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PubMed1998

Barriers to acceptance of medical error: the case for a teaching program (695).

There is need for a teaching programme aiming to impart a tolerance of error to undergraduate medical students. The implementation of such a programme may have to challenge the institutional norms that encourage authoritarianism, intolerance of uncertainty and denial of error. Acceptance of error is a prerequisite for its candid reporting, and reporting of errors is a prerequisite for their analysis with a view to their prevention. A curriculum on medical error may, therefore, not only help medical students cope with their future mistakes, but also reduce their frequency. Teaching intervention aiming to promote an acceptance of medical error as both inevitable and reducible may also encourage students' epistemological development by making them realize that their doubts and uncertainties are shared by their peers and instructors.

Curriculum↗
PubMed2003

Use of chart and record reviews to detect medication errors in a state psychiatric hospital.

OBJECTIVE: This study compared the effectiveness of using a review team and the usual self-reporting method in detecting different types of medication errors in a state psychiatric hospital. METHODS: Medication errors were defined by using widely accepted criteria. Rates of prescription, transcription, administration, and dispensing errors were determined, and the risk of harm from each error was rated as high, moderate, or low. A review team was assigned to retrospectively review 31 patient records for prescription, transcription, and administration errors for a total of 1,448 patient-days. Dispensing errors, which can only be determined concurrently, were reported for an equivalent number of patient-days. The error rate was compared with the rate that was determined by the usual method of self-reports from all nursing and medical staff. RESULTS: In the 31 charts retrospectively reviewed and the dispensing events concurrently reviewed, the team detected a total of 2,194 medication errors, whereas a total of nine errors were self-reported for the same patient group. Administration errors accounted for more than half of the total (66 percent), followed by transcription errors (23 percent), prescription errors (11 percent), and dispensing errors (less than 1 percent). Nineteen percent of errors were rated as having a low risk of harm, 23 percent as having a moderate risk, and 58 percent as having a high risk. CONCLUSIONS: Use of a review team should be considered as a method for detecting and reporting medication errors.

Hospitals, Psychiatric↗
PubMedDate not supplied

Medication errors: ethical implications.

Errors in health care are receiving much attention today, although committing such errors is not a new phenomenon. Nurses are taught procedures so that they are less likely to make mistakes. Yet nurses do make errors. Although many types of errors can and do occur in the health care setting, this article focuses on a discussion of medication errors and related ethical implications. Several ethical issues may arise as a result of medication errors: harm to patients, whether to disclose the error, erosion of trust, and impact on quality care. Nurses' appropriate ethical responses to medication errors need to be supported. Changing the health care system will help nurses to promote patient welfare, lessen the chance of harm, and reduce the likelihood of medication errors occurring.

Ethics↗
PubMed2006

Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness.

OBJECTIVE: To assess whether patients' perceptions of a hypothetical medical error are influenced by staff responsiveness, disclosure of error, and health consequences of the error. DESIGN: Hypothetical scenario describing a medication error submitted by mail. Three factors were manipulated at random: rapid v slow staff responsiveness to error; disclosure v non-disclosure of the error; and occurrence of serious v minor health consequences. PARTICIPANTS: Patients discharged from hospital. MEASURES: Assessment of care described in the scenario as bad or very bad, rating of care as unsafe, and intent to not recommend the hospital. RESULTS: Of 1274 participants who evaluated the scenario, 71.4% rated health care as bad or very bad, 60.2% rated healthcare conditions as unsafe, and 25.5% stated that they would not recommend the hospital. Rating health care as bad or very bad was associated with slow reaction to error (odds ratio (OR) 2.8, 95% CI 2.1 to 3.6), non-disclosure of error (OR 2.0, 95% CI 1.5 to 2.6), and serious health consequences (OR 3.4, 95% CI 2.6 to 4.5). Similar associations were observed for rating healthcare conditions as unsafe and the intent to not recommend the hospital. Younger patients were more sensitive to non-disclosure than older patients. CONCLUSIONS: Former patients view medical errors less favorably when hospital staff react slowly, when the error is not disclosed to the patient, and when the patient suffers serious health consequences.

Adolescent↗
PubMedDate not supplied

Perceptions of medical errors by internal medicine residents: development and validation of a new scale.

