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PubMed2002

Does critical incident reporting contribute to medication error prevention?

UNLABELLED: Medication-related critical incidents (CIs) comprise harmful and potentially harmful events. The aim of CI monitoring is quality improvement through system changes. In a prospective survey, we analysed our drug-related CIs of the year 2001 with an emphasis on how they contributed to system changes. A voluntary, anonymous, non-punitive CI reporting was used. The study was performed in a multidisciplinary, 23-bed, neonatal-paediatric intensive care unit (ICU). CI severity was graded: minor (no interventions required), moderate (requiring routine therapy, available outside the ICU), major (need for therapeutic interventions specific to the ICU). There were 284 drug-related CIs, 76% (95% confidence interval 71%-81%) of minor, 19% of moderate and 5% of major severity. A total of 24 CIs were potentially life threatening (if not detected). Some 27% of CIs were intercepted, 17% before preparation and 10% before administration of the drug to the patient. There was a negative correlation between median delay (from CI to detection) and mean severity of the different drug classes involved (P = 0.027). As to the impact on quality, 46 CIs were followed by system changes and 63% (95% confidence interval 49%-77%) of these CIs were of minor severity. Examples of system changes are: double checking for potentially harmful drugs, standardised prescription form and contact to the national drug control agency regarding misleading drug labels. CONCLUSION: most of the system changes were based on minor critical incidents which were often detected only after a longer period of time. This shows the value of our "low-threshold" critical incident monitoring. Repeated checks along the drug delivery process (prescription, preparation, administration) are an important means to reduce adverse drug events.

Child↗
PubMed2001

A physician-based voluntary reporting system for adverse events and medical errors.

OBJECTIVE: To create a voluntary reporting method for identifying adverse events (AEs) and potential adverse events (PAEs) among medical inpatients. DESIGN: Medical house officers asked their peers about obstacles to care, injuries or extended hospitalizations, and problems with medications that affected their patients. Two independent reviewers coded event narratives for adverse outcomes, responsible parties, preventability, and process problems. We corroborated house officers' reports with hospital incident reports and conducted a retrospective chart review. SETTING: The cardiac step-down, oncology, and medical intensive care units of an urban teaching hospital. INTERVENTION: Structured confidential interviews by postgraduate year-2 and -3 medical residents of interns during work rounds. MEASUREMENTS AND MAIN RESULTS: Respondents reported 88 events over 3 months. AEs occurred among 5 patients (0.5% of admissions) and PAEs among 48 patients (4.9% of admissions). Delayed diagnoses and treatments figured prominently among PAEs (54%). Clinicians were responsible for the greatest number of incidents (55%), followed by workers in the laboratory (11%), radiology (15%), and pharmacy (3%). Respondents identified a variety of problematic processes of care, including problems with diagnosis (16%), therapy (26%), and failure to provide clinical and support services (29%). We corroborated 84% of reported events in the medical record. Participants found voluntary peer reporting of medical errors unobtrusive and agreed that it could be implemented on a regular basis. CONCLUSIONS: A physician-based voluntary reporting system for medical errors is feasible and acceptable to front-line clinicians.

Adverse Drug Reaction Reporting Systems↗
PubMedDate not supplied

Intravenous medication errors.

In a clinical study, it was reported that based on the number of adult patients admitted to two hospitals, medication errors amounted to almost 4,000, an alarming figure considering that many were thought to be preventable. Today's healthcare environment dictates the type of care patients receive and from whom, and the potential for medication errors. This article discusses the factors concerning the prescribing of i.v. medications, preparing the medications, and administering them competently by nurses and pharmacists.

Adult↗
PubMed2005

How to avoid paediatric medication errors: a user's guide to the literature.

The National Health Service, in its report An organisation with memory, has called for a fundamental rethinking of the way the healthcare system learns from error. The NHS further details its goal to reduce serious medication errors by 40% in a second report entitled Building a safer NHS: improving medication safety. This report calls for a review of paediatric medication delivery systems to assess safety for children.

Child↗
PubMed1984

Effect of an automated bedside dispensing machine on medication errors.

The effect of an automated bedside dispensing machine on medication errors was studied on a 32-bed surgical unit of an 848-bed hospital. The experimental system (McLaughlin Dispensing System) included at each patient's bedside a locked medication cabinet that was electronically programmed to allow the nurse access to doses due at a particular time. The control system was a decentralized unit dose system. A crossover study design with random assignment of subjects and treatments was used. In the 14-day study period, nurses were observed by a pharmacist for 28 five-hour periods as they administered medications on the day and evening shifts. The mean error rates were significantly different--10.6% for the experimental system and 15.9% for the control system. Wrong time errors were the most common type. No significant differences were found between day and evening shifts or workloads of individual nurses. There was no treatment order effect. The error rate was significantly lower for the automated dispensing system than for the system using unit doses dispensed from a satellite pharmacy. Automated dispensing systems may be useful in reducing errors in administration time and dose omissions.

