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Biomedical subjects

Benjamin C Grasso

Publications and source records attributed to Benjamin C Grasso.

5 recordsLinked to original sources
PubMed2005

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.

Research in the last decade has identified medication errors as a more frequent cause of unintended harm than was previously thought. Inpatient medication errors and error-prone medication usage are detected internally by medication error reporting and externally through hospital licensing and accreditation surveys. A hospital's rate of medication errors is one of several measures of patient safety available to staff. However, prospective patients and other interested parties must rely upon licensing and accreditation scores, along with varying access to outcome data, as their sole measures of patient safety. We have previously reported that much higher rates of medication errors were found when an independent audit was used compared with rates determined by the usual process of self-report. In this study, we summarize these earlier findings and then compare the error detection sensitivity of licensing and accreditation surveys with that of an independent audit. When experienced surveyors fail to detect a highly error prone medication usage system, it raises questions about the validity of survey scores as a measure of safety (i.e., lack of medication errors). Replication of our findings in other hospital settings is needed. We also recommend measures for improving patient safety by reducing error rates and increasing error detection.

Cross-Sectional Studies↗
PubMed2003

What do we know about medication errors in inpatient psychiatry?

BACKGROUND: Adverse drug events (ADEs) have been implicated as a cause of substantial morbidity and mortality. Psychiatrists have successfully characterized one category of ADE--adverse drug reactions (ADRs), which have been studied from a medication-specific psychopharmacology frame of reference. The literature on ADEs, both preventable and nonpreventable, was reviewed within the broader patient safety framework. METHODS: English-language studies involving ADEs and medication errors in psychiatry for 1996 through 2003 were identified on MEDLINE and by using a hand search of bibliographies. RESULTS: Few reports on the incidence and characteristics of medication errors in psychiatric hospitals could be found. Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture. PREVENTION STRATEGIES: Application of a systems-oriented approach to ADE reduction and the promotion of a nonpunitive culture are essential. Clinical and pharmacy staff could monitor the literature for published reports of preventable adverse events and review those reports in multidisciplinary team meetings. CONCLUSIONS: Psychiatry would benefit from learning about the terminology used in describing medication errors and ADEs. Relatively few data are available regarding the frequency and consequences of medication errors in psychiatry; more research is needed.

Antipsychotic Agents↗
PubMed2003

Use of chart and record reviews to detect medication errors in a state psychiatric hospital.

OBJECTIVE: This study compared the effectiveness of using a review team and the usual self-reporting method in detecting different types of medication errors in a state psychiatric hospital. METHODS: Medication errors were defined by using widely accepted criteria. Rates of prescription, transcription, administration, and dispensing errors were determined, and the risk of harm from each error was rated as high, moderate, or low. A review team was assigned to retrospectively review 31 patient records for prescription, transcription, and administration errors for a total of 1,448 patient-days. Dispensing errors, which can only be determined concurrently, were reported for an equivalent number of patient-days. The error rate was compared with the rate that was determined by the usual method of self-reports from all nursing and medical staff. RESULTS: In the 31 charts retrospectively reviewed and the dispensing events concurrently reviewed, the team detected a total of 2,194 medication errors, whereas a total of nine errors were self-reported for the same patient group. Administration errors accounted for more than half of the total (66 percent), followed by transcription errors (23 percent), prescription errors (11 percent), and dispensing errors (less than 1 percent). Nineteen percent of errors were rated as having a low risk of harm, 23 percent as having a moderate risk, and 58 percent as having a high risk. CONCLUSIONS: Use of a review team should be considered as a method for detecting and reporting medication errors.

Hospitals, Psychiatric↗
PubMed2002

Reducing errors in discharge medication lists by using personal digital assistants.

This study examined whether the number of errors in discharge medication lists at a psychiatric hospital would decrease when the practice of transcribing the lists by hand from physicians' discharge orders was replaced by the use of personal digital assistants (PDAs) to create and directly print out such lists. In a four-month period before the use of PDAs was introduced, 20 of the 110 hand-transcribed lists (22 percent) contained errors. In the four-month period after the use of PDAs was implemented, seven of the 90 PDA-generated lists (8 percent) contained errors. Use of a PDA may be helpful in providing safer patient care.

Computers, Handheld↗