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PubMed1975

Medication errors in a multidose and a computer-based unit dose drug distribution system.

The medication error rates of a hospital's multidose and computer-based unit dose drug distribution systems were compared; in addition, the medication error rate of the unit dose system was compared to that reported for noncomputerized unit dose systems in other hospitals. Two similar adult, medical, patient care units, each serviced by a different drug distribution system, were studied for 60 days. Information about the medications administered was obtained by the disguised observation technique during intermittent periods. The observer's notations on the medications administered were compared to the physicians' orders to determine if errors had been committed. Only medication "errors of commission" were recorded. There were significantly fewer medication errors and significantly fewer medications administered at the wrong time in the unit dose system. The medication error rate associated with the unit dose system compared favorably with that of most other unit dose systems. No particular benefit, in terms of the medication error rate, was attributed to the computer element of the unit dose system.

Computers↗
PubMed2006

Hospitals educate patients to reduce medical errors, improve patient safety.

Hospitals educate patients to reduce medical errors, improve patient safety. Educating patients on the effective use of the health care system is sweeping through the nation's hospitals as the effort to reduce medical errors and improve patient safety takes another step to incorporate the team approach.

Humans↗
PubMed1994

Nurses' medication errors.

This paper reports on a qualitative study of nurses' experiences with medication errors. Using discourse analysis within a framework of an interpretive research design, the phenomenon of a not too uncommon occurrence in nursing practice was examined. Insight into nurses' involvement with medication errors was gained from interviews, group discussions and self-reports. Documents of disciplinary proceedings, where the Professional Conduct Committee of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting has dealt with incidents of medication errors, supplemented the data. Decisions made in situations of medication errors have moral implications at personal, institutional, and professional levels. The moral courage that is needed to learn from mistakes can be enhanced through honest dealings with the situation. Where the attention is shifted from the person involved onto the problem at hand, fair judgement may be advanced and the fear of owning up to a mistake be diminished. Only when reflected upon, can personal experience merge into the stream of development and progress. This study contributes to such reflection. Three key issues are discussed in-depth as they evolved during analysis of the data: These issues deal with identification and change; with guilt and shame and the reconciliation with human precariousness; and with teaching and learning. The manner in which discourse analysis was used here represents an innovative attempt to advance qualitative methodology in nursing research.

Adaptation, Psychological↗
PubMed2006

Medication errors related to computerized order entry for children.

OBJECTIVE: The objective of this study was to determine the frequency and types of pediatric medication errors attributable to design features of a computerized order entry system. METHODS: A total of 352 randomly selected, inpatient, pediatric admissions were reviewed retrospectively for identification of medication errors, 3 to 12 months after implementation of computerized order entry. Errors were identified and classified by using an established, comprehensive, active surveillance method. Errors attributable to the computer system were classified according to type. RESULTS: Among 6916 medication orders in 1930 patient-days, there were 104 pediatric medication errors, of which 71 were serious (37 serious medication errors per 1000 patient-days). Of all pediatric medication errors detected, 19% (7 serious and 13 with little potential for harm) were computer related. The rate of computer-related pediatric errors was 10 errors per 1000 patient-days, and the rate of serious computer-related pediatric errors was 3.6 errors per 1000 patient-days. The following 4 types of computer-related errors were identified: duplicate medication orders (same medication ordered twice in different concentrations of syrup, to work around computer constraints; 2 errors), drop-down menu selection errors (wrong selection from a drop-down box; 9 errors), keypad entry error (5 typed instead of 50; 1 error), and order set errors (orders selected from a pediatric order set that were not appropriate for the patient; 8 errors). In addition, 4 preventable adverse drug events in drug ordering occurred that were not considered computer-related but were not prevented by the computerized physician order entry system. CONCLUSIONS: Serious pediatric computer-related errors are uncommon (3.6 errors per 1000 patient-days), but computer systems can introduce some new pediatric medication errors that are not typically seen in a paper ordering system.

Adolescent↗
PubMed2001

[Reducing medical error and improving patient safety].

