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PubMed2006

Clarification of terminology in medication errors: definitions and classification.

We have previously described and analysed some terms that are used in drug safety and have proposed definitions. Here we discuss and define terms that are used in the field of medication errors, particularly terms that are sometimes misunderstood or misused. We also discuss the classification of medication errors. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Errors can be classified according to whether they are mistakes, slips, or lapses. Mistakes are errors in the planning of an action. They can be knowledge based or rule based. Slips and lapses are errors in carrying out an action - a slip through an erroneous performance and a lapse through an erroneous memory. Classification of medication errors is important because the probabilities of errors of different classes are different, as are the potential remedies.

Chemistry, Pharmaceutical↗

PubMed2006

Pharmacists at the forefront: reducing medication errors.

Pharmacists are in a constant battle to prevent medication errors. It is something most pharmacists do not even realize they are doing every day. Some people call it "pharmacist radar." As pharmacists review charts, talk with patients and staff, and interact with prescribers, they are constantly filtering information about medications from numerous sources to ensure that something has not "slipped by" that might cause a medication error. Is that the right dose? Why did the prescriber choose that drug? Where has the facility been keeping that medication? These are just a few questions that are part of the internal dialogue swirling around in senior care pharmacists' heads as they try to ensure the highest level of care for patients.

Drug Prescriptions↗

PubMedDate not supplied

[Medication errors and risk management].

Healthcare risks in general, and those related to medication errors in particular, constitute a serious problem with consequent human, medical, and economic repercussions which healthcare authorities are recognizing and addressing as priority matters in some countries. However, though the magnitude of the problem is similar in Spain, this country has yet to become fully aware of the transcendence of the situation. Risk management activities in healthcare centers are presently evolving as risk managers adopt preventive and proactive approaches requiring the collaboration of other healthcare professionals in developing risk reduction programs, including those focused on medication error prevention. This article briefly describes the principal bases for safety improvement strategies, and outlines a risk management program for medication error prevention in hospitals. In short, it is assumed that risk managers form part of a team whose job it is to analyze incidents when they occur, use this information to establish actions for improving healthcare services through risk reduction, and ensure that the principles of risk management form an integral part in the activities and the culture of organizations. The final result of risk management is the establishment and maintenance of significant system changes which enhance the quality of healthcare services and achieve greater patient safety.

Hospitals↗

PubMed2004

The pharmacist shortage and medication errors: issues and evidence.

The paper, as part of this special issue in error prevention, reviews and discusses evidence in the literature related to the impact of the pharmacist shortage on medication errors. The paper examines past research regarding the impact of pharmacists on medication errors, as well as a recent unique survey that attempted to directly examine the impact of the shortage on medication errors. The paper finds a collection of suggestive anecdotal evidence indicating the pharmacist shortage is having a negative impact on medication errors. In addition, several suggestions are made for future research regarding the relationship between pharmacists, the health system, and medication errors.

Humans↗

PubMed2003

Reported medication errors in obstetric inpatients in 1 hospital.

OBJECTIVE: To describe reported medication errors in the obstetric inpatients in 1 hospital. STUDY DESIGN: We analyzed all errors, reported voluntarily in a nonpunitive manner, from December 1996 to November 2001. RESULTS: The 164 medication errors led to 154 class 1 (no harm), 10 class 2 (additional therapy but no additional harm) and 0 class 3 (permanent harm) adverse drug events. Omissions and incorrect timing of drug administration were the most common reasons. The rate of class 1 adverse drug events was lower in labor and delivery than on the ward (0.8 versus 1.4 per 1,000 patient days; P < .05). Excess dosing with intravenous magnesium sulfate was the most common class 2 event. CONCLUSION: Reported medication errors on 1 inpatient obstetric service were very rare and not associated with permanent harm. Reporting these errors may identify system improvements and avoid recurrences.

Female↗

PubMed2006

Commentary: Medical errors, sentinel events, and malpractice.

