TITLE:
Analysis of 3 Serious Medication Errors in Provincial Hospital
AUTHORS:
Ning Hou, Hui Tang
KEYWORDS:
Medication Error; Cause Analysis; Medication Safety; Prevent Measure
JOURNAL NAME:
Pharmacology & Pharmacy,
Vol.5 No.4,
April
22,
2014
ABSTRACT: Background: Medication
errors are a common problem in Chinese hospital, with potentially harmful
consequences for patients. The objective of this study was to analyze the cause
of typical serious medication errors in some first-class provincial hospital to
prevent medication error and improve rational use of drug and ensure patients
administration security. Medication errors were collected between September 1,
2012 and August 31, 2013. 332 cases’ medication errors were categorized as
harmful or not according to NCC MERP’s Index and other indexes such as type of
error and causes of error. We focus on analyzing the 3 serious cases (0.9%, n =
3) among the all MEs that may have contributed to or resulted in temporary harm
to the patient and required intervention, including the process and the cause
and the background of the errors. The case analysis reminds us to pay more
attention to prevent medication errors. The preventive medication error’s measures
are explored through the analysis of the causes, such as forcing functions and
constraints, automation and standardization, double-checking systems, rules and
policies, information and more careful working. Conclusion: This analytical
study demonstrates that medication error is an objective existent in hospital.
It is especially important to ensure patient medication safety for reporting
and analyzing medication error in order to explore measures preventing
medication error.