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At least 487 records · Page 27Linked to original sources
PubMed2004

Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department.

OBJECTIVES: To characterise the incidence and nature of medication errors during paediatric resuscitations. DESIGN: A prospective observational study of simulated emergencies. SETTING: Emergency department of a tertiary paediatric hospital. PARTICIPANTS: Teams that included a clinician who commonly leads "real" resuscitations, at least two assisting physicians, and two or three paediatric nurses. INTERVENTIONS: The teams conducted eight mock resuscitations, including ordering medications. Exercises were videotaped and drugs ordered and administered during the resuscitation were recorded. Syringes and drugs prepared during the resuscitation were collected and analysed for concentrations and actual amounts. MAIN OUTCOME MEASURES: Number and type of drug errors. RESULTS: Participants gave 125 orders for medications. In 21 (17%) of the orders the exact dose was not specified. Nine dosing errors occurred during the ordering phase. Of these errors, five were intercepted before the drug reached the patient. Four 10-fold errors were identified. In nine (16%) out of 58 syringes analysed, measured drug concentrations showed a deviation of at least 20% from the ordered dose. A large deviation (at least 50%) from the expected dose was found in four (7%) cases. CONCLUSIONS: Medication errors commonly occur during all stages of paediatric resuscitation. Many errors could be detected only by analysing syringe content, suggesting that such errors may be a major source of morbidity and mortality in resuscitated children.

Child↗
PubMed2005

Medication errors involving wrong administration technique.

Wrong administration technique has consistently been one of the most harmful types of medication error in health systems participating in MEDMARX. Administration technique errors typically are made by nurses administering medications on the patient care unit, although errors in administration technique also occur in other phases of medication use and involve other health care personnel and locations. The most commonly reported causes of error have been performance deficit, failure to follow procedures or protocols, and knowledge deficit. Educating and training health care personnel on proper administration techniques and use of infusion pumps and dispensing devices could reduce the risk of error. The drug products most often associated with administration technique errors and patient harm could be targeted in staff education and training programs.

Drug Administration Routes↗
PubMed1986

Justifying a pediatric critical-care satellite pharmacy by medication-error reporting.

As a part of an evaluation of the need for a satellite pharmacy to serve two pediatric critical-care units, an observational study was conducted to determine the incidence of medication errors in the units. A pharmacist observed nurses preparing and administering medications in 18 12-hour shifts. Of the nine shifts observed in each unit, five were day shifts and four were night shifts. Five nurses were observed per shift in the intensive-care nursery (ICN) and three nurses per shift in the pediatric intensive-care unit (PICU). The classification of errors was based on the definitions established by the American Society of Hospital Pharmacists. The total error rate was 17.4% in the ICN and 38.0% in the PICU. When the error rates were calculated excluding wrong-time errors, they were 7.1% in the ICN and 11.7% in the PICU. Of 147 errors, 124 (84.4%) occurred with medications with a high potential for serious consequences. The error rates were similar on the day and night shifts in the PICU (42.1% and 31.3%, respectively), but they were significantly higher on the day shifts than the night shifts in the ICN (24.5% and 8.4%, respectively). The number of medication errors in the two units was substantial, and steps were taken to implement a 24-hour pediatric critical-care satellite pharmacy with unit dose drug distribution to reduce the incidence of errors.

Centralized Hospital Services↗
PubMedDate not supplied

Reducing medication errors.

This article describes initiatives one institution developed to improve systems for detecting and preventing adverse medication events. Our discussion focuses on issues regarding the frequency and incidence of medication errors, the trials of traditional versus anonymous incident reporting, and the efforts to improve systems rather than placing blame and punishment on individuals. Initiatives such as improved documentation of pediatric patient weights and hepatic and renal function, increase of direct physician order entry into our Medical Information System (MIS), elimination of nonemergent verbal orders, and new and improved MIS ordering matrices (incorporating medical protocols and pathways) have led to more rational and efficient practices. Improved error prevention and critical incident review have identified on-going opportunities for improvement. Although the direct impact on patient outcomes is not yet measurable, numerous positive results have allowed for improved clinical decision making, streamlining of processes, increased regulatory compliance, and a positive culture change.

Adverse Drug Reaction Reporting Systems↗
PubMedDate not supplied

Focus on medical errors provides clinical engineering opportunities.

