-5. http://dx.doi.org/10.2146/ajhp080355
  11. Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, et al. Effect of bar-code technology on the safety of medication administration. The New England Journal of Medicine. 2010;362(18):1698-707. http://dx.doi.org/10.1056/NEJMsa0907115
  12. Lee YM. Safety accident occurrence to perceptions of patient safety culture of hospital nurses. Journal of the Korea Academia-Industrial Cooperation Society. 2012;13(1):117-24. https://doi.org/10.5762/KAIS.2012.13.1.117
  13. Reason J. Beyond the organizational accident: The need for "error wisdom" on the frontline. Quality & Safety in Health Care. 2004;13:28-33. http://dx.doi.org/10.1136/qshc.2003.009548
  14. Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L. Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital. Pediatrics. 2006;118(4):e1124-9. https://doi.org/10.1542/peds.2005-3183
  15. Anderson JG, Ramanujam R, Hensel D, Anderson MM, Sirio CA. The need for organizational change in patient safety initiatives. International Journal of Medical Informatics. 2006;75(12):809-17. http://dx.doi.org/10.1016/j.ijmedinf.2006.05.043
  16. Kim YM, Kim SY, Kim MY, Kim JH, Lee SK, Jang MK. Patient safety program and safety culture. Journal of Korean Academy of Nursing Administration. 2010;16(4): 455-65. https://doi.org/10.11111/jkana.2010.16.4.455
  17. Nam MH, Lim JH. The influences of the awareness of patient safety culture on safety care activities among nurse in smallmedium sized general hospitals. The Journal of Digital Policy and Management. 2013;11(1):349-59.
  18. Tabachnick BG, Fidell LS. Using multivariate statistics. 4th ed. Boston: Needham heights; 2001. p117.
  19. Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation: Cross-sectional surveys. British Medical Journal. 2000;320(7237):745-9. https://doi.org/10.1136/bmj.320.7237.745
  20. McFadden KL, Henagan SC, Gowen CR. The patient safety chain: Transformational leadership's effect on patient safety culture, initiatives, and outcomes. Journal of Operations Management. 2009;27:390-404. http://dx.doi.org/10.1016/j.jom.2009.01.001
  21. Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. International Journal of Production Economics. 2007;106:368-92. http://dx.doi.org/10.1016/j.ijpe.2006.07.005
  22. Raftopoulos V, Pavlakis A. Safety climate in 5 intensive care units: a nationwide hospital survey using the Greek-Cypriot version of the safety attitudes questionnaire. Journal of Critical Care. 2013;28(1):51-61. http://dx.doi.org/10.1016/j.jcrc.2012.04.013
  23. Seo JW. U-Health, the blue ocean of medicine & healthcare. Paper presented at: Induction of safety and convenient electric chart. In B. C. Jang (Chair); 2008 May; Seoul.
  24. Tsai SL, Sun YC, Taur FM. Comparing the working time between bar-code medication administration system and traditional medication administration system: An observational study. International Journal of Medical Informatics. 2010;79 (10):681-9. http://dx.doi.org/10.1016/j.ijmedinf.2010.07.002
  25. Mekhjian HS, Bentley TD, Ahmand A, Marsh G. Development of a web based event reporting system in an academic environment. Journal of the American Medical Informatics Association. 2004;11(1):11-8. http://dx.doi.org/10.1197/jamia.M1349
  26. Kim MS, Kim JS, Jung IS, Kim YH, Kim HJ. The effectiveness of error reporting promoting program on the nursing error incidence rate in Korean operating rooms. Journal of Korean Academy of Nursing. 2007;37(2):185-91. https://doi.org/10.4040/jkan.2007.37.2.185
  27. Winterstein AG, Johns TE, Rosenberg EI, Hatton RC, Gonzalez-Rothi R, Kanjanarat P. Nature and causes of clinically significant medication errors in a tertiary care hospital. American Journal of Health-System Pharmacy. 2004;61(18):1908-16.
  28. Lu MC, Yu S, Chen IJ, Wang KW, Wu HF, Tang FI. Nurses' knowledge of high-alert medications: A randomized controlled trial. Nurse Education Today. 2013;33(1):24-30. http://dx.doi.org/10.1016/j.nedt.2011.11.018
  29. Muething SE, Goudie A, Schoettker PJ, Donnelly LF, Goodfriend MA, Bracke TM, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130(2):e423-31. http://dx.doi.org/10.1542/peds.2011-3566.
  30. Nakajima K, Kurata Y, Takeda H. A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital. Quality and Safety in Health Care, 2005;14(2):123-9. http://dx.doi.org/10.1136/qshc.2003.008607