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At least 199 records · Page 11Linked to original sources

PubMed2003

Incidence of medical error and adverse outcomes on a pediatric general surgery service.

BACKGROUND/PURPOSE: The Institute of Medicine has identified medical error as a leading cause of death and injury, with deaths resulting from medical error exceeding those caused by motor vehicle collisions, breast cancer, or AIDS. The authors examined the incidence and sources of medical error in relation to adverse events on a pediatric general surgery service. METHODS: All intensive care unit (ICU) and ward admissions to 2 staff pediatric general surgeons during a 1-month period were identified prospectively and in-patient care was reviewed daily by a 3-person panel consisting of a staff surgeon, a surgical fellow, and a nonmedical observer. Medical errors, identified through daily patient encounters, nursing rounds, medical rounds, and chart examinations, were evaluated based on type, hospital setting, personnel involved, and outcome. Adverse outcomes were evaluated based on type and contributing factors. RESULTS: Our study group included 64 patients. A total of 108 errors were identified; 28% of these errors resulted in adverse outcomes. One or more medical errors were identified in the care of two thirds of patients (43 of 64), with medical error contributing to adverse outcomes in one third of patients (21 of 64). Errors occurred most frequently in communication, postoperative monitoring and care, and diagnosis, with errors in postoperative care and diagnosis having the highest likelihood of resulting in an adverse outcome. Seventy-four adverse outcomes were identified in 31 patients; 35 (47%) of these outcomes, occurring in 21 patients, were attributable to medical error. The most common adverse outcomes identified were additional nonoperative procedures, of which, 92% resulted from medical error. There were no deaths. CONCLUSIONS: Medical error occurs in more than one half of hospital admissions on a general pediatric surgery service and contributes to a substantial number of adverse outcomes.

Adolescent↗

PubMedDate not supplied

Workload and environmental factors in hospital medication errors.

Nine hospital workload factors and seasonal changes in daylight and darkness were examined over a 5-year period in relation to nurse medication errors at a medical center in Anchorage, Alaska. Three workload factors, along with darkness, were found to be significant predictors of the risk of medication error. Errors increased with the number of patient days per month (OR/250 patient days = 1.61) and the number of shifts worked by temporary nursing staff (OR/10 shifts = 1.15); errors decreased with more overtime worked by permanent nursing staff members (OR/10 shifts = .85). Medication errors were 95% more likely in midwinter than in the fall, but the effect of increasing darkness was strongest; a 2-month delay was found between the level of darkness and the rate of errors. More than half of all medication errors occurred during the first 3 months of the year.

Alaska↗

PubMed2004

Preventing vincristine sulfate medication errors.

PURPOSE/OBJECTIVES: To review the clinical pharmacology of vincristine sulfate, describe three types of medication errors associated with its use, and suggest strategies for vincristine sulfate medication error prevention. DATA SOURCES: Published books and journal articles, online newsletters and documents, pharmaceutical manufacturers package inserts, and personal experience. DATA SYNTHESIS: Medication errors involving vincristine sulfate include overdosage (wrong dose), name confusion (wrong drug), and incorrect administration (wrong route). CONCLUSIONS: Vincristine medication errors are preventable errors that usually result in serious patient harm and often are lethal. IMPLICATIONS FOR NURSING: Nurses need to be aware of the types of medication errors that can occur with chemotherapy agents and be familiar with clinical signs and symptoms associated with these errors. Nurses also need to promote patient safety by implementing specific strategies to prevent vincristine medication errors.

Adult↗

PubMed1993

[Factors effecting medication errors].