Computers↗
PubMed2003

Medication errors: protecting both patient and provider.

Administering the right medication in the right dose via the right route to the right patient is essential to quality patient care. Providers must be educated on all related policies and periodically reviewed. In addition, providers must take personal responsibility to assure knowledge and ability to determine the correct medication in any given scenario and calculate the correct dose. EMS administrators, employers, providers and medical directors must work together to identify system problems and establish policies and procedures for efficient and effective prevention of medication errors. Until next time, be safe!.

Education, Continuing↗
PubMed2005

Risk of medication errors at hospital discharge and barriers to problem resolution.

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.

Aged↗
PubMed2001

[Medication error rate in the hospital setting: a pilot study at the Jury-lès-Metz Hospital Center].

OBJECTIVES: Medication error rate (TEM) is seen as the performance rate of the process leading from drug prescription to drug administration. Jury-lès-Metz Psychiatric Hospital conducted a pilot study whose aim was to determine feasibility of drug error rate calculation. METHODS: TEM was calculated as the number of errors divided by the number (n) of all the doses ordered. Four different steps of the process were studied with a specific rate for each step: drug prescription error rate (TEMp), drug delivery calculation error rate (TEMr), drug missing before administration rate (TEMm) and nursing error in drug preparing rate (TEMc). RESULTS: TEMp (n = 15,699): 1.92% [1.74-2.10], TEMr (n = 3457): 2.7% [2.2-3.2], TEMm (n = 3457): 6.9% [6.1-7.7], TEMc (n = 956): 5.9% [4.4-7.4]. DISCUSSION: The research topic presented here is quite new. In spite of certain limitations, the most important point is to focus attention on four specific steps and not to limit the study to the entire process. Our pilot work demonstrates that drug errors are made and must not be neglected. The TEM is not simply the sum of specific errors because of the interactions between the underlying causes of the different types of errors, each affecting the value of specific TEMs. CONCLUSION: Before to deal with quality improvement of hospital medication process, we had to prove that drug error exists. Now, two solve the problem of medication error in our hospital, we have to observe what exactly happens and to try to multidisciplinary understand the causes leading to process defects.

Data Interpretation, Statistical↗
PubMed2006

A multifacited approach to improve patient safety, prevent medical errors and resolve the professional liability crisis.

The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises are the rising cost of professional liability insurance and a diminishing number of sources available to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney contingency fees is a back end approach and will do little to solve this crisis or prevent future ones. The current situation can only be solved by placing an increased emphasis on improving patient safety and elimination of all preventable medical errors. A national electronic medical record must be developed and rapid response teams need to be available in most hospitals. The protective devices of privileged communication and peer review are counterproductive and must be eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians must be taught proper communication skills and the importance of teamwork. Providers with frequent patient, nursing or medical staff complaints must be critically reviewed. The present system of risk management needs to move from a reactive position to a role of being proactive for both patient and physician. Claims management should offer the patient early compensation when appropriate and pursue a vigorous defense when medical care is adequate. Experts should be identified who will render fair, unbiased reviews of medical care with all of their findings being disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for common medical conditions.

Humans↗
PubMed1989

Monitoring the patient with diabetes mellitus--how to avoid medication errors.

The hospital pharmacist is in a unique position to assist in the management and monitoring of the diabetic patient. He can alert the nurse and physician concerning medication errors involving the use of insulin and oral sulfonylureas. Medication errors may not only jeopardize the metabolic control of a person with diabetes but may also result in the development of significant hypoglycemia. Insulin orders should be written clearly and concisely. The advocation for intensive split-dose regimens and the use of insulin infusion devices require careful attention to technique, administration times and insulin doses. Inappropriate doses of insulin given to patients suffering from diabetic ketoacidosis may lead to significant morbidity. The hospital pharmacist must also carefully survey insulin orders for patients requiring hyperalimentation solutions and those persons requiring reduced caloric intake. The rational use of oral sulfonylureas requires a knowledge of potency differences and appropriate dosage adjustments in order to avoid hypoglycemic reactions.

Diabetes Mellitus, Type 1↗
PubMed2000

A systems approach to medication error reduction.

