مجال التميز | تميز دراسي وبحث + جائزة تفوقية |
البحوث المنشورة |
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البحث (1): | |
عنوان البحث: | Prevalence and Nature of Medication Errors and Preventable Adverse Drug Events in Paediatric and Neonatal Intensive Care Settings: A Systematic Review |
رابط إلى البحث: | https://link.springer.com/article/10.1007/s40264-019-00856-9 |
تاريخ النشر: | 13/08/2019 |
موجز عن البحث: |
Introduction: Children admitted to paediatric and neonatal intensive care units may be at high risk from medication errors and preventable adverse drug events. Objective: The objective of this systematic review was to review empirical studies examining the prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care units. Data Sources: Seven electronic databases were searched between January 2000 and March 2019. Study Selection: Quantitative studies that examined medication errors/preventable adverse drug events using direct observation, medication chart review, or a mixture of methods in children ≤ 18 years of age admitted to paediatric or neonatal intensive care units were included. Data Extraction: Data on study design, detection method used, rates and types of medication errors/preventable adverse drug events, and medication classes involved were extracted. Results: Thirty-five unique studies were identified for inclusion. In paediatric intensive care units, the median rate of medication errors was 14.6 per 100 medication orders (interquartile range 5.7–48.8%, n = 3) and between 6.4 and 9.1 per 1000 patient-days (n = 2). In neonatal intensive care units, medication error rates ranged from 4 to 35.1 per 1000 patient-days (n = 2) and from 5.5 to 77.9 per 100 medication orders (n = 2). In both settings, prescribing and medication administration errors were found to be the most common medication errors, with dosing errors the most frequently reported error subtype. Preventable adverse drug event rates were reported in three paediatric intensive care unit studies as 2.3 per 100 patients (n = 1) and 21–29 per 1000 patient-days (n = 2). In neonatal intensive care units, preventable adverse drug event rates from three studies were 0.86 per 1000 doses (n = 1) and 0.47–14.38 per 1000 patient-days (n = 2). Anti-infective agents were commonly involved with medication errors/preventable adverse drug events in both settings. Conclusions: Medication errors occur frequently in critically ill children admitted to paediatric and neonatal intensive care units and may lead to patient harm. Important targets such as dosing errors and anti-infective medications were identified to guide the development of remedial interventions. |
البحث (2): | |
عنوان البحث: | A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children’s Intensive Care |
رابط إلى البحث: | https://link.springer.com/article/10.1007/s40272-021-00442-6 |
تاريخ النشر: | 08/04/2021 |
موجز عن البحث: |
Background: Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas. Objective: This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs). Methods: We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010–2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents. Results: In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols. Conclusions: Neonates were commonly involved in medication-related incidents reported in children’s intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk. |
المؤتمرات العلمية |
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المؤتمر (1): | |
عنوان المؤتمر: | The Prescribing and Research in Medicines Management (UK & Ireland) 30th Annual Conference |
تاريخ الإنعقاد: | 14/12/2018 |
مكان الإنعقاد: | London. UK |
طبيعة المشاركة: | Oral presentation |
عنوان المشاركة: | The Burden of Medication Errors and Preventable Adverse Drug Events in Critically Ill Children: A Systematic Review |
ملخص المشاركة: |
Introduction: Children admitted to paediatric and neonatal intensive care units (P/NICUs) are at high risk from medication errors (MEs) and preventable adverse drug events (pADEs). Aim: To systematically review and critically appraise empirical studies examining the prevalence and nature of MEs and pADEs in PICUs and NICUs. Method: Seven electronic databases were searched (January 2000 to July 2017) as well as the grey literature. Quantitative observational studies published in English reporting rates of MEs or pADEs in children ≤18 years of age admitted to PICUs or NICUs were included. Studies were heterogeneous in nature and were presented using ranges or median with interquartile ranges (IQRs). Results: Thirty‐six unique studies were eligible for inclusion, with the majority originating from the United States of America (USA) (n = 10, 27.7%) and 21 (58.3%) being published from January 2010 onwards. In PICUs, overall ME rates ranged from 5.7 to 48.8 per 100 medication orders (n = 3) and 6.4 to 9.1 per 1000 patient days (n = 2). In NICUs, MEs rates ranged from 5.5 to 77.9 per 100 medication orders (n = 2) and from 4 to 35.1 per 1000 patient days (n = 2). Across both settings prescribing and medication administration errors (P/MAEs) were found to be most commonly associated with MEs and that dosing errors were a common subtype of MEs. Most studies examined PEs (n = 19, 52.8%) with a median prevalence of PEs per 100 orders of 13.3 (IQR 9.5‐29.55) in PICUs (n = 12) and 14.9 (IQR 4.25‐29.9) in NICUs (n = 6). MAEs occurred in 28.9% of orders (n = 1) and 8.2% of administrations (n = 1) in PICUs and ranged from 8.2% to 84.8% of administrations in NICUs (n = 3). Rate of pADEs in NICUs ranged from 0.47 to 14.38 per 1000 patient days (n = 2). A total of three studies in PICUs reported pADEs rates using different denominators. Commonly involved drugs with MEs or pADEs were anti‐infectives, analgesics, and sedatives in PICUs and anti‐infectives in NICUs. Conclusion: MEs are a common problem in PICUs and NICUs. Our review has identified important targets that could help set an improvement agenda for both health care leaders and researchers. There is also a need for research from countries outside of the USA and for future work to explore in more detail outcomes such as MAEs and pADEs that have received limited attention in the current evidence base. |
