English abstract
A Bifocal Study of Medication Errors at Sultan Qaboos University Hospital.
Background: Medication errors are a serious concern of many healthcare organizations around the world. Ensuring patient safety is prime motive of many healthcare professionals. The human errors can be prevented if the system is made more resilient to errors, rather than working on individuals. A study conducted in Vienna revealed that almost one in five (19%) patients experienced one medication error and 14% experienced more than one error in intensive care units (ICUS). Medication errors in intensive care units affect one of the most vulnerable populations in the hospital. Since previous studies suggest that these errors can be reduced by improving organizational factors such as error reporting systems and routine checks, the purpose of this study was to help understand the underlying factors behind these errors and help us in prevention of these responsible factors. Pharmacists are playing a major role in catching these errors and reporting them. Interventions conducted by pharmacists are central in any organization, in order to ensure patient safety.
1. Occurrence of Parenteral Drug Administration Errors in Intensive Care Units.
Objective: To determine the frequency, characteristics and contributing factors of parenteral drug administration errors in Intensive care units and to suggest preventive measures.
Methods:
ii.
Design: A prospective cohort study over a period of three months by using self reporting method by hospital staff. Setting: All intensive care units in Sultan Qaboos University Hospital (SQUH). Participants: All patients staying in intensive care units in three months period.
iii.
Results: The occupancy rate of 120 patients in 558 bed days was 4.65 patients per bed day. In about 48.8% of patient bed-days, Continuous IV was used. Bolus IV was used in 44.6% and Subcutaneous in 6.6%. Antimicrobials were found to be used the most parenterally (21.4%), followed by Insulin (18.6%) and Sedatives/Analgesics (14.3%). No error report was received over a period of three months.
Conclusion: The issue of under-reporting needs to be addressed. The blame-free environment needs to be developed absence of which is hampering the healthcare staff to report errors independently.
2. Pharmacists' Interventions at Out-Patient Department on Issued Prescriptions.
Objective: To characterize the interventions carried out by the pharmacists at pharmacy department of SQUH.
Methods:
ii,
Design: A prospective study conducted over a period of 6 months by using pharmacist intervention form. Setting: Pharmacy department receiving prescriptions from Sultan Qaboos University Hospital (SQUH), Sultanate of Oman. Subjects: All completed interventions forms.
Results: Total 530 interventions were carried out for six months on 104055 prescriptions (rate = 0.5%). The administrative interventions were 0.4% whereas the clinical interventions were 99.6% (choice of drug = 22.5% and regimen = 77.1%). Dose related errors were the highest (40.9%) followed by frequency (15.8%. In 10% of the cases, a wrong drug was prescribed. Efficacy improved in 53% of the cases, avoided toxicity in 27.4% and avoided unnecessary exposure in 16.8%, Interventions prevented death or major organ damage in 2.1% cases, major in 31.9% and moderate in 40.8% cases. The average time consumed per prescription was 15.8 minutes.
Conclusion: Pharmacists play a vital role on catching the errors and reporting them thus ensuring patient safety.
