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Medication errors in the care transition of trauma patients

  • Pharmacoepidemiology and Prescription
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Rationale, aims, and objective

Traumatological patients are vulnerable to medication error given multiple handoffs throughout the hospital since they often require rapid diagnosis and management of multiple concurrent complex conditions. The purpose of this study was to analyze the medication errors (MEs) occurring in the care transition of the traumatological patient. The secondary objectives were to classify the MEs and the level of risk of the pharmacological groups involved. In addition, the causes and contributing factors of those MEs were analyzed.

Methods

An observational, descriptive, and prospective study, spanning 4 months, was performed in a tertiary hospital. All patients admitted to the traumatology service were selected for the study. Data were collected in different locations of the hospital stay: Emergency Service, Resuscitation and Post-Anaesthesia Unit, and Traumatology Hospitalization Unit. In each location, data from the different processes (reconciliation, prescription, validation, dispensing, and administration of medicines) were collected. The medication error (ME) was established as a dependent variable.

Results

A total of 31.3% (132) of the patients analyzed showed some ME. The Traumatology Unit was the location where most errors were detected, followed by the Emergency Service. Having analyzed all the locations, it was observed that 64.2% (172) of the MEs were detected in the reconciliation process, 29.5% (79) in the prescription, 3.7% (10) in the dispensing, 1.5% (4) in the administration, and 1.1% (3) in the validation. In terms of risk weighting, the drugs involved in the MEs detected were 53.8% of medium risk, 20.7% of high risk, and 20.3% of low risk.

Conclusions

There is a high prevalence of MEs in the reconciliation process of medication in traumatological patients (64.2%) from our hospital setting. Interestingly, most MEs occurred in this process regardless of the location in the healthcare chain.

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References

  1. Grau J, Santiñá M, Combalia A, Prat A, Suso S, Trilla A (2010) Fundamentos de seguridad clínica en cirugía ortopédica y traumatología. Rev esp cir ortop traumatol (4):251–258

    Article  Google Scholar 

  2. Helo S, Moulton CE (2017) Complications: acknowledging, managing, and coping with human error. Transl Androl Urol 6(4):773–782. https://doi.org/10.21037/tau.2017.06.28

    Article  PubMed  PubMed Central  Google Scholar 

  3. Otero López MJ (2010) El papel del farmacéutico en la gestión de la seguridad de los medicamentos diez años después de la publicación del informe “Errar es Humano”. Farm Hosp 34(4):159–162. https://doi.org/10.1016/j.farma.2010.05.001

    Article  PubMed  Google Scholar 

  4. Ministerio de Sanidad y Consumo (2008) Estudio de evaluación de la seguridad de los sistemas de utilización de los medicamentos en los hospitales españoles (2007). Informe Mayo:2007

  5. Vargas M, Recio M (2008) Versión española de University of Michigan Health System Patient Safety Toolkit. Mejorando la seguridad del paciente en los hospitales: de las ideas a la acción. Traducción de, vol 2008

  6. Muñoz García M (2013) Criterios stopp/start versus criterios de beers, aplicación en diferentes unidades de hospitalización. Universidad Complutense de Madrid, Madrid

    Google Scholar 

  7. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL (2006) Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 166(9):955–964. https://doi.org/10.1001/archinte.166.9.955

    Article  PubMed  Google Scholar 

  8. Jacobi J (2016) Farmacéuticos clínicos: profesionales esenciales del equipo de atención clínica. Rev Med Clin Condes (5):578–584

    Article  Google Scholar 

  9. Ministerio de Sanidad y Consumo. Estudio nacional sobre los efectos adversos ligados a la hospitalización: ENEAS 2005. 2006

    Google Scholar 

  10. Guerro-Prado M, Olmo-Revuelto MA, Catalá-Pindado M (2018) Prevalence of medication-related problems in complex chronic patients and opportunities for improvement. Farm Hosp 42(5):197–199. https://doi.org/10.7399/fh.10899

