[Medication safety in the home care setting: error-prone process steps].
So far, little is known about drug-related problems in the homecare setting. It is estimated that up to 30% of homecare patients experience a potential medication error, most frequently happening during preparation and administration of drugs. In order to identify error-prone process steps in a Swiss homecare organisation caring for 1854 patients per year, direct observation of the medication use process, including the analysis of 10% of all prescriptions, was executed. Three complimentary methods were combined for the assessment of qualitative aspects of the medication use process: the analysis of a critical incident reporting system, a survey among homecare nurses, and a failure, mode and effects analysis. The medication use process is complex, consisting of 20 individual steps. Patients are prescribed an average of 7.5 ± 3.5 drugs per day, including 1 to 9 doses not suitable for deblistering into weekly dispensing systems. Of 84 reported errors, 74% happened during drug preparation. Communication with physicians, patients interrupting drug preparation and not transmitted changes of the drug regimen were considered the most critical process steps.
Departement für Pharmazeutische Wissenschaften, Universität Basel und Stiftung für Patientensicherheit, Zürich. meyer@patientensicherheit.ch
C
C
Meyer-Massetti
E
E
Kaiser
B
B
Hedinger-Grogg
S
S
Luterbacher
K
K
Hersberger
D003299:Cooperative Behavior; D006699:Home Care Services; D006801:Humans; D007318:Inservice Training; D008508:Medication Errors / Q000451:nursing* / Q000517:prevention & control; D019555:Physician-Nurse Relations; D012307:Risk Factors; D013557:Switzerland; D013647:Task Performance and Analysis