The purpose of this paper is to reveal factors that may occur or that may prevent medication errors, and to consider some measures of patients' safety. For this aim, we explored the characteristics of each ward and the characteristics of each nurse as well as their experiences about medication errors. The investigation was conducted at a approximately 650-bed university hospital located in a large urban center in Tokyo, and at a approximately 150-bed private hospital located in a suburb of Tokyo. Questionnaires were distributed in October 1991 and asked nurses to identify medication errors in which they had been personally committed within the past one-month. A response rate was approximately 70%. We were informed other information of each unit from head nurses--such as the unit size, case mix, nurse staffing and working schedule of nurses. Results indicate that on the questionnaires the nurses reported 10 times medication errors than they reported to head nurses. 56 percent of 155 nurses (except nurses who were working at an ICU and a mental ward) stated they had made medication errors or near misses during the 1-month reporting period. 30 percent of 155 stated they actually dealt with medication errors occurred by others. Several factors that effect medication errors have been identified by a stepwise discriminant analysis. The proportion of serious patient and the bed occupancy rate influenced the occurrence of medication errors. The educational career of a nurse, especially whether the nurse had been offered an assistant nursing program or not, related to dealing with and/or preventing medication errors.(ABSTRACT TRUNCATED AT 250 WORDS)

Discriminant Analysis↗

PubMed2003

Medication errors at Queen Sirikit National Institute of Child Health.

BACKGROUND: In the past two years, medication errors have been recognized as having been unacceptably high among hospitalized patients. OBJECTIVE: To determine the incidence and type of medication errors, severity of events, patient outcomes and categories of drugs involved in the largest pediatric hospital in Thailand over a fifteen-month-period. PATIENTS AND METHOD: Retrospective review of in-patient medication errors documented in standard reporting forms from September 2001 to November 2002. Main outcome measure was the incidence of errors reported. RESULTS: Medication errors occurred in 1 per cent of admissions (322 errors of 32,105 admissions). The most common error type was prescription error (35.40%). The majority of errors were detected and prevented before the drugs were administered (76.71%). There was only one case of permanent brain damage; no deaths occurred in the study period. The most common group of drugs involved in medication errors was antibiotics and the most common route of administration was oral. CONCLUSION: Medication errors are not uncommon. There is a need to change the behaviors of recognizing and acknowledging clinical errors, including drug errors. Careful review of errors highlights the many opportunities to change how drug errors are addressed and to make them less likely.

Hospitals, Pediatric↗

PubMed2004

Computerized physician order entry and medication errors in a pediatric critical care unit.

OBJECTIVE: Medication errors are a major concern of health care professionals and medical institutions, especially errors involving children. Studies in adults have shown that computerized physician order entry (CPOE) systems reduce medication errors and adverse drug events (ADEs). The effect of CPOE implementation in a pediatric population has not been reported. The objective of this study was to evaluate the impact of CPOE on the frequency of errors in the medication ordering process in a pediatric critical care unit (PCCU). METHODS: A prospective trial was conducted of 514 pediatric patients who were admitted to a 20-bed PCCU in a tertiary-care children's hospital before and after implementation of CPOE. Medication errors were identified after review of all orders during the study period and then further classified as potential ADEs, medication prescribing errors (MPE), and rule violations (RV). RESULTS: A total of 13 828 medication orders were reviewed. Before implementation, potential ADEs occurred at a rate of 2.2 per 100 orders, MPEs at a rate of 30.1 per 100 orders, and RVs at a rate of 6.8 per 100 orders. After implementation, the rate of potential ADEs was reduced to 1.3 per 100 orders, MPEs to 0.2 per 100 orders, and RVs to 0.1 per 100 orders. The overall error reduction was 95.9%. Potential ADEs were reduced by 40.9%, and MPEs and RVs were reduced by 99.4% and 97.9%, respectively. CONCLUSIONS: The implementation of CPOE resulted in almost a complete elimination of MPEs and RVs and a significant but less dramatic effect on potential ADEs.

Child↗

PubMed2004

Health plan members' views about disclosure of medical errors.

