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PubMed2003

Medication errors. A bitter pill.

According to the Agency for Healthcare Research and Quality, over 770,000 hospitalized Americans are injured or die each year from adverse drug events. The scope of the problem is now recognized by governmental and professional agencies. Traditionally, the legal and healthcare systems have focused on identifying incompetent and poorly performing healthcare providers as the cause of patient injury instead of systematically making the system safer. The solution to this problem lies in understanding how and why medication errors occur and identifying what can be done to prevent them. This article will identify the factors that contribute to adverse medication events in healthcare and discuss current initiatives to prevent errors. The role of nursing in improving medication administration and reducing adverse events will be detailed.

Disclosure↗
PubMed1996

Outsourcing inpatient i.v. compounding: expense and medication error implications.

A quasi-experiment was conducted to evaluate differences in intravenous (i.v.) drug compounding costs and frequency of medication administration errors of omission before and after outsourcing the hospital's i.v. admixture refill program to an alternate site home i.v. infusion pharmacy. As part of the outsourcing changes, the pharmacy redeployed an i.v. admixture technician to do i.v. recycling on the nursing units. The study was a single subject, pretest, posttest (within subjects) design using an observer. The independent variables were outsourcing and having an i.v. recycling technician. The dependent variables were medication errors of omission and costs directly associated with the two i.v. programs. A statistically significant reduction in the frequency of medication administration errors of omission was associated with implementation of the outsourcing program. In addition, first year expenses were reduced by an estimated $86,356.

Clinical Pharmacy Information Systems↗
PubMed2001

Nurses and medication error: a discursive reading of the literature.

Medication management is a part of everyday nursing practice. In carrying out this aspect of their role, nurses are subject to a range of practices and procedures, which are dictated through legal, management and medical requirements to ensure safe administration of medications. The literature addresses a range of areas related to the nurse's role in medication management, including knowledge required by nurses, practices and procedures related to administration, procedures for identifying and reducing errors and measuring error rates, and professional and ethical issues. The literature is a part of the discursive ensemble of nursing - as a written text it contributes to how nurses and colleagues construct and view nursing practice. This paper presents a discursive reading of that literature, exploring how nurses are positioned in relation to medication errors. I argue that the voice of nursing is mostly heard through discourses of biomedical science, law and management and draw on the work of Michel Foucault to illustrate some of the ways in which these discourses shape nursing practice.

Attitude of Health Personnel↗
PubMed2003

[Medication errors: who is responsible?].

New diagnostic and therapeutic technologies are used with growing frequency, improving the quality of medical assistance and increasing life expectancy. Health care, however, is becoming progressively more expensive and complex. Adverse events related to medical assistance, particularly errors, are becoming public, being debated and judged in courts. Given their training, health workers are not prepared to deal with errors, which are associated with shame, fear and punishment. The approach to errors in the health system is usually individualistic, considering such events as acts of insecurity performed by careless, non-motivated and ill-trained persons. The tendency is to hide errors when they occur, with the result that an important learning opportunity is lost. There is another way to deal with errors, a systemic view that has obtained positive results in sectors such as aviation, anesthesiology and unit-dose drug distribution systems. These systems have varied degrees of safety and should take into account human limitations when designed and applied. A change in paradigm is needed when dealing with drugs, as it is not enough for a drug to have quality assurance, but the complete process of drug use should be safe. Medication errors, avoidable by definition, are at present a serious public health issue, leading to loss of lives and significant financial losses. A systemic approach to medication errors may disclose failures in the process as a whole, and improvements can be implemented to reduce their occurrence.

Attitude of Health Personnel↗
PubMed1997

When a physician harms a patient by a medical error: ethical, legal, and risk-management considerations.

Errors that harm patients are infrequently brought to the attention of these patients. The full disclosure of such medical errors is in the best interest of patients because it allows them to understand what has occurred, and to gain appropriate compensation for the harm that they have suffered. Physicians have been given little guidance regarding how to conduct a relationship with the patient after such an injury. We argue that the physician must continue to respect the patient, and communicate honestly with him or her throughout their relationship, even after the patient has been injured. It is painful to admit our errors, especially to those who have been harmed by them. Nevertheless, offering an apology for harming a patient should be considered to be one of the ethical responsibilities of the profession of medicine. Monetary compensation alone is not to be offered as a charitable gesture; rather, it should be accompanied by an apology to demonstrate the responsibility of the physician to the trusting patient. Full and honest disclosure of errors is most consistent with the mutual respect and trust patients expect from their physicians. Clearly, physicians' ethical responsibilities sometimes differ from their legal and risk-management responsibilities.

Adult↗
PubMed2003

Medication errors caused by confusion of drug names.

Many drug names can look or sound like other drug names, which leads to confusion and potentially harmful medication errors. While various types of drug names exist, brand (proprietary) names are most commonly confused. Examples of the numerous drug names that have been confused because they look and/or sound similar include Celebrex (celecoxib), Cerebyx (fosphenytoin), and Celexa (citalopram). Factors such as poor handwriting and clinical similarity may exacerbate the problem. This problem can be alleviated through actions by regulatory agencies, pharmaceutical manufacturers, healthcare professionals, and patients. To address the problem, significant changes in the pharmaceutical regulatory process have occurred in the US and Europe.

