• Asian Pacific Journal of Cancer Prevention
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• v.17 no.5
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• pp.2611-2617
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• 2016

Background: Medication errors are common but most often preventable events in any health care setup. Studies on medication errors involving chemotherapeutic drugs are limited. Objective: We studied three aspects of medication errors - prescription, transcription and administration errors in 500 cancer patients who received ambulatory cancer chemotherapy at a resource limited setting government hospital attached cancer centre in South India. The frequency of medication errors, their types and the possible reasons for their occurrence were analysed. Design and Methods: Cross-sectional study using direct observation and chart review in anmbulatory day care unit of a Regional Cancer Centre in South India. Prescription charts of 500 patients during a three month time period were studied and errors analysed. Transcription errors were estimated from the nurses records for these 500 patients who were prescribed anticancer medications or premedication to be administered in the day care centre, direct observations were made during drug administration and administration errors analysed. Medical oncologists prescribing anticancer medications and nurses administering medications also participated. Results: A total of 500 patient observations were made and 41.6% medication errors were detected. Among the total observed errors, 114 (54.8%) were prescription errors, 51(24.5%) were transcribing errors and 43 (20.7%) were administration errors. The majority of the prescription errors were due to missing information (45.5%) and administration errors were mainly due to errors in drug reconstitution (55.8%). There were no life threatening events during the observation period since most of the errors were either intercepted before reaching the patient or were trivial. Conclusions: A high rate of potentially harmful medication errors were intercepted at the ambulatory day care unit of our regional cancer centre. Suggestions have been made to reduce errors in the future by adoption of computerised prescriptions and periodic sensitisation of the responsible health personnel.

• Journal of Korean Critical Care Nursing
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• v.14 no.3
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• pp.62-72
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• 2021

Purpose : This study aimed to identify factors influencing clinical nurses' intention to report medication administration errors. Methods : This cross-sectional study collected data from 121 nurses in charge of administering medication at a university hospital in Korea using structured questionnaires. Data were analyzed using descriptive statistics, independent t-test, one-way ANOVA, Pearson's correlation coefficient, and multiple linear regression. Results : Participants' mean age was 26.90±3.99 years, and 89.3% were women. Their mean clinical career duration was 3.88±4.26 years. The average levels of patient safety culture, attitude toward reporting medication administration errors, and intention to report medication administration errors were 7.51 out of 10, 3.36 out of 5, and 4.85 out of 6, respectively. The multiple regression analysis results indicated that the statistically significant influencing factors were patient safety culture (𝛽=.21, p =.018) and attitude toward reporting medication administration errors (𝛽=.22, p =.015). Conclusion : To improve the intention to report medication administration errors among clinical nurses, a patient safety culture must be established, along with an education provision for improving their attitudes toward reporting such administration errors.

• Journal of Korean Academy of Nursing Administration
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• v.17 no.4
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• pp.462-473
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• 2011

Purpose: This study was done to identify the factors affecting the perception of patient-safety-culture and the level of safety-care-activity among nurses in small-medium sized general hospitals. Method: Data were collected during April and May 2011, from 241 nurses of five hospitals. A hospital survey questionnaire on patient-safety-culture and safety-care-activity was used. Collected data were analyzed using descriptive statistics, Pearson correlation, t-test, ANOVA, Scheffe test and multiple-regression. Results: There were significant differences in the level of perception of patient-safety-culture according to the nurses' age, type of hospital, position, work department, and knowing whether there was a Patient-Safety committee in their hospitals. Nurses with higher perceived level of the patient-safety-culture performed more safety-care-activities. Factors influencing on the safety-care-activities were general patient safety, having had safety-education, patient-to-nurse ratio, employment status, and the level of reporting medical errors. These factors explained 22.9% of the safety-care-activity. Conclusions: The study findings suggest that in order to improve the nurses' perceived level of patient-safety-culture and safety-care-activity, the hospitals need to establish patient-safety committees and communication systems, and openness to reporting medical errors are needed. Better work conditions to ensure appropriate work time, regulate patient-to-nurse ratio, and nursing education standards and criteria, are also required.

