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Prescription, Transcription and Administration Errors in Out-Patient Day Care Unit of a Regional Cancer Centre in South India

  • Mathaiyan, Jayanthi;Jain, Tanvi;Dubashi, Biswajit;Batmanabane, Gitanjali
    • Asian Pacific Journal of Cancer Prevention
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    • v.17 no.5
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    • pp.2611-2617
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    • 2016
  • Background: Medication errors are common but most often preventable events in any health care setup. Studies on medication errors involving chemotherapeutic drugs are limited. Objective: We studied three aspects of medication errors - prescription, transcription and administration errors in 500 cancer patients who received ambulatory cancer chemotherapy at a resource limited setting government hospital attached cancer centre in South India. The frequency of medication errors, their types and the possible reasons for their occurrence were analysed. Design and Methods: Cross-sectional study using direct observation and chart review in anmbulatory day care unit of a Regional Cancer Centre in South India. Prescription charts of 500 patients during a three month time period were studied and errors analysed. Transcription errors were estimated from the nurses records for these 500 patients who were prescribed anticancer medications or premedication to be administered in the day care centre, direct observations were made during drug administration and administration errors analysed. Medical oncologists prescribing anticancer medications and nurses administering medications also participated. Results: A total of 500 patient observations were made and 41.6% medication errors were detected. Among the total observed errors, 114 (54.8%) were prescription errors, 51(24.5%) were transcribing errors and 43 (20.7%) were administration errors. The majority of the prescription errors were due to missing information (45.5%) and administration errors were mainly due to errors in drug reconstitution (55.8%). There were no life threatening events during the observation period since most of the errors were either intercepted before reaching the patient or were trivial. Conclusions: A high rate of potentially harmful medication errors were intercepted at the ambulatory day care unit of our regional cancer centre. Suggestions have been made to reduce errors in the future by adoption of computerised prescriptions and periodic sensitisation of the responsible health personnel.

Medication Errors in Chemotherapy Preparation and Administration: a Survey Conducted among Oncology Nurses in Turkey

  • Ulas, Arife;Silay, Kamile;Akinci, Sema;Dede, Didem Sener;Akinci, Muhammed Bulent;Sendur, Mehmet Ali Nahit;Cubukcu, Erdem;Coskun, Hasan Senol;Degirmenci, Mustafa;Utkan, Gungor;Ozdemir, Nuriye;Isikdogan, Abdurrahman;Buyukcelik, Abdullah;Inanc, Mevlude;Bilici, Ahmet;Odabasi, Hatice;Cihan, Sener;Avci, Nilufer;Yalcin, Bulent
    • Asian Pacific Journal of Cancer Prevention
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    • v.16 no.5
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    • pp.1699-1705
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    • 2015
  • Background: Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. Materials and Methods: This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Results: Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Conclusions: Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

Validation of Sea Surface Temperature (SST) from Satellite Passive Microwave Sensor (GPM/GMI) and Causes of SST Errors in the Northwest Pacific

  • Kim, Hee-Young;Park, Kyung-Ae;Chung, Sung-Rae;Baek, Seon-Kyun;Lee, Byung-Il;Shin, In-Chul;Chung, Chu-Yong;Kim, Jae-Gwan;Jung, Won-Chan
    • Korean Journal of Remote Sensing
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    • v.34 no.1
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    • pp.1-15
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    • 2018
  • Passive microwave sea surface temperatures (SST) were validated in the Northwest Pacific using a total of 102,294 collocated matchup data between Global Precipitation Measurement (GPM) / GPM Microwave Sensor(GMI) data and oceanic in-situ temperature measurements from March 2014 to December 2016. A root-mean-square (RMS) error and a bias error of the GMI SST measurements were evaluated to $0.93^{\circ}C$ and $0.05^{\circ}C$, respectively. The SST differences between GMI and in-situ measurements were caused by various factors such as wind speed, columnar atmospheric water vapor, land contamination near coastline or islands. The GMI SSTs were found to be higher than the in-situ temperature measurements at low wind speed (<6 m/s) during the daytime. As the wind speed increased at night, SST errors showed positive bias. In addition, other factors, coming from atmospheric water vapor, sensitivity degradation at a low temperature range, and land contamination, also contributed to the errors. One of remarkable characteristics of the errors was their latitudinal dependence with large errors at high latitudes above $30^{\circ}N$. Seasonal characteristics revealed that the errors were most frequently observed in winter with a significant positive deviation. This implies that SST errors tend to be large under conditions of high wind speeds and low SSTs. Understanding of microwave SST errors in this study is anticipated to compensate less temporal capability of Infrared SSTs and to contribute to increase a satellite observation rate with time, especially in SST composite process.

