• 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.

• The Journal of the Convergence on Culture Technology
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• v.10 no.3
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• pp.625-633
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• 2024

This study was attempted to identify the perception and experience of hospital nurses on medication errors of high-risk intravenous drugs, and to identify the causes of medication errors and ways to improve them. The subjects of the study were nurses with work experience related to high-risk intravenous administration working at a university hospital located in D City, and data were collected between May 16 ~ 30, 2021. As a result of the study, six key factors were identified as the key factors in the safety of high-risk intravenous injections: the lack of a protocol for the administration of major drugs in each ward, the lack of training in the operation of the injection machine, the lack of standardized procedures for administering high-risk intravenous injections, the lack of individualized medication training for nurses, the lack or lack of the hospital's own drug list, and the lack of identification of drugs packaged in similar containers. At the nursing practice level, it is proposed to apply a high-risk intravenous medication safety program and conduct a future study to identify safety outcome indicators.

• Journal of Korean Biological Nursing Science
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• v.26 no.2
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• pp.83-98
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• 2024

Purpose: This study investigated how interprofessional education (IPE) related to medication for undergraduate healthcare students, including nursing students, has been designed and conducted. Furthermore, the outcomes of these IPE programs were evaluated. Methods: A scoping review was performed to understand the content and methods of IPE on medication for undergraduate healthcare students, including nursing students. A literature search was done using PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Research Information Sharing Service, and Korean Nursing Database in English between January 2000 and December 2022. In total, 14 papers were selected and reviewed. Results: Eleven research studies were conducted on the implementation of one-time IPE on medication safety or errors. Among them, six studies focused on providing IPE to nursing students alongside medical and pharmacy students, while three studies targeted nursing and medical students, and two studies focused on nursing and pharmacy students. The most commonly employed educational method was simulation, which was utilized in 12 studies. All studies consistently reported a positive impact on attitudes toward IPE and effective communication. Additionally, five studies evaluating medication knowledge reported improvements in participants' understanding of drugs. Conclusion: The effects of IPE related to medication for undergraduate nursing students have been confirmed. It is necessary to introduce IPE in the field of pharmacology.

• Korean Journal of Adult Nursing
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• v.27 no.1
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• pp.1-10
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• 2015

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.

• Child Health Nursing Research
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• v.28 no.4
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• pp.259-268
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• 2022

Purpose: Nursing students are susceptible to medication safety incidents in the neonatal intensive care unit (NICU) related to a lack of communication experience. The purpose of the present study was to investigate the impact of a NICU medication safety simulation (NMSS) focusing on communication clarity, patient hand-off confidence, and patient safety competency in senior-year nursing students. Methods: The study utilized a nonequivalent control group pretest-posttest design. In total, 60 nursing students were assigned to two groups. The experimental group participated in the NMSS, which included three medication error scenarios. Pairs of students completed the scenarios together in 10 to 20 minutes. Data were analyzed using the chi-squared test, independent t test, and ANCOVA. Results: The experimental group showed significant improvements in communication clarity (p=.015), and patient safety competency (p<.001) compared to the control group. Using the pretest values as covariates, patient hand-off confidence scores significantly increased (p=.027). Conclusion: Implementing the NMSS focusing on communication in the pediatric nursing curriculum helped students to communicate clearly and concisely about medication errors, and its use is recommended to promote patient safety competency in the NICU.

• 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.

• Korean Journal of Clinical Pharmacy
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• v.32 no.2
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• pp.116-124
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• 2022

Background: High-alert medications (HAMs) are medications that bear a heightened risk of causing significant patient harm if used in error. To facilitate safe use of HAMs, identifying specific HAM lists for clinical setting is necessary. We aimed to develop the national level HAM list for acute care setting. Methods: We used three-step process. First, we compiled the pre-existing lists referring HAMs. Second, we analyzed medication related incidents reported from national patient safety incident report data and adverse events indicating medication errors from the Korea Adverse Event Reporting System (KAERS). We also surveyed the assistant staffs to support patient safety tasks and pharmacist in charge of medication safety in acute care hospital. From findings from analysis and survey results we created additional candidate list of HAMs. Third, we derived the final list for HAMs in acute care settings through expert panel surveys. Results: From pre-existing HAM list, preliminary list consisting of 42 medication class/ingredients was derived. Eight assistant staff to support patient safety tasks and 39 pharmacists in charge of medication safety responded to the survey. Additional 44 medication were listed from national patient safety incident report data, KAERS data and common medications involved in prescribing errors and dispensing errors from survey data. A list of mandatory and optional HAMs consisting of 10 and 6 medication classes, respectively, was developed by consensus of the expert group. Conclusion: We developed national level HAM list for Korean acute care setting from pre-existing lists, analyzing medication error data, survey and expert panel consensus.