• Journal of Preventive Medicine and Public Health
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• v.47 no.5
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• pp.273-280
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• 2014

Objectives: To evaluate the occurrence of patient adverse events in Korean hospitals as perceived by nurses and examine the correlation between patient adverse events with the nurse practice environment at nurse and hospital level. Methods: In total, 3096 nurses working in 60 general inpatient hospital units were included. A two-level logistic regression analysis was performed. Results: At the hospital level, patient adverse events included patient falls (60.5%), nosocomial infections (51.7%), pressure sores (42.6%) and medication errors (33.3%). Among the hospital-level explanatory variables associated with the nursing practice environment, 'physician-nurse relationship' correlated with medication errors while 'education for improving quality of care' affected patient falls. Conclusions: The doctor-nurse relationship and access to education that can improve the quality of care at the hospital level may help decrease the occurrence of patient adverse events.

• Quality Improvement in Health Care
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• v.14 no.2
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• pp.125-132
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• 2008

Background : The number of outpatient injected anticancer drug is increasing. and the pathway of prescribing, compounding, and injecting anticancer drug is processed very rapidly in out-patient department. Moreover, Dose of anticancer drug is often changed depending on side effect of patients. So we need more effective inspection of anticancer drug prescriptions. The purpose of this study was to analyze the prescription errors for anticancer drugs in Out-Patient Department and to suggest system to prevent them. Method : The study took place at Asan Medical Center from July to September 2007. The pharmacists performed inspection of anticancer drug prescriptions before compounding and injecting. We used protocol-based anticancer drug order program and Electronic Medical Record (EMR). Result : During the study period, we analyzed 4683 prescriptions for out-patient. And we detected 55 medication errors (1.2%). Most common errors included dosage above or below the correct ones (56.3%), followed by incorrect treatment duration. Because most of dosing errors were in the range of usual dosage, it was hard to detect them. So when inspecting the prescription, we considered the medical records of individual patients. As a result, we could raise the efficiency of intervention. Therefore inspection using EMR could possibly reduce the number of anticancer drug errors. Conclusion : we are preventing the medication errors on stability and dosage above or below the maximum therapeutic dose according to the previous inspection system. However most of dosing errors were in the range of usual dosage according to the result of this study. Because of there was interpatient variability of dosage depending adverse effect. For improvement of quality assurance, we suggest inspection system based on patient's medical history.

• Child Health Nursing Research
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• v.28 no.4
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• pp.259-268
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• 2022

Purpose: Nursing students are susceptible to medication safety incidents in the neonatal intensive care unit (NICU) related to a lack of communication experience. The purpose of the present study was to investigate the impact of a NICU medication safety simulation (NMSS) focusing on communication clarity, patient hand-off confidence, and patient safety competency in senior-year nursing students. Methods: The study utilized a nonequivalent control group pretest-posttest design. In total, 60 nursing students were assigned to two groups. The experimental group participated in the NMSS, which included three medication error scenarios. Pairs of students completed the scenarios together in 10 to 20 minutes. Data were analyzed using the chi-squared test, independent t test, and ANCOVA. Results: The experimental group showed significant improvements in communication clarity (p=.015), and patient safety competency (p<.001) compared to the control group. Using the pretest values as covariates, patient hand-off confidence scores significantly increased (p=.027). Conclusion: Implementing the NMSS focusing on communication in the pediatric nursing curriculum helped students to communicate clearly and concisely about medication errors, and its use is recommended to promote patient safety competency in the NICU.