Medical errors do not necessarily represent negligence. Even when a mental health professional deviates from the standard of care, minor injury to a patient is unlikely to result in a lawsuit. The standard of care is not the same as the quality of care. Quality of care refers to the total care a patient receives, the patient's health care decisions, and the available mental health services. As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), "sentinel events," such as a patient's suicide, do not necessarily imply that a deviation in the standard of care occurred. Psychiatrists and hospital staff are held to an "ordinarily employed" standard of practice. The Institute of Medicine (IOM) guidelines recommend evidence-based care related to patient needs and values. Both JCAHO and IOM promote best practices. Experts err when they testify to a best practice standard in malpractice cases.

Humans↗

PubMed2004

Anonymity or transparency in reporting of medical error: a community-based survey in South Australia.

OBJECTIVES: To seek public opinion on the reporting of medical errors and the anonymity of healthcare workers who report medical errors. DESIGN AND PARTICIPANTS: A random, representative survey of 2005 South Australians in April 2002, using telephone interviews based on a vignette provided. MAIN OUTCOME MEASURES: When a medical error occurs (i) whether the incident should be reported, and (ii) whether the report should disclose the healthcare worker's identity. RESULTS: (i) Most respondents (94.2%; 95% CI, 93.0%-95.2%) believed healthcare workers should report medical errors. (ii) 68.0% (95% CI, 65.5%-70.5%) of those in favour of reporting believed the healthcare worker should be identified on the report, while 29.2% (95% CI, 26.7%-31.7%) favoured anonymous reporting. CONCLUSIONS: Most respondents believed that, when a healthcare worker makes an error, an incident report should be written and the individual should be identified on the report. Respondents were reluctant to accept healthcare worker anonymity, even though this may encourage reporting.

Adolescent↗

PubMed2006

Addressing medication errors--The role of undergraduate nurse education.

Medication errors are a persistent problem in today's National Health Service (NHS). Many factors contribute to drug incidents occurring, from the initial prescription stage through to administration and arise from both individual and system failures. The literature identifies the multi-disciplinary nature of the problem and highlights the important contribution that nurses make with regards to ensuring medication safety. However limited evidence exists in the literature regarding the extent to which the current content of undergraduate pharmacology education prepares nurses for their role in the prevention of errors. The report "Building a safer NHS for patients-improving medication safety" [Department of Health, 2004. Building a Safer NHS for Patients: Improving Medication Safety. The Stationary Office, London] concludes that it is now imperative that undergraduate education should emphasise the issue of medication safety. An educational initiative was therefore introduced to address this problem. A "Medication Safety Day" which focused on the causes of medication errors was implemented to highlight how and why drug incidents may occur. This initiative recognises that nurse education should not only ensure adequate theoretical knowledge of pharmacology but should also equip students with an awareness of how many diverse factors may contribute to the occurrence of medication errors.

Attitude of Health Personnel↗

PubMed2005

Medical professional liability insurance and its relation to medical error and healthcare risk management for the practicing physician.

PURPOSE: To review the history and current issues surrounding medical professional liability insurance and its relationship to medical error and healthcare risk management. DESIGN: Focused literature review and authors' experience. METHODS: Medical professional liability insurance issues are reviewed in association with the occurrence of medical error and the role of healthcare risk management. RESULTS: The rising frequency and severity of claims and lawsuits incurred by physicians, as well as escalating defense costs, have dramatically increased over the past several years and have resulted in accelerated efforts to reduce medical errors and control practice risk for physicians. Medical error reduction and improved patient outcomes are closely linked to the goals of the medical risk manager by reducing exposure to adverse medical events. Management of professional liability risk by the physician-led malpractice insurance company not only protects the economic viability of physicians, but also addresses patient safety concerns. CONCLUSIONS: Physician-owned malpractice liability insurance companies will continue to be the dominant providers of insurance for practicing physicians and will serve as the primary source for loss prevention and risk management services. To succeed in the marketplace, the emergence and importance of the risk manager and incorporation of risk management principles throughout the professional liability company has become crucial to the financial stability and success of the insurance company. The risk manager provides the necessary advice and support requested by physicians to minimize medical liability risk in their daily practice.