Efforts to identify the underlying structure of 40 survey items dealing with perceptions of medical errors are reported on the basis of responses from 195 medical residents. Factor analysis revealed that the medical errors perceptions were represented by a 10-factor solution. The external validity of these factors was examined relative to perceptions about the cost of medical errors, the cost of errors to health care, and the need for education and interventions to address errors. Results indicated that 13.9% of the variation in the perceived cost of medical errors and 17.1% of the variation in the perceived need for additional physician education was explained by the factor structure.

Adult↗
PubMedDate not supplied

Turning the tide on medical errors in intensive care units: a human factors approach.

Errors occur in all nursing settings. The current healthcare climate tends to focus on individuals as the cause of errors rather than addressing issues that may be inherently wrong with the healthcare system that predisposes the individual to make errors. Human factors engineering (HFE), which is focused on removing human factors as much as possible from errors, has the potential to greatly impact medical errors in intensive care units. Applied in other high-risk industries, HFE has been critical in understanding and preventing errors at a systems level. Knowledge concerning the role systems play in errors and improvements to medical systems using HFE is intended to empower nurses to be advocates for systems change, resulting in a safer work environment and a safer healthcare delivery system.

Critical Care↗
PubMed2003

Medication errors: an analysis comparing PHICO's closed claims data and PHICO's Event Reporting Trending System (PERTS).

Clinical pharmacologists are all dedicated to improving the use of medications and decreasing medication errors and adverse drug reactions. However, quality improvement requires that some significant parameters of quality be categorized, measured, and tracked to provide benchmarks to which future data (performance) can be compared. One of the best ways to accumulate data on medication errors and adverse drug reactions is to look at medical malpractice data compiled by the insurance industry. Using data from PHICO insurance company, PHICO's Closed Claims Data, and PHICO's Event Reporting Trending System (PERTS), this article examines the significance and trends of the claims and events reported between 1996 and 1998. Those who misread history are doomed to repeat the mistakes of the past. From a quality improvement perspective, the categorization of the claims and events is useful for reengineering integrated medication delivery, particularly in a hospital setting, and for redesigning drug administration protocols on low therapeutic index medications and "high-risk" drugs. Demonstrable evidence of quality improvement is being required by state laws and by accreditation agencies. The state of Florida requires that quality improvement data be posted quarterly on the Web sites of the health care facilities. Other states have followed suit. The insurance industry is concerned with costs, and medication errors cost money. Even excluding costs of litigation, an adverse drug reaction may cost up to $2500 in hospital resources, and a preventable medication error may cost almost $4700. To monitor costs and assess risk, insurance companies want to know what errors are made and where the system has broken down, permitting the error to occur. Recording and evaluating reliable data on adverse drug events is the first step in improving the quality of pharmacotherapy and increasing patient safety. Cost savings and quality improvement evolve on parallel paths. The PHICO data provide an excellent opportunity to review information that typically would not be in the public domain. The events captured by PHICO are similar to the errors and "high-risk" drugs described in the literature, the U.S. Pharmacopeia's MedMARx Reporting System, and the Sentinel Event reporting system maintained by the Joint Commission for the Accreditation of Healthcare Organizations. The information in this report serves to alert clinicians to the possibility of adverse events when treating patients with the reported drugs, thus allowing for greater care in their use and closer monitoring. Moreover, when using high-risk drugs, patients should be well informed of known risks, dosage should be titrated slowly, and therapeutic drug monitoring and laboratory monitoring should be employed to optimize therapy and minimize adverse effects.

Adverse Drug Reaction Reporting Systems↗
PubMedDate not supplied

Factors associated with a perceived harmful outcome from medication errors: a pilot study.

The purpose of this pilot study was: 1) to describe factors associated with a perceived harmful outcome following medication errors made by nurses and 2) to refine the Medication Error Risk Profile (MERP) (Wolf, 1992). Ninety-four registered nurses and licensed practical nurses completed the MERP. Multiple stepwise regression analyses were used to explain the variance in the dependent variable of perceived patient harm with: 1) phases of preparation and administration; 2) categories of person responsible for the error; 3) interventions needed following the error and symptoms related to the error. The exploratory regression analysis suggests a model in which the dispensing phase of administration, the physician and pharmacist categories of persons responsible for the error, and the interventions of patient transfer to another unit and additional medications given following the error explain 53% of the variance in perceived harmful outcome for patients consequent to medication errors. A moderately strong correlation (r = .46, P < .001) existed between perceived patient harm as measured on the four-point scale and total intervention score following medication errors.

