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Results for “Medication Errors”

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At least 523 records · Page 29Linked to original sources
PubMed2000

Medication error reporting: a survey of nursing staff.

The objective of this article is to describe findings from a medication error (ME) survey, to estimate the extent of ME underreporting by comparison of survey results with written incident reports (IRs), and to determine factors associated with IR reporting of MEs. Participants were registered nurses from the 38-bed infant unit of a pediatric hospital. Most recent ME in each of four stages of the medication process was classified as to: timing, nature, whether the error was prevented from the patient, patient injury, and completed IR. Surveys were administered to nurses during mandatory skills session and were compared with IRs for MEs for the previous 6 months. The survey response rate was 93.5 percent; 72 nurses described 177 errors, 40.3 percent observed an ME in the previous week, 62.1 percent were prevented from reaching the patient and the likelihood of prevention was reduced in the later stages of the medication process. About 30 percent of MEs resulted in IRs. Administration errors were more likely to result in IRs compared with ordering errors, especially when the error was not prevented from the patient. There were 51 IRs for MEs. A multivariate logistic regression with completed IRs as the dependent variable showed a decreased likelihood of IRs for ordering than administration errors. IRs were more likely for wrong medication or dose errors and IRs were less likely for errors prevented from reaching the patient. The study found that by augmenting IR reporting of MEs and classifying errors by stage, anonymous ME surveys can be used for monitoring and guiding improvements to hospital medication systems.

Adverse Drug Reaction Reporting Systems↗
PubMed2004

Poor interface design and lack of usability testing facilitate medical error.

BACKGROUND: A fictional scenario based on a compilation of several real events describes seven medical errors that at first appear to be caused by the paramedics and nurses involved. HUMAN FACTORS ENGINEERING (HFE) ANALYSIS: An emergency medical services paramedic attempted to use a debrillator on a 67-year-old man with ventricular tachycardia Yet nothing happened. The defibrillator displayed an indication that it was in synchronized mode but provided no feedback to tell the user that it was not prepared to shock because of low QRS amplitude. USABILITY TESTING: A hands-on approach to discovering the difficulties and potential for error that people encounter when trying to use a product, usability testing can help to create medical devices and systems that are not only more "user friendly" and efficient-but safer. RECOMMENDATIONS: Recommendations are presented to enable health care leaders to apply human factors considerations in their product evaluation and purchasing decisions. Medical device manufacturers should involve human factors engineers in the design process from the outset and should perform usability testing. Health care organizations should expect an optimized and tested user interface in the medical devices they purchase. SUMMARY: Many adverse events in medicine are the result of poor interface design rather than human error. The HFE concepts of usability and standardization are critical to patient safety.

Aged↗
PubMed2005

Medication errors and drug-dispensing systems in a hospital pharmacy.

Pharmacies permeate and interconnect various actions developed in different sectors within the complex process of the use of drugs in a hospital. Dispensing failures mean that a breach has occurred in one of the last safety links in the use of drugs. Although most failures do not harm patients, their existence suggests fragility in the process and indicates an increased risk of severe accidents. Present concepts on drug-related incidents may be classified as side effects, adverse effects, and medication errors. Among these are dispensing errors, usually associated with poor safety and inefficient dispensing systems. Factors associated with dispensing errors may be communication failures, problems related to package labels, work overload, the physical structure of the working environment, distraction and interruption, the use of incorrect and outdated information sources and the lack of patient knowledge and education about the drugs they use. So called banal dispensing errors reach significant epidemiological levels. The purpose of this paper, which is part of a study on the occurrence of dispensing errors in the pharmacy of a large hospital, is to review the main concepts that guide studies on adverse effects and to provide an update on dispensing errors.

Humans↗
PubMed2000

Medical errors.

Explore the source record for details and available documents.

Capital Expenditures↗
PubMed2003

One hospital's journey toward reducing medication errors.