Use and Misuse of Statistical Methods in the Journal of Korean Academy of Nursing Administration (간호행정학회지 게재논문의 통계학적 방법 사용과 오류)

  • Song, Kijun
    • Journal of Korean Academy of Nursing Administration
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    • v.19 no.1
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    • pp.146-154
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    • 2013
  • Purpose: To do nursing research effectively requires an understanding of fundamental principles of statistical methods. In this article, some key statistical methods which are commonly used in nursing research are identified and summarized. Methods: Ninety-two original articles from the Journal of Korean Academy of Nursing Administration were reviewed. Statistical methods were classified and summarized for usage in research and occurrence of common errors. Results: Among the original articles reviewed, 58 statistical usages contained errors. Most errors were found in linear regression analysis, Pearson correlation analysis, and chi-square test. From the detection of statistical errors in usage, suggestions for appropriate statistical methods were made. Conclusion: In order to improve validity of original articles in the Journal of Korean Academy of Nursing Administration, clearly stated statistical usage and close editorial attention to statistical methods are needed. Understanding statistical methods is part of the process that researchers must use to determine both quality and usefulness of the research. Research findings will be used to guide nursing practice and reduce uncertainty in decision making. However, to understand how to interpret research results, it is important to be able to understand basic statistical concepts. Researchers should also choose statistical methods that match their purposes.

Extratropical Prediction Skill of KMA GDAPS in January 2019 (기상청 전지구 예측시스템에서의 2019년 1월 북반구 중고위도 지역 예측성 검증)

  • Hwang, Jaeyoung;Cho, Hyeong-Oh;Lim, Yuna;Son, Seok-Woo;Kim, Eun-Jung;Lim, Jeong-Ock;Boo, Kyung-On
    • Atmosphere
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    • v.30 no.2
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    • pp.115-124
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    • 2020
  • The Northern Hemisphere extratropical prediction skill of the Korea Meteorological Administration (KMA) Global Data Assimilation and Prediction System (GDAPS) is examined for January 2019. The real-time prediction skill, evaluated with mean squared skill score (MSSS) of 30-90°N geopotential height field at 500 hPa (Z500), is ~8 days in the troposphere. The MSSS of Z500 considerably decreases after 3 days mainly due to the increasing eddy errors. The eddy errors are largely explained by the eddy-phased errors with minor contribution of amplitude errors. In particular, planetary-scale eddy errors are considered as a main reason of rapidly increasing errors. It turns out that such errors are associated with the blocking highs over North Pacific (NP) and Euro-Atlantic (EA) regions. The model overestimates the blocking highs over NP and EA regions in time, showing dependence of blocking predictability on blocking initializations. This result suggests that the extratropical prediction skill could be improved by better representing blocking in the model.

DICS Behavior Pattern and Medication Errors by Nurses (간호사의 DICS 행동유형과 투약오류)

  • Kim, Eun-Kyung;Lee, Soon-Young;Eom, Mi Ran
    • Journal of Korean Academy of Nursing Administration
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    • v.19 no.1
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    • pp.28-38
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    • 2013
  • Purpose: Human factor is one of the major causes of medication errors. The purpose of this study was to identify nurses' perception and experience of medication errors, examine the relationship of Dominance, Influence, Steadiness, Conscientiousness (DISC) behavior patterns and medication errors by nurses. Methods: A descriptive survey design with a convenience sampling was used. Data collection was done using self-report questionnaires answered by 308 nurses from one university hospital and two general hospitals. Results: The most frequent DISC behavioral style of nurses was influence style (41.9%), followed by steadiness style (23.7%), conscientiousness style (20.4%), and dominance style (14.0%). Differences in the perception and experience level of medication errors by nurses' behavioral pattern were not statistically significant. However, nurses with conscientiousness style had the lowest scores for in experience of medication errors and the highest scores for perception of medication errors. Conclusion: The results of this study show that identification of the behavior pattern of nurses and application of this education program can prevent medication errors by nurses in hospitals.