Adult↗
PubMedDate not supplied

[A new tool for evaluation of medication errors applied to pediatric hematology].

This study was conducted in a haematological paediatric department and was aimed at evaluating drug medication errors. Their frequency was studied, but also and mainly their degree of severity and preventability. Only adverse drug events that were identified as possibly due to pharmacological properties of drugs or medication errors were collected. An original method was used, based on a multidimensional mathematical tool, called Factorial Analysis of Multiple Correspondences (FAMC), in order to assess the grade of severity and preventability for each adverse drug event. A total of 155 adverse drug events were detected for 34 out of 52 patients hospitalized during the study period. The prevalence rate was 65 per cent and among these adverse drug events, 16 per cent were serious and 53 per cent were avoidable. Apart from the fact that the FAMC helped to determine the grade of preventability, FAMC allowed one to demonstrate that allergy and medication errors were the most avoidable adverse drug events. In this way the method used was validated. This study permitted the assessment of drug medication errors in this department and helped to choose the priorities for the management of preventive actions.

Child↗
PubMed2003

Assessment of medication errors that involved drug allergies at a university hospital.

OBJECTIVES: To determine the reporting accuracy of true patient-related allergies to drugs in a large teaching institution (908 licensed beds), and to identify factors contributing to medication errors that involved drug allergies. Of particular interest was the accuracy of allergy information in the medical record and the occurrence of medication errors that involved penicillin antibiotics. METHODS: From a sample population of 340 patients, 50 adult patients admitted to our university-affiliated hospital who met criteria and had an allergy to selected drugs that was documented in the hospitalwide computer system were randomly selected and interviewed to determine the timing, nature, and extent of the reaction. Furthermore, data were collected from identified Medication Error Reports when an agent was prescribed for a patient with a reported allergy to that agent or class. Prospective data collection was conducted from November 2000-February 2001. Using the information obtained by the patient interview and chart documentation, we assessed the reported allergy. In addition, contributing factors for medication errors that involved drug allergies were identified. RESULTS: Of the sample population, 133 patients (39%) reported allergies to at least one drug. Allergies to beta-lactams, sulfonamides, and opioid narcotics were reported in 12.6% (43 patients), 9.1% (31), and 14.4% (49) of the sample population, respectively. Most agents involved in medication errors were beta-lactam antibiotics, with an overwhelming number of these errors due to piperacillin-tazobactam (51.4%, 36 errors). Other drugs involved were ampicillin (10%, 7 errors), other beta-lactams (24.3%, 17 errors), opioid narcotics (10%, 7 errors), and sulfonamides (4.3%, 3 errors). Most contributing factors were classified as "MD [prescribing physician] not aware of allergy." CONCLUSION: These results suggest a need for ensuring that prescribers review each patient's allergy profile before order entry.

Adult↗
PubMed2001

Medication errors in anesthetic practice: a survey of 687 practitioners.

PURPOSE: The objectives of this study were to determine: 1) if anesthesiologists had experienced a medication error and 2) to identify causal factors. The perceived value of a Canadian reporting agency for medication errors and improved standards for labels on drug ampoules was also investigated. METHODS: A self-reporting survey was mailed to members of the Canadian Anesthesiologists' Society (n = 2,266). Respondents provided free-text descriptions of medication errors and answered fixed response questions. RESULTS: Surveys from 687 anesthesiologists (30% response rate) revealed that 85% of the participants had experienced at least one drug error or "near miss". Although most errors (1,038) were of minor consequence (98%), four deaths were reported. The commonest error involved the administration of muscle relaxants instead of a reversal agent. "Syringe swaps" (70.4%) and the misidentification of the label (46.8%) were common contributing factors. Anesthesiologists (97.9%) reported that they read the ampoule label "most of the time" although the label colour was an important secondary cue. Approximately half of the participants would report the error if a reporting program existed and 84% agreed that improved standards for drug labels would reduce the incidence of error. CONCLUSIONS: Most anesthesiologists experienced at least one drug error. The commonest error was a "syringe swap" that involved a muscle relaxant. Most errors were of minor consequence, however, serious morbidity and mortality resulted from clearly preventable events. These results support the development of improved standards for drug labels and the establishment of a Canadian reporting program for medication errors.

