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PS-017 Corrective actions after participating in the study multicentre watching for detection of medication errors (EMOPEM)
  1. I Plasencia Garcia,
  2. D Montero,
  3. MA Ocaña Gomez,
  4. M Suarez Gonzalez,
  5. J Merino Alonso,
  6. MA Navarro Davila,
  7. JA Morales Barrios
  1. Hospital Universitario Nuestra Señora de Candelaria, Pharmacy Service, Santa Cruz de Tenerife, Spain

Abstract

Background In 2014, we participated in the study EMOPEM through observation of drug administration errors.

Purpose To describe the corrective measures implemented after participating in the EMOPEM project.

Material and methods The study was conducted for a week, including holidays and weekdays and three nursing shifts. 4 hospitalisation floors representative of a general hospital were selected. After entering the data into the national database we obtained the following results: 306 observations, 201 (65.7%) with errors (considering time and patient information) and 24.51% regardless of patient information. The distribution of errors regardless of patient information was: omission (38%), error time (16%), incorrect speed of administration (12%), wrong dose (excess) (8%), failure to register (8%), erroneous preparation plant (8%) and others (10%). These results were presented in the functional unit risk.

Results The following measures were implemented:

change in the management and description of the active ingredients in drugs, in addition to describing possible routes of drug administration. A multidisciplinary working group on drug safety was established, consisting of nurses, doctors, quality unit and the pharmacy. This group has generated a guidesafe medication administration, including updates on antibiotic tables, annexes published on parenteral administration or subcutaneous administration, regulations for high risk medications and proper administration of low molecular weight heparins. Within the newsletter, edited by the pharmacy department, a section on safety and prevention of medication errors is included. The electronic health record programme now has a portal information pharmacy services, including programme therapeutic equivalents, and a part with information regarding medication administration accessible to all medical personnel. Regarding the errors of omission detected, it has been found that there were no differences in turn and several therapeutic groups were affected, whose causality is because nurses have fixed computers, but distant patients and sites of administration, so a pilot on the use of tablets has been suggested.

Conclusion The EMOPEM, as indicated by its objectives, has served to obtain an error rate, to identify and implement corrective measures to help reduce medication administration errors. The pharmacist must be proactive and lead this process.

References and/or acknowledgements Farm Hosp2012;365:356–67.

No conflict of interest

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