Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Medication Errors”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 469 records · Page 26Linked to original sources
PubMed2006

Unscheduled returns to the emergency department: an outcome of medical errors?

BACKGROUND: The causes of unscheduled returns to the emergency department (ED) within 72 hours of discharge are unclear. A study was undertaken to identify factors associated with this quality care indicator. METHODS: 250 cases and 250 controls from the ED were prospectively studied. Outcomes measured were unscheduled returns, post-ED destination, and patient dissatisfaction. Possible medical errors (in diagnosis, treatment, prognosis or patient information) and errors in follow up care were identified. Other factors examined included chief complaint at presentation, discharge diagnosis, level of triage, category of treating physician, observation or not, application of emergency treatment, ancillary studies, accessibility to ED, ED time band or work shift, day of the week, past medical history, and demographic data (age, sex, educational level and economic status). RESULTS: The main factor associated with unscheduled returns was error in prognosis (odds ratio 18.62, 95% CI 9.60 to 36.09). Advanced age and a chief complaint of dyspnoea were also associated with unscheduled returns and with admission to hospital. Post-ED destination worsened by 0.61 (95% CI 0.33 to 0.90) with diagnostic errors and by 0.60 (95% CI 0.30 to 0.90) with errors in follow up care. Patient dissatisfaction increased by 0.68 (95% CI 0.55 to 0.80) with information errors, by 0.63 (95% CI 0.17 to 1.09) with errors in follow up care, and by 0.52 (95% CI 0.09 to 0.94) with diagnostic errors. CONCLUSION: Unscheduled returns are associated with medical errors in prognosis, treatment, follow up care, and information. A worse post-ED destination is associated with these medical errors and patient factors (dyspnoea and advanced age). Patient dissatisfaction is associated with medical errors, level of triage or care zone, patient educational level and ED time work shift. Most of these factors are modifiable.

Adolescent↗
PubMed2006

Recovery from medical errors: the critical care nursing safety net.

BACKGROUND: Safety initiatives have primarily focused on physicians despite the fact that nurses provide the majority of direct inpatient care. Patient surveillance and preventing errors from harming patients represent essential nursing responsibilities but have received relatively little study. METHODS: The study was conducted between July 2003 and July 2004 in a 10-bed academic coronary care unit. Direct observation of nursing care and solicited and institutional incident reports were used to find potential incidents. Two physician reviewers rated incidents as to the presence, preventability, and potential severity of harm of errors and associated factors. RESULTS: Overall data were collected for 147 days, including 150 hours of direct observation. One hundred forty-two recovered medical errors were found, including 61% (86/142) during direct observations. Most errors (69%; 98/142) were intercepted before reaching the patients. Errors that reached patients included 13% that were mitigated before resulting in harm and 18% that were ameliorated before more severe harm could occur. DISCUSSION: Protecting patients from the potentially dangerous consequences of medical errors is one of the many ways critical care nurses improve patient safety. Interventions designed to increase the ability of nurses to recover and promptly report errors have the potential to improve patient outcomes.

Academic Medical Centers↗
PubMed2005

[The epidemiology of medical errors: a few issues in methodology].

Epidemiological research is needed to determine how many medical errors are made in hospitals. An estimation of error risk requires knowledge of the number of errors made and the total number of patients treated. But how do we define the term 'error'? The outcome of a medical intervention alone is insufficient; the entire treatment process has to be taken into account. For the estimation of error, two different approaches are available: retrospective chart review or prospective ethnographic observation. Both methods should account for processes and outcomes. Both methods have their limitations and can produce measurement errors. In particular, the low reproducibility of the determination of error is worrisome. To achieve safer health care, emphasis should be placed on control of processes, rather than outcomes.

Delivery of Health Care↗
PubMed2005

Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error.