Within the last years in the public discussion medical error became a new issue. Several studies have addressed problems in the delivery of medical services, which create a breakdown of trust in doctors and the health care system. One of the reasons may be a broader and faster (global) information network system together with media which search extensively for mistakes and problems, despite the fact that diagnostic and therapeutic methods, skills and accuracy could be improved. Nevertheless, the medical system has to address these challenges in order to definitively reduce medical errors and improve patient safety. In contrast to the discussion about quality assurance and management systems in health care, medical errors and patient safety do not have the smell of expensive or not really necessary products, but they are urgent and very important. So the topics "medical error" and "patient safety" have in fact the potential to enhance quality management systems (QMS), which are an accepted technology to solve these problems.

Health Services↗
PubMed2006

Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system.

OBJECTIVE: To more closely assess medication errors in gout care, we examined data from a national, Internet-accessible error reporting program over a 5-year reporting period. METHODS: We examined data from the MEDMARX database, covering the period from January 1, 1999 through December 31, 2003. For allopurinol and colchicine, we examined error severity, source, type, contributing factors, and healthcare personnel involved in errors, and we detailed errors resulting in patient harm. Causes of error and the frequency of other error characteristics were compared for gout medications versus other musculoskeletal treatments using the chi-square statistic. RESULTS: Gout medication errors occurred in 39% (n = 273) of facilities participating in the MEDMARX program. Reported errors were predominantly from the inpatient hospital setting and related to the use of allopurinol (n = 524), followed by colchicine (n = 315), probenecid (n = 50), and sulfinpyrazone (n = 2). Compared to errors involving other musculoskeletal treatments, allopurinol and colchicine errors were more often ascribed to problems with physician prescribing (7% for other therapies versus 23-39% for allopurinol and colchicine, p < 0.0001) and less often due to problems with drug administration or nursing error (50% vs 23-27%, p < 0.0001). CONCLUSION: Our results suggest that inappropriate prescribing practices are characteristic of errors occurring with the use of allopurinol and colchicine. Physician prescribing practices are a potential target for quality improvement interventions in gout care.

Adverse Drug Reaction Reporting Systems↗
PubMed2005

Medication errors in anaesthesia and critical care.

There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers. However, study of medication error is hampered by difficulty with definitions, research methods and study populations. Few doctors are as involved in the process of prescribing, selecting, preparing and giving drugs as anaesthetists, whether their practice is based in the operating theatre, critical care or pain management. Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. New technology, theories of human error and lessons learnt from the nuclear, petrochemical and aviation industries are being used to tackle the problem.

Anesthesia↗
PubMed2002

Preventing medication errors in home care.

This practice brief highlights the results of two home health care studies on medication errors. The first study determined how often medication errors occur in home health care. The second study tested a strategy to reduce these errors. Although nearly one third of home care patients are at risk for potential medication errors, adding a simple, practical program can reduce the potential for errors. These results should encourage home care agencies to be more vigilant in monitoring medication errors and to institute programs that help prevent errors from occurring.

Aged↗
PubMed2004

Adverse drug events and medication errors: detection and classification methods.

Investigating the incidence, type, and preventability of adverse drug events (ADEs) and medication errors is crucial to improving the quality of health care delivery. ADEs, potential ADEs, and medication errors can be collected by extraction from practice data, solicitation of incidents from health professionals, and patient surveys. Practice data include charts, laboratory, prescription data, and administrative databases, and can be reviewed manually or screened by computer systems to identify signals. Research nurses, pharmacists, or research assistants review these signals, and those that are likely to represent an ADE or medication error are presented to reviewers who independently categorize them into ADEs, potential ADEs, medication errors, or exclusions. These incidents are also classified according to preventability, ameliorability, disability, severity, stage, and responsible person. These classifications, as well as the initial selection of incidents, have been evaluated for agreement between reviewers and the level of agreement found ranged from satisfactory to excellent (kappa = 0.32-0.98). The method of ADE and medication error detection and classification described is feasible and has good reliability. It can be used in various clinical settings to measure and improve medication safety.

