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PubMed2006

Emergency physicians and disclosure of medical errors.

Error in medicine is a subject of continuing interest among physicians, patients, policymakers, and the general public. This article examines the issue of disclosure of medical errors in the context of emergency medicine. It reviews the concept of medical error; proposes the professional duty of truthfulness as a justification for error disclosure; examines barriers to error disclosure posed by health care systems, patients, physicians, and the law; suggests system changes to address the issue of medical error; offers practical guidelines to promote the practice of error disclosure; and discusses the issue of disclosure of errors made by another physician.

Communication↗
PubMed1998

Reducing adverse drug events and medication errors using rapid cycle improvement.

The article describes Fairview Health System's participation in the Institute for Healthcare Improvement Breakthrough Series on adverse drug events and medication errors. Fairview commissioned an interdisciplinary team to design, plan, and lead activities focused on reducing adverse drug events and medication errors. This team managed, facilitated, or led 15 separate projects, each focusing on a specific aspect of the medications process. Specific systems improvements were identified, leading to reductions in errors or adverse events. As a result of this effort, Fairview has committed to a long-term plan to reduce the risk of adverse drug events and medication errors to the lowest possible rate.

Anticoagulants↗
PubMed2006

[Medication errors on hospital admission].

INTRODUCTION: This study investigated the number of medication errors on hospital admission and the clinical relevance of these errors. The new personal electronic medicine profile (PEM) was tested to establish whether it can contribute further information about the patient's medication on admission. MATERIALS AND METHODS: This cross-sectional study included patients admitted to an acute medical admissions ward. In addition to the ward's usual admission procedure, a clinical pharmacist created an extra medication history by carrying out semi-structured interviews and obtaining additional information from the patient's GP. Information was then obtained from the PEM. A clinical expert panel assessed the potential clinical relevance of the discrepancies. RESULTS: Of 67 patients admitted, 48 were interviewed. The patients' average age was 71, and they used an average of 6.4 medications each. There were 309 prescriptions registered, producing 85 errors: the extra medication history highlighted 73 of these errors, and the subsequent check of the PEM revealed a further 12 errors. Thirty-three patients (69%) were affected by one or more errors, of which the expert panel considered six (18%) to be potentially serious. CONCLUSION: Medication errors on admission to hospital reduce the quality of treatment and can lead to adverse events. The PEM cannot replace the traditional medication history, but the use of a PEM and the increased focus on medication histories can contribute to an improved hospital stay.

Adult↗
PubMed2006

Case-control analysis of the financial cost of medication errors in hospitalized patients.

The cost of medication errors (MEs), and by extension their impact on the running of hospitals, is generally unknown to hospital managers. This study estimated the financial costs involved in the additional use of hospital resources as a result of MEs. For this we used a database covering 20,014 hospital admissions, with clinical and personal information about each patient, the costs related to his/her stay, and physicians' prescriptions. Analyses were carried out using cases and control techniques to calculate the additional cost of MEs. During the study period, 2001, the analysis indicated that the MEs analyzed caused an additional 303 days of hospital stay, with an overall annual cost of nearly 6,000 euros. Our study confirms that MEs are a costly reality. The presence of MEs doubled the cost per patient.

Case-Control Studies↗
PubMed2006

Medication errors: not just a few "bad apples"

Objective: The purpose of this study is to describe the distribution of medication errors among physicians.Design: Data on a cohort of internal medicine physicians were gathered prospectively over a seven-month period.Setting: The study was conducted in four adult primary care practices.Participants: Twenty-four physicians from Boston, MA participated in this study. A total of 661 patients agreed to participate in the study. The researchers surveyed patients to identify possible adverse drug events (ADEs). This information was supplemented by a chart review for each participating patient.Measurements: The principal measurement collected in this study was total medication errors per physician. The number of prescriptions written during the study period was also collected.Results: Twenty-two of the 24 physicians made at least one error. Although there was one outlier, the error rate among this cohort of physician was evenly distributed.Conclusion: The wide distribution of errors among this group of physicians undermines the argument that the majority of medication errors are due to a "few bad apples,"

Journal Article↗
PubMed1997

Medication errors could lead to high variance rates.

Medication errors could be contributing to high variance rates and treatment costs for patients placed on your clinical pathways, and you might not even know it, experts say. The problem is potentially severe. One recent study found a 9% error rate in admixtures overall and potentially catastrophic 34.4% to 56.7% error rates for potassium chloride mixtures. However, experts claim that hospitals could go a long way toward solving their admixture error problems by simply switching to ready-to-use products and having nurses record actual medications per day on clinical pathways. Meanwhile, HCFA is about to make official a new ceiling for errors: 2%, vs. the old 5% rate. This could pose serious problems for hospitals dependent on Medicare and Medicaid reimbursements.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2004

Profiles in patient safety: authority gradients in medical error.

