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PubMed2003

Medication errors in the OR--a secondary analysis of Medmarx.

Although medication errors can result in serious patient complications or even death, a paucity of information regarding medication errors that occur in the OR exists. AORN and the US Pharmacopeia (USP) collaboratively conducted a secondary analysis of reports of medication errors that occurred in the OR. These reports were submitted to the USP via the Medmarx program. The findings will give perioperative clinicians further insight into the types and causes of medication errors that occur in the OR and will help them develop potential prevention strategies.

Databases, Factual↗

PubMedDate not supplied

A "near-miss" model for describing the nurse's role in the recovery of medical errors.

Approximately 44,000 patients die each year as a result of medical errors. Nurses play an important role in ensuring patient safety and preventing adverse outcomes. As frontline providers of care, nurses are in key positions to intercept a medical error before it affects a patient. The Eindhoven model for investigating a "near-miss" situation has been used successfully in the chemical industry to elucidate the concept of human recovery, that is, the ability of operators to detect, localize, and correct system faults. In this article, we propose applying the Eindhoven model to the clinical setting, in which nurses play the role of operators by identifying, interrupting, and correcting medical errors. After describing the model, we present clinical scenarios to illustrate how it can be applied. More research is needed to explicate the nurse's role in managing medical errors. Interventions to decrease medical errors require insight into strategies that frontline clinicians can use to identify and mitigate potentially harmful incidents. The Eindhoven model can help researchers, administrators, and clinicians to conceptualize the role for nurses in developing such interventions.

Drug Hypersensitivity↗

PubMed1998

Medication errors in paediatric practice: insights from a continuous quality improvement approach.

UNLABELLED: The objective was to assess the incidence and consequences of medication errors, highlight sources of recurrent error and institute changes in practice to prevent their recurrence. Utilising a continuous quality improvement approach, a 2-year prospective cohort study was undertaken using an adverse incident reporting scheme. A multidisciplinary committee analysed medication error reports, classifying them according to type (prescription, supply or administration), severity (serious or not serious) and clinical outcome. Changes in policy and practice were implemented to reduce the frequency of errors. There were 441 reported medication errors in the study period, during which 682 patients were admitted for 5315 inpatient days. Errors were more seven times likely to occur in the intensive care setting. Doctors accounted for 72% of errors and prescription errors doubled when new doctors joined the rotation. Most errors (68%) were detected prior to drug administration. Twenty-four serious medication errors were not detected in advance, but only 4 had overt clinical consequences. Excluding prevented errors and appropriate deviations from prescribed therapy, there were 117 actual medication errors (1/5.8 admissions, or 1/45 inpatient days). During the 2nd year of the scheme, the incidence of all reported errors, administration errors and serious errors fell, but the prescription error rate remained constant. CONCLUSIONS: Medication errors occurred commonly in this study, but adverse consequences were rare. The non-punitive, multidisciplinary approach to medication errors utilised in this study increased staff vigilance, highlighted sources of recurrent error, and led to changes in drug policies and staff training, which resulted in improved patient safety and quality of care.

Cohort Studies↗

PubMed1999

Chemotherapy medication errors: descriptions, severity, and contributing factors.

PURPOSE/OBJECTIVES: To expand the limited body of knowledge of medication errors involving chemotherapy. DESIGN: Exploratory, descriptive. SAMPLE: 160 (26%) of 620 randomly selected Oncology Nursing Society members employed in direct patient-care positions and 26 nonmembers with chemotherapy administration responsibilities employed in different settings. METHODS: Mailed investigator-developed questionnaire containing 24 demographic and open-ended questions. MAIN RESEARCH VARIABLES: Nurses' descriptions of the nature and severity of chemotherapy medication errors. FINDINGS: Chemotherapy medication errors were reported to have occurred in the workplace of 63% of the respondents, and 140 errors were described. Errors included under- and overdosing, schedule and timing errors, wrong drugs, infusion-rate errors, omission of drugs or hydration, improper preparation of drugs, and chemotherapy given to the wrong patients. Stress, understaffing, lack of experience, and unclear orders were cited as factors believed to contribute to the occurrence of the errors. Most of the errors were reported internally, but only 3% were known to be reported to national reporting databases or drug manufacturers. CONCLUSIONS: Chemotherapy medication errors are not uncommon and infrequently are reported externally to databases or manufacturers. IMPLICATIONS FOR NURSING PRACTICE: Risk management strategies to promote safe chemotherapy administration include comprehensive chemotherapy administration training, adherence to basic principles of medication administration, and adequate staffing. Oncology nurses need to know how and when to report chemotherapy medication errors to national databases and drug manufacturers.