• Quality Improvement in Health Care
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• v.8 no.1
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• pp.22-42
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• 2001

Background : A study comparing unit dose drug distribution system(UDS) versus traditional drug distribution system(TDS) was conducted in Seoul National University Hospital. The objectives of this study were to identify safer drug distribution system and to measure the efficiency of both systems in utilizing nursing and pharmacist's time. Methods : The study was designed to compare the data on medication errors, nursing time and pharmacists' time before and after implementation of the UDS in the internal medicine and otorhinolaryngology care units. The data on actual medications administered to patients were obtained by a disguised observer during the study period. The data collected were then compared with the physicians' orders to determine the rate of medication errors. In addition, using ten-minute interval work-sampling method nursing and pharmacists' time were measured. Results : About 6% of medications were administered incorrectly in the TDS, in comparison to 1.6% in the UDS. The rate of medication error decreased significantly in the UDS compared with the TDS. Mean times spent on medication-related activities by nurses were 34.1% in the TDS and 28.5% in the UDS. In the internal medicine care unit, nursing time associated with medications decreased significantly after the implementation of the UDS, but the reduction in medication-related nursing time in the otorhinolaryngology care unit was not significant. Pharmacist's medication-related work activities, increased from 2% in the TDS to 20% in the UDS. Pharmacist's time spent on therapy-related activities increased significantly. Conclusion : The rate of medication errors in the UDS decreased significantly compared with the TDS. Time spent on medication-related activities decreased for nurses while it increased for pharmacists. In summary, the UDS was estimated to be safer and to utilize of pharmacists' and nursing time more efficiently than the TDS.

• Journal of Preventive Medicine and Public Health
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• v.47 no.5
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• pp.273-280
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• 2014

Objectives: To evaluate the occurrence of patient adverse events in Korean hospitals as perceived by nurses and examine the correlation between patient adverse events with the nurse practice environment at nurse and hospital level. Methods: In total, 3096 nurses working in 60 general inpatient hospital units were included. A two-level logistic regression analysis was performed. Results: At the hospital level, patient adverse events included patient falls (60.5%), nosocomial infections (51.7%), pressure sores (42.6%) and medication errors (33.3%). Among the hospital-level explanatory variables associated with the nursing practice environment, 'physician-nurse relationship' correlated with medication errors while 'education for improving quality of care' affected patient falls. Conclusions: The doctor-nurse relationship and access to education that can improve the quality of care at the hospital level may help decrease the occurrence of patient adverse events.

• Journal of Korean Academy of Fundamentals of Nursing
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• v.21 no.4
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• pp.403-412
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• 2014

Purpose: Shift work disrupts the synchronization between the human biological clock and the environment. Sleep disturbances are common for shift work nurses, and may threaten patient safety. This study was done to investigate the sleep characteristics and medication errors (ME) of intensive care unit (ICU) nurses who work shifts, and ascertain if there is an association between these factors. Methods: Data were collected using a self-report questionnaire from 126 ICU nurses on three shifts. Collected data included their sleep characteristics including sleep patterns and sleep disturbances, and ME for the past 2 weeks. Results: There were significant differences in sleep duration and sleep latency according to shift. Day shift nurses had the shortest sleep duration, and their sleep latency was the longest (about 49 minutes) compared to nurses on evening and night shifts; 54% reported sleep disturbances, 16% experienced ME, and among these nurses 50% were on the night shift. Logistic regression analysis revealed significant associations between nurses' sleep duration and ME (adjusted OR 0.52 [95% CI 0.32-0.85]). Conclusions: The results confirmed that shift work nurses in the ICUs experience sleep disturbance, and that less sleep is associated with ME.