Delivery of Health Care↗

PubMed2001

Evidence on interventions to reduce medical errors: an overview and recommendations for future research.

OBJECTIVE: To critically review the existing evidence on interventions aimed at reducing errors in health care delivery. DESIGN: Systematic review of randomized trials on behavioral, educational, informational and management interventions relating to medical errors. Pertinent studies were identified from MEDLINE, EMBASE, the Cochrane Clinical Trials Registry, and communications with experts. SETTING: Both inpatients and outpatients qualified. No age or disease restrictions were set. MEASUREMENTS: Outcomes were medical errors, including medication, prescription, and diagnostic errors, and excluding preventive medicine errors and simple ordering of redundant tests. MAIN RESULTS: Thirteen randomized studies qualified for evaluation. The trials varied extensively in their patient populations (mean age, 2 weeks to 83 years), study setting, definition of errors, and interventions. Most studies could not afford masking and rigorous allocation concealment. In 9 of 13 studies, error rates in the control arms were very high (10% to 63%), and large treatment benefits from the studied interventions were demonstrated for the main outcome. Interventions were almost always effective in a sample of 24 nonrandomized studies evaluated for comparison. Actual patient harm from serious errors was rarely recorded. CONCLUSIONS: Medical errors were very frequent in the studies we identified, arising sometimes in more than half of the cases where there is an opportunity for error. Relatively simple interventions may achieve large reductions in error rates. Evidence on reduction of medical errors needs to be better categorized, replicated, and tested in study designs maximizing protection from bias. Emphasis should be placed on serious errors.

Humans↗

PubMedDate not supplied

The relationship between a calculation test given in nursing orientation and medication errors.

This article presents a descriptive study that investigates the relationship between pass/fail scores on a medication test given to registered nurses in orientation and medication errors made on nursing units. Medication errors made during a 3-year period of time were reviewed to determine number of errors made and the nurses who made the errors. Pass/fail scores from the medication test given in orientation were checked to see whether the nurses who made the errors had passed or failed the test. Chi square, t test, and multiple regression analysis were used to evaluate the data. Results showed that nurses who failed the medication test were more likely to make medication errors than nurses who had passed the medication test.

Educational Measurement↗

PubMed2000

Thrombolysis medication errors: benefits of bolus thrombolytic agents.

A recent report has highlighted the high incidence of medical errors in clinical practice and the important fact that errors are associated with increased mortality. This issue is now being examined closely in the field of thrombolytic therapy for acute myocardial infarction. Numerous trials have found that the dose of the thrombolytic agent is closely related to outcome, with too low a dose associated with lower rates of infarct-related artery patency and higher doses associated with increased bleeding and intracranial hemorrhage. Thus, the "therapeutic window" for thrombolytic therapy is small, and the potential for adverse outcome from dosing errors is high. In the Global Use of Strategies To Open occluded arteries (GUSTO)-I trial, 13.5% of patients treated with streptokinase and 11.5% of patients treated with tissue plasminogen activator (t-PA) were subjected to a medication error (e.g., incorrect dose or infusion length). Most importantly, 30-day mortality was significantly higher in patients with medication errors: For t-PA dosing errors, mortality was 7.7% versus 5.5% for patients who received the correct t-PA dose (p<0.001); findings were similar for streptokinase. More recent data from the Intravenous n-PA for Treatment of Infarcting Myocardium Early (InTIME)-II trial and other studies showed that use of a bolus thrombolytic agent reduced the rate of medication errors. Thus, use of the simpler bolus thrombolytic agents may improve overall clinical outcome.

Fibrinolytic Agents↗

PubMed2003

Medication reconciliation: a practical tool to reduce the risk of medication errors.

Preventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.

Continuity of Patient Care↗

PubMed2001

Possible medication errors in home healthcare patients.

OBJECTIVE: To determine the frequency of possible medication errors in a population of older home healthcare patients according to expert panel objective criteria. DESIGN: A cross-sectional survey. SETTING: Two of the largest urban home healthcare agencies in the United States. PARTICIPANTS: Home healthcare patients age 65 and older admitted to selected offices of these agencies between October 1996 and September 1998. MEASUREMENTS: We used two sets of consensus-based expert panel criteria to define possible medication errors. The Home Health Criteria identify patients with patterns of medication use and signs and symptoms that indicate sufficient likelihood of a medication-related problem to warrant reevaluating the patient. The Beers criteria identify medications that experts have deemed generally inappropriate for older patients. RESULTS: The 6,718 study subjects took a median of five drugs; 19% were taking nine or more medications. A possible medication error was identified for 19% of patients according to Home Health Criteria, 17% according to the Beers criteria, and 30% according to either. Possible errors increased linearly with number of medications taken. When patients taking one to three medications were compared with those taking nine or more drugs, the percentages with possible errors were, respectively, 10% and 32% for the Home Health Criteria, 8% and 32% for the Beers criteria, and 16% and 50% for both. CONCLUSION: Nearly one-third of the home healthcare patients surveyed had evidence of a potential medication problem or were taking a drug considered inappropriate for older people. More-effective methods are needed to improve medication use in this vulnerable population.

Aged↗

PubMedDate not supplied

Strategies for identifying and minimizing medication errors in health care settings.

For many years, medication errors have been a source of serious concern within the health care community. This article examines the definition and assessment of medication errors and some of the emerging technologies used to alleviate them. In addition, recommendations are proposed to improve the drug placement and promotion dimension of the marketing function in the pharmaceuticals industry.

Drug Industry↗

PubMed2005

Toward a theoretical approach to medical error reporting system research and design.

The release of the Institute of Medicine (Kohn et al., 2000) report "To Err is Human", brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation.

Equipment Design↗

PubMed2004

Design elements for a primary care medical error reporting system.

PROBLEM CONSIDERED: State and federal initiatives to develop medical error reporting systems are being proposed. For these to lead to an effective error reporting system to improve primary care, the needs of primary care professionals must be understood. METHODS: This study was based on the answers to key questions directed at primary care physicians and clinical assistants. A series of focus groups was held to determine what elements need to be included in the design of a medical error reporting system for ambulatory care. RESULTS: Participants addressed the purposes of an error reporting system, the barriers and motivators to the use of a system, the types of events that should be reported, how the reporting should be done, and how the data should be analyzed and used. During the sessions, 87 different themes emerged that were distilled down to the general principles and operating design elements deemed most important. CONCLUSIONS: The participating physicians and clinical assistants supported a primary care medical error reporting system designed to provide useful information to improve health care. The system should not be punitive.

Focus Groups↗

PubMed2006

The state of the art in the reduction of medical errors.

The IOM report, To Err is Human, Building a Better Health System, galvanized public and political attention to the prevalence of medical errors in the Unites States. The IOM set a clear goal, "given the current knowledge about the magnitude of the problem, the committee believes it would be irresponsible to expect anything less than a 50 percent reduction over five years." As part of the IOM's four-part strategy was a recommendation that error reporting systems be established. No one denies that errors that occur in medicine can not be reduced if they cannot be defined. To achieve this goal of reducing errors, we have established a definition of a "medical error", described the current taxonomies that have been created over the last five years for their classification, and suggested a conceptual model for designing and testing a medical error reporting system. A system that facilitates identification, relies on health professionals and electronic repositories of clinical information to report events, and tracks and monitors medical errors, reliably, efficiently, and accurately is the objective of our design. Our next step is to implement, test, and evaluate this system based on our research.

Classification↗