    Article  PubMed  Google Scholar 

  11. Ministerio de Sanidad Servicios Sociales e Igualdad. Estrategia de Seguridad del Paciente del Sistema Nacional de Salud. Periodo 2015–2020. 2015

  12. World Health Organization, Safety. WAfP. Patient safety solutions. 2007

  13. Lashoher A, Schneider EB, Juillard C, Stevens K, Colantuoni E, Berry WR, Bloem C, Chadbunchachai W, Dharap S, Dy SM, Dziekan G, Gruen RL, Henry JA, Huwer C, Joshipura M, Kelley E, Krug E, Kumar V, Kyamanywa P, Mefire AC, Musafir M, Nathens AB, Ngendahayo E, Nguyen TS, Roy N, Pronovost PJ, Khan IQ, Razzak JA, Rubiano AM, Turner JA, Varghese M, Zakirova R, Mock C (2017) Implementation of the World Health Organization trauma care checklist program in 11 centers across multiple economic strata: effect on care process measures. World J Surg 41(4):954–962. https://doi.org/10.1007/s00268-016-3759-8

    Article  PubMed  Google Scholar 

  14. de Cantabria G (2014) Consejería de Sanidad y Servicio Sociales. Manual de seguridad del paciente quirúrgico, Servicio Cántabro de Salud

  15. Dolejs SC, Janowak CF, Zarzaur BL (2017) Medication errors in injured patients. Am Surg 83(7):780–785

    PubMed  Google Scholar 

  16. Otero López MJ, Castaño Rodríguez B, Pérez Encinas M, Codina Jané C, Tamés Alonso MJ, Sánchez Muñoz T et al (2008) Updated classification for medication errors by the Ruiz-Jarabo 2000 group. Farm Hosp 32(1):38–52. https://doi.org/10.1016/S1130-6343(08)72808-3

    Article  PubMed  Google Scholar 

  17. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to enhance accuracy of dispensing medications.1999. Available from: https://www.nccmerp.org/recommendations-statements. (Accessed 10 Feb 2019)

  18. Vélez-Díaz-Pallarés M, Delgado-Silveira E, Carretero-Accame ME, Bermejo-Vicedo T (2013) Using healthcare failure mode and effect analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients. BMJ Qual Saf 22(1):42–52

    Article  Google Scholar 

  19. Vicente Oliveros N, Pérez Menéndez Conde C, Álvarez Díaz AM, Bermejo Vicedo T, Martín-Aragón Álvarez S, Montero Errasquín B et al (2018) Grading the potential safety risk of medications used in hospital care. Farm Hosp 42(2):53–61. https://doi.org/10.7399/fh.10840

    Article  PubMed  Google Scholar 

  20. Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV (2006) Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg 244(3):371–380. https://doi.org/10.1097/01.sla.0000234655.83517.56

    Article  PubMed  PubMed Central  Google Scholar 

  21. Wright A, Grady K, Galante J (2018) Automated postdischarge trauma patient call program. J Trauma Nurs 25(5):298–300. https://doi.org/10.1097/JTN.0000000000000391

    Article  PubMed  Google Scholar 

  22. Rentero L, Iniesta C, Urbieta E, Madriga M, Pérez MD (2014) Causas y factores asociados a los errores de conciliación en servicios médicos y quirúrgicos. Farm Hosp 38(5):398–404. https://doi.org/10.7399/fh.2014.38.5.1136

    Article  CAS  PubMed  Google Scholar 

  23. Delgado Sánchez O, Nicolás Picó J, Martínez López I, Serrano Fabiá A, Anoz Jiménez L, Fernández Cortés F (2009) Reconciliation errors at admission and departure in old and polymedicated patients. Prospective, multicenter randomized study. Med Clin (Barc) 133(19):741–744. https://doi.org/10.1016/j.medcli.2009.03.023

    Article  Google Scholar 

  24. Zoni AC, Durán García ME, Jiménez Muñoz AB, Salomón Pérez R, Martin P, Herranz Alonso A (2012) The impact of medication reconciliation program at admission in an internal medicine department. Eur J Intern Med 23(8):696–700. https://doi.org/10.1016/j.ejim.2012.08.013

