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- Fyhr, AnnSofie, et al.
(författare)
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Characteristics of medication errors with parenteral cytotoxic drugs.
- 2012
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Ingår i: European Journal of Cancer Care. - : Hindawi Limited. - 1365-2354 .- 0961-5423.
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Tidskriftsartikel (refereegranskat)abstract
- FYHR A. & AKSELSSON R. (2012) European Journal of Cancer Care Characteristics of medication errors with parenteral cytotoxic drugs Errors involving cytotoxic drugs have the potential of being fatal and should therefore be prevented. The objective of this article is to identify the characteristics of medication errors involving parenteral cytotoxic drugs in Sweden. A total of 60 cases reported to the national error reporting systems from 1996 to 2008 were reviewed. Classification was made to identify cytotoxic drugs involved, type of error, where the error occurred, error detection mechanism, and consequences for the patient. The most commonly involved cytotoxic drugs were fluorouracil, carboplatin, cytarabine and doxorubicin. The platinum-containing drugs often caused serious consequences for the patients. The most common error type were too high doses (45%) followed by wrong drug (30%). Twenty-five of the medication errors (42%) occurred when doctors were prescribing. All of the preparations were delivered to the patient causing temporary or life-threatening harm. Another 25 of the medication errors (42%) started with preparation at the pharmacies. The remaining 10 medication errors (16%) were due to errors during preparation by nurses (5/60) and administration by nurses to the wrong patient (5/60). It is of utmost importance to minimise the potential for errors in the prescribing stage. The identification of drugs and patients should also be improved.
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- Fyhr, AnnSofie, et al.
(författare)
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From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types
- 2015
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Ingår i: European Journal of Cancer Care. - : Hindawi Limited. - 1365-2354 .- 0961-5423.
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Tidskriftsartikel (refereegranskat)abstract
- A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs)in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason’s Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips,one-third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self-evaluation tool that would work as a complement to already incident reporting and event and risk analyses.
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- Fyhr, AnnSofie, et al.
(författare)
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Misstag med koncentrerade kalium- och natriumlösningar. Analys och lärdomar av anmälda ärenden
- 2011
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Ingår i: Läkartidningen. - 0023-7205. ; 108:16-17, s. 923-927
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Tidskriftsartikel (refereegranskat)abstract
- I en retroaktiv kvalitativ analys av 32 lex Maria- och HSAN-ärenden har vi undersökt vad som hände, bakomliggande orsaker och vilka lärdomar som finns. Konsekvenserna för patienterna var i flera fall allvarliga, med dödsfall, livshotande arytmier och svåra hudnekroser. Att förpackningarna liknade varandra var en vanlig bakomliggande orsak till misstagen. Hemsjukvården svarade för nästan en tredjedel av ärendena. Svårigheter att kunna arbeta ostört, dålig belysning och läkemedel som placeras olämpligt var bokomliggande orsaker. Lokala åtgärder som rekommenderas är bl a att begränsa tillgången till koncentrerade elektrolyter, speciellt kalium, och att upphandla för säkerhet. Nationellt behövs samarbete mellan läkemedelsindustrin, Läkemedelsverket och Socialstyrelsen för att förbättra förpackningarna, vilket minskar risken för fel. Erfarenheter från händelseanalyser och lex Maria-ärenden ska hanteras lokalt men bör också aggregeras på nationell nivå för att dra lärdom och för effektiva motåtgärder.
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- Fyhr, AnnSofie, et al.
(författare)
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National e-library for standardized chemotherapy regimens
- 2020
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Ingår i: Acta Oncologica. - 0284-186X. ; 59:9, s. 1079-1083
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- The aim was to develop a method, an e-library, with standardized nomenclature and content in chemotherapy regimens. In developing the method, an iterative improvement process was applied, following a PDSA Cycle (Plan, Do, Study, Act). The entire process of developing the e-library was documented, through e.g. meeting notes and e-mail archives. The development process used participatory design, involving the professions related to chemotherapy.The e-library can be found at: https://kunskapsbanken.cancercentrum.se/
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- Fyhr, AnnSofie
(författare)
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Risks in the chemotherapy process and possibilities for improvement
- 2011
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Medications are of considerable help if healthcare providers are able to administer them to patients safely and appropriately. The medication use process is complex and a team of professionals – doctors, nurses, and pharmacists – work together with the patient for optimal treatment effect. The process involves many sub-processes and in every step there is a possibility for an error. Cytotoxic drugs have high toxicity and a narrow therapeutic index, which means that there is little difference between a lethal and therapeutic dose. The use of such drugs may entail great risks for the patient. The general aim of the research presented in this thesis is to identify these risks and to identify actions and strategies for improving safety in the chemotherapy process. The research focuses on errors in the medication use process of parenteral cytotoxic drugs and how to prevent them. The main objectives are: o To proactively disclose system weaknesses in the process of prescribing and administering cytotoxic drugs in order to suggest interventions. o To identify the characteristics of the medication errors involving cytotoxic drugs in Sweden in order to gain increased knowledge about them. Two approaches have been applied: a proactive one using the disturbance effect barrier (DEB) method, and a retrospective one using a qualitative analysis of the data. The proactive method revealed system weaknesses mainly at the stage of prescribing and the medication use process was found to involve great risks for the patient. In the retrospective analysis, the most commonly involved drug was fluorouracil and the platinum containing drugs were the ones that often caused serious consequences for the patients. The most common error types were too high doses and use of the wrong drug. Fully 40% of the errors occurred at the prescribing and transcribing stage. All of these were delivered to the patient causing temporary or life-threatening harm. Fully 40% of the errors occurred at the preparation stage and were made by pharmacists. The rest of the errors occurred during preparation or administration by nurses. The stage of prescribing by doctors was identified as a major risk. The most commonly identified error types were wrong dose, drug or patient. This indicates that there are possibilities for improvements, such as by using computerised prescriber order entry (CPOE) systems and bar coding for identification of drug and patient. Other strategies for improvement of the chemotherapy process have been suggested in the literature. Among these are standardisation of prescribing vocabulary, multidisciplinary co-operation, working with pharmaceutical manufacturers, and education of the patients. As described in this thesis, the chemotherapy process is complex and involves a great deal of risks for the patients. There is great awareness of the risks and there are many suggestions for actions and strategies for improvements. Some of hese needs to be further evaluated and implemented for better safety for the patients.
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