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Using Home Visits to Understand Medication Errors in Children - Advances in Patient Safety: New Directions and Alternative Approaches (Vol. Near misses and unsafe conditions reported in a Pediatric Emergency Research Network -- Ruddy et al. Design This is a secondary analysis of 1a€…year of incident reports (IRs) from 18 EDs in 2007a€“2008. Conclusions Medication and process-related issues are important causes of near miss and unsafe conditions in the network.
IR systems at the start of the study under-represent latent safety threats at most of the institutions. Descriptive statistics were used to present the frequency and proportion of types, staff involved and contributing factors. FiguresA 2 and 3 depict the rates for each of near misses and unsafe condition for all 18 hospitals, expressed as reports per 1000 patients. FigureA 5 depicts the numbers of IRs from all reporting sites by type or category and separate bars for near miss and unsafe conditions. Medication near misses predominate, followed closely by laboratory, radiology and process-related IRs. There were 461 of 487 IRs (94.7%) where a contributing factor could be identified by the investigators (table 1). TablesA 2 and 3 demonstrate the human factors issues reported in near miss and unsafe condition reports. Medication and process-related report selection by the PI were performed when these types described latent safety conditions. Overall, within the network, there are increased reporting of latent safety threats since 2008. Contributors RMR, JMC and KNS contributed to the conception of the work, acquisition of data and interpretation of results.
43 (Prepared by the University of California at San Franciscoa€“Stanford Evidence-based Practice Center under Contract No.
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Dr Gene Ong received his MBBS in National University of Singapore during the period of  1995-2000. He is a clinical tutor in paediatric medicine for Yong Loo Lin Medical School and Duke’s Medical University, Singapore and is a faculty member in the Accreditation Council for Graduate Medicine in Emergency Medicine, Joint Committee on Basic Specialty Training in Emergency Medicine, Singapore. After observation of medication administration and pill counts, the labels of all medications in the home are compared to a list of home medications obtained from the chart, and the parent is asked about any discrepancies.
If a specific incident involving two patients or two distinct events occurred, we analysed each separately.
The investigators elicited more than one contributing factor in some IRs; thus the totals are greater than 100%. He successfully obtained his postgraduate qualifications (MRCPCH, UK) in Paediatric Medicine in 2004.

Ong is also a course instructor in Adanced Cardiac Life Support, Advanced Trauma Life Support, Advanced Resuscitation in Children, Emergency Airway Management and Hazmat Medical Life Support Courses.
The primary measure for this portion of the study is percent of home visits where the prescription medication list is accurate.
Currently, he is working as a Consultant in the Department of Paediatric Emergency Medicine in Kandang Kerbau Hospital, Singapore. The purpose of the interview is to identify parents’ perception of barriers to effective home use of medications for their child(ren) with chronic disease and to describe possible prior medication errors occurring in the clinic or in the home. He is also serving as a member of the National Resuscitation Council, Paediatric Subcommittee (Singapore), Emergency Airway Management Course Scientific Committee, KK Hospital Resuscitation and Emergency Code Committee and core member of the State of Emergency Medical Care in Singapore Workgroup and chairperson of its Paediatric Emergency Care Subcommittee. Parents are also asked for recommendations for systemic changes that would help them to avoid outpatient and home medication errors in the future. Questions were developed from a clinic-based pilot survey of parents of children with chronic conditions and were refined in pilot home visits (Table 3). 2009]An exploratory comparison of medication lists at hospital admission with administrative database records.Warholak TL, McCulloch M, Baumgart A, Smith M, Fink W, Fritz W. Gurwitz, MD.*From the Meyers Primary Care Institute, a joint endeavor of the University of Massachusetts Medical School, the Fallon Clinic Foundation, and Fallon Community Health Plan, Worcester, MA (Dr. Physician Review and Event ClassificationAll possible medication errors detected during observation, medication label review, and potentially dangerous errors in medication reconciliation are recorded on a standardized error reporting form.
A prospective observational study of medication errors in general medicine department in a tertiary care hospital.[Drug Metabol Drug Interact. This form is an adaptation of forms utilized in outpatient adults and inpatient children, with modifications based on results of the literature review and pilot work30, 50 (Appendix B). 2013]A prospective observational study of medication errors in general medicine department in a tertiary care hospital.Karthikeyan M, Lalitha D. Gurwitz); The Department of Pediatrics, University of Massachusetts School of Medicine, Worcester, MA (Dr.
The error reporting form provides space for a detailed description of the incident, including information about any systems failures that may have caused the error and any patient injury that resulted from the error. Additional sections support this description, by naming the system failures that occurred and possible improvements to the system that may have prevented the error.Possible medication errors are subsequently reviewed by two trained study physicians.
One challenge we found in scheduling the visits is that home medication administration usually occurs before school or during evening hours for those children enrolled full time in school.
Interrater reliability for severity was not calculated due to the small sample size.Preliminary DataThe rate of errors from our pilot work was surprisingly high.
In 12 pilot home visits, 16 medication errors were detected, including seven serious medication errors. Errors detected during observation included the use of a twice-a-day medication once a day and carrying EpiPen®s for a nut allergy that were expired.
Parents discussed problems with medication use such as using syringes where none of the markings were visible or a child taking and vomiting twice-concentrated medication for 5 days before the family recognized that the medicine was incorrectly reconstituted.When assessing an error-detection method, it is also important to consider whether the data collected during home visits will be valuable in developing systems-based improvements. Direct observation was found to be more efficient and accurate than chart review and incident reports.10LimitationsOne concern with the use of observation to measure error rates is the idea that people will avoid making errors when being observed (Hawthorne effect).