Based upon the IOM report and the reaction it has already generated, as well as any new requirements that could emerge, we can expect to see increased pressure on health care to learn from its mistakes over the next few years. Clinical engineering professionals, who bring a breadth of experience and understanding in engineering, management and clinical principles to the table, have the ability to be an essential part of the team working to make the recommendations in the IOM report a reality. It is up to each of us to prepare ourselves to assume a prominent role within our hospitals as they tackle the challenge of reducing medical errors and improving patient safety.

Biomedical Engineering↗
PubMed2004

Defining and classifying medical error: lessons for patient safety reporting systems.

BACKGROUND: It is important for healthcare providers to report safety related events, but little attention has been paid to how the definition and classification of events affects a hospital's ability to learn from its experience. OBJECTIVES: To examine how the definition and classification of safety related events influences key organizational routines for gathering information, allocating incentives, and analyzing event reporting data. METHODS: In semi-structured interviews, professional staff and administrators in a tertiary care teaching hospital and its pharmacy were asked to describe the existing programs designed to monitor medication safety, including the reporting systems. With a focus primarily on the pharmacy staff, interviews were audio recorded, transcribed, and analyzed using qualitative research methods. RESULTS: Eighty six interviews were conducted, including 36 in the hospital pharmacy. Examples are presented which show that: (1) the definition of an event could lead to under-reporting; (2) the classification of a medication error into alternative categories can influence the perceived incentives and disincentives for incident reporting; (3) event classification can enhance or impede organizational routines for data analysis and learning; and (4) routines that promote organizational learning within the pharmacy can reduce the flow of medication error data to the hospital. DISCUSSION: These findings from one hospital raise important practical and research questions about how reporting systems are influenced by the definition and classification of safety related events. By understanding more clearly how hospitals define and classify their experience, we may improve our capacity to learn and ultimately improve patient safety.

Humans↗
PubMed2006

Introduction to medication errors and the error prevention initiatives in a teaching hospital in Western Nepal.

Pharmacotherapy is a complex process and involves interaction of the patient and the healthcare professionals at various levels. Prevention of medication errors is important however, errors may occur even in a carefully monitored healthcare setup. The out comes of the errors may range from mild inconvenience to the patient to even fatal toxic reactions. There are several predisposing factors for the occurrence of errors starting from improper drug selection to errors in administration technique by the healthcare providers' and patients. Several methods can be employed to detect the occurrence of errors. At the Manipal Teaching Hospital, Pokhara, Nepal, the Department of Hospital and Clinical Pharmacy has taken the initiative in identifying the error prone situations and has taken remedial measures including educational and managerial interventions to minimize the occurrence of errors.

Counseling↗
PubMed2004

A review of the literature examining linkages between organizational factors, medical errors, and patient safety.

The potential role of organizational factors in enhanced patient safety and medical error prevention is highlighted in the systems approach advocated for by the Institute of Medicine and others. However, little is known about the extent to which these factors have been shown empirically to be associated with these favorable outcomes. The present study conducted an intensive review of the clinical and health services literatures in order to explore this issue. The results of this review support the general conclusion that there is little evidence for asserting the importance of any individual, group, or structural variable in error prevention or enhanced patient safety at the present time. Two major issues bearing on the development of future research in this area involve strengthening the theoretical foundations of organizational research on patient safety and overcoming definitional and observability problems associated with error-focused dependent variables.

Humans↗
PubMed2003

[More safety for patients requires confidentiality in the enquiry into medical errors].

Recently, a seven-month-old baby died after a cardiac intervention and a medical error was presumed. An independent committee investigated this mishap after the confidentiality of the report was guaranteed. However, because of a judicial ruling, the report had to be made public, which caused great upheaval. To improve safety, error management requires confidential investigation to ensure co-operation of all parties involved. There are two conflicting and irreconcilable aims: medical professionals want to establish what went wrong, legal professionals want to establish who is at fault. The position of investigative committees should be (legally) fortified with a guarantee of confidentiality and sound underlying principles of investigation should be delineated.

Confidentiality↗
PubMed1997

[Structure and negative sequelae of medical errors in care for angina pectoris].

