38th Annual Meeting of the European Group for Blood and Marrow Transplantation
Geneva, Switzerland

01.04.2012 - 04.04.2012
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Home - 02.04.2012 - NURSES POSTER SESSIONS


Monday, April 02, 2012, 17:30 - 19:00

Patient safety in medication; a retrospective inspection of reported errors and near misses

Merja Stenvall (Helsinki, FI)

This development work is part of Patient safety studies (30 ECTS) in The Patient Safety and Learning Center of Arcada in Helsinki Finland. These studies will be finished by spring 2012.
Children's hospital K10 Division of Haematology-Oncology and Stem Cell Transplantation is combined with several units. There is the paediatric transplant unit (10 beds, JACIE accreditated since 2008), haematology/oncology unit offering conventional treatment (9beds), day- hospital, outpatient unit, home care, anaesthesia unit (BM biopsies, lumbar punctures) and hsc collection unit. Physicians and nursing staff is working in all these units after specific training. There are 6-7 paediatric haematologists, 1 anaesthesiologist and nearly 70 nurses. There is a pharmacologist in both wards. All the patients have inserted cvc’s (transplant patients have 2 catheters with one or two lumens).
Procedure for handling patient safety incident reports has been in place since 2006. There has been a web-based patient safety incidents reporting system (HaiPro) since 2009. Reports are gathered every 3 months and discussed in division’s management group (medical and nursing lead present). In these meetings is also decided actions to be taken and information to the staff. This is a no blame practice.
Retrospective inspection of reported errors and near misses from the HaiPro-system (9/2009-9/2011) will be done. HaiPro web-based reporting system allows one to choose from 5 subgroups when making the report from medication error (preparation, prescription, documentation, distribution, administration and unexpected reaction for the medication). All subgroups are more detailed and allow one to be more precise. There are approx. 90 error reports made yearly, out of which more 50% are related to medication.
Reporting the results of this retrospective inspection of medication errors and near misses: total number of medication errors, how these errors are divided in different subgroups, what action has already been taken and possible impact to the reported errors. It will be also discussed if new interventions are needed? Follow up after ˝ months after intervention, which will take place in autumn 2012.