BACKGROUND: Various authorities and national organizations encourage disclosing medical errors, but there is little information on how patients respond to disclosure. OBJECTIVE: To examine how the type of error, severity of adverse clinical outcome, and level of disclosure affect patients' responses to error and disclosure. DESIGN: Mail questionnaire survey (8 versions were developed) varying 3 factors in a completely crossed, randomized, factorial design. Each questionnaire included a vignette describing 1) a medical error (failure to check for penicillin allergy or inadequate monitoring of antiepileptic medication); 2) an associated clinical outcome (life-threatening or less serious); and 3) a physician-patient dialogue, with either full disclosure (acceptance of responsibility and an apology) or nondisclosure (expression of regret without acceptance of responsibility or an apology). SETTING: New England-based health plan. PARTICIPANTS: Random sample of 1500 adult members received the questionnaire, with a 66% response rate. MEASUREMENTS: Likelihood of changing physicians, likelihood of seeking legal advice, ratings of patient satisfaction, trust and emotional reaction in response to a vignette and dialogue, and views on medical error and disclosure. RESULTS: Full disclosure reduced the reported likelihood of changing physicians and increased patient satisfaction, trust, and positive emotional response. Full disclosure reduced the reported likelihood of seeking legal advice in only 1 error-and-outcome vignette. In the other vignettes, the percentage of patients indicating that they would seek legal advice was relatively high even with full disclosure. Almost all respondents (98.8%) wanted to be told of errors, most (83%) favored financial compensation if harm occurred, and few (12.7%) favored compensation if no harm occurred. LIMITATIONS: Since the study was done in the context of a managed care plan in one geographic area, it could not assess whether the results are generalizable to other populations. In addition, it could not determine whether responses to the simulated situations used predict responses to real situations. CONCLUSIONS: Patients will probably respond more favorably to physicians who fully disclose medical errors than to physicians who are less forthright, but the specifics of the case and the severity of the clinical outcome also affect patients' responses. In some circumstances, the desire to seek legal advice may not diminish despite full disclosure.

Adult↗

PubMed2004

The environmental context of patient safety and medical errors.

The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural: healthcare organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events associated with learning, information flows, triage and transfer decisions, and culture of safety). Relevant organizational theories and strategies fo medical error reduction and prevention in rural health care settings were identified. Financial and technical assistance are needed to support the systematic collection of data from rural hospitals and other entities and to enhance relevant patient safety practices for rural America.

Humans↗

PubMed2005

Teaching and medical errors: primary care preceptors' views.

PURPOSE: To assess primary care preceptors' perceptions of the issues involved in teaching when medical errors occur. In particular, we examined preceptors' responses to trainees involved in medical errors, factors influencing their response, and their perceptions of barriers to teaching from medical errors. METHODS: A total of 38 primary care preceptors participated in 7 focus groups on teaching and medical errors. Participants were drawn from medical schools throughout the northeastern USA. Content analysis of transcripts identified major themes. RESULTS: We developed a framework describing how preceptors and learners respond to medical errors, the factors that influence these responses, and the relationships between these. We also identified barriers to teaching from medical errors. Preceptors are especially sensitive to learners' distress as a result of errors. Emotional distress and self-doubt are seen as inimical to learning, possibly causing more attention to be directed to emotional support than to correction and instruction. At the same time, accepting responsibility for errors was seen as prerequisite to learning. For many preceptors, vivid recollections of their own errors during training were influential in determining how they in turn responded as preceptors; none reported having received training in this area. CONCLUSION: This study describes preceptors' experiences of responding to trainees' medical errors, and identifies barriers to teaching from errors. The intersection of patient safety and medical education is a critical area for future research. We propose a framework that may help guide future research efforts, which should focus on identifying factors that promote faculty development to optimise learning and reduce the likelihood of future errors.

Attitude of Health Personnel↗

PubMed2006

Patients as actors: the patient's role in detecting, preventing, and recovering from medical errors.

PURPOSE: Patients have the most to gain from reducing medical errors; yet, little research has been done to investigate the role they could or already do play in detecting and preventing errors in their own health care. The purpose of this study is to examine patient's role in detecting, preventing, and recovering from medical errors in outpatient oncology. METHODS: In this paper, we use cognitive work analysis and Rasmussen's taxonomy of human performance to describe five cases of medical errors that occurred in an outpatient, cancer-care setting. We detail the role of the patient in each case, and analyze each role using constructs from previous studies of human behavior and errors. RESULTS: Observational data indicates that patients engage in a range of tasks that identify, prevent, and recover from medical errors in outpatient cancer care. The results of this study point to the importance of considering patients and their work in both the design of patient-care information systems and the structure of clinical-care environments that enable safe and effective health care.

Ambulatory Care↗

PubMed1998

Survey of hospital systems and common serious medication errors.

