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PubMed2000

Reducing medication errors in hospitals: a peer review organization collaboration.

BACKGROUND: Motivated by published reports of the incidence, costs, causes, and nature of adverse drug events (ADEs) in hospitalized patients, in 1997 the Medicare peer review organization for Nevada and Utah initiated a voluntary project of medication error reduction for Utah hospitals. METHODS: Through project activities, hospital teams were encouraged to make changes to their medication processes based on direct evaluation of medication systems characteristics, informed by ergonomic principles and published studies of medication errors. Assessment of project effects included an evaluation of the changes implemented and results from an anonymous medication errors survey of clinical staff from participating organizations. RESULTS: Thirteen of the 39 acute care hospitals in Utah participated in 1997-1998 in the collaborative project. Participants reported substantive medication system changes that were expected to result in improved patient safety. Baseline and follow-up survey data were available for 8 of the participating hospitals. Analysis of 560 responses showed a 26.9% decrease in overall error frequency, a 12.5% increase in error detection and prevention, and a 24.1% increase in formal written reporting of errors that reached the patient. CONCLUSIONS: This project demonstrated community interest in a proactive and collaborative approach to improving patient safety. The improvement efforts were substantive and sustainable. Survey results suggest that the changes implemented in participating organizations may have reduced medication errors and improved capacity for error detection and prevention.

Aged↗
PubMed1975

Medication errors.

Explore the source record for details and available documents.

Medication Errors↗
PubMed2002

Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities.

The validity and cost-effectiveness of three methods for detecting medication errors were examined. A stratified random sample of 36 hospitals and skilled-nursing facilities in Colorado and Georgia was selected. Medication administration errors were detected by registered nurses (R.N.s), licensed practical nurses (L.P.N.s), and pharmacy technicians from these facilities using three methods: incident report review, chart review, and direct observation. Each dose evaluated was compared with the prescriber's order. Deviations were considered errors. Efficiency was measured by the time spent evaluating each dose. A pharmacist performed an independent determination of errors to assess the accuracy of each data collector. Clinical significance was judged by a panel of physicians. Observers detected 300 of 457 pharmacist-confirmed errors made on 2556 doses (11.7% error rate) compared with 17 errors detected by chart reviewers (0.7% error rate), and 1 error detected by incident report review (0.04% error rate). All errors detected involved the same 2556 doses. All chart reviewers and 7 of 10 observers achieved at least good comparability with the pharmacist's results. The mean cost of error detection per dose was $4.82 for direct observation and $0.63 for chart review. The technician was the least expensive observer at $2.87 per dose evaluated. R.N.s were the least expensive chart reviewers at $0.50 per dose. Of 457 errors, 35 (8%) were deemed potentially clinically significant; 71% of these were detected by direct observation. Direct observation was more efficient and accurate than reviewing charts and incident reports in detecting medication errors. Pharmacy technicians were more efficient and accurate than R.N.s and L.P.N.s in collecting data about medication errors.

Chi-Square Distribution↗
PubMed2006

The pharmacist-physician relationship in the detection of ambulatory medication errors.

BACKGROUND: Expenditures on outpatient prescription drugs have increased enormously in the last decade. Despite this growth in expenditures, prescription medication safety in the ambulatory setting is lacking. Prior research in outpatient care has centered around the physician-patient encounter. What remains unexamined in the ambulatory care literature is the pharmacist's role as interceptor, detector, and reporter of medication errors to the physician. METHODS: Data about the role, responsibilities, and expectations to inform physicians about this subject were collected from pharmacist (N = 30) and patient (N = 31) focus groups conducted between July 2002 and July 2003. Pharmacists in outpatient practices and patients were randomly selected from the state licensure database and the Jackson Metropolitan phonebook, respectively. ANALYSIS: Grounded theory provided the perspective on which data were interpreted. Data patterns were linked using key words and phrases for theme analysis. Arbitration between coders resulted in an inter-rater reliability of 0.85. RESULTS: : Three complementary patterns were identified from the data: 1) patients likely see multiple physicians and only one pharmacist; 2) patients are more likely to report medication errors to the pharmacist than to the physician; and 3) pharmacists are the final interceptors, detecting medication errors before they reach patients. CONCLUSIONS: Ambulatory pharmacists are in a privileged position to gather data regarding adverse responses to prescribed medication or incidents of medication mishaps. The failure of pharmacists to report information back to physicians is a missed opportunity to improve patient safety.

Ambulatory Care↗
PubMed2006

Strategies used by nurses to recover medical errors in an academic emergency department setting.