الرابط: | Link |
المؤتمر (2): | |
عنوان المؤتمر: | The World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS) 10th conference |
تاريخ الإنعقاد: | 01/12/2020 |
مكان الإنعقاد: | Mexico (virtual) |
طبيعة المشاركة: | Poster presentation |
عنوان المشاركة: | A Mixed-Methods Analysis of Medication Safety Incidents Reported in Children’s Intensive Care Settings Across England And Wales |
ملخص المشاركة: |
Aims & Objectives: Medication safety incidents may occur more frequently in children’s intensive care units (ICUs) than other clinical areas. System-wide learning from a national incident reporting system could support the identification of areas of risk to patients and the design of preventive strategies. This study aimed to determine the frequency, nature and contributory factors associated with medication-related safety incidents reported in children’s ICUs across England and Wales over a 9-year period. Methods: A retrospective mixed methods study using anonymised medication safety incident reports involving children (≤18 years of age) admitted to ICUs and submitted to the National Reporting and Learning System between 2010-2018. Content analysis of harmful incident reports was carried out to understand potential contributory factors involved in incidents. Results: A total of 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during medicines administration (13,668/25,567, 53.5%) and prescribing stages (7,412/25,567, 29%), and involved drug omission (4,812/25,567, 18.8%) and wrong dose (4,475/25,567, 17.5%) errors. Anti-infectives (6,483/25,567, 25.4%) were the most commonly implicated agents in the reports. 3,129 (12.2%) incidents were reported to cause patient harm. Common contributing factors to harmful incidents involved individual-related factors such as failure to adhere to policies, which were associated largely with organisation-related antecedents such as heavy workload and inadequate guidelines and systems (e.g. paper-based prescribing systems). Conclusions: This study adds understanding the environmental, organisational and inter-personal factors within which medication safety incidents arise. Clear targets for remedial interventions were identified and future research will need to focus on the treatment of infections and addressing systemic organisational factors. |
الرابط: | Link |
المؤتمر (3): | |
عنوان المؤتمر: | The World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS) 10th conference |
تاريخ الإنعقاد: | 01/12/2020 |
مكان الإنعقاد: | Mexico (virtual) |
طبيعة المشاركة: | Poster presentation |
عنوان المشاركة: | Incidence and Nature of Adverse Drug Events in Paediatric Intensive Care Units: A Prospective Multicentre Study |
ملخص المشاركة: |
Aims & Objectives: The burden and nature of adverse drug events (ADEs) in paediatric intensive care units (PICUs) are not well understood. This study aimed to assess the incidence, nature, preventability and severity of ADEs across three English PICUs. Methods: A prospective observational cohort study was carried out over a three-month period during 2019. PICU patients (≤18 years of age) who stayed for a minimum of 24-hours were included. Intensive surveillance for suspected ADEs was performed by trained clinical pharmacists. An expert panel assessed causality, preventability and severity of detected events. Results: Of 302 patients included, one or more ADEs was detected in 47 (15.6%) patients. A total of 62 ADEs were confirmed, with an estimated rate of 20.5/100 patients (95% CI, 15.3-27.5) and 16.7/1000 patient-days (95% CI, 9.3-29.9). The majority of ADEs were preventable (36/62, 58.1%). Most ADEs (42/62, 67.7%) caused temporary harm and associated with medicines prescribing (29/62, 46.8%). Medicines for the central nervous system (14/62, 22.6%) and infections (13/62, 20.9%) were commonly involved. Children with a hospital stay of 7 or more days (OR 5.28, 95% CI, 2.12-13.14) were more likely to experience an ADE compared to patients with a stay of 1-6 days. Rates of ADEs varied among the three PICUs (p<0.006). Conclusions: We report findings from the first epidemiological study to examine the frequency, nature, preventability and severity of ADEs in PICUs in the UK. Further study addressing underlying contributory factors of preventable ADEs is now needed to identify targets for remedial interventions and reduce the risk of avoidable patient harm. |
الرابط: | Link |
جوائز التكريم |
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الجائزة (1): | |
مسمى الجائزة: | TOP VIEWED E-POSTER PRESENTATION AWARD |
الجهة المانحة: | The World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS) 10th conference |
تاريخ الجائزة: | 01/12/2020 |
مجال التكريم: | TOP VIEWED E-POSTER PRESENTATION AWARD for the E-Poster Titled: “A MIXED-METHODS ANALYSIS OF MEDICATION SAFETY INCIDENTS REPORTED IN CHILDREN’S INTENSIVE CARE SETTINGS ACROSS ENGLAND AND WALES” presented at the WFPICCS 2020 Virtual Congress |
المرفقات
- https://uksacb.org/wp-content/uploads/1st_conference_Certificate_WFPICCS.pdf
- https://uksacb.org/wp-content/uploads/2rd_conference_Certificate_WFPICCS.pdf
- https://uksacb.org/wp-content/uploads/3rd_conference_Certificate_WFPICCS.pdf
- https://uksacb.org/wp-content/uploads/AWARD_WFPICCS-2020-Top-E-Poster-Award-Anwar-Alghamdi-.pdf