Antineoplastic Agents↗

PubMed2003

Family physicians' solutions to common medical errors.

In two U.S. studies about medical errors in 2000 and 2001, family physicians offered their ideas on how to prevent, avoid, or remedy the five most often reported medical errors. Almost all reports (94 percent) included at least one idea on how to overcome the reported error. These ideas ranged from "do not make errors" (34 percent of all solutions offered to these five error types) to more thoughtfully proposed solutions relating to improved communication mechanisms (30 percent) and ways to provide care differently (26 percent). More education (7 percent) and more resources such as time (2 percent) were other prevention ideas.

Family Practice↗

PubMedDate not supplied

Clinical inference by nursing students and experienced nurses concerning harmful outcomes occurring after medication errors: a comparative study.

Clinical inference is part of the clinical decision-making process and precedes judgment and action. It is an integrated response to patient cues and other evidence and a necessary skill for all nurses. The purpose of this study was to compare undergraduate and graduate nursing students' use of clinical inference in rating harmful outcomes for patients occurring after medication errors. The Medication Error Outcome Scale, a simulation methodology using medication error vignettes, was used to compare undergraduate and graduate students' use of clinical inference. Kruskal-Wallis analysis of variance showed that there was a statistically significant difference (P = .04) among freshman, junior, senior, baccalaureate, and Master's students' use of clinical inference in regard to perceived harm occurring after a medication errors. Post hoc Mann-Whitney U tests indicated that senior and baccalaureate students' use of clinical inference differed significantly (P = .005). This study suggests that clinical experience shapes clinical inference.

Adult↗

PubMed2006

Effective strategies to increase reporting of medication errors in hospitals.

A major concern for patient safety in hospitals is accurate medication administration. To improve the medication administration process, nurses and pharmacists must report system problems. Although staff supported the concept of medication error reporting, they did not report errors. Inherent fear of retribution, punitive actions, and professional humiliation prevented self-reporting of medication errors. Our hospital's quality improvement department developed, implemented, and evaluated a program called LifeSavers. Its purpose was to build a nonpunitive culture and to increase medication error reporting by staff. In one year, the LifeSavers program increased medication error disclosures from 14 to 72 reports per month. The successful development of a nonblame culture of medication error reporting led to identified sources of problems and improvement of the medication administration system.

Communication↗

PubMed2005

Factors influencing preceptors' responses to medical errors: a factorial survey.

BACKGROUND: Preceptors must respond to trainees' medical errors, but little is known about what factors influence their responses. METHOD: A total of 115 primary care preceptors from 16 medical schools responded to two medical error vignettes involving a trainee. Nine trainee-related factors were randomly varied. Preceptors indicated whether they would discuss what led to the error, provide reassurance, share responsibility, express disappointment, and adjust their written evaluation of the trainee. RESULTS: Almost all preceptors would discuss what led to the error; relatively few would express disappointment. The trainee's prior history of errors, knowledge level relative to peers, receptivity to feedback, training level, emotional reaction, offering to apologize, and offering an excuse were predictive of preceptors' responses; gender and time-in-office were not. CONCLUSION: This study identified seven trainee-related factors as predictive of preceptors' responses to medical errors. More research is needed to identify other influential factors, and to improve teaching from medical errors.

Communication↗

PubMedDate not supplied

Medication errors result in costly claims for ophthalmologists.

Medication errors are a frequent cause of medical malpractice claims. Because serious injury often results, medication errors can be costly to defend, indemnify or settle. A review of five closed claims involving glucocorticoids, corticosteroids, antibiotics and silver nitrate offers insight into how ophthalmologists can protect themselves against medication malocurrences.

Adult↗

PubMedDate not supplied

How physicians can prevent medication errors: practical strategies.

To eliminate and reduce medication errors, health care organizations must develop a consistent approach that allows examination of errors in a supportive atmosphere with a bias toward preventing future errors rather than punishing past ones. Until improved systems are in place, physicians can help prevent many of the most serious medication errors by observing some basic safety practices, such as writing orders whenever possible and limiting verbal orders to urgent or emergency situations, writing clearly and neatly, and avoiding abbreviations.

Drug-Related Side Effects and Adverse Reactions↗

PubMed2002

Views of practicing physicians and the public on medical errors.