The Institute for Safe Medication Practices and the University of Illinois at Chicago, College of Pharmacy, undertook a hospital survey of medical-surgical hospitals to determine systems-oriented factors that allow the highest level of medication safety. The study incorporated a peer-reviewed and pretested questionnaire, which focused on critical information necessary to yield quality data for comparison. Through analysis, it was shown that over one third of all medication errors reported in the survey involve just six categories--allergies, insulin, heparin, opiates, PCA devices, and potassium concentrates.

Chicago↗

PubMed2004

Hospital-reported medical errors in premature neonates.

OBJECTIVE: To determine the national rate of hospital-reported medical errors in premature neonates and describe the patient and organizational characteristics associated with their occurrence. DESIGN: Nonconcurrent, cohort study. SETTING: The Healthcare Cost and Utilization Project (HCUP) contains discharge data collected at community hospitals sited in >20 states. PATIENTS: All neonatal discharges from the 1997 edition of HCUP were included in these analyses. The definition of prematurity included any hospitalized neonate with a birth weight <2500 g, which corresponds to approximately 37 wks gestation. Medical error was defined as an International Classification of Diseases-9 discharge diagnosis of 996-999 in any of the diagnosis fields associated with the discharge. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The national rate of hospital-reported medical errors in premature neonates is 1.2 per 100 discharges. There was a significant linear increase in the rate of medical errors based on birth weight (Cochran-Armitage test for trend, p <.001). After we controlled for case mix and organizational characteristics using a logistic regression model, medical errors continued to be associated with birth weight, gender, insurance status, and hospital characteristics. CONCLUSIONS: The rate of hospital-reported medical errors in premature neonates is lower than that reported in both the adult and pediatric populations. Specific patient and organizational characteristics are associated with an increased risk of medical errors. These characteristics may help to identify opportunities to improve patient safety efforts in this vulnerable population.

Child, Hospitalized↗

PubMed1999

Factors contributing to medication errors: a literature review.

Drug administration is an integral part of the nurse's role. Responsibility for correct administration of medication rests with the nurse, yet medication errors are a persistent problem associated with nursing practice. This review examines what constitutes a medication error and documents contributory factors in medication errors. These factors have been derived from reported medication errors and opinions of nurses as to factors which predispose to errors. A number of definitions exist as to what constitutes a medication error. The definition used should facilitate interpretation and comparison of a wide range of research reports. Medication errors are a multidisciplinary problem and a multidisciplinary approach is required in order to reduce the incidence of errors.

Attitude of Health Personnel↗

PubMed2006

Computer based medication error reporting: insights and implications.

BACKGROUND: Despite the growing use of error reporting tools, the healthcare industry is inexperienced in receiving, understanding, and analyzing these reports. OBJECTIVE: To assess the accuracy and define the epidemiology of medication error reports. DESIGN, SETTING, AND PATIENTS: A retrospective cohort study of 581 error reports containing 1010 medication errors reported between July 2001 and January 2003 at a large academic children's institution. MAIN OUTCOME MEASURES: Correct classification and types of medication errors. RESULTS: Of the 1010 medication errors reviewed, 298 (30%) were prescribing errors, 245 (24%) were dispensing errors, 410 (41%) were administration errors, and 57 (6%) involved medication administration records (MAR). Following expert review, 208 errors (21%) were deleted because they had been inappropriately coded as errors and 97 (10%) were added as they were not initially coded despite having occurred. In addition, 352 medication error reports needed to have the subtype of error reclassified; 207 (59%) of these involved the reporter choosing the non-descript "other" category on the reporting tool (such as "Prescribing other") which was able to be reclassified by expert review. The overall distribution of error type categories did not change significantly with expert review, although only MAR errors were underreported by the reporters. The most common medications were anti-infectives (17%), pain/sedative agents (15%), nutritional agents (11%), gastrointestinal agents (8%), and cardiovascular agents (7%). CONCLUSIONS: Despite clear imperfections in the data captured, medication error reporting tools are effective as a means of collecting reliable information on errors rapidly and in real time. Our data suggest that administration errors are at least as common as prescribing errors in children. Further research is needed, not only in the area of computerized physician order entry (CPOE) for children, but also on ways to make the dispensing and administration of medications safer.

