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PubMed1999

A validated, reliable method of scoring the severity of medication errors.

A method of scoring the severity of medication errors that does not require knowledge of patient outcomes was developed and tested. Thirty health care professionals from four U.K. hospitals scored 50 medication errors in terms of potential patient outcomes on a scale of 0 to 10, where 0 represented a case with no potential effect and 10 a case that would result in death. Sixteen error cases reported in the literature with actual patient outcomes were included among the cases to assess the validity of the scores. Ten of the errors were scored twice. The severity of the error cases, the occasion on which they were scored, the judge, each judge's profession, and the interactions between these were considered as potential sources of variability in scoring. The data were analyzed by applying generalizability theory to two models: one based on the 10 cases that were scored twice and ignoring the effect of differences in profession and one based on all 50 cases and ignoring the effect of the occasion of scoring. Generalizability coefficients for different numbers of judges and scoring occasions were calculated. A generalizability coefficient of 0.8 or more was considered to represent acceptable reliability. Most of the variance was attributable to differences in the cases. The analysis showed that, to achieve a generalizability coefficient of more than 0.8, at least four judges would have to score each case, each on one occasion, with the mean score used as a severity indicator. A reliable, valid method of scoring the severity of medication errors that did not require knowledge of patient outcomes was developed; at least four judges were required in order to achieve reliable scores, and reliability was not affected by the professions of the judges or the number of occasions on which the errors were scored.

Hospitals, Public↗
PubMed2000

Medication errors in a paediatric teaching hospital in the UK: five years operational experience.

BACKGROUND: In the past 10 years, medication errors have come to be recognised as an important cause of iatrogenic disease in hospital patients. AIMS: To determine the incidence and type of medication errors in a large UK paediatric hospital over a five year period, and to ascertain whether any error prevention programmes had influenced error occurrence. METHODS: Retrospective review of medication errors documented in standard reporting forms completed prospectively from April 1994 to August 1999. Main outcome measure was incidence of error reporting, including pre- and post-interventions. RESULTS: Medication errors occurred in 0.15% of admissions (195 errors; one per 662 admissions). While the highest rate occurred in neonatal intensive care (0.98%), most errors occurred in medical wards. Nurses were responsible for most reported errors (59%). Errors involving the intravenous route were commonest (56%), with antibiotics being the most frequent drug involved (44%). Fifteen (8%) involved a tenfold medication error. Although 18 (9.2%) required active patient intervention, 96% of errors were classified as minor at the time of reporting. Forty eight per cent of parents were not told an error had occurred. The introduction of a policy of double checking all drugs dispensed by pharmacy staff led to a reduction in errors from 9.8 to 6 per year. Changing the error reporting form to make it less punitive increased the error reporting rate from 32.7 to 38 per year. CONCLUSION: The overall medication error rate was low. Despite this there are clear opportunities to make system changes to reduce error rates further.

Adolescent↗
PubMed2003

The frequency and nature of medical error in primary care: understanding the diversity across studies.

BACKGROUND: The identification and reduction of medical error has become a major priority for all health care providers, including primary care. Understanding the frequency and nature of medical error in primary care is a first step in developing a policy to reduce harm and improve patient safety. There has been scant research into this area. OBJECTIVES: This review had two objectives; first, to identify the frequency and nature of error in primary care, and, secondly, to consider the possible causes for the diversity in the stated rates and nature of error in primary care. METHODS: Literature searches of English language studies identified in the National Patient Safety Foundation bibliography database, in Medline and in Embase were carried out. Studies that were relevant to the purpose of the study were included. Additional information was obtained from a specialist medico-legal database. RESULTS: Studies identified that medical error occurs between five and 80 times per 100000 consultations, mainly related to the processes involved in diagnosis and treatment. Prescribing and prescription errors have been identified to occur in up to 11% of all prescriptions, mainly related to errors in dose. There are a wide variety of definitions and methods used to identify the frequency and nature of medical error. Incident reporting, systematic identification and medico-legal databases reveal differing aspects, and there are additional perspectives obtained from GPs, primary health care workers and patients. CONCLUSION: An understanding of the true frequency and nature of medical error is complicated by the different definitions and methods used in the studies. Further research is warranted to understand the complex nature and causes of such errors that occur in primary care so that appropriate policy decisions to improve patient safety can be made.

