الفهرس 
review of literature
methodsOnly 14 pages are availabe for public view
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Abstract
Medication error is one of the most important problems in any
health care system. According to the institute of medicine in 2006,
there are 1.5 million medication errors resulting in patient harm every
year in U.S. Medication errors can be defined as: ””any preventable
event that may cause or lead to inappropriate medication use or
patient harm while the medication is in the control of the health care
professional, patient, or consumer. Such events may be related to
professional practice, health care products, procedures, and systems,
including prescribing; order communication; product labeling,
packaging, and nomenclature; compounding; dispensing; distribution;
administration; education; monitoring; and use.”
In order to prevent or decrease medication errors, first we
need to detect them. One of the best methods for error detection is the
voluntary reporting of errors from health professionals. Medication
errors should be periodically reported not only within the health care
organization but also to national patient safety organizations.
Through this we can learn from our previous experiences and design
new educational programs. Such national reporting systems is found
all over the world e.g. in United states, Canada, England, France,
Spain, New Zeeland and others.
Despite the clear benefit of voluntary reporting of errors,
unfortunately, there are a very small percent of error actually
reported. A number of previous researches have studied those
reporting barriers from health care professionals’ perspective. Of the
most important barriers were fear of blaming, lack of time, lack of
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believe in the importance of reporting, unavailability of suitable
reporting system, inability to know all the details of the event, and
finally lack of clear definition of medication errors.
Safe medication use is the main core of pharmacy profession,
and medication use is a very complex process, into which pharmacist
can be involved in all its steps to prevent error occurrence.
Accordingly, pharmacists must learn to detect errors, identify their
causes and suggest specific action to prevent patient harm.
This study aims at quantitatively describing the medication
error problem in Egypt on the national level. This was done by
gathering medication error reports, analyzing the results and drawing
trends that show most common types, causes and medications
involved in errors. In this study we have analyzed reports submitted
to the Egyptian medication error (ME) reporting system from June to
December 2014. The study also investigated reporting barriers from
the pharmacists’ perspective, before and after using the national
reporting system.
In order to achieve our aim, we have established the national
office for handling and reduction of medication errors (NO HARMe)
and we designed the national online medication error reporting
system. The main objective of this system is to benefit from previous
errors and to share experiences between different health care
organizations in Egypt. This reporting system was characterized by
being internet based, voluntary and non punitive, confidentiality and
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safety of all personal information of patients, reporters and health
professionals and finally by the optional anonymity of the reporter.
After establishing the system we have trained 50 hospital
pharmacists from different organizations on how to detect and report
medication errors through the new system. The pharmacists started
reporting errors through the national system and after 6 months, we
have reviewed and analyzed all the submitted reports. Analysis of
data included patients age and gender, health care setting, stage at
which the error occurred, type of error, medications involved, patient
outcome, causes and recommendations for error prevention.
By the end of the study, pharmacists were surveyed to assess
the reporting barriers from their perspective before using the new
system and how it changed after being trained on the new national
system. They have been also asked to evaluate the reporting form and
provide their feedback on the system.
Over the course of 6 months, 12 000 valid reports were
gathered and included in
this analysis. The majority (66%) came from inpatient settings, while
23% came from
intensive care units, and 11% came from outpatient departments.
Prescribing errors were
the most common type of MEs (54%), followed by monitoring (25%)
and administration
errors (16%). The most frequent error was incorrect dose (20%)
followed by drug
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interactions, incorrect drug, and incorrect frequency. Most reports
were potential (25%),
prevented (11%), or harmless (51%) errors; only 13% of reported
errors lead to patient
harm.
The top three medication classes involved in reported MEs were
antibiotics, drugs
acting on the central nervous system, and drugs acting on the
cardiovascular system.
Causes of MEs were mostly lack of knowledge, environmental
factors, lack of drug
information sources, and incomplete prescribing. Recommendations
for addressing MEs
were mainly staff training, local ME reporting, and improving work
environment.
from the questionnaire analysis; four reasons represented the
major reporting barriers for pharmacists before training on the new
system. Those barriers were, lack of knowledge that MEs should be
reported, lack of knowledge on how to report them, unavailability of
specific reporting form and inability to know the details of the
medication incident or event. The main barrier that stills prevent
some participants from reporting, is their inability to be directly
involved in the medication use process. Generally all barriers reduced
after training and availability of the national form. According to their
feedback two criteria can be considered successful with the mode of
selection being (excellent). Those criteria are; ease of access to the
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online form and feeling safe because their information is confidential
and secured. On the other hand, five other items identify possible
areas for system improvement with the mode of selected evaluation
was (good).
As a conclusion, we can say that though there are many
difference between health care organizations and despite the well
known limitations of voluntary reported data, there is no doubt that
analyzing reports submitted to this national system is very useful in
determining priorities for future research in the field of medication
safety in Egypt and for suggesting error prevention strategies. From
the results we can conclude that prescribing was the most common
stage involved in errors and that incorrect dose is the most common
error type. We have also found the antibiotics is the medication class
mostly prone to medication errors.
Within the scope of our study we can also say that the new
online reporting system along with training programs both had a great
impact on motivating pharmacists to report errors and substantially
reduce the reporting barriers. However, pharmacists must be more
engaged into the medication use process and able to communicate
directly with patients and other health team members to further
activate their role in detecting and preventing medication errors.