• Title/Summary/Keyword: Prescribing errors

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Analysis of Chemotherapy Prescribing Errors Detected by Pharmacists (약사에 의해 탐지된 항암제 처방오류 분석)

  • Lee, Hyun-Ju;Yang, Mi-Kyung;Jo, Ju-Hee;Kim, Sung-Eun;Seok, Hyun-Ju;Kim, Hyun-Ah
    • Korean Journal of Clinical Pharmacy
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    • v.20 no.2
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    • pp.120-127
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    • 2010
  • Objective: The purpose of this study was to identify the type and frequency of chemotherapy-related prescribing errors and assess the pharmacist intervention in preventing potential harm. Methods: This study was performed in satellite pharmacy of oncology/hematology unit in tertiary teaching hospital from April to September, 2009. All chemotherapy prescribing errors detected by pharmacists were recorded. Frequency and characteristics of prescribing errors were analyzed. Pharmacists reviewed 28, 495 chemotherapy orders from 12,719 patients during 6-month periods. Results: A total of 835 prescription errors (2.93%) in 734 patients (5.77%) were detected by pharmacists. Alkylating agents (37.6%) followed by antimetabolite (23.35%), and mitotic inhibitors (21.44%) were the most prevalent classes in which errors occurs. The most common types of error detected were incorrect dose (34%), incorrect solution (33%), incorrect route (9%) and omission errors (8%). Changes in chemotherapy order due to pharmacists' intervention occurred in all error cases. Conclusion: Pharmacists' intervention in reviewing chemotherapy and drug orders intercepted potential harm due to prescribing errors. The current study provided strategies for reduction of medication errors.

Guideline of Improvement and Evaluation of Prescribing Errors in Colorectal Chemotherapy (대장암 항암 화학요법의 처방 오류 평가 및 개선안 제시)

  • Lim, Hyun-Soo;Lim, Sung Cil
    • Korean Journal of Clinical Pharmacy
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    • v.23 no.2
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    • pp.158-166
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    • 2013
  • Background: Colorectal cancer shows a significant increase in South Korea due to westernization of diet, lack of dietary fiber, drinking and smoking, irregular defecation. There are surgery, chemotherapy, radiation therapy in treatment of colorectal cancer. There may be a medication errors in the process of chemotherapy because of its high toxicity, narrow therapeutic index and the health status of cancer patients. Consequently medication errors can cause increasing the risk of death, prolonging hospital stay and increasing the cost. Among medication errors on medication use process, prescribing errors are of particular concern due to higher risk of serious consequences. It is important for pharmacist to prevent the prescribing errors before reaching patient. Therefore we analyzed the prescriptions of colorectal cancer, classified prescribing errors, suggested guideline to reduce prescribing errors and verified the importance of pharmacist's role in prevention of medication errors activity. Methods: We collected the numbers of prescriptions of colorectal cancer(n=2,373) through anti cancer management program and EMR and analyzed the errors of prescriptions by categories from Oct 1st 2011 to Sep 30th 2012 at Chungbuk National University Hospital. We reviewed the prescriptions as follows - patients' characteristics, the result of test, previous prescriptions, characteristics of antineoplastic agents and patients' allergy, drug sensitivity, adverse events. Prescriptions are classified into inpatient and outpatient and analyzed the errors of prescriptions by categories (dosage form, dose, input, diluents, regimen, product). Results: Total prescription number of inpatient and outpatient of colorectal cancer was 1,193 and 1,180 and that of errors was 107(9%) and 22(1.9%), respectively. In case of errors of categories, the number of errors of dosage form is 69 and 8, errors of dose is 15 and 5, errors of input is 9 and 9 in inpatient and outpatient prescriptions, respectively. Errors of diluents is 8, errors of regimen is 3, errors of product is 3 in only inpatient prescriptions. In case of errors of categories by inpatient department, the number of errors of dosage form is 34 and 35, errors of dose is 7 and 8, errors of input is 6 and 3, errors of diluents is 4 and 4, errors of regimen is 2 and 1, errors of product is 2 and 1 in SG and HO, respectively. In case of outpatient department, the number of errors of dosage form is 8 in HO, errors of dose is 5 in HO, errors of input is 5 and 4 in SG and HO, respectively. Conclusions: The rate of errors of inpatient is higher than that of outpatient. Junior doctors are engaged in prescriptions of inpatient and pharmacist need to pay attention to review all prescriptions. If prescribing errors are discovered, pharmacist should contact the prescriber and correct the errors without delay. The guideline to reduce prescribing errors might be upgrading software of anti cancer management program, education for physicians as well as pharmacists and calling prescriber's attention to preventing recurrence of errors.