    Article  PubMed  Google Scholar 

  25. Moriel MC, Pardo J, Catalá RM, Segura M (2008) Prospective study on conciliation of medication in orthopaedic patients. Farm Hosp 32(2):65–70. https://doi.org/10.1016/S1130-6343(08)72816-2

    Article  CAS  PubMed  Google Scholar 

  26. Allende Bandrés M, Arenere Mendoza M, Gutiérrez Nicolás F, Calleja Hernández M, Ruiz La Iglesia F (2013) Pharmacist-led medication reconciliation to reduce discrepancies in transitions of care in Spain. Int J Clin Pharm 35(6):1083–1090. https://doi.org/10.1007/s11096-013-9824-6

    Article  CAS  PubMed  Google Scholar 

  27. Pastó-Cardona L, Masuet-Aumatell C, Bara-Oliván B, Castro-Cels I, Clopés-Estela A, Pàez-Vives F et al (2009) Estudio de incidencia de los errores de medicación en los procesos de utilización del medicamento: prescripción, transcripción, validación, preparación, dispensación y administración en el ámbito hospitalario. Farm Hosp 33(5):257–268. https://doi.org/10.1016/S1130-6343(09)72465-1

    Article  PubMed  Google Scholar 

  28. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE (2005) Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 173(5):510–515

    Article  Google Scholar 

  29. Iniesta Navalón C, Urbieta Sanz E, Gascón Cánovas JJ, Madrigal de Torres M, Piñera Salmerón P (2011) Evaluación de la anamnesis farmacoterapéutica realizada en el servicio de urgencias al ingreso hospitalario. Emergencias. 23:365–371

    Google Scholar 

  30. Vélez-Díaz-Pallarés M (2012) Análisis modal de fallos y efectos en el proceso de prescripción, validación y dispensación de medicamentos. Madrid: Universidad Complutense de Madrid

  31. Bermejo Vicedo T, Álvarez Díaz A, Delgado Silveira E, Gómez de Salazar López de Silanes E, Pérez Menéndez Conde C, Pintor Recuenco R, et al. Análisis de los fallos detectados en el proceso de dispensación de medicamentos y los factores contribuyentes. Fundación MAPFRE2007

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Acknowledgements

The authors would like to thank all the members of the Trauma Safety Group. They made this study feasible by their dedication to improving patient safety and safe practice in the healthcare chain.

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Authors and Affiliations

  1. Servicio de Farmacia, Hospital Universitario Ramón y Cajal, Madrid, Spain

    Mª Ángeles Parro Martín, M. Muñoz García, E. Delgado Silveira & T. Bermejo Vicedo

  2. Departamento de Farmacología, Facultad de Farmacia, Universidad Complutense, Madrid, Spain

    S. Martin-Aragón

Authors
  1. Mª Ángeles Parro Martín
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  2. M. Muñoz García
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  3. E. Delgado Silveira
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  4. S. Martin-Aragón
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  5. T. Bermejo Vicedo
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Contributions

1. Design and conception of the manuscript: Parro Martín MA, Muñoz García M.

2. Data collection: Parro Martín MA.

3. Analysis and interpretation of data: Parro Martín MA, Muñoz García M.

4. Drafting, review, and approval of the submitted manuscript: Parro Martín MA, Muñoz García M, Delgado Silveira E, Martín-Aragón S, Bermejo Vicedo T.

Corresponding author

Correspondence to Mª Ángeles Parro Martín.

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The authors declare that they have no conflict of interest.

Ethics approval

All the procedures performed in this study, which involved human participants, were conducted in accordance with the ethical standards of the institutional and/or national research committees, with the 1964 Helsinki declaration and its later amendments, or with comparable ethical standards.

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Martín, M.Á.P., García, M.M., Silveira, E.D. et al. Medication errors in the care transition of trauma patients. Eur J Clin Pharmacol 75, 1739–1746 (2019). https://doi.org/10.1007/s00228-019-02757-3

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  • DOI: https://doi.org/10.1007/s00228-019-02757-3

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