Academic Medical Centers↗

PubMed2004

Selected medication-error data from USP's MEDMARX program for 2002.

PURPOSE: Records from USP's MEDMARX database of medication errors for 2002 were studied. METHODS: Records of medication errors submitted to MEDMARX by participating health care institutions during 2002 were analyzed for error category index (whether a medication error actually occurred, whether it reached the patient, and, if so, the effect), node (the point in the medication-use process where the error occurred), type of error, cause, contributing factors, and drug products involved. RESULTS: The number of participating institutions was 482, and the number of medication error records released to MEDMARX was 192,477, an 82.2% increase from 2001. Errors that did not reach the patient were seen in 35% of the records, errors that reached the patient were seen in 49%, and errors that may have contributed to or resulted in harm were seen in 2%. The nodes, types of errors, causes of errors, contributing factors, and leading products by generic name are discussed. CONCLUSION: An analysis of over 192,000 records of medication errors submitted by nearly 500 health care facilities to USP's MEDMARX database in 2002 produced detailed information on the scope and nature of medication errors.

Adverse Drug Reaction Reporting Systems↗

PubMedDate not supplied

Paramedic self-reported medication errors.

BACKGROUND: Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, and treatment. METHODS: A survey was given to paramedics in San Diego County. The survey tool was established on the basis of previous literature reviews and questions developed with previous CQI data. RESULTS: A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average of 25.4 hours and 6.7 calls/shift. Thirty-two (9.1%) responding paramedics reported committing a medication error in the last 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), and wrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, and incorrect dosage given. Fatigue, training, and equipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% being reported by the base hospital radio nurse, 8.3% found upon chart review, and 4.2% noted by paramedic during call but never reported. CONCLUSIONS: Nine percent of paramedics responding to an anonymous survey report medication errors in the last 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.

California↗

PubMedDate not supplied

Paramedic self-reported medication errors.

BACKGROUND: Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, and treatment. METHODS: A survey was given to paramedics in San Diego County. The survey tool was established based on previous literature reviews and questions developed based on previous CQI data. RESULTS: A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average shift length of 25.4 hours and 6.7 calls/shift. Thirty-two responding paramedics (9.1%) reported committing a medication error in the past 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), and wrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, and incorrect dosage given. Fatigue, training, and equipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% reported by the base hospital radio nurse, 8.3% found on chart review, and 4.2% noted by the paramedic during the call but never reported. CONCLUSIONS: Nine percent of paramedics responding to an anonymous survey reported medication errors in the past 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.

Adult↗

PubMed2005

Patient concerns about medical errors in emergency departments.

OBJECTIVE: Despite large numbers of emergency encounters, little is known about how emergency department (ED) patients conceptualize their risk of medical errors. This study examines how safe ED patients feel from medical errors, which errors are of greatest concern, how concerns differ by patient and hospital characteristics, and the relationship between concerns and willingness to return for future care. METHODS: Multiwave telephone interviews of 767 patients from 12 EDs were conducted. Patients were asked about their medical safety, concern about eight types of medical errors, and satisfaction with care. RESULTS: Eighty-eight percent of patients believed that their safety from medical errors had been good, very good, or excellent; 38% of patients reported experiencing at least one specific error-related concern, most commonly misdiagnosis (22% of all patients), physician errors (16%), medication errors (16%), nursing errors (12%), and wrong test/procedure (10%). Concerns were associated with gender (p < 0.01), age (p < 0.0001), ethnicity (p < 0.001), length of stay (p < 0.001), ED volume (p < 0.0001), day of week (p < 0.0001), and hospital type (p < 0.0001). Concerns were highly related to a patient's willingness to return to the ED. CONCLUSIONS: The majority of ED patients felt relatively safe from medical errors, yet a significant percentage of patients experienced concern about a specific error during their emergency encounter. Concerns varied by both patient and hospital characteristics and were highly linked to patient satisfaction. The selective nature of concerns may suggest that patients are attuned to cues they perceive to be linked to specific medical errors, but efforts to involve patients in error detection/prevention programs will be challenging given the stressful and intimidating nature of ED encounters.

Adolescent↗