Prescribing
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All errors that occur during the decision process and in prescribing/ordering a medication for a patient. Includes: dose errors, wrong drug, wrong regimen and inappropriate drug. |
Transcription
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All errors associated with the transfer of verbal or written information from an order sheet or prescription to patient, medication chart or medical records. Includes: discrepancies in drug name, formulation, route, dose, dosing regimen and omission. |
Dispensing
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All errors that occur during the interpretation of medication prescriptions by the pharmacy staff and the subsequent selection, preparation, labelling and distribution of medication. |
Administration
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All errors that occur whilst a medication is being administered to a patient. Includes: omission, wrong drug, wrong dose, wrong time and wrong route. |
Monitoring
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All errors associated with the monitoring of clinical and/or laboratory data that assess the patient’s response to the administered drug therapy i.e. through therapeutic drug-monitoring practices. Includes: error in interpreting results, wrong dose suggestions, omission of suggestions and wrong drug suggestions to reverse condition. |
Contributing factors for medication error in each patient group
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Neonate
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Higher number of medications, lack of physician experience, high-intensity physician workloads, length of stay, low birth weights, gestational ages, similar-sounding or identical names and surnames, multiple-birth babies (i.e. twins), inability to communicate, more vascular lines, long hospitalizations and dispensing medications 2 hours after being ordered. |
Paediatric
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Seriously ill patients, inexperienced physicians, human error, equipment dysfunction and communication failures. |
Adult
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Polymedication prescriptions, physicians’ lack of pharmacology knowledge, stressful and high-paced work environment, staff performance deficits, failure to consider patient information, memory lapses and dose-checking processes. |
Elderly
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Taking five or more medications, prescribed nine or more medications, hospitalizations 13 days or longer, incidence of more than one chronic disease and multiple pathologies. |