BACKGROUND: In response to the report by the Institute of Medicine on medical errors, national groups have recommended actions to reduce the occurrence of preventable medical errors. What is not known is the level of support for these proposed changes among practicing physicians and the public. METHODS: We conducted parallel national surveys of 831 practicing physicians, who responded to mailed questionnaires, and 1207 members of the public, who were interviewed by telephone after selection with the use of random-digit dialing. Respondents were asked about the causes of and solutions to the problem of preventable medical errors and, on the basis of a clinical vignette, were asked what the consequences of an error should be. RESULTS: Many physicians (35 percent) and members of the public (42 percent) reported errors in their own or a family member's care, but neither group viewed medical errors as one of the most important problems in health care today. A majority of both groups believed that the number of in-hospital deaths due to preventable errors is lower than that reported by the Institute of Medicine. Physicians and the public disagreed on many of the underlying causes of errors and on effective strategies for reducing errors. Neither group believed that moving patients to high-volume centers would be a very effective strategy. The public and many physicians supported the use of sanctions against individual health professionals perceived as responsible for serious errors. CONCLUSIONS: Though substantial proportions of the public and practicing physicians report that they have had personal experience with medical errors, neither group has the sense of urgency expressed by many national organizations. To advance their agenda, national groups need to convince physicians, in particular, that the current proposals for reducing errors will be very effective.

Attitude of Health Personnel↗

PubMedDate not supplied

[The medication preparation and administration process: problem identification in order to propose improvements and prevent medication errors].

This exploratory study analyzed the medication preparation and administration process in medical-clinical units at four Brazilian hospitals located in the Southeast, Central-West and Northeast, identified problems that can contribute to the occurrence of medication errors and proposed improvement measures. Data were collected through non-participant and direct observation of nursing professionals' activities during one week. The results revealed the following main problems: the environment in Hospital B; preparation errors related to technique and anticipated medication preparation in C and D; technical, communication and patient identification mistakes in Hospital A. Suggestions to achieve greater quality and safety in patient care include the constitution of a multidisciplinary commission to evaluate the system, nursing discussion groups, environmental improvements, permanent courses and training and actual presence of a nurse during the process.

Drug Compounding↗

PubMed2005

Medication error in the care of HIV/AIDS patients: electronic surveillance, confirmation, and adverse events.

BACKGROUND: Medication error occurring during the care of HIV-infected patients may lead to treatment failure, drug toxicity, or even death. OBJECTIVE: The objective of this study was to ascertain and confirm 5 categories of medication error in the care of HIV-infected patients. RESEARCH DESIGN: This study was a retrospective study to describe the occurrence of preventable medication error and to determine if adverse events were associated with confirmed errors. A roster of medications for each category of potential errors was created. Computerized pharmacy records were scanned for all dispensing of these medications. Potential errors were confirmed by medical records abstraction. For the incorrect dosing, coadministration of contraindicated medications, and antiretroviral monotherapy error categories, random samples were chart reviewed for confirmation. For the remaining 2 error categories, all potential errors were chart reviewed. The positive predictive value (PPV) of potential errors, the incidence of confirmed error among all new prescription orders filled and the patient characteristics predicting likelihood of error confirmation were estimated for each error category. SUBJECTS: The study sample involved 5473 HIV-infected patients of the Kaiser Permanente Northern California (KPNC) health plan. RESULTS: Among the 5 error categories, PPVs ranged from a high of 80% for coadministration of contraindicated medications to <1% for antiretroviral monotherapy. Incidence of confirmed errors was 9.80 errors per 1000 new prescriptions dispensed for incorrect dosing, 9.51 errors per 1000 for contraindicated medications, and <1.00 for all other categories. Adverse events associated with confirmed errors were observed only in the contraindicated medications error category. The likelihood of a contraindicated medications error was significantly increased among patients >or=50 years of age and decreased among black patients. CONCLUSIONS: Use of electronic pharmacy records to ascertain true medication errors appears most reliable when conducting surveillance for contraindicated medications errors and less reliable for other error categories. Lack of confirmation is likely the result of patients' lack of adherence to drug regimens or providers' intentional deviation from accepted prescribing guidelines. Only confirmed contraindicated medications errors appear to be linked to adverse events.

AIDS-Related Opportunistic Infections↗

PubMed1995

Effect of an automated, nursing unit-based drug-dispensing device on medication errors.

The effect of an automated drug-dispensing system on medication error rates was studied. Disguised observations were made on nursing units just before (phase 1) and two months after (phase 2) the implementation of Medstation Rx (Pyxis, San Diego, CA) at a 600-bed hospital. Information gathered included the time of drug administration, the time the medication as ordered to be given, a description of what happened during administration of the dose, and the type of medication error, if any. During phase 1 there were 873 observations and 148 medication errors, for an error rate of 16.9%. During phase 2 the error rate was 10.4% (97 errors in 929 observations). In both study phases, most of the errors were wrong-time errors. The mean +/- S.D. difference between actual and scheduled administration times was 34.5 +/- 48.9 minutes in phase 1 and 30.1 +/- 31.6 minutes in phase 2. Both the decrease in the error rate and the decrease in the departure from scheduled administration times were statistically significant. Medstation Rx was associated with a reduction in the rate of medication errors at a large hospital.