12 cardiologists trained as experts in assessment of medical care quality (MCQ) made a computer-assisted expertise of the care rendered to 110 anginal patients. Of these 68 patients had angina of effort (AE) and 42 had unstable angina (UA). This made up 10% of annual number of anginal patients treated in the cardiological clinic in 1996. Medical errors were of the same type in both the groups. Inadequate collection of information, erroneous diagnosis, treatment, continuity occurred in 50, 30, 15 and 5% of all the errors, respectively. Negative effects of the errors were mild (less seriously suffered AE patients), but led to waste of health service resources.

Angina Pectoris↗
PubMed2005

Influence of computerised medication charts on medication errors in a hospital.

INTRODUCTION: In hospitals where computerised physician order entry systems will not be available in the near future, there is a need to explore other ways of reducing medication errors that occur in the drug ordering and delivery system. One of these ways is the use of a computerised medication chart that is updated daily. The aim of this study was to evaluate the frequency, types and potential clinical significance of drug prescription and administration errors by comparing a traditional medication distribution system (where the transcription of handwritten into printed medication orders takes 3-5 days and the transfer of medication orders was not complete) with the use of a computerised medication chart (which was updated daily by pharmacy assistants on the ward). METHODS: Data were collected during two 3-week periods, from a 32-bed internal medicine unit, before and after the introduction of the computerised medication charts. Prescribing errors were observed by evaluation of all new and changed medication orders and administration errors were detected by using the disguised-observation technique. RESULTS: For prescribing errors, a total of 611 prescriptions before and 598 prescriptions after the intervention were evaluated. The total prescription error rate (of medication orders with >or=1 error) was found to be significantly higher with the computerised charts when compared with the old system (50.0% [299 of 598] vs 20.3% [124 of 611], odds ratio [OR] 3.80 [95% CI 2.94, 4.90]). This increase was caused by an increase in administrative prescription errors with a low potential clinical significance (mainly omission of the prescriber's name and the prescription date). The error rate for errors with a potential clinical significance was found to be significantly lower because the prescription error 'duplicate therapy' was eliminated (3.4% with the traditional medication chart vs 0% with the computerised chart). For administration errors, a total of 1122 drugs before the intervention and 1175 drugs after the intervention was observed to be administered. The total administration error rate was found to be significantly lower after the intervention (6.1% [72 of 1175] vs 10.5% [118 of 1122], OR 0.61 [95% CI 0.45, 0.84]), as was the error rate with a potential clinical significance. The contribution of handwritten medication orders to the total amount of medication orders was significantly decreased after the intervention (12.8% vs 20.6% [95% CI 4.6, 11.0]) and the administration of a drug ordered by a handwritten medication order resulted in a significantly higher administration rate than with administration of a drug ordered by a printed medication order (before the intervention 20.7% vs 8.0%, OR 2.99 [95% CI 1.96, 4.56], after the intervention 11.4% vs 5.6%, OR 2.18 [95% CI 1.16, 4.11]). CONCLUSION: This observational study shows a significant reduction in clinically relevant, administration and (therapeutic) prescription error rates when applying a system using computerised and daily updated medication charts compared with a system using traditional medication charts. Therefore, the use of computerised and daily updated medication charts has the potential to improve the quality of the medication distribution process in hospitals waiting for the implementation of a computerised physician order entry system.

Aged↗
PubMed2004

Reducing medication errors through naming, labeling, and packaging.

Errors due to look-alike or sound-alike medication names are common in the United States, and are responsible for thousands of deaths and millions of dollars in cost each year. Up to 25% of all medication errors are attributed to name confusion, and 33% to packaging and/or labeling confusion. Thousands of medication name pairs have been confused based on similar appearances or sounds when written or spoken, or have been identified as having the potential for confusion. Systems and recommendations have been developed that may reduce the occurrence of such errors.

Drug Labeling↗
PubMed2000

[The pattern of medication errors in connection with intravenous administration at an intensive care unit].

In a static study, medication errors in intravenous administration were registered in a multidisciplinary intensive care unit. The most frequent type of errors included administration of incorrect doses, but also administration of diluted drugs over an excessive time period, use of previously opened ampoules, administration of unauthorized drugs, wrong infusion rates, dissolution of drugs in incorrect media, dissolution of drugs in incorrect volumes of dissolution media and wrong dosage form errors were observed.

Denmark↗
PubMed2000

Medical errors, airplanes, and information technology.

The IOM says tens of thousands die each year from medical errors. Learn lessons from the aviation industry and how we can build a culture of safety with information technology and clinical information systems.

Accidents, Aviation↗