• Journal of Korean Academy of Fundamentals of Nursing
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• v.17 no.1
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• pp.64-72
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• 2010

Purpose: This study was performed to measure hospital nurses' perceived patient safety culture and their safety care activities, and to investigate the relationship between these two factors. Method: This study was a cross-sectional survey. The participants were 301 nurses working at 4 general hospitals, and data collection was done from June 22 to June 30, 2009 by self-administrated questionnaires. Results: With a possible score of 5 points, the average score for nurses' perceived patient safety culture was 3.34, and for their safety care activities, 4.25. There were perceived differences in patient safety culture and safety care activities according to age, position, length of work experience and number of patient safety education sessions attended. All sub-factors in patient safety culture had a positive relationship with safety care activities. Factors influencing nurses' safety care activities were number of patient safety education sessions attended, hospital environment, and supervisor/manager. These factors explained 58.2% of the variance. Conclusion: The findings indicate that patient safety education is very important to improve nurses' safety care activity. So nursing supervisors/ managers should develop strategies encourage patient safety education, and make nurses' working environment safer.

• Journal of Korean Critical Care Nursing
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• v.8 no.2
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• pp.13-22
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• 2015

Purpose: This study identified the current status and perception of intensive care unit nurses' handover. Methods: A cross sectional descriptive survey was employed. The population included nurse managers and staff nurses who worked in intensive care units in hospitals with more than 500 beds and excluded nursing homes, psychiatric hospitals, and military hospitals. Results: Of the nurses, 61.7% were satisfied with the current handover method, 68.36% had no handover-related guidelines, and 83.2% of them perceived that the handover was important for patients' safety. The most frequent cause for errors related to handover was that the "nursing workload is heavy." The nurses perceived that their handover was informative ($5.62{\pm}0.79$) and efficient ($5.04{\pm}0.98$). The variables associated with their perception of the handover were the level of satisfaction with the current handover method, existence of handover guidelines, and importance of handover for patient safety. Conclusion: The development of standardized handover guidelines, especially for intensive care units, is necessary to reduce handover time and errors and to improve handover quality for patients'safety and high standards of nursing care.

• Journal of Korean Academic Society of Home Health Care Nursing
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• v.28 no.3
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• pp.285-294
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• 2021

Purpose: The study examined the effects of knowledge, attitude, and confidence on the education needs of nursing students with respect to patient safety management. The participants were 119 students from nursing college. Data were analyzed using descriptive statistics, t-test, analysis of variance(ANOVA), Pearson's correlation coefficient, and multiple regression analysis with the SPSS program. Results: The student's educational needs with respect to patient safety management differed significantly by experience of patient safety accidents (p=.026) and experience of reporting medical errors (p<.001). Additionally, the educational needs with respect to patient safety management were found to have statistically significant positive relationships with both attitude (r=.39) and confidence (r=.37). Further, a total of 23% of the education needs with regard to patient safety management were explained by attitude and confidence. Conclusion: These results can be used to develop nursing students' education programs to enhance patient safety management competence be emphasizing the experience of patient safety accidents and reporting medical errors as well as improving the attitude and confidence of the students.

• Korean Journal of Clinical Pharmacy
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• v.32 no.2
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• pp.116-124
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• 2022

Background: High-alert medications (HAMs) are medications that bear a heightened risk of causing significant patient harm if used in error. To facilitate safe use of HAMs, identifying specific HAM lists for clinical setting is necessary. We aimed to develop the national level HAM list for acute care setting. Methods: We used three-step process. First, we compiled the pre-existing lists referring HAMs. Second, we analyzed medication related incidents reported from national patient safety incident report data and adverse events indicating medication errors from the Korea Adverse Event Reporting System (KAERS). We also surveyed the assistant staffs to support patient safety tasks and pharmacist in charge of medication safety in acute care hospital. From findings from analysis and survey results we created additional candidate list of HAMs. Third, we derived the final list for HAMs in acute care settings through expert panel surveys. Results: From pre-existing HAM list, preliminary list consisting of 42 medication class/ingredients was derived. Eight assistant staff to support patient safety tasks and 39 pharmacists in charge of medication safety responded to the survey. Additional 44 medication were listed from national patient safety incident report data, KAERS data and common medications involved in prescribing errors and dispensing errors from survey data. A list of mandatory and optional HAMs consisting of 10 and 6 medication classes, respectively, was developed by consensus of the expert group. Conclusion: We developed national level HAM list for Korean acute care setting from pre-existing lists, analyzing medication error data, survey and expert panel consensus.