Analysis of Effects of Chemotherapy using Failure Mode and Effect Analysis (FMEA) on Patient Safety and Safe Nursing (고장유형영향분석을 활용한 항암화학요법의 환자안전간호 효과분석)

  • Yang, Nam Young;Lee, Mi Hyang
    • Journal of Korean Academy of Nursing Administration
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    • v.21 no.3
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    • pp.254-262
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    • 2015
  • Purpose: This study was done to apply failure mode & effect analysis (FMEA) to chemotherapy in order to reduce prescribing, dispensing and administering errors related to treatment and provide patients with a safe medical environment. Methods: A one group pre-post test design was used to verify the effects using the tool for FMEA in chemotherapy. Results: There was a statistically significant decrease in prescribing errors from 11.47% to 3.18%; administering errors decreased but they were not statistically significant. In a addition, there was no change in dispensing errors. Conclusion: The results show that FMEA removed risk factors that might occur during the process of chemotherapy and that it was an effective tool for prevention of negligent accident occurring in actual patients.

Therapeutic Duplication as a Medication Error Risk in Fixed-Dose Combination Drugs for Dyslipidemia: A Nationwide Study

  • Wonbin Choi;Hyunji Koo;Kyeong Hye Jeong;Eunyoung Kim;Seung-Hun You;Min-Taek Lee;Sun-Young Jung
    • Korean Journal of Clinical Pharmacy
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    • v.33 no.3
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    • pp.168-177
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    • 2023
  • Background & Objectives: Fixed-dose combinations (FDCs) offer advantages in adherence and cost-effectiveness compared to free combinations (FCs), but they can also complicate the prescribing process, potentially leading to therapeutic duplication (TD). This study aimed to identify the prescribing patterns of FDCs for dyslipidemia and investigate their associated risk of TD. Methods: This was a retrospective cohort study involving drugs that included statins, using Health Insurance Review & Assessment Service-National Patient Sample (HIRA-NPS) data from 2018. The unit of analysis was a prescription claim. The primary outcome was TD. The risk ratio of TD was calculated and adjusted for patient, prescriber, and the number of cardiovascular drugs prescribed using a multivariable Poisson model. Results: Our study included 252,797 FDC prescriptions and 515,666 FC prescriptions. Of the FDC group, 46.52% were male patients and 56.21% were aged 41 to 65. Ezetimibe was included in 71.61% of the FDC group, but only 0.25% of the FC group. TD occurred in 0.18% of the FDC group, and the adjusted risk ratio of TD in FDC prescriptions compared to FC was 6. 44 (95% CI 5. 30-7. 82). Conclusions: Prescribing FDCs for dyslipidemia was associated with a higher risk of TD compared to free combinations. Despite the relatively low absolute prevalence of TD, the findings underline the necessity for strategies to mitigate this risk when prescribing FDCs for dyslipidemia. Our study suggests the potential utility of Clinical Decision Support Systems and standardizing nomenclature in reducing medication errors, providing valuable insights for clinical practice and future research.

A Case Study of Implementation of Concurrent Drug Utilization Review System at a General Hospital (동시적 의약품 사용평가(cDUR) 시스템 구축 및 적용 사례 연구 : 국내 한 대학병원을 중심으로)

  • Choi, Jong Soo;Kim, Dongsoo
    • Journal of Korean Institute of Industrial Engineers
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    • v.39 no.1
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    • pp.20-29
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    • 2013
  • Medical errors such as adverse drug event, improper transfusion, wrong-site surgery, mistaken patient identity and so on commonly occur at health care practice. Information technology, like Drug Utilization Review(DUR) system which reviews, analyzes, and interprets medication data when prescribing, can play a key role in reducing such medical errors and improving patient safety. Korean Government has guided all hospitals to implement concurrent DUR(cDUR) system, which is the first case worldwide in that all healthcare providers have to use cDUR system when prescribing. This paper introduced a case study that a tertiary hospital has integrated the cDUR system into its comprehensive Hospital Information System(HIS) and analyzed the whole prescription data during a week right after adoption of cDUR system. Considering technical strength and weakness, the cDUR system was integrated into the HIS, using Broker Servers for minimizing doctors' anxiety. As the quantitative analysis of the whole prescription data, DUR conflict events, which mainly included duplicate medications and contra-indicated drug interactions for outpatients, were 2.77%. Although only 0.7% is for the contra-indicated drug interactions, it will be greatly devoted to achieve the purpose of DUR such as improving patient safety.

Medication Errors in Chemotherapy Preparation and Administration: a Survey Conducted among Oncology Nurses in Turkey

  • Ulas, Arife;Silay, Kamile;Akinci, Sema;Dede, Didem Sener;Akinci, Muhammed Bulent;Sendur, Mehmet Ali Nahit;Cubukcu, Erdem;Coskun, Hasan Senol;Degirmenci, Mustafa;Utkan, Gungor;Ozdemir, Nuriye;Isikdogan, Abdurrahman;Buyukcelik, Abdullah;Inanc, Mevlude;Bilici, Ahmet;Odabasi, Hatice;Cihan, Sener;Avci, Nilufer;Yalcin, Bulent
    • Asian Pacific Journal of Cancer Prevention
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    • v.16 no.5
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    • pp.1699-1705
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    • 2015
  • Background: Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. Materials and Methods: This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Results: Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Conclusions: Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

Prescription, Transcription and Administration Errors in Out-Patient Day Care Unit of a Regional Cancer Centre in South India

