Dissemination of Direct Healthcare Professional Communications on Medication Errors for Medicinal Products in the EU: An Explorative Study on Relevant Factors

How do medication errors occur in the nursing communication process? Investigating the relationship between error types and error factors

BACKGROUND

Human error types and error factors are two important elements of error analysis. Understanding the relationship between them can contribute to new case analyses, the tendency of error occurrence statistics, error factor identification, and prevention of error recurrence.

OBJECTIVE

To provide evidence and guidance for the prevention and improvement of medication communication errors by quantitatively exploring the relationship between error types and error factors.

METHODS

Data were collected on self-reported errors in the medication administration process by nurses in all departments of three cooperative medical institutions, and an error sheet of specified style was adopted. Error types were determined by the systematic human error reduction and prediction approach method and human cognition processes. Error factors were extracted using the root cause analysis combined with Berlo's communication model, and the relationship between error types and error factors was quantitatively studied using the partial least-squares regression method.

RESULTS

After a one-by-one analysis of 303 error cases, the communication errors occurring in the nursing medication process could be explained by six error types and 12 error factors. In addition, 20 correlation patterns between the error types and error factors were quantitatively obtained, and their path coefficient distributions ranged from 0.088 to 0.467.

CONCLUSION

The results of this study may provide reference to understand errors and establish countermeasures from the statistics of error occurrence trends, extract error factors related to error types and determine key error factors.

Regulatory experience of handling Risk Management Plans (RMPs) for medicinal products in the EU

Introduction: Risk Management Plans (RMPs) aim to optimize a medicinal product's benefit/risk balance for the individual patient and the target population. Despite differences in regulatory RMP requirements between jurisdictions worldwide, their ultimate aim is to protect public health.Areas covered: The review presents findings of different RMP requirements by different regulatory authorities and additional risk minimization measures (issued between January 2010 and December 2018) indicate how RMPs and additional risk minimization measures translate into actions to protect public health within the European Union (EU) member states and worldwide. Areas covered also include the different International Council for Harmonization (ICH) regional requirements of RMPs by the different regulatory authorities as well as data regarding the number of RMP assessments carried out by the EMA, FDA and Japan, and number of safety communications issued in Malta (taken as an example of a typical small EU member state) and in the United States of America (USA).Expert opinion: The EU legislation adopted in 2010 required RMPs to be included in all new applications for medicinal products in the EU, both for EU centrally authorized and nationally authorized medicinal products. Lessons learnt by EU regulators during this process are discussed in this review.