PURPOSE: The purpose of this study was to gain insight into how nurses recover medical errors in the emergency department (ED) setting. METHODS: The research method was of exploratory descriptive design with qualitative analysis. Subjects who signed the informed consent participated in one of four focus groups centering on nurse's role in recovering errors. Questions were asked during the focus groups to elicit information regarding nurse's role in the three phases of error recovery, namely, identifying, interrupting, and correcting the error. RESULTS: Five themes emerged to describe methods used by nurses to identify errors in the ED setting. These themes included: surveillance, anticipation, double checking, awareness of the "big picture," and experiential "knowing." Five themes emerged as methods used to interrupt errors: patient advocacy, offer of assistance, clarification, verbal interruption, and creation of delay. The themes for correcting an error were assembling the team and involving leadership. CONCLUSION: The results of this study provide preliminary evidence of the strategies used by ED nurses in the recovery of medical error. Further research is needed to generalize these findings to other ED settings. Knowledge of effective recovery strategies can ultimately be used to develop interventions for reducing medical error and improving patient safety.

Adaptation, Psychological↗
PubMed2006

Patient-physician racial and ethnic concordance and perceived medical errors.

In this paper, I use nationally representative survey data to examine the relationship between patient-physician racial/ethnic concordance and perceived medical errors in the USA. After adjusting for potential confounding factors, we find that White patients treated by White physicians have 33% lower odds of reporting medical errors than White patients treated by non-White physicians. In contrast, patient-physician racial/ethnic concordance has no effect on perceived medical errors among non-White patients. The results suggest that the role of racial/ethnic concordance in perceptions of health care safety varies by patients' racial/ethnic background.

Adult↗
PubMed1989

Prediction of medication error probability based on patient characteristics.

This paper describes the development of a model for classifying the patient population into risk groups according to their medication error probability. The methodology utilizes patient demographic and health care data combined with medication error reports. Variable selection is based on a measure of the amount of information that they provide. Using data from a 360-bed hospital, the model identified patient characteristics related to the health care services received as being the main variables related to medication error probability and divided the patient population into three risk groups defined in terms of these characteristics. The model provides information valuable to risk management and quality assurance efforts in the areas of detection of risk exposure, performance monitoring and resource allocation.

Adult↗
PubMed2003

The physician's perception of medical error and its application to the development of an educational training tool.

It is becoming clear that if we are to impact the rate of medical errors it will have to be done at the practicing physician level. The purpose of this project was to survey the attitude of physicians in Alabama concerning their perception of medical error, and to obtain their thoughts and desires for medical education in the area of medical errors. The information will be used in the development of a physician education program.

Alabama↗
PubMedDate not supplied

Using the Web to improve seniors' awareness of their role in preventing medical errors.

The purpose of this project was to assess the value of using the Web to teacholder consumers about their role in preventing medical errors. Consumers were recruited from a metropolitan Detroit senior community center. The majority of the participants had little or no experience with the Internet. After being taught how to use the computer and Internet, seniors completed a Web-based intervention on quality health care and medical errors. Seniors increased their knowledge about quality care and their role in preventing medical errors and highly rated the Websites.

Aged↗
PubMed2006

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.

PURPOSE: In order to better understand physicians' perspectives about the use of clinical information technology (CIT) to reduce medical errors, we asked physicians about opportunities and issues around clinical use of computerized physician order entry (CPOE) systems, order sets within CPOE, and handheld computers (HHCs). METHODS: We conducted 10 focus groups including 71 physicians involved in technology implementation efforts across the US between April 2002 and February 2005. RESULTS: Two major themes emerged across focus groups around reliance on CIT to reduce errors: (1) can it work? and (2) at what cost to the medical profession? Within the first theme, physicians expressed concern about the appropriateness of physician-directed CIT as a solution for medical errors, concerns regarding the current technical capabilities and level of technical support for CIT solutions, and concern about the introduction of new errors. Within the second theme, physicians were particularly concerned about time efficiency and workload redistribution associated with the introduction of CIT. Across focus groups, physicians tended to generalize about the role of all IT in their lives, potentially biasing opinions about specific technologies. CONCLUSIONS: Health care organizations attempting to promote physician use of CIT are advised to deepen consideration of physicians' perspectives about technology adoption and use in order to address their concerns, reduce skepticism, and increase the likelihood of implementation success.

Attitude to Computers↗
PubMed2003

Does full disclosure of medical errors affect malpractice liability? The jury is still out.

