1. Hue University of Medicine and Pharmacy
THE 17th ASIAN CONFERENCE ON CLINICAL PHARMACY
MEDICATION ERRORS RELATED TO ANTIBIOTICS: PREVALENCE, POTENTIAL CLINICAL OUTCOME & RISK FACTORS
Thi-Ngan-Thao NGUYEN1, Thi-Hang DO1, Thi-Hong-Lien DUONG2, Quang-Phuc TRAN3, Ha-Minh-Khue DUONG3, Thi-Ha VO1,3
1Faculty of Pharmacy, Hue University of Medicine and Pharmacy, Hue, Vietnam 2Depart of Nursing, Hue University Hospital, Hue, Vietnam 3Depart of Pharmacy, Hue University Hospital, Hue, Vietnam
Thi-Ngan-Thao Nguyen1, Thi – Hang Do1, Thi-Hong-Lien Duong2, Quang-Phuc Tran3, Ha-Minh-Khue Duong3, Thi-Ha Vo1,3
Indonesia, 07/2017
Hue University of Medicine and Pharmacy

2. CONTENT
BACKGROUND 1
METHODS 2
RESULTS 3
CONCLUSIONS 4 5
Kiến nghị

3. I
BACKGROUND 3
Antibiotics was a drug group with highest risk of ME (79,6%) (3). Dealth rate related antibiotics was 7.5%, 4th in drug group (4) . 2
Medication errors (ME): 3rd cause of dealth in USA. (1)
In Vietnam, %/dose administration by nurses having ME. (2)
Vietnamese Minister of Health issued “Guidelines of antibiotic use” in 2015 & “Hospital antibiotic stewardship programs» in
Detecting MEs related antibiotics => solutions
=> Improve quality of hospital antibiotic stewardship
Martin A Makary and Michael Daniel. Medical error—the third leading cause of death in the US ,
Dương Thị Thanh Tâm (2014), Đánh giá an toàn trong thực hành thuốc cho trẻ em tại một cơ sở y tế ở Việt Nam, Luận văn Thạc sĩ Dược học, Đại Học Dược Hà Nội.
Huong Thao Nguyen, et al., Medication Errors in Vietnamese Hospitals: Prevalence, Potential Outcome and Asscociated Factors, in PLOS ONE
Phillips J. et al (2001), "Retrospective analysis of mortalities associated with medication errors", Am J Health Syst Pharm. 58(19), pp

4. I OBJECTIVES Objectives
1. Detect MEs during antibiotic administration to patients by nurses
Objectives
2. Evaluate potential clinical severity of those MEs
Text in here
Text in here
3. Determine risk factors of those MEs

5. II
METHODS
Process
Direct observation of preparation and administration of each antibiotic dose performed by nurses to patients
Place A 600-bed university hospital in 3 clinical wards:
Cardiovascular Medicine
Internal Medicine
Gastroenterology Surgery
Thời gian
12/ /2017
7h h30 daily
7 consecutive days/each ward

6. II METHODS Inclusion criteria Exclusion criteria
All observation of preparation and administration of antibiotics peformed by nurses to patients with the same injection trolleys
Exclusion criteria
Emergency case

7. Tổng cơ hội xảy ra sai sót TOEII
METHODS
Definition
Medication error
Is defined as any difference preparation and administration by nurses compared to:
(1): Physician prescription
(2): Guide of Manufacturer Company
(3): Books: Injectable Drugs Guide
I.V. Drug Handbook
Nursing Drug Handbook
STABILIS
Cơ hội xảy ra sai sót OE
Tổng cơ hội xảy ra sai sót TOE

8. II METHODS Each ME was evaluated independently by 2 pharmacists.
Evaluate potential clinical severity
Each ME was evaluated independently by 2 pharmacists.
Modified NCC MERP.

9. II METHODS Determine risk factors of MEs
Binary logistic regression with α < 0,05
Independent variables included:
complexity of preparation,
administration time (day of the week, drug round)
experience of nurse
clinical ward

10. Gastroenterology Surgery
III
RESULTS
1. Rates of MEs ME OE
Rate (%)
3 wards
820
992
82,7
Cardiovascular
166
185*
89,7
Internal
262
303*
86,5
Gastroenterology Surgery
392
504*
78,8

11. III RESULTS 1. Rates of MEs according to routes ME OE** Rate (%) IVME
OE**
Rate (%) IV
505
100,0 IM 33
IV infusion
282
407
70,5 PO 47
0,0
Total
820
992
82,7

12. III RESULTS 1. Rates of types of MEs Types of MEs ME Rate (%)
Drug wrong
0,0
Dose wrong 1
0,1
Drug form wrong
Preparation technique wrong
503
29,2
Drug obmission
Time wrong
353
20,5
Route wrong 9
0,5
Injection/Infusion rate wrong
718
41,6
Incompability
140
8,1
Total
1724
100,0

13. Potential clinical severity
III
RESULTS
2. Potential clinical severity
Types
Potential clinical severity
No harm
(A - C)
Need following-up (D)
Possibly harm
(E - I)
Technique wrong
15 (0,9%)
488 (28,3%)
Time wrong
353 (2,5%)
0 (0,0%)
Route wrong
9 (0,5%)
Rate wrong
130 (7,5%)
588 (34,1%)
Incompability
140 (8,1%)
Dose wrong
1 (0,1%)
Total
498 (28,9%)
1226 (71,1%)

14. Complexity of preparation
III
RESULTS
3. Risk factors of MEs
Factor
RR (95% CI) p
Complexity of preparation
45.58 (16.51 – )
< 0.01
Day of the week
0.64 (0.40 – 1.03)
0.07
Drug round
0.97 (0.60 – 1.55)
0.89
Experience of nurse
1.18 (0.90 – 1.54)
0.22
Clinical ward
0.82 (0.58 – 1.17)
0.27
administration time (day of the week, drug round)

15. IV
CONCLUSIONS
Rate of general ME is 82.7%
100% antibiotics IM and IV having MEs
38.4% quan sát có 2 loại sai sót.
Injection/Infusion rate wrong having high rate (41.6%).
1. Rates of MEs related antibiotics preparation and administration
77.1% MEs possibly harm
2. Potential clinical severity
Complexity of preparation is an independent risk factor of MEs
3. Risk factors of MEs

16. V
NEXT STEPS
Develop a protocol of preparation of injectable antibiotics.
Train and evaluate nurses timely.
Determine rates and severities of MEs after interventions. Evaluate effectiveness of interventions for improvement.

17. Hue University of Medicine and Pharmacy
Vo Thi Ha.
Hue University of Medicine and Pharmacy
Thank you !