Browsing by Subject "vaaratapahtuma"
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(2023)Medication safety is an important target of development in health and social services systems internationally. Medication errors are one of the biggest risk factors in medication safety. Majority of the medication incidents could be avoided by improving the medication treatment process. Patient safety incident reporting systems enable health and social services to collect systematic data from risk factors within the medication treatment process. This study was conducted as a retrospective registry-based study where medication incidents that occurred in health and social care units reported by community pharmacies to the incident reporting system HaiPro from 21st of September 2021 to 31st of October 2022 were analysed. Cases that did not meet the criteria for this study (n=55) were removed from the original data (n=3841). If needed, the nature and type of the reported error were corrected. A descriptive quantitative analysis was conducted for the final data (n=3786) using Microsoft Excel. The number, natures, types, observers, and prescription types of medication errors were investigated from the data. In addition, the most common groups of medicinal substance and high risk medicines were identified. A qualitive content analysis was performed to near miss cases involving high-risk medications (n=446) using the Atlas.ti program. Interventions, measures following the interventions and risks prevented by the measures were identified from the open description in the incident reports. The qualitative analysis was performed as an abductive content analysis. Of the medication errors included in the study (n=3786) 91% were detected by community pharmacies and the majority (68%) of the reported incidents were near misses. Most (96%) of the safety incidents (n=3786) were associated with the patient’s medication treatment and had occurred mostly during the prescribing process (92%). As a result from the prescribing errors, patients were most commonly prescribed wrong dose or strength of the medicine (26%) or the prescription lacked SIC marking (26%). High-risk medications occurred in 16% (n=591) of the incidents (n=3786). Most frequently detected high-risk medications were opioids (35 %). Three quarters (76 %) of safety incidents associated with high-risk medications were near misses (n=446). The majority (92 %) of interventions (n=471) made to prevent safety incidents associated with high-risk medications were made by community pharmacies. The most frequent intervention was community pharmacies contacting the doctor. Based on the HaiPro incident reports made about medication errors in health and social care units reported by community pharmacies, it can be concluded that community pharmacies are a central barrier in primary care medication treatment process. Community pharmacies detect and report medication errors that have occurred in other health and social care units. Safety incidents reported by pharmacies systematically accumulate important information that can be used in the development of medication safety in primary care at a unit, wellbeing services county and national levels.
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(2024)Medication safety is critical in health and social care, and community pharmacies significantly participate in managing medication safety risks. The information systems in community pharmacies are pivotal, yet understudied tools supporting this task. This study investigates community pharmacy information system-related medication safety incidents reported by Finnish community pharmacies, focusing on how information systems act as defences or contributing factors to such incidents. The study is based on 1222 information system-related medication safety incident reports from the HaiPro system between October 2022 and September 2023. The structured fields of the incident reports were analysed with descriptive quantitative analysis using Microsoft Excel. An abductive content analysis was performed on narrative texts of the incident reports to identify information system-related risks or defences in the incidents. Reason's human error theory acted as a theoretical framework in this study. Results indicated that in 96% (n=1168) of the incidents, information systems were contributing factors, primarily during the selection of medicinal products for dispensing (n=945). The most common issue was the community pharmacy information system not offering generic substitutes for market-exited medicinal products (n=282). Another notable issue was compatibility problems between community pharmacy information systems and Electronic Patient Record (EPR) systems or between different community pharmacy information systems (n=154). Conversely, barcode recognition emerged as the most reported defence, preventing errors in 96% (n=52) of defensive cases (n=54). The study underscores the dual role of community pharmacy information systems in medication safety both as defences and contributing factors. It highlights the need for continuous system development and possible regulatory changes to enhance their effectiveness as defences. Future research should explore these systems' roles using alternative methodologies to address underreporting and better quantify their impact on medication safety.
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