The term "authority gradient" was first defined in aviation when it was noted that pilots and copilots may not communicate effectively in stressful situations if there is a significant difference in their experience, perceived expertise, or authority. A number of unintentional aviation, aerospace, and industrial incidents have been attributed, in part, to authority gradients. The concept of authority gradient was introduced to medicine in the Institute of Medicine report To Err Is Human, yet little has been written or acknowledged in the medical literature regarding its role in medical error. The practice of medicine and medical training programs are highly organized, hierarchical structures that depend on supervision by authority figures. The concept that authority gradients might contribute to medical error is largely unrecognized. This article presents one case and a series of examples to detail how authority gradients can contribute to medical error, and describes methods used in other disciplines to avoid their potentially negative impact.

Chickenpox↗
PubMed2005

Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France.

BACKGROUND: Previous studies have identified medication errors in preparing and administering intravenous medicines of 13-84% in hospitals in individual countries. OBJECTIVE: To compare the effect of the design and implementation of systems for the preparation and administration of intravenous therapy in hospitals in three European countries on the number of observed medication errors. To gain a better understanding of these risks and the methods used in each country to manage them. DESIGN: Prospective audit. SETTING: Six hospital departments in the UK, Germany and France willing to participate in the audit as part of a quality improvement programme. METHODS: Direct observation of the preparation and the administration of intravenous drugs made by a single observer in each country. MAIN OUTCOME MEASURES: Medication process errors. RESULTS: 824 doses were prepared and 798 doses administered. The product was either not labelled or incorrectly labelled in 43%, 99%, and 20% of doses administered in the UK, German and French hospitals, respectively. The wrong diluent was used in 1%, 49% and 18% of cases, respectively, and the wrong rate of administration was selected for 49%, 21% and 5% of doses observed, respectively. At least one deviation from aseptic technique was observed among 100%, 58%, and 19% of cases in the three countries. CONCLUSION: Uncontrolled risks in the intravenous systems studied were observed in all three countries. Intravenous therapy must be regarded as a high risk activity where the use of risk management procedures to minimise risk to patients is seen as a high priority by all those involved with these duties. There is a requirement to develop better national (possibly international) procedures for safe intravenous practice.

Confidence Intervals↗
PubMed1997

[Medication errors in a pediatric department].

In a prospective study, iatrogenic medication errors were registered among paediatric admissions. The two most common causes of incidents were neglecting to give a medication on schedule and administration of an incorrect dose-but extra dose errors, errors of omission, wrong rate errors and administration of unauthorized drugs also occurred. After implementation of a satellite pharmacy, medication error rates were compared, and a reduction of the more serious and potentially harmful incidents was shown.

Denmark↗
PubMedDate not supplied

[Medication errors resulting from drug preparation and administration].

BACKGROUND: The risks associated with drug use are not confined to adverse reactions. Failures can occur in the process of drug prescribing, dispensing and administration. Such preventable events are termed 'medication errors'. Errors in preparation and administration, the last step in the medication process, constitute a good indicator of the quality of the medication process, and are irredeemable. METHODS: A protocol for measuring errors in the preparation and administration of medication has been developed and used in an internal medicine department at the University Hospital of Dijon. RESULTS: This protocol has enabled several different rates of medication errors to be determined depending on the calculation approach used: 15.1% with respect to interventions by nurses, 41% relating to the total number of opportunities for error, and 8.8% with respect to a methodological problem analysed in the study. The potential clinical significance, incidence and causes of errors during the medication process were also analysed. DISCUSSION AND CONCLUSION: Medical errors are not detected in our health system and are thus not preventable. Their consequences are incompatible with a well organised treatment process. The rate of medication errors is therefore a good indicator of the quality of the medication system in a hospital that is following the current steps for risk reduction and accreditation.

Drug Compounding↗
PubMedDate not supplied

[Strategies for prevention of medication errors in emergengy services].

This study identified situations indicating medication errors or near misses by analyzing medication orders and the nursing staff's performance. It also implemented a cycle of lectures and a course on safety in medication administration for professionals at the emergency room in a hospital in the northeastern region of Brazil. The results showed that of 1,585 orders under analysis, 83,9% did not clearly express the medication presentation and 84.6% did not define the dosage from prescribed medication, in 34.2%, the administration time was unchecked; in 22.5%, the time had been circled. Among the non-administered medication, 26% were antibiotics and anticoagulants and 15% analgesics. The professionals participated in the implemented strategies with good attendance levels.

Emergency Nursing↗
PubMed2006

Disclosure of medical errors.