Anesthesiology↗
PubMed2003

Common types of medication errors on long-term psychiatric care units.

OBJECTIVE: This multi-center study identified the most frequent types of medication errors in long-term psychiatric care hospitals. SETTING: Japan. DESIGN AND STUDY PARTICIPANTS: We asked 132 units in 44 Japanese psychiatric hospitals to introduce an in-patient incident reporting system on potential adverse drug events (PADEs) for the period 1 October to 30 November 2000. We analyzed types of PADE, outcomes, and characteristics of patients, staff, and units. RESULTS: We received 221 PADE incident reports from 85 units of 44 hospitals. One-quarter (24.9%) of the incidents were intercepted before reaching patients. The frequency of monitoring of the patients by clinical staff in response to medication errors increased by 8.1%. Wrong drug administration, i.e. giving a drug to a patient that was not the drug prescribed for that patient, was the most common type of incident (35.7%). Logistic regression analysis revealed that wrong drug administration occurred more frequently on units with either fewer registered nurses, or two or more patients with the same (or similar) name staying on the same unit. Incident reporters evaluated wrong drug administration as being potentially more serious than the other types of medication error. Wrong drug administration was seen more frequently in units with no patient name printed on medication drug pouches. CONCLUSIONS: Wrong drug administration was the most common type of PADE, and may result in more serious consequences than others. Even a simple organizational quality improvement effort, in which printed patients' names are placed on the drug pouch (not only with each prescription but with each drug administration), could reduce risk to patients from adverse outcomes due to medication errors.

Adult↗
PubMed2004

Medication error due to ambiguous labelling of a commercial product.

Medication errors may involve prescribing, dispensing, preparation and administration of drugs. We report a case in which an administration error occurred due to ambiguous labelling of a commercial drug. Tablets were packed in sets of two tablets per blister with the print on the blister 'Zelitrex 500', making the amount of drug per tablet unclear. A short survey among nurses and pharmacy technicians showed that the majority interpreted the strength of the tablets incorrectly. This case shows that, despite regulations for controlling and accepting labelling before marketing, ambiguous labelling may occur and can lead to medication errors.

Acyclovir↗
PubMedDate not supplied

Medication error prevention. Progress of initiatives.

This article provides a literature review of studies reporting on the incidence and factors that contribute to medication errors. It retraces the steps taken by the Institute of Medicine (IOM) to focus government agency strategy on medication error reduction policy and ranks successful solutions for reducing medication errors. In addition, it summarizes the effectiveness of historic and potential public policy and private payer initiatives.

Health Policy↗
PubMed2005

What do we know about medication errors made via a CPOE system versus those made via handwritten orders?

This commentary on the article by Shulman et al. examines what we understand by 'medication errors', what we mean by 'computerized physician order entry (CPOE) systems', how we measure errors, and what types of errors we are 'reducing' with CPOE systems. As the research of Shulman and colleagues highlights, much of the existing research on CPOE systems does not differentiate among: types of medication errors; consequential versus inconsequential medication errors; CPOE systems that include/exclude formal decision support packages; and the extent to which decision support information is implicitly presented to physicians via the CPOE system, for example, pull down menus with dosages. I discuss these issues and their implications for the evaluation of CPOE systems and of other emerging healthcare technologies.

Clinical Pharmacy Information Systems↗
PubMedDate not supplied

[Medication errors: standarizing the terminology and taxomany. Ruiz Jarabo 2000 grand results].

OBJECTIVE: To make available a consistent terminology and taxonomy that permits standardization in medication error detection, analysis, classification, and recording. METHODS: A working group consisting of healthcare professionals from four hospitals of varying characteristics was established to develop the terminology and the taxonomy, which was validated through a qualitative analysis of 423 medication errors registered in the participating hospitals. RESULTS: A document with a terminology and a taxonomy for classifying medication errors is presented. CONCLUSIONS: This document will facilitate analysis of the information collected on incidents caused by medication, and will allow comparisons to be made among data gathered in different kinds of settings. In addition, it will be a useful tool for medication safety committees in hospitals in their efforts to set up internal reporting programs designed to identify shortcomings in their medication use systems and to adopt effective measures to reduce the incidence of medication errors.

Adverse Drug Reaction Reporting Systems↗