This article proposes that knowledge of cultural expectations concerning ethical responses to unintentional harm can help students and physicians better to understand patients' distress when physicians fail to disclose, apologize for, and make amends for harmful medical errors. While not universal, the Judeo-Christian traditions of confession, repentance, and forgiveness inform the cultural expectations of many individuals within secular western societies. Physicians' professional obligations concerning truth telling reflect these expectations and are inclusive of the disclosure of medical error, while physicians may express a need for self-forgiveness after making errors and should be aware that patients may also rely upon forgiveness as a means of dealing with harm. The article recommends that learning how to disclose errors, apologize to injured patients, ensure that these patients' needs are met, and confront the emotional dimensions of one's own mistakes should be part of medical education and reinforced by the conduct of senior physicians.

Attitude of Health Personnel↗
PubMedDate not supplied

[Adverse effects and medication errors: incidence and role of the organization of drug distribution].

The true incidence of adverse drug events is controversial and there are few data concerning the percentage of potentially preventable adverse drug events. Over 2 months, in two internal medicine units, we asked the staff to report adverse drug events. All incidents were evaluated: adverse drug events (preventable and non-preventable) and potential adverse drug events (non-intercepted potential adverse drug events and intercepted potential adverse drug events). The severity, the stage in the process at which the error occurred and the type of error were evaluated by a physician reviewer. Over the 240 admissions, the incidence of adverse drug events is 18 per 1000 patient-days. The system design caused 77 per cent of the incidents. The medication errors occurred at all stages from ordering to administration. Adverse drug events resulting in medication errors (n = 22) were more serious than non-preventable adverse drug events (n = 26) (p = 0.003). A prevention strategy by pharmacovigilance centres (Centres Régionaux de Pharmacovigilance) should target all stages of the drug delivery process.

Drug-Related Side Effects and Adverse Reactions↗
PubMed2003

Preventing medical errors by designing benign failures.

BACKGROUND: One way to successfully reduce medical errors is to design health care systems that are more resistant to the tendencies of human beings to err. One interdisciplinary approach entails creating design changes, mitigating human errors, and making human error irrelevant to outcomes. This approach is intended to facilitate the creation of benign failures, which have been called mistake-proofing devices and forcing functions elsewhere. USING FAULT TREES TO DESIGN FORCING FUNCTIONS: A fault tree is a graphical tool used to understand the relationships that either directly cause or contribute to the cause of a particular failure. A careful analysis of a fault tree enables the analyst to anticipate how the process will behave after the change. EXAMPLE OF AN APPLICATION: A scenario in which a patient is scalded while bathing can serve as an example of how multiple fault trees can be used to design forcing functions. The first fault tree shows the undesirable event--patient scalded while bathing. The second fault tree has a benign event--no water. Adding a scald valve changes the outcome from the undesirable event ("patient scalded while bathing") to the benign event ("no water") LIMITATIONS: Analysis of fault trees does not ensure or guarantee that changes necessary to eliminate error actually occur. Most mistake-proofing is used to prevent simple errors and to create well-defended processes, but complex errors can also result. CONCLUSIONS: The utilization of mistake-proofing or forcing functions can be thought of as changing the logic of a process. Errors that formerly caused undesirable failures can be converted into the causes of benign failures. The use of fault trees can provide a variety of insights into the design of forcing functions that will improve patient safety.

Causality↗
PubMed2003

Adverse drug events and medication errors in Australia.