BACKGROUND: Mandatory disclosure of medical errors has been advocated to improve patient safety. Many resist mandatory disclosure policies because of concerns about increasing malpractice exposure. It has been countered that malpractice liability actually decreases when there is full disclosure of medical errors. A comprehensive literature search was conducted to determine what is known about the impact of full disclosure on malpractice liability. METHODS: Electronic searches of multiple databases were supplemented with hand searches of bibliographies and communication with recognized experts in the field. RESULTS: Screening the titles, abstracts, and, in many cases, the full articles from more than an estimated 5,200 citations resulted in identification of one published study directly examining malpractice liability when a policy of full disclosure was implemented. DISCUSSION: Despite extensive literature on the impact of disclosure on malpractice liability, few well-designed studies have focused on the real-world impact on the volume and cost of suits following implementation of a full disclosure policy. Many articles examine why patients sue their doctors, suggesting that some lawsuits may be averted by disclosure, but the articles do not allow us to estimate the additional suits that would be created by disclosure. Additional studies addressing the effect of disclosure on malpractice liability are needed.

Compensation and Redress↗
PubMed2003

Causes of intravenous medication errors: an ethnographic study.

BACKGROUND: Intravenous (IV) medication errors are frequent events. They are associated with considerable harm, but little is known about their causes. Human error theory is increasingly used to understand adverse events in medicine, but has not yet been applied to study IV errors. Our aim was to investigate causes of errors in IV drug preparation and administration using a framework of human error theory. METHODS: A trained and experienced observer accompanied nurses during IV drug rounds on 10 wards in two hospitals (one university teaching hospital and one non-teaching hospital) in the UK. Information came from observation and talking informally to staff. Human error theory was used to analyse the causes of IV error. RESULTS: 265 IV drug errors were identified during observation of 483 drug preparations and 447 administrations. The most common type of error was the deliberate violation of guidelines when injecting bolus doses faster than the recommended speed of 3-5 minutes. Causes included a lack of perceived risk, poor role models, and available technology. Mistakes occurred when drug preparation or administration involved uncommon procedures such as the preparation of very small volumes or the use of unusual drug vial presentations. Causes included a lack of knowledge of preparation or administration procedures and complex design of equipment. Underlying problems were the cultural context allowing unsafe drug use, the failure to teach practical aspects of drug handling, and design failures. CONCLUSIONS: Training needs and design issues should be addressed to reduce the rate of IV drug preparation and administration errors. This needs a coordinated approach from practitioners, regulators, and the pharmaceutical industry.

Anthropology, Cultural↗
PubMed2006

Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?

OBJECTIVES: To determine if the three types of emergency medicine providers--physicians, nurses, and out-of-hospital providers (emergency medical technicians [EMTs])--differ in their identification, disclosure, and reporting of medical error. METHODS: A convenience sample of providers in an academic emergency department evaluated ten case vignettes that represented two error types (medication and cognitive) and three severity levels. For each vignette, providers were asked the following: 1) Is this an error? 2) Would you tell the patient? 3) Would you report this to a hospital committee? To assess differences in identification, disclosure, and reporting by provider type, error type, and error severity, the authors constructed three-way tables with the nonparametric Somers' D clustered on participant. To assess the contribution of disclosure instruction and environmental variables, fixed-effects regression stratified by provider type was used. RESULTS: Of the 116 providers who were eligible, 103 (40 physicians, 26 nurses, and 35 EMTs) had complete data. Physicians were more likely to classify an event as an error (78%) than nurses (71%; p = 0.04) or EMTs (68%; p < 0.01). Nurses were less likely to disclose an error to the patient (59%) than physicians (71%; p = 0.04). Physicians were the least likely to report the error (54%) compared with nurses (68%; p = 0.02) or EMTs (78%; p < 0.01). For all provider and error types, identification, disclosure, and reporting increased with increasing severity. CONCLUSIONS: Improving patient safety hinges on the ability of health care providers to accurately identify, disclose, and report medical errors. Interventions must account for differences in error identification, disclosure, and reporting by provider type.

Academic Medical Centers↗
PubMed2006

Impact of computerised chemotherapy prescriptions on the prevention of medication errors.

