Affiliations: [a]
School of Pharmacy and Biomedical Sciences, Curtin University, Perth, WA, Australia
| [b] Faculty of Pharmacy, Pancasila University, Srengseng Sawah Jagakarsa, Jakarta Selatan, Indonesia
Correspondence:
[*]
Address for correspondence: Dr Hesty Utami Ramadaniati, Faculty of Pharmacy, Pancasila University, Srengseng Sawah
Jagakarsa, Jakarta Selatan, 12640, Indonesia. Tel.: +62 7864727; Fax: +62 7864723;
E-mail: h.ramadaniati@graduate.curtin.edu.au.
Abstract: OBJECTIVE:To determine multi-disciplinary perceptions of the clinical significance of medication errors (MEs), the responsible health professional(s), the contributing factors and potential preventive strategies. METHODS:The five simulated ME cases represented errors from five wards at a children’s hospital in Australia. Pre-determined answers for each case were developed through consensus among the researchers. The root cause analysis (RCA) was undertaken via a questionnaire disseminated to physicians, nurses and pharmacists at the study hospital to seek their opinions on the ME cases. Agreement model between the participants and pre-determined responses regarding the contributing factors was conducted using general estimating equation (GEE) analysis. RESULTS:Of the 111 RCA questionnaires distributed, 25 were returned. The majority (93%) of respondents rated the significance of the MEs as either ‘moderate’ or ‘life-threatening’. Furthermore, they correctly identified two contributing factors relevant to all cases: dismissal of policies/procedures or guidelines (90%) and human resources issues (87%). GEE analysis revealed varied agreement patterns across the contributing factors. Suggested prevention strategies focused on policy and procedures, staffing and supervision, and communication. CONCLUSION:Simulated case studies had potential use to seek front-line healthcare professionals’ understanding of the clinical significance and contributing factors to MEs, along with preventive measures.
Keywords: Medication error, root cause analysis, paediatrics