Analysis of Effects of Chemotherapy using Failure Mode and Effect Analysis (FMEA) on Patient Safety and Safe Nursing (고장유형영향분석을 활용한 항암화학요법의 환자안전간호 효과분석)

  • Yang, Nam Young;Lee, Mi Hyang
    • Journal of Korean Academy of Nursing Administration
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    • v.21 no.3
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    • pp.254-262
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    • 2015
  • Purpose: This study was done to apply failure mode & effect analysis (FMEA) to chemotherapy in order to reduce prescribing, dispensing and administering errors related to treatment and provide patients with a safe medical environment. Methods: A one group pre-post test design was used to verify the effects using the tool for FMEA in chemotherapy. Results: There was a statistically significant decrease in prescribing errors from 11.47% to 3.18%; administering errors decreased but they were not statistically significant. In a addition, there was no change in dispensing errors. Conclusion: The results show that FMEA removed risk factors that might occur during the process of chemotherapy and that it was an effective tool for prevention of negligent accident occurring in actual patients.

Predictability of the Seasonal Simulation by the METRI 3-month Prediction System (기상연구소 3개월 예측시스템의 예측성 평가)

  • Byun, Young-Hwa;Song, Jee-Hye;Park, Suhee;Lim, Han-Chul
    • Atmosphere
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    • v.17 no.1
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    • pp.27-44
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    • 2007
  • The purpose of this study is to investigate predictability of the seasonal simulation by the METRI (Meteorological Research Institute) AGCM (Atmospheric General Circulation Model), which is a long-term prediction model for the METRI 3-month prediction system. We examine the performance skill of climate simulation and predictability by the analysis of variance of the METRI AGCM, focusing on the precipitation, 850 hPa temperature, and 500 hPa geopotential height. According to the result, the METRI AGCM shows systematic errors with seasonal march, and represents large errors over the equatorial region, compared to the observation. Also, the response of the METRI AGCM by the variation of the sea surface temperature is obvious for the wintertime and springtime. However, the METRI AGCM does not show the significant ENSO-related signal in autumn. In case of prediction over the east Asian region, errors between the prediction results and the observation are not quite large with the lead-time. However, in the predictability assessment using the analysis of variance method, longer lead-time makes the prediction better, and the predictability becomes better in the springtime.

Development of the Selected Multi-model Consensus Technique for the Tropical Cyclone Track Forecast in the Western North Pacific (태풍 진로예측을 위한 다중모델 선택 컨센서스 기법 개발)

  • Jun, Sanghee;Lee, Woojeong;Kang, KiRyong;Yun, Won-Tae
    • Atmosphere
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    • v.25 no.2
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    • pp.375-387
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    • 2015
  • A Selected Multi-model CONsensus (SMCON) technique was developed and verified for the tropical cyclone track forecast in the western North Pacific. The SMCON forecasts were produced by averaging numerical model forecasts showing low 70% latest 6 h prediction errors among 21 models. In the homogeneous comparison for 54 tropical cyclones in 2013 and 2014, the SMCON improvement rate was higher than the other forecasts such as the Non-Selected Multi-model CONsensus (NSMCON) and other numerical models (i.e., GDAPS, GEPS, GFS, HWRF, ECMWF, ECMWF_H, ECMWF_EPS, JGSM, TEPS). However, the SMCON showed lower or similar improvement rate than a few forecasts including ECMWF_EPS forecasts at 96 h in 2013 and at 72 h in 2014 and the TEPS forecast at 120 h in 2013. Mean track errors of the SMCON for two year were smaller than the NSMCON and these differences were 0.4, 1.2, 5.9, 12.9, 8.2 km at 24-, 48-, 72-, 96-, 120-h respectively. The SMCON error distributions showed smaller central tendency than the NSMCON's except 72-, 96-h forecasts in 2013. Similarly, the density for smaller track errors of the SMCON was higher than the NSMCON's except at 72-, 96-h forecast in 2013 in the kernel density estimation analysis. In addition, the NSMCON has lager range of errors above the third quantile and larger standard deviation than the SMCON's at 72-, 96-h forecasts in 2013. Also, the SMCON showed smaller bias than ECMWF_H for the cross track bias. Thus, we concluded that the SMCON could provide more reliable information on the tropical cyclone track forecast by reflecting the real-time performance of the numerical models.