Clinical Pharmacy Information Systems↗

PubMed2006

Medication errors in mental healthcare: a systematic review.

BACKGROUND: It has been estimated that medication error harms 1-2% of patients admitted to general hospitals. There has been no previous systematic review of the incidence, cause or type of medication error in mental healthcare services. METHODS: A systematic literature search for studies that examined the incidence or cause of medication error in one or more stage(s) of the medication-management process in the setting of a community or hospital-based mental healthcare service was undertaken. The results in the context of the design of the study and the denominator used were examined. RESULTS: All studies examined medication management processes, as opposed to outcomes. The reported rate of error was highest in studies that retrospectively examined drug charts, intermediate in those that relied on reporting by pharmacists to identify error and lowest in those that relied on organisational incident reporting systems. Only a few of the errors identified by the studies caused actual harm, mostly because they were detected and remedial action was taken before the patient received the drug. The focus of the research was on inpatients and prescriptions dispensed by mental health pharmacists. CONCLUSION: Research about medication error in mental healthcare is limited. In particular, very little is known about the incidence of error in non-hospital settings or about the harm caused by it. Evidence is available from other sources that a substantial number of adverse drug events are caused by psychotropic drugs. Some of these are preventable and might probably, therefore, be due to medication error. On the basis of this and features of the organisation of mental healthcare that might predispose to medication error, priorities for future research are suggested.

Antipsychotic Agents↗

PubMed2003

Medical errors on an inpatient neurology service.

It has been proposed that "near misses" or "close calls" could serve as a focus for corrective action. Voluntary, anonymous error data were collected for 4 weeks and 235 events were reported: 168 were near misses and 67 resulted in adverse patient consequences. Of the 35 errors relating to diet, 17 (49%) resulted in adverse patient consequences, compared with only 5 of 43 (12%) of the errors related to medication.

Academic Medical Centers↗

PubMed2005

The impact of hospitalwide computerized physician order entry on medical errors in a pediatric hospital.

PURPOSE: Medication errors contribute significantly to the morbidity and costs of pediatric health care. The authors hypothesized that hospitalwide computerized physician order entry (CPOE) in a pediatric hospital would lead to a decrease in medication errors. METHODS: The authors retrospectively evaluated and prospectively analyzed inpatient discharge and usage and adverse drug event (ADE) rate data pre- and postintroduction of a hospitalwide implementation of CPOE in a tertiary care pediatric hospital. They compared pre- and postintervention ADEs (Student's t test) and computed the number needed to treat (NNT) analog. RESULTS: Over the 9-month study period, there were 45,615 in patient days and 8619 discharges. Pre-CPOE verbal order regulatory compliance was 80%, whereas post-CPOE increased to 95%. Transcription errors were eliminated. All ADEs pre-CPOE were 0.3 +/- 0.04 per 1000 doses, whereas post-CPOE ADEs were 0.37 +/- 0.05 per 1000 doses (P = .3). Harmful ADEs pre-CPOE were 0.05 +/- 0.017 per 1000 doses, while post-CPOE ADEs were 0.03 +/- 0.003 per 1000 doses (P = .05). Our NNT data demonstrate that CPOE would prevent 1 ADE every 64 (95% CI 25-100) patient days. CONCLUSIONS: CPOE decreases harmful ADEs in a pediatric hospital, thus leading to increased patient safety. In addition, CPOE provides an automated system for monitoring and improving health care quality.

Adverse Drug Reaction Reporting Systems↗

PubMed1995

A seasonal pattern of hospital medication errors in Alaska.

Specific behavioral consequences of seasonal affective disorder have not been closely examined. Length of daylight is evaluated in relation to medication errors in a medical center located in the far north. Factors such as numbers of patient admissions, discharges, and deaths were controlled with data collected in Anchorage, Alaska, over 5 consecutive years, 1985-89. These data revealed that 58% of all medication errors occurred during the first quarter of the year. Medication errors were 1.95 times more likely in December than September. The best statistical prediction was for errors associated with levels of darkness 2 months earlier. There may be not only an impairment of work performance among hospital nursing staff that reaches a peak in late winter but, more importantly, medication errors appear to follow a pattern that is closely associated with the annual cycle of daylight and darkness.

Alaska↗