An interdisciplinary process for the reduction of medication errors was implemented at East Jefferson General Hospital in Metairie, Louisiana, a suburb of New Orleans. The Medication Administration Review and Safety Committee expanded the error reporting system with a comprehensive concurrent chart review process. Safe administration of medications through a systems approach has led to a reduction of documentation deficiencies, a new follow-up process, and an increase in reported errors.

Adverse Drug Reaction Reporting Systems↗
PubMedDate not supplied

Reducing medical errors through barcoding at the point of care.

Medical errors are a major concern in health care today. Errors in point-of-care testing (POCT) are particularly problematic because the test is conducted by clinical operators at the site of patient care and immediate medical action is taken on the results prior to review by the laboratory. The Performance Improvement Program at Baystate Health System, Springfield, Massachusetts, noted a number of identification errors occurring with glucose and blood gas POCT devices. Incorrect patient account numbers that were attached to POCT results prevented the results from being transmitted to the patient's medical record and appropriately billed. In the worst case, they could lead to results being transferred to the wrong patient's chart and inappropriate medical treatment. Our first action was to lock-out operators who repeatedly made identification errors (3-Strike Rule), requiring operators to be counseled and retrained after their third error. The 3-Strike Rule significantly decreased our glucose meter errors (p = 0.014) but did not have an impact on the rate of our blood gas errors (p = 0.378). Neither device approached our ultimate goal of zero tolerance. A Failure Mode and Effects Analysis (FMEA) was conducted to determine the various processes that could lead to an identification error. A primary source of system failure was the manual entry of 14 digits for each test, five numbers for operator and nine numbers for patient account identification. Patient barcoding was implemented to automate the data entry process, and after an initial familiarization period, resulted in significant improvements in error rates for both the glucose (p = 0.0007) and blood gas devices (p = 0.048). Despite the improvements, error rates with barcoding still did not achieve zero errors. Operators continued to utilize manual data entry when the barcode scan was unsuccessful or unavailable, and some patients were found to have incorrect patient account numbers due to hospital transfer, multiple wristbands on a single patient, and selection of expired account numbers from previous hospitalizations when printing the barcoded wristbands. Barcoding can thus improve the incidence of identification errors, but hospitals need to take additional steps to ensure successful barcode scanning and to verify that patient wristbands contain correct information. Implementation of patient barcoding was successful in significantly reducing identification errors with POCT, improving patient care, and enhancing interdisciplinary communication.

Delivery of Health Care, Integrated↗
PubMed2004

A case study in medical error: the use of the portfolio entry.

The Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement competency incorporates lifelong learning techniques and self-reflection. Resident portfolios have received attention as a useful method for addressing this competency. A recent patient encounter provided an experienced clinical educator with the opportunity to develop a portfolio entry that was distributed to all of the residents and faculty in an emergency medicine residency. This report may assist educators in explaining how one could approach the development of the portfolio as a tool for self-assessment. A candid discussion by a senior faculty member about issues that contributed to medical error has been underreported in the medical literature.

Canada↗
PubMed2003

Consequences of medical errors observed by family physicians.

In two studies about medical errors, family physicians reported health, time, and financial consequences in nearly 85 percent of their error reports. Health consequences occurred when the error caused pain, extended or created illness, or placed patients, their families, and others at greater risk of harm. Care consequences included delayed diagnosis and treatment (sometimes of serious health conditions such as cancer), and disruptions to care that sometimes even resulted in patients needing care in a hospital. Other important consequences were financial and time costs to patients, health care providers, and the health system generally. However, sometimes no consequence was apparent.

Family Practice↗
PubMed2006

Ambiguities of chronic illness management and challenges to the medical error paradigm.

In recent decades, an interdisciplinary quality assurance (QA) movement has emerged in health care studies, which has included increased attention to medical errors. Implicit in this QA effort is a conflict between (1) external agents encouraging the medical profession to adopt strategies for reducing errors and (2) sociological characteristics of medical practice that systematically inhibit the uptake of these strategies. Using interviews with providers and observations in two diabetes clinics in a large Midwestern city in the USA, we examine how providers understand error in their work, as well as how they think about failures in care and efforts to standardize and impose guidelines in care. We find that the prototypical vocabularies of medical error and QA, which have been largely oriented to acute illness care, are systematically mismatched to ambiguities introduced by chronic illness. These ambiguities create problems for the definition of medical errors, the collection of relevant information, the determination of long-term treatment goals, and the application of standardization efforts. Considered together, these mismatches imply diminishing returns for health policy efforts focused on reducing medical error as part of a larger QA agenda.

Chronic Disease↗