Adverse Drug Reaction Reporting Systems↗
PubMed2005

Improving end of life care: an information systems approach to reducing medical errors.

Chronic and terminally ill patients are disproportionately affected by medical errors. In addition, the elderly suffer more preventable adverse events than younger patients. Targeting system wide "error-reducing" reforms to vulnerable populations can significantly reduce the incidence and prevalence of human error in medical practice. Recent developments in health informatics, particularly the application of artificial intelligence (AI) techniques such as data mining, neural networks, and case-based reasoning (CBR), presents tremendous opportunities for mitigating error in disease diagnosis and patient management. Additionally, the ubiquity of the Internet creates the possibility of an almost ideal network for the dissemination of medical information. We explore the capacity and limitations of web-based palliative information systems (IS) to transform the delivery of care, streamline processes and improve the efficiency and appropriateness of medical treatment. As a result, medical error(s) that occur with patients dealing with severe, chronic illness and the frail elderly can be reduced.The palliative model grew out of the need for pain relief and comfort measures for patients diagnosed with cancer. Applied definitions of palliative care extend this convention, but there is no widely accepted definition. This research will discuss the development life cycle of two palliative information systems: the CONFER QOLP management information system (MIS), currently used by a community-based palliative care program in Brooklyn, New York, and the CAREN case-based reasoning prototype. CONFER is a web platform based on the idea of "eCare". CONFER uses XML (extensible mark-up language), a W3C-endorced standard mark up to define systems data. The second system, CAREN, is a CBR prototype designed for palliative care patients in the cancer trajectory. CBR is a technique, which tries to exploit the similarities of two situations and match decision-making to the best-known precedent cases. The prototype uses the opensource CASPIAN shell developed by the University of Aberystwyth, Wales and is available by anonymous FTP. We will discuss and analyze the preliminary results we have obtained using this CBR tool. Our research suggests that automated information systems can be used to improve the quality of care at the end of life and disseminate expert level 'know how' to palliative care clinicians. We will present how our CBR prototype can be successfully deployed, capable of securely transferring information using a Secure File Transfer Protocol (SFTP) and using a JAVA CBR engine.

Artificial Intelligence↗
PubMed2003

The epidemiology of medical errors: a review of the literature.

BACKGROUND: Medical errors are one of the most important quality problems in health care today. The best insight into the incidences and characteristics of medical errors is through studies on adverse events (AEs) since a considerable fraction of AEs are results of errors and as such preventable. Even though prevention is where effort should be directed to, only a few studies report on the preventability of AEs. Our aim is to give an overview of the literature reporting on AEs and their preventability. METHODS: We systematically searched Medline and Embase for literature published between 1980 and June 2002. All articles reporting primary data on incidences of AEs and their preventability were included. RESULTS: The 8 articles retrieved were divided into two categories. 1) Four large scale retrospective studies: They reported incidences of AEs between 2.9% and 16.6% of all hospitalizations that were judged as preventable in 48.0-69.6% and negligent in up to 32.3%. 2) Four prospective studies: The reported rates of AEs vary remarkably (0.0037-39.0%) because of different detection methods used, different definitions applied and different health care settings studied. One prospective observational study identified AEs in 39.0% of hospitalized patients with a preventability of 18.0%. Two other studies, using process oriented incidence reporting detected rather low rates of AEs (4.2-5.4%) which were preventable in up to 62.5%. One prospective study in the outpatient setting, using voluntary incidence reporting detected only about 3.7 events per 100,000 clinic visits of which a high fraction was judged to be preventable (83.0%). IMPLICATIONS: Incidence, medical outcome and costs of AEs warrant this issue to be high on any countries health care agenda. The U.S., Australia and Britain have adopted this challenge by creating a centre for quality improvement and patient safety within the health service and by enacting new laws. But real improvement of patient safety will need a fundamental change in medicine from a culture of individual blame and guilt to a culture of learning, system thinking and executive responsibility.

Cross-Cultural Comparison↗
PubMed2005

Medication errors in an internal medicine department. Evaluation of a computerized prescription system.