However, in a study of direct observation of nurses for administration errors, Dean found no difference between observation and no observation periods in the percentage of omitted doses and no change in the error rates with repeated observations.43 In addition, our literature review demonstrates that parents are frequently unaware that they are making errors and are therefore unable to consciously avoid making errors when being observed.
Study nurses are trained in nonintrusive, nonjudgmental methods to avoid altering the normal pattern of home medication use.
In this setting, if the observer notices a potentially dangerous medication error that is about to negatively affect the patient, the observer is obligated to intercept the error prior to medication administration.It is possible, however, that given a few more seconds, the parent may have intercepted the error himself or herself.
In pilot testing, the research nurse never observed an error that required her intervention.
In addition, home visits require a significant time commitment, compared with chart review or telephone survey methods.
Nevertheless, in inpatient research, direct observation is considered a better method to detect administration errors.ConclusionIn the outpatient setting, pediatric home medication errors have not been studied with sufficiently rigorous methods to provide the information needed to guide development of interventions to support self-management of medicines. Building on existing research, we described the use of home visits with observation of medication administration to identify pediatric home medication errors. The home visit could be expanded to measure rates of errors in medication use among the entire family, rather than just children with chronic disease. Therapeutic misadventures with acetaminophen: Hepatoxicity after multiple doses in children. These home visit and ethnographic methods may aid those interested in cultural differences in medication use, compliance, and disease care. Health literacy could be evaluated during home visits to assess the relationship between parent health literacy and parent administration errors. Similar methods could also be used to understand medication use by children with chronic disease in schools. Implication of dispensing cups in dosing errors and pediatric poisonings: A report from the American Association of Poison Control Centers.
These methods may be used to develop and test interventions to prevent systems failures associated with serious medication errors in outpatient children with chronic disease.In summary, little information is available about pediatric medication errors in the home, where the vast majority of pediatric medications are taken, in part because current research methods are not adequate for the home setting.
Building on approaches utilized in outpatient adults and children and on prior inpatient observation studies of nurse administration, we developed home visit methods to detect pediatric home medication errors. These home visit methods may be used to understand and quantify home medication errors in many different patient populations, providing information needed to better support safe medication self-management.AcknowledgmentsDr.
Parents as advocates: Stories of surplus suffering when a child is diagnosed and treated for cancer.
Preventing medication errors in ambulatory care: The importance of establishing regimen concordance.
Validity and reliability of observational methods for studying medication administration errors. Insufficient communication about medication use at the interface between hospital and primary care.

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