The 1999 release of the Institute of Medicine's document To Err is Human was akin to removing the lid of Pandora's box. Not only were the magnitude and impact of medical errors now apparent to those working in the health care industry, but consumers or health care were alerted to the occurrence of medical events causing harm. One specific solution advocated was the disclosure to patients and their families of adverse events resulting from medical error. Knowledge of the historical perspective, ethical underpinnings, and medico-legal implications gives us a better appreciation of current recommendations for disclosing adverse events resulting from medical error to those affected.

Disclosure↗
PubMed2005

A spike in fatal medication errors at the beginning of each month.

At the beginning of each month, there is a spike in government payments to individuals, resulting in a beginning-of-the-month spike in purchases of prescription drugs and in increased pharmacy workloads. Studies suggest that pharmacy error rates increase with increased workloads. These facts raise an important and previously unanswered question: is there a spike in fatal medication errors at the beginning of each month? We examined all United States death certificates from 1979-2000 (> 47,000,000 deaths) and showed that medication error deaths for which the decedent was dead on arrival or died in the emergency room or as an outpatient spiked by 25% above normal at the beginning of each month. This beginning-of-the-month spike (25% +/- 4%) was larger than for any other major cause of death. The beginning-of-the-month spike did not vary by socioeconomic status and was not larger for substance abusers than for others. Five explanations for the findings were tested. Evidence suggested that the spike in medication error deaths cannot be solely attributed to a spike in the consumption of alcohol or drugs. An increase in pharmacy error rates might play a role.

Alcohol Drinking↗
PubMed1990

[Carbon monoxide poisoning caused by medical error. Fatalities in connection with medical measures in Leipzig and Hannover].

There are significant differences in the frequency of CO intoxication and its relation to other not natural causes of death between the autopsy cases of Leipzig (DDR) and Hannover (BRD). While the percentage of all autopsies in Leipzig runs up to 7.6%, in Hannover it runs up to only 1.5%. Beside the well-known cases of not recognized CO intoxication at the autopsy with or without following intoxication of other persons, two concrete cases of not recognized CO intoxication with the survival of the victims discussed. The not noticed CO intoxication followed by the death of the victim is usually considered in medicolegal opinious as "medical malpractice". In cases of survived not noticed CO intoxications this opinion ist only supposed in special cases with longer anamnesis and a typical seasonal rythmic of symptoms.

Adult↗
PubMed2001

Managing medication errors by design.

It is estimated that over 7,000 U.S. citizens perish each year from medication errors. The critically ill are among the patient group at highest risk for a medication error. Knowledge is the key to error prevention. Applying information such as risk factors for error commission, new regulatory standards, and approaches to error management will maximize your patients' and your own safety.

Humans↗
PubMed2000

Responses and concerns of healthcare providers to medication errors.

This descriptive, correlational study examined the responses and concerns of healthcare professionals about making medication errors and estimated patient harm from such errors. A systematic random sample of nurses, pharmacists, and physicians (N = 402) completed a self-report survey about a medication error they judged to be serious. Respondents were guilty, nervous, and worried about the error. They feared for the safety of the patient, disciplinary action, and punishment. A few subjects indicated that they never reported the errors. The most frequent symptoms associated with errors were neurologically based. The injury suffered by patients was not severe overall according to the harm scales. Weak correlations were found for the harm scales and responses and concerns. The authors suggest a supportive environment for the provider following an error and continuous quality improvement efforts to eliminate system-based errors.

Attitude of Health Personnel↗
PubMed2003

Medication errors: more basic than a system issue.

The Institute of Medicine's 2000 report drew attention to both U.S. health care agencies and the medication errors that occur within them. However, this attention focused on a more basic and fundamental issue within the medication error concern: nurses' mathematical skills and competence. This article describes a nationwide study assessing processes to validate mathematical skills for medication administration. Practices within educational and acute care institutions are explored, and recommendations for future action are noted with a call for 100% accuracy on all mathematical examinations for medication administration.

Clinical Competence↗
PubMedDate not supplied

[Medication errors and non-compliance in polymedicated elderly patients].

OBJECTIVE: To detect and describe medication errors and adherence to therapy in polymedicated (> 5 drugs) elderly patients (> 65 years). METHOD: A descriptive, observational study using a phone survey to polymedicated elderly outpatients. Sociodemographic, clinical, and pharmacotherapeutic data were collected, as well as information on their functional and mental capability. The number, type and severity of medication errors were measured, as was non-adherence. RESULTS: Errors were detected in 42.5% of 73 responders, with a total of 55 errors, and a mean 1.77 errors per patient. Most commonly found errors included inappropriate administration frequency and therapeutic duplicity. Regarding adherence, 43.8% were non-compliants, being sporadic in 68.8% and sequential in 31.2% of the cases. A positive relationship between error number and drug number or adherence was found. CONCLUSIONS: Actions are required from a multidisciplinary standpoint to reduce this high percentage of errors.

Aged↗