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National Repository of Grey Literature 2 records found  Search took 0.00 seconds. 
Prevention of patient harm caused by wrong drug administration
 Ratzová, Hana ; Marx, David (advisor)
The diploma thesis surveys the most important problematic fields of the patient safety issue; particularly in the context of drug administration. In the general part there are described the risks associated with LASA medications, using of concentrated electrolyte solutions, incorrect patient identification and wrong communication. Reported clinical cases of medication errors that occurred in connection with the triggers mentioned above are demonstrated and there are listed recommendations aimed at preventing the adverse events and assuring safe care. The closing part of the thesis describes and compares how the Antwerp University Hospital and three teaching hospitals in Prague ensure the safety of drug administration. The thesis manifests a noticeably more elaborate system of education and promotion of the patient safety issues both among the staff and among the patients and their families in the Antwerp University Hospital. Also the technical assuring of the right medication (barcode scanners, automated dispensing devices in certain wards etc.) was in the Belgian hospital on higher level comparing to the average of the followed Czech hospitals.
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Identification of medication errors by nurses during simulated situations
 KELBLOVÁ, Kateřina
Current status: Medication errors within the context of safe and high quality health care are one of the most frequently discussed topics of recent years. They are part of the medical process, occur in different forms, affect patients of all ages and decrease the quality of provided health care. Prescriptions of medication in medical documentation have to be clearly legible and include all the required information. Nurses' role within the medicaiton process could be described as an ultimate "safeguard" that can prevent medication errors. Goals: The objectives of this research are to assess nurses' awareness of medication errors, ssess their ability to detect medication errors and find out the level of their knowledge regarding the correct procedures and measures following medication error detection.Methodology: The research was conducted using a qualitative research method. The in-depth interviews with nurses were carried out at a surgical critical care unit at the hospital in Jindrichuv Hradec. Following the collection of a sufficient amount of data the interviews were coded using the "pen and pencil" technique and then divided into categories.Research file: In order to achieve the highest level of objectivity the research was carried out with a group of nurses who work at the same unit of a hospital department. The research file included nurses who had varied levels of education and numbers of years of experience. Results: Surgical critical care unit nurses are not aware of the exact definition of medication errors. Only one nurse was able to discuss adverse events with related consequences. The remaining nurses' awareness of medication errors corresponded to the classification described in the relevant foreign and Czech academic literature. None of the interviewed nurses detected all the errors included in the simulated scenarios. Only one nurse, who is currently completing her qualification in this specialty, detected a wrongly prescribed antidote. The simulated scenarios also included a group of high-risk medications that is commonly used at the unit. The first medication included in this group was a 7.45% solution of potassium (KCl). A majority of the participants detected the high concentration of this high-risk medication. Another high-risk medication was a 10% concentrate of NaCl in an infusion; this error was also detected by the majority of the nurses. The third high-risk medication was a wrongly prescribed insulin (it lacked the detailed description of units, time and route). This prescription error was not detected by the majority of participating nurses. Another type of medication error included in the simulated scenarios was a group of medications used specifically in critical care. Only half of the participating nurses successfully detected the errors related to the prescription of this group of medications. The last type or medication errors focused on incomplete prescription by doctors. The most frequently detected error was a prescription of an opiate that lacked the route and the least frequently detected error was a wrong prescription of an infusion administration. It is evident that the nurses always inform the doctor when they detect a medication error. They are more willing to inform the ward sister in cases of incidents caused by somebody else. Only a small group of nurses are willing to inform the senior consultant, the head nurse or the hospital management. Only one nurse associated medication error reporting with an audit. However the majority of nurses agrees that it is important to report any medication errors.Conclusion: The analysed data suggested that the nurses were aware of medication errors. The analysis of the results of the simulated scenarios suggested that nurses' ability to detect medication errors in prescriptions was related to the number of years of experience and the level of education.
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