Clinical Pharmacy Information Systems↗
PubMedDate not supplied

Strategies to reduce medication errors with reference to older adults.

This information on best practice is based on a systematic review (Hodglkinson et a/ 2006) conducted by the Australian Centre for Evidence Based Aged Care, formerly a collaborating centre of the Joanna Briggs Institute (JBI). The primary references on which this information is based are available online via Blackwell Synergy: www.blackwell-synergy.com and to members of the institute via the web site: www.joannabriggs.edu.au. This information sheet discusses the following: Types and causes of medication errors. Interventions, including computerised systems, individual patient medication supply, education and training, use of pharmacists and nursing care models. Implications for practice and research. Recommendations.

Aged↗
PubMed2003

Voluntary medication error reporting program in a Japanese national university hospital.

BACKGROUND: In Japan, as in other countries, medical accidents arising from human error can seriously damage public confidence in medical services, as well as being intrinsically undesirable. OBJECTIVE: Errors voluntarily reported by the healthcare practitioners in our institution (Kanazawa University Hospital) were considered to assess the contributory factors by using the accumulated error database in the hospital information system. METHODS: Medical errors in our institution during the period from July 1, 2000, to June 30, 2002, were counted using the error reporting system database and were classified. RESULTS: The number of errors reported during the investigation period was 1378, of which 78% were reported by nursing staff. Medication errors involving administration of injectable or oral drugs to inpatients, dispensing, and prescription accounted for about 50% of that number. Among dispensing errors, 53% were detected by patients or their families and 36% by nurses. CONCLUSIONS: The best method of error prevention is to learn from previous errors. For this purpose, the error reporting program is effective. In patient safety management, it is important to take into account the potential risks of future errors, as well as to capture information about errors that have already happened. For safety management, adoption of appropriate information technology (e.g., implementation of a prescription order entry system) is effective in reducing medication errors. However, it is important to note that serious errors can also arise in computer-based systems.

Health Occupations↗
PubMed2006

Effects of working conditions on intravenous medication errors in a Japanese hospital.

AIM: The aim of this study was to explore quantitatively which working conditions influence the occurrence of medical near-miss errors related to intravenous medication at a hospital in Japan. BACKGROUND: Although working conditions such as stress, fatigue and inexperience have been reported to contribute to medical errors, countermeasures to these conditions have been delayed, and working conditions have deteriorated in many Japanese medical sites. METHODS: A self-reporting questionnaire analysing working conditions that can lead to near-miss errors relating to intravenous medication was sent to 90 nurses working in four wards of one Japanese hospital in 2001. Eighty-eight subjects responded (response rate: 97.8%). Among 534 person-days in which 88 nurses attended works, 525 person-days of data were used for the analyses. RESULTS: Among 525 person-days, the number of near-miss errors was 94 (17.9%). There was no significant difference in the occurrence of near-miss errors among the three shifts (day shift, 19.2%; evening shift, 19.2%; night shift, 12.5%). During the day shift, errors were reported at a significantly higher frequency when the nursing services were delayed longer due to workload. During the evening shift, errors were reported when the nursing services were delayed longer due to workload and when years of experience at the current ward were shorter. In addition, nurses whose perceived level of fatigue before work was lower during the day shift, and nurses whose years of experience as a nurse were longer and who had longer sleep duration during the evening shift experienced near-miss errors with a significantly higher frequency than other nurses. These latter factors could be important conditions that encourage the detection of errors before they occur. CONCLUSIONS: Workload and lack of experience at the current ward are two conditions that can lead to errors. Furthermore, lack of fatigue and long experience as a nurse may help encourage the detection of errors before they occur. It is important to improve working conditions so that health care workers can detect errors before patients are harmed and decrease the number of errors that occur.

Humans↗
PubMed2006

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

PROBLEM: Sliding scale insulin (SSI) is frequently used for inpatient management of hyperglycemia and is associated with a large number of medication errors and adverse events including hypoglycemia and hyperglycemia. DESIGN: Observational before and after study evaluating the impact of implementation of a standardized SSI protocol and preprinted physician order form. SETTING: University Hospital in Pittsburgh, PA, USA. STRATEGY FOR CHANGE: Guidelines for the use of SSI were created by an interdisciplinary committee and implemented in non-intensive care units. In addition, a preprinted physician order sheet was developed which included the guidelines and an option for ordering one of three standardized insulin sliding scales or a patient specific scale. EFFECT OF CHANGE: One year after implementation the physician order form was used for 91% of orders and, overall, 86% of SSI orders followed the guidelines. The number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient-days at baseline to 1.2 at 1 year (p = 0.03). The number of hyperglycemia episodes 1 year after implementation decreased from 55.9 to 16.3 per 100 SSI patient-days. LESSONS LEARNT: The protocol was readily accepted by hospital staff and was associated with decreased prescribing errors and decreased frequency of hyperglycemia.

Blood Glucose↗