PURPOSE: To review information about adverse drug events (ADEs) and medication errors in Australia. DATA SOURCES: Systematic literature reviews and reports from data collections of the Australian Bureau of Statistics, Institute of Health and Welfare, Council for Health Care Standards and Patient Safety Foundation. RESULTS: (medical record reviews): We have shown that 2-4% of all hospital admissions, and up to 30% for patients > 75 years of age, are medication-related; up to three-quarters are potentially preventable. RESULTS (routine data collections): Routine death certificate and hospital discharge data coded using the International Classification of Diseases capture less than half as many ADEs as medical record reviews. Of coded adverse events that contributed to death, 27% involved an ADE, as did 20% of adverse events identified at discharge and 43% at general practice encounters. There is a strong correlation between increases in medication use and rates of adverse drug reactions (ADRs) associated with hospitalization. RESULTS (drugs implicated): These were similar in all the above studies: anticoagulants, anti-inflammatory drugs, opioids, anti-neoplastics, antihypertensives, antibiotics, cardiac glycosides, diuretics, hypoglycaemic agents, steroids, hypnotics, anticonvulsants, and antipsychotics. RESULTS (clinical indicators): An ADE is reported in 1% of hospital admissions, while some hospitals do not report ADRs to the national collection. Only three-quarters of patients with acute myocardial infarction receive thrombolytics within 1 hour of presentation. Five per cent of patients on warfarin record an international normalized ratio > 5, and 1%, 0.05%, and 0.2% -suffer abnormal bleeding, cerebral haemorrhage, or death, respectively. RESULTS (the Australian Incident Monitoring System): Twenty-six per cent of 27 000 hospital-related incidents were medication-related, as were 36% of 2000 anaesthesia-related incidents, and 50% of 2500 general practice incidents. RESULTS (errors): Errors occur in 15-20% of drug administrations when ward stock systems are used and 5-8% when individual patient systems are used. Previous allergic reactions to drugs may not be recorded more than 75% of the time. CONCLUSION: ADEs are common in the Australian health system. Anticoagulant, anti-inflammatory, and cardiovascular drugs feature prominently as preventable, high impact problems, and collectively make up over one-half of all ADEs. Methods for monitoring and preventing ADEs should be progressively improved.

Australia↗
PubMed2005

Detection and prevention of medication errors using real-time bedside nurse charting.

OBJECTIVE: Charting systems with decision support have been developed to assist with medication charting, but many of the features of these programs are not properly used in their clinical application. An analysis of medication error reports at LDS Hospital revealed the occurrence of errors that should have been detected and prevented by decision support features if real-time entry at the bedside had taken place. The aim of this study was to increase the real-time bedside charting behavior of nurses. DESIGN: A quasiexperimental before and after design was used. The study took place in two 40-bed surgical units, one of which served as the study unit, the other as control unit. The study unit received educational intervention about error avoidance through real-time bedside charting, and 12 weeks of monitoring and performance feedback. The real-time and bedside charting rates for the study and control units were measured before and after the intervention. RESULTS: Before the intervention on the study unit, the real-time charting rate was 59% and the bedside rate was 40%. At the conclusion of a 12-week intervention period, the real-time rate increased to 73% and the bedside rate increased to 63%. Postintervention real-time rates were 75% after eight weeks and remained at 75% after one year. Equivalent control unit real-time rates varied from 53% to 57%, and bedside rates varied from 34% to 44% during the same intervals. CONCLUSION: Targeted educational intervention and monitored feedback yielded measurable improvements in the effective use of the computerized medication charting system and must be an ongoing process.

Computer Systems↗
PubMed2005

Medical errors in primary care: results of an international study of family practice.

OBJECTIVE: To describe errors Canadian family physicians found in their practices and reported to study investigators. To compare errors reported by Canadian family physicians with those reported by physicians in five other countries. DESIGN: Analytical study of reports of errors. The Linnaeus Collaboration was formed to study medical errors in primary care. General practitioners in six countries, including a new Canadian family practice research network (Nortren), anonymously reported errors in their practices between June and December 2001. An evolving taxonomy was used to describe the types of errors reported. SETTING: Practices in Canada, Australia, England, the Netherlands, New Zealand, and the United States. PARTICIPANTS: Family physicians in the six countries. MAIN OUTCOME MEASURES: Types of errors reported. Differences in errors reported in different countries. RESULTS: In Canada, 15 family doctors reported 95 errors. In the other five countries, 64 doctors reported 413 errors. Although the absence of a denominator made it impossible to calculate rates of errors, Canadian doctors and doctors from the other countries reported similar proportions of errors arising from health system dysfunction and gaps in knowledge or skills. All countries reported similar proportions of laboratory and prescribing errors. Canadian doctors reported harm to patients from 39.3% of errors; other countries reported harm from 29.3% of errors. Canadian physicians considered errors "very serious" in 5.8% of instances; other countries thought them very serious in 7.1% of instances. Hospital admissions and death were among the consequences of errors reported in other countries, but these consequences were not reported in Canada. CONCLUSION: Serious errors occur in family practice and affect patients in similar ways in Canada and other countries. Validated studies that analyze errors and record error rates are needed to better understand ways of improving patient safety in family practice.