  • Mathaiyan, Jayanthi;Jain, Tanvi;Dubashi, Biswajit;Batmanabane, Gitanjali
    • Asian Pacific Journal of Cancer Prevention
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    • v.17 no.5
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    • pp.2611-2617
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    • 2016
  • Background: Medication errors are common but most often preventable events in any health care setup. Studies on medication errors involving chemotherapeutic drugs are limited. Objective: We studied three aspects of medication errors - prescription, transcription and administration errors in 500 cancer patients who received ambulatory cancer chemotherapy at a resource limited setting government hospital attached cancer centre in South India. The frequency of medication errors, their types and the possible reasons for their occurrence were analysed. Design and Methods: Cross-sectional study using direct observation and chart review in anmbulatory day care unit of a Regional Cancer Centre in South India. Prescription charts of 500 patients during a three month time period were studied and errors analysed. Transcription errors were estimated from the nurses records for these 500 patients who were prescribed anticancer medications or premedication to be administered in the day care centre, direct observations were made during drug administration and administration errors analysed. Medical oncologists prescribing anticancer medications and nurses administering medications also participated. Results: A total of 500 patient observations were made and 41.6% medication errors were detected. Among the total observed errors, 114 (54.8%) were prescription errors, 51(24.5%) were transcribing errors and 43 (20.7%) were administration errors. The majority of the prescription errors were due to missing information (45.5%) and administration errors were mainly due to errors in drug reconstitution (55.8%). There were no life threatening events during the observation period since most of the errors were either intercepted before reaching the patient or were trivial. Conclusions: A high rate of potentially harmful medication errors were intercepted at the ambulatory day care unit of our regional cancer centre. Suggestions have been made to reduce errors in the future by adoption of computerised prescriptions and periodic sensitisation of the responsible health personnel.

A Study on the Individualized Teaching method for Underachievers in Mathematics (수학 학습 부진아의 개별화 교수 방법)

  • 류성림
    • Education of Primary School Mathematics
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    • v.3 no.2
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    • pp.115-131
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    • 1999
  • The purpose of this study is to examine meaning, factors, and diagnostic method of underachievers in mathematics and to propose the idea of the individualized teaching method for underachievers. For the first purpose, previous literatures on underachievers are reviewed. For the second purpose, this study described the procedure of developing the individualized instructional program, and the method of diagnosing and prescribing errors in mathematics. In the future, individualized instructional program need to be developed based on correct diagnosis of factors effecting under achievement for the effective teaching of underachievers.

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A Study on Developing the Teachers' Guide Book for Diagnosis and Prescription of Students' Mathematical Errors (수학과 오류의 진단과 처방에 관한 교사용 자료 개발 연구)

  • 김수미
    • School Mathematics
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    • v.5 no.2
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    • pp.209-221
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    • 2003
  • This study focuses on the necessity of developing the material for teachers who are involved in diagnosing and prescribing students' mathematical errors. And it also intends to stimulate the related research of this area. For this, it tries to suggest the fundamental components-(1)types and frequencies of errors, (2) diagnostic test kit, (3)causes of errors, (4)ideas for prevention, (5)ideas for correction, (6)practice for settlement, and (7) performance test kit and frame of the teaching guide book for the teachers according to the general procedure of diagnosis and prescription. Finally it provides the concrete research areas for the future study.

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Efficacy of new inspection system of Anticancer Drug Prescription (새로운 항암제 처방 감사 시스템 도입을 통한 의료의 질 향상)

  • Kim, M.S.;Kim, Y.K.;Lee, Y.J.;Choi, Y.J.;Shin, H.Y.;Song, Y.C.
    • Quality Improvement in Health Care
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    • v.14 no.2
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    • pp.125-132
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    • 2008
  • Background : The number of outpatient injected anticancer drug is increasing. and the pathway of prescribing, compounding, and injecting anticancer drug is processed very rapidly in out-patient department. Moreover, Dose of anticancer drug is often changed depending on side effect of patients. So we need more effective inspection of anticancer drug prescriptions. The purpose of this study was to analyze the prescription errors for anticancer drugs in Out-Patient Department and to suggest system to prevent them. Method : The study took place at Asan Medical Center from July to September 2007. The pharmacists performed inspection of anticancer drug prescriptions before compounding and injecting. We used protocol-based anticancer drug order program and Electronic Medical Record (EMR). Result : During the study period, we analyzed 4683 prescriptions for out-patient. And we detected 55 medication errors (1.2%). Most common errors included dosage above or below the correct ones (56.3%), followed by incorrect treatment duration. Because most of dosing errors were in the range of usual dosage, it was hard to detect them. So when inspecting the prescription, we considered the medical records of individual patients. As a result, we could raise the efficiency of intervention. Therefore inspection using EMR could possibly reduce the number of anticancer drug errors. Conclusion : we are preventing the medication errors on stability and dosage above or below the maximum therapeutic dose according to the previous inspection system. However most of dosing errors were in the range of usual dosage according to the result of this study. Because of there was interpatient variability of dosage depending adverse effect. For improvement of quality assurance, we suggest inspection system based on patient's medical history.

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