OBJECTIVE: Evaluation of a computerized physician order entry in an Internal Medicine Department, with a unit-dose distribution system. SETTING: Pharmacy Department, Internal Medicine Department. S. Francisco Xavier Hospital, Lisbon, Portugal. METHOD: This study was carried out in December 2001 and January 2002. After two years experience of the CPOE system, medication errors were evaluated prospectively, in an internal medical department of a 360-bed academic hospital. Data were collected once a week. Pharmacists reviewed all medical prescriptions as part of their routine work. Medication errors detected were recorded on a data collection form with a design based on the types of errors as defined by the American Society of Hospital Pharmacists (ASHP). Completed forms were reviewed and medication errors were classed according to ASHP guidelines. RESULTS: A total of 2268 orders were monitored (162 patients). In these orders, 73 medication errors (22.4% of the patients) were detected and documented (59 prescribing errors and 14 monitoring errors). The most common prescribing errors were deficiencies related to the right class but wrong drug (28.3%): omeprazole vs. ranitidine/sucralfate in stress ulcer prophylaxis; incorrect dose (30%) and unclear orders (13.3%). Errors related to incorrect frequency of administration (5%); maintenance of IV route (5%); duplicated drug therapy (11.7%); drug interactions (1.7%) and length of therapy (3.3%) were also detected. The 14 monitoring errors detected were failures to review a prescribed regimen for appropriateness and detection of problems. CONCLUSIONS: Computerized prescription order entry has demonstrated effectiveness in eliminating medication errors related to transcribing and patient identification. Nevertheless, medication errors related to prescription and monitoring still occur. The use of clinical decision support systems and pharmacist involvement is vital to achieve maximum medication safety and reduce medication error rates.

Drug Prescriptions↗
PubMed2006

Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection.

OBJECTIVE: To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence. DESIGN: Prospective, direct observation study. SETTING: Tertiary care academic medical center. PATIENTS: Patients in a medical/surgical intensive care unit. INTERVENTIONS: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. MEASUREMENTS AND MAIN RESULTS: The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%). CONCLUSIONS: Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.

Academic Medical Centers↗
PubMed2005

Insights from the sharp end of intravenous medication errors: implications for infusion pump technology.

BACKGROUND: Intravenous (IV) medication errors are a common type of error identified in hospitals and can lead to considerable harm. Over the past 20 years there have been several hundred FDA reported incidents involving IV pumps, many of which have led to patient deaths. OBJECTIVE: To determine the actual types, frequency, and severity of medication errors associated with IV pumps. To evaluate the likelihood that smart pump technology without an interface to other systems could have prevented errors. METHODS: Using a point prevalence approach, investigators prospectively compared the medication, dose, and infusion rate on the IV pump with the prescribed medication, doses, and rate in the medical record. Preventability with smart pump technology was retrospectively determined based on a rigorous definition of currently available technology. RESULTS: A total of 426 medications were observed infusing through an IV pump. Of these, 285 (66.9%) had one or more errors associated with their administration. There were 389 documented errors overall; 37 were "rate deviation" errors and three of these were judged to be due to a programming mistake. Most of the documented events would not have caused patient harm (NCC MERP category C). Only one error would have been prevented by smart pump technology without additional interface and software capabilities. CONCLUSION: Medication errors associated with IV pumps occur frequently, have the potential to cause harm, and are epidemiologically diverse. Smart pumps are a necessary component of a comprehensive safe medication system. However, currently available smart pumps will fail to generate meaningful improvements in patient safety until they can be interfaced with other systems such as the electronic medical record, computerized prescriber order entry, bar coded medication administration systems, and pharmacy information systems. Future research should focus on the effectiveness of new technology in preventing latent and active errors, and on new types of error that any technology can introduce.

Academic Medical Centers↗
PubMed2004

Effect of reducing interns' work hours on serious medical errors in intensive care units.

BACKGROUND: Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors. METHODS: We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an "every third night" call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident. RESULTS: During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001). CONCLUSIONS: Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.

Humans↗