Adolescent↗
PubMedDate not supplied

[Medication errors in pediatrics: analysis of nursing records on the patient chart].

Descriptive and correlational study which aimed to verify medication errors through the analyzes of medical charts of children admitted in three pediatric wards of a university hospital. The errors could represent record gaps verified on the care process documentation, that do not compromise the patient safety. In the 68 medical charts 1717 errors were verified, 21.1% of the 8152 drugs doses or solutions ordered during the studied period. More than 13 categories of errors were identified, omission errors (dose or records) were the most frequents (75.7%). The types of errors indicated the need of continuous education and the implementation of management tools that allowed the development of the practice and monitoring results.

Child↗
PubMed2005

Reports of preventable medical errors from the Alberta Patient Safety Survey 2004.

The Health Quality Council of Alberta (HQCA) is charged with reporting to Albertans on the quality, safety and performance of the healthcare system. In 2004, the HQCA conducted a telephone survey (response rate: 55%) of 1,500 adult Albertans to assess their perceptions of and personal experiences with preventable medical errors (PMEs). A total of 559 (37.3%) respondents reported that they or a family member had ever experienced a PME. The most common PMEs were related to clinical performance (n=128), medication (n=123), diagnosis (n=121) and communication (n=73). Through this research, patients have provided an orientation to interventions to improve patient care and prevent medical errors.

Adolescent↗
PubMed2006

Between a rock and a hard place: disclosing medical errors.

BACKGROUND: Healthcare-related errors cause patient morbidity and mortality. Despite fear of reprimand, laboratory personnel have a professional obligation to rapidly report major medical errors when they are identified. Well-defined protocols regarding how and when to disclose a suspected error by a colleague do not exist. PATIENT: We describe a woman with a well documented allergy to sulfamethoxazole who was treated with sulfadiazine that led to toxic epidermal necrolysis. After the patient's death, the laboratory medicine resident was asked by one of the patient's physicians to measure serum sulfadiazine, but only if the results were not reported in the patient's electronic medical record. The case was brought to the attention of a laboratory medicine faculty member and the hospital risk management team. ISSUES: Laboratorians are patient fiduciaries and are responsible for reporting errors. Most medical associations have codes of ethics that address disclosure of incompetence and errors, although the AACC's Guide to Ethics does not. New types of error, risk management, and root-cause analyses help to shift the focus to system errors and away from individuals' errors. This can lead to a healthcare environment that encourages truth and disclosure rather than fear and reprimand. Disposition: The individuals involved in the presented case fulfilled their fiduciary duty to the patient by reporting this incident. An extensive investigation showed that, in fact, no medical errors or misconducts had occurred in the care of the patient.

AIDS-Related Opportunistic Infections↗
PubMed2002

Neurologic complications including paralysis after a medication error involving implanted intrathecal catheters.

PURPOSE: Long-term continuous intrathecal infusion of medications for chronic medical problems is common. We investigated the cause of a cluster of severe neurologic complications in patients with intrathecal catheters. METHODS: We performed an epidemiologic cohort study of patients who had intrathecal catheters in place in one neurosurgical practice, to assess the presence of new neurologic complications and associated risk factors. RESULTS: The practice included 61 patients who received pain medication through implanted intrathecal catheter pumps, 19 of whom were treated with morphine, either alone or in combination with other medications. None of the 42 patients whose drug regimen did not include morphine developed a complication, whereas 8 of 13 patients who received morphine in refills of their pumps during one 4-week period experienced neurologic complications. Three persons underwent laminectomy for sterile abscesses and were left with new paralysis or leg weakness. Testing of two stock bottles from the involved pharmacy, both labeled as containing pure morphine, revealed the presence of methadone in addition to morphine. One of these bottles also contained trace ethanol. A sample of medication aspirated from the pump of a patient prescribed morphine from the same pharmacy was also found to have contained methadone and methanol. CONCLUSIONS: A variety of severe neurologic complications was associated with inadvertent administration of methadone, and perhaps other unintended substances, by means of implanted intrathecal catheters to a group of patients. Medical errors in an outpatient pharmacy led to this outbreak.

Adult↗