OBJECTIVES: The authors sought to evaluate the impact of computerised chemotherapy prescription on the reduction of medication errors. The purpose of this study was to assess the incidence of errors present in electronic versus manual prescription. MATERIAL AND METHODS: The data gathered from computerised chemotherapy prescription sheets were submitted to a prospective analysis as cases of the intervention groups. The control group was comprised of the handwritten chemotherapy prescription sheets. Chemotherapy prescriptions for consecutive oncology patients were analysed by 2 independent examiners, who investigated errors of omission, commission, interpretation of dates, abbreviations and illegible handwriting. The proportion of treatment prescriptions containing one or more errors and the median of errors were calculated in order in both groups. RESULTS: At least one error was detected in 100% of the manual prescriptions and in 13% of computerised prescriptions (p < 0.001). The median of errors per computerised prescription was 0 (range: 0- 1), whereas in manual prescriptions the median was 5 (range: 1-12) (p < 0.001). Errors of omission were predominant in manual prescriptions. Errors of commission were limited to 1 case of unjustified cytostatic agent infra-dosage in a computerised prescription. This error was present in 3 cases in handwritten prescriptions and, in addition, 1 case of premedication drug substitution was detected. Errors of interpretation of the date, use of abbreviations and illegible handwriting were frequent among manual prescriptions and were absent from computerised prescriptions. CONCLUSIONS: Electronic chemotherapy prescription is a powerful tool. In this study it has been shown to decrease chemotherapy-related medication errors and ensure that safe chemotherapy practices were followed.

Antineoplastic Agents↗
PubMed2001

Gone but not forgotten: the search for the lost surgical specimens: application of quality improvement techniques in reducing medical error.

A lost surgical specimen prompted an investigation of both the human processes and the systemic factors involved in surgical specimen handling regarding how health care organizations approach medical error prevention and patient safety promotion. Quality improvement techniques and the conceptual error model of James Reasons were employed to understand the interaction between the local process of specimen handling and the systemic influences to medical error management. Error management recognizes the inevitability of both individual and systemic error. Through the use of quality improvement techniques and models of error analysis, health care organizations can investigate the error potential of health care delivery and address the human and organizational interaction necessary to improve patient safety and manage medical error.

Hospitals, Veterans↗
PubMed2003

[To make good use of medical error].

Error, even if not made through negligence, always affects the physician. That probably explains why the literature on medical error is so sparse. Thanks to large surveys carried out mainly in American hospitals, awareness of the major role of this risk factor begins to appear. These studies demonstrate: three important facts: 1/ The frequency of errors with serious consequences is nearly 3% of all hospitalizations. 2/ Because of the growing complexity of modern health care system, medical errors have new characteristics. Even if they apparently originate from individual behaviour, they are in fact frequently rooted in the health care organisation and so are in fact systemic errors. 3/ A lot of these systemic errors could be prevented or corrected by measures at the level of the organisation. The study of mistakes is vital in implementing quality management of health care. Consequently it is the responsibility of the organisation to record and analyse adverse events. Each error can be an opportunity for safety improvement, provided it is acknowledged.

Delivery of Health Care↗
PubMedDate not supplied

System review: a method for investigating medical errors in healthcare settings.

System analysis is a process of evaluating objectives, resources, structure, and design of businesses. System analysis can be used by leaders to collaboratively identify breakthrough opportunities to improve system processes. In healthcare systems, system analysis can be used to review medical errors (system occurrences) that may place patients at risk for injury, disability, and/or death. This study utilizes a case management approach to identify medical errors. Utilizing an interdisciplinary approach, a System Review Team was developed to identify trends in system occurrences, facilitate communication, and enhance the quality of patient care by reducing medical errors.

Drug Utilization Review↗
PubMed2000

A continuous-improvement approach for reducing the number of chemotherapy-related medication errors.

A comprehensive, interdisciplinary approach for reducing the number of chemotherapy-related medication errors at the National Institutes of Health Clinical Center, where approximately 8500 doses of chemotherapy agents are dispensed annually, is described. Heightened awareness of the seriousness of chemotherapy-related medication errors prompted formation of an interdisciplinary task force in June 1995 to analyze and improve the hospital's system for ordering, checking, processing, and administering cancer chemotherapy agents. Problems were analyzed and rectified in accordance with the hospital's plan-do-check-act performance-improvement model. Performance monitors for the improvements included a system to record and categorize all chemotherapy-related prescribing errors and a hospital-wide occurrence-reporting system. The task force identified seven major categories in which improvements were needed: protocol development, computer-system enhancements, dose verification, information access, education for health care practitioners, error follow-up, and infusion pumps. Despite the Clinical Center's good safety-net system, 23 modifications were made to the existing system through December 1999. These changes resulted in an overall 23% decrease in prescribing errors and a 53% decrease in serious prescribing errors. The task force membership was recently broadened to include representatives of additional departments where chemotherapy agents are used, and this group recommended more than 20 additional system changes. The changes are being implemented, and their effect on reducing the number of chemotherapy-related errors will be measured. The continuous-improvement process used prospectively by the task force helps ensure that safe chemotherapy practices are instituted uniformly throughout the hospital.

Antineoplastic Agents↗