BACKGROUND: The Valley Hospital, a 451-bed acute care facility in Ridgewood, New Jersey, has made substantial progress in the reduction of medication administration errors. METHODS: Reduction in medication administration errors were accomplished through (1) becoming intimately familiar with the errors, including where, when, why, and how they were occurring; (2) establishing a nonpunitive environment and encouraging reporting of errors, including near-miss errors; (3) trending error report data to identify areas of concentrated errors in the medication use process; (4) simplifying and standardizing process steps; and (5) selecting the right technology to address error-prone steps in the hospital's systems. RESULTS: The establishment of a nonpunitive environment led to a dramatic increase in the number of nearmiss errors reported, and the information gained proved to be valuable and diagnostic. Establishing an interview process with the caregivers directly involved in occurrences enabled us to gather detailed information about errors. This forum led the way to an early understanding of human factors, system failures, and root cause analysis. Those errors were trended, addressed, and reduced through manual system changes and technological system developments designed to ensure the "five rights" of safe medication administration. CONCLUSIONS: Keeping on course requires constant and continuous review of medication use processes to ensure that they support instead of unnecessarily limit actual practices.

Hospital Bed Capacity, 300 to 499↗
PubMed2000

Shaping the medical error movement.

The 1999 Institute of Medicine's report. "To Err is Human," shifted government and public focus to medical errors. Read how errors occur and what's being done to stop them, then check your answers at http://www.nursingmanagement.com.

American Hospital Association↗
PubMed2004

Medical errors: impact on clinical laboratories and other critical areas.

The Institute of Medicine (IOM) report (1999) stated that the prevalence of medical errors is high in today's health care system. Some specialties in health care are more risky than others. A varying blunder/error rate of 0.1-9.3% in clinical diagnostic laboratories has been reported in the literature. Many of these errors occur in the preanalytical and postanalytical phases of testing. It has been suggested that the errors occurring in clinical diagnostic laboratories are smaller in number than those occurring elsewhere in a hospital setting. However, given the quantum of laboratory tests used in health care, even this small rate may reflect a large number of errors. The surgical specialties, emergency rooms, and intensive care units have been previously identified as areas of risk for patient safety. Though the nature of work in these specialties and their interdependence on clinical diagnostic laboratories presents abundant opportunities for error-generating behavior, many of these errors may be preventable. Appropriate attention to system factors involved in these errors and designing intelligent system approaches may help control and eliminate many of these errors in health care.

Clinical Laboratory Information Systems↗
PubMed2005

Medical errors: getting the incentives right.

This work examines the role of penalties as providers of incentives to prevent medical errors and ensure that such incidents, once they occur, become common knowledge. It is shown that a scheme with two penalties (accountability and non-report) induces the first-best solution. However, this scheme does not necessarily imply a punitive environment, but may, under given circumstances, yield insignificant and even negative penalties. Alternative sanction systems, such as voluntary reporting and immunity, are found to have less desirable properties. An exception is confidentiality (anonymity) which turns out to be an optimal scheme. Finally, the examination of various penalty restrictions (scope and scale) shows that such barriers may promote both tougher and softer sanction schemes.

Confidentiality↗
PubMed2000

Medication error prevention by pharmacists--an Israeli solution.

OBJECTIVE: The purpose of this study was to record prospectively the frequency of medication order errors in a general hospital in Israel with the objective of assessing the impact of pharmacist intervention in preventing potential harm. METHODS: The study was conducted during a 6-month period. A total of 160 medication order errors were detected at the hospital of which 60.6% were prescription errors and 39.4% were therapy ones. Principal types of errors detected were incorrect dosage (27.5%), interactions between drugs (20%), incorrect drug (12.5%), route (11.2%) and frequency (11.2%). Medication error rate by degree of severity was calculated per 100 patient days. The highest rate was found in Hemato-Oncology (2.48), followed by Intensive Care (0.82), Surgery (0.48) and Internal Medicine (0.26). Anti-infective drugs were the most prevalent class of drugs in which errors occurred (38.7%) followed by total parenteral nutrition preparations (21.8%), antineoplastics (15.6%) and anticoagulants (11.3%). Changes in medication orders due to pharmacists' intervention only occurred in 73.8% of error cases, most referring to dosage or route change (37.5%). CONCLUSIONS: This study underestimates the actual number of medication errors. However, it identified problem areas and trends so that better measures to improve drug use could be implemented.

Hospital Departments↗