On a smaller scale, in an analysis of 11 studies in South East Asia, it was found that the frequency of administration errors range from 15.2% to 88.6% of the time. Early or delayed dosage is the most common type of error, followed by omission errors and wrong dosages given.
Closer to home, a 2009 study published in the Singapore Medical Journal analysed medication errors in the neonatal ICU and revealed lapses in medication administrations. 95% did not involve another nurse to witness drug administration, 88% did not label individual medications before administration, and 71% did not visually inspect a patient’s ID tag. These lapses were usually preventable administration errors, that occur 31% of the time.
Medication errors due to human-calculation errorsExperts say that this can be partially blamed due to the prescription of drugs depending on weight, which is normally subject to human-calculation errors. As medications are packaged in dosages only suitable for adults, there is often a need for dilution by pharmacists and providers (often parents), who frequently use spoons or other utensils instead of quantitative equipments.
“This scenario plays out with dozens of patients a day. You may not be giving them enough medication to reduce their pain. The opposite is you could give them more or overdose them,” as Jamie Irizarry, medication safety nurse at the Children’s Hospital of Philadelphia, explains.
Medication errors by parents can be solved in many ways. Jamie Harris, a nurse at Boston Children's hospital, has developed a special kit equipped with medications, instructions and dosage tools that comes with a bright red warning sign displaying “Distraction Free Zone”, designed to keep parents alert and on-task.
Another solution, developed by assistant professor Shonna Yin at the paediatrics and population health at NYU Langone Medical Center, uses cartoonlike diagrams with dosages written in layman language. This resulted in parents becoming less prone to errors as they are more knowledgeable and are able to accurately give the prescribed dosage.
Hospitals adopt sophisticated technology to address errorsIn hospitals, medication delivery systems can be used to prevent administration errors such as keying in one misplaced number or decimal point into software that programs pumps to automatically drip a medication at a prescribed rate. The systems are directly connected to physicians, allowing the direct delivery of instructions and thus minimising communicative and human errors.
“It would either warn me, ‘Do you really want to do this?’ or, in fact, stop me (from giving the medication),” explains Michelle Mandrack, previously an acute-care nurse and now a consultant for a Philadelphia-based Safe Medication Practices. It provides a safety net for healthcare professionals, taking away additional stress.
Local inventions to help enhance hospital efficiencyIn Singapore, a healthcare technology company, Cadi Scientific, has developed a temperature and location tracker that will alert caregivers when the patient is running a temperature, and update the hospital database on the patient’s whereabouts accordingly. The tracker, only slightly larger than a 50 cent coin (23mm), is now implemented in Thomson Medical Centre, Gleneagles Hospital as well as hospitals in Malaysia, Thailand, Taiwan and China.
The company has also invented a contact tracing smart tag for hospital staff to track how long a nurse has spent with a particular patient. The tag automatically logs reports and has reportedly streamlined the hospital staff’s task scheduling and enhanced efficiency. MIMS
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