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      Impacto del Servicio de Farmacia en la disminución de errores en la medicación en pediatría Translated title: Impact of the pharmaceutical actions to decrease medication errors in pediatrics

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          Abstract

          RESUMEN Estudio descriptivo de errores de medicación en el Tecnológico de Monterrey, Hospital San José Tec Salud, Escuela de Medicina y Ciencias de la Salud. Objetivo: Describir las intervenciones farmacéuticas que contribuyen a tener una tasa de error de medicación por debajo de los estándares internacionales. Material y métodos: Se consideró como error de medicación cualquier fallo en el proceso de medicación. Se revisaron prescripciones por el método de reporte de incidentes en expedientes de pacientes de 0-17 años de los últimos 12 meses (2017-2018). Resultados: Se detectaron 776 errores de 6.119 prescripciones (2,47%). El error más común fue aquel relacionado con la dosificación (60,3%). No se reportaron errores que resultaran en daño letal al paciente. El grupo terapéutico con mayor incidencia de errores fue el de los antibióticos seguido de los analgésicos. Conclusión: La intervención multidisciplinaria con el farmacéutico en el proceso de medicación permite una detección oportuna de errores que impacta la seguridad del paciente.

          Translated abstract

          SUMMARY Descriptive and retrospective study of medical errors at, San Jose Monterrey Hospital School of medicine and Health science. Objective: To describe pharmaceutical interventions in order to keep a low incidence of medical errors. Material and methods: Medical error was defined as any unintended error in medication. We present a 12 Month (2017-2018) retrospective study using incident reports. Results: We identified 776 medication errors over a total of 6,119 reviewed prescriptions. (2.4%) The most frequent errors in prescription were dosage associated (60.3%). No lethal outcomes were reported. The most common group of medication errors were antibiotics followed by analgesics. Conclusion: Involving pharmacists in checking drug prescriptions has been the main factor for detecting and improving pediatric dosages leading to an important improvement in patient safety.

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          Error in Medicine

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            Systematic review of medication errors in pediatric patients.

            To systematically locate and review studies that have investigated the incidence of medication errors (MEs) in pediatric inpatients and identify common errors. A systematic search of studies related to MEs in children was performed using the following databases: MEDLINE (1951-April 2006), EMBASE (1966-April 2006), Pharm-line (1978-April 2006), International Pharmaceutical Abstracts (1970-April 2006), Cumulative Index to Nursing and Allied Health Literature (1982-April 2006), and British Nursing Index (1994-April 2006). Studies of the incidence and nature of MEs in pediatrics were included. The title, abstract, or full article was reviewed for relevance; any study not related to MEs in children was excluded. Three methods were used to detect MEs in the studies reviewed: spontaneous reporting (n = 10), medication order or chart review (n = 14), or observation (n = 8). There was great variation in the definitions of ME used and the error rates reported. The most common type of ME was dosing error, often involving 10 times the actual dose required. Antibiotics and sedatives were the most common classes of drugs associated with MEs; these are probably among the most common drugs prescribed. Interpretation of the literature was hindered by variation in definitions employed by different researchers, varying research methods and setting, and a lack of theory-based research. Overall, it would appear that our initial concern about MEs in pediatrics has been validated; however, we do not know the actual size of the problem. Further work to determine the incidence and causes of MEs in pediatrics is urgently needed, as well as evaluation of the best interventions to reduce them.
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              Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group.

              To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. Prospective cohort study. All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. Adverse drug events and potential ADEs. Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process.
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                Author and article information

                Journal
                ofil
                Revista de la OFIL
                Rev. OFIL·ILAPHAR
                Organización de Farmacéuticos Ibero-Latinoamericanos (Madrid, Madrid, Spain )
                1131-9429
                1699-714X
                2021
                : 31
                : 2
                : 161-165
                Affiliations
                [2] Monterrey Nuevo León orgnameHospital San José. TEC Salud orgdiv1Servicio de Pediatría México
                [3] Monterrey Nuevo León orgnameHospital San José orgdiv1Departamento de Farmacología México
                [1] Ciudad de México orgnameAcademia Mexicana de Pediatría México
                [4] Monterrey Nuevo León orgnameHospital San José. TEC Salud orgdiv1Dirección General México
                Article
                S1699-714X2021000200161 S1699-714X(21)03100200161
                10.4321/s1699-714x2021000200009
                ffd6a3d1-70c7-4658-be84-c9b2cfa24628

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 17 April 2019
                : 15 June 2019
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 25, Pages: 5
                Product

                SciELO Spain

                Categories
                Originales

                pharmacist,security,Errores de medicación,farmacéuticos,seguridad,Medication errors

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