Communication↗
PubMedDate not supplied

Searching for the final answer: factors contributing to medication administration errors.

Medication errors have reached epidemic proportions in the United States with proposed resolutions having little effect. Many errors go unreported because of nurses' fear of retaliation. Yet these unreported errors may contain the very information needed to uncover system flaws. Until all causes are examined and researched thoroughly, systems will continue to fail. These unknown factors contributing to medication errors will remain elusive unless health care providers are willing and able to focus attention where it is needed-on systems rather than individuals. Patients have enough fears when entering health care institutions; medication errors should not be one of them.

Clinical Pharmacy Information Systems↗
PubMed2003

Medication errors in the emergency department: a systems approach to minimizing risk.

Adverse drug events caused by medication errors represent a common cause of patient injury in the practice of medicine. Many medication errors are preventable and hence particularly tragic when they occur, often with serious consequences. The enormous increase in the number of available drugs on the market makes it all but impossible for physicians, nurses, and pharmacists to possess the knowledge base necessary for fail-safe medication practice. Indeed, the greatest single systemic factor associated with medication errors is a deficiency in the knowledge requisite to the safe use of drugs. It is vital that physicians, nurses, and pharmacists have at their immediate disposal up-to-date drug references. Patients presenting for care in EDs are usually unfamiliar to their EPs and nurses, and the unique patient factors affecting medication response and toxicity are obscured. An appropriate history, physical examination, and diagnostic workup will assist EPs, nurses, and pharmacists in selecting the safest and most optimum therapeutic regimen for each patient. EDs deliver care "24/7" and are open when valuable information resources, such as hospital pharmacists and previously treating physicians, may not be available for consultation. A systems approach to the complex problem of medication errors will help emergency clinicians eliminate preventable adverse drug events and achieve a goal of a zero-defects system, in which medication errors are a thing of the past. New developments in information technology and the advent of electronic medical records with computerized physician order entry, ward-based clinical pharmacists, and standardized bar codes promise substantial reductions in the incidence of medication errors and adverse drug events. ED patients expect and deserve nothing less than the safest possible emergency medicine service.

Adult↗
PubMed2003

Reducing medication errors: a regional approach for hospitals.

Since the Institute of Medicine's report, To Err Is Human, and the subsequent publication, Crossing the Quality Chasm, the subject of reducing medical errors has gained considerable attention from patients, healthcare providers, employers and government organisations in the US. Most nonoperative errors are related to medications. Medication errors lead not only to negative repercussions subjectively experienced by both the patient and the healthcare staff, but also to additional expenditures due to complications. Education, adapting new safety systems and technology, and having clinical pharmacists play a larger role in the medication process can all help in solving the problem of medication errors. Designing and executing a rational system to reduce medication errors is particularly germane in the current era of increased demands for quality healthcare in the setting of cost-containment pressures. In the Delaware Valley (Philadelphia and surrounding area) of Pennsylvania, USA, a consortium of healthcare providers in cooperation with the Health Care Improvement Foundation (HCIF), and two non-profit oganisations--the ECRI (formerly the Emergency Care Research Institute) and the Institute for Safe Medication Practices (ISMP)--have combined to establish and promote safe medication practices under a programme known as the Regional Medication Safety Program for Hospitals. At the core of the programme are 16 medication safety goals, which centre on establishing an institutional culture of safety, modifying infrastructure and clinical practice to reflect this culture, and using technology to facilitate these changes. It is believed that this rational campaign to improve patient safety may serve as a paradigm for other regions around the world.

Humans↗
PubMed2002

A preliminary taxonomy of medical errors in family practice.

OBJECTIVE: To develop a preliminary taxonomy of primary care medical errors. DESIGN: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. SETTING: The National Network for Family Practice and Primary Care Research. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Medical error category, context, and consequence. RESULTS: Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. CONCLUSIONS: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Adult↗
PubMed2003

The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients.

OBJECTIVE: Computerized physician order entry (CPOE) has the potential to reduce patient injury resulting from medication errors. We assessed the impact of a CPOE system on medication errors and adverse drug events (ADEs) in pediatric inpatients. DESIGN: A retrospective cohort study. SETTING: Tertiary care pediatric hospital. PARTICIPANTS: Pediatric inpatients on 3 medical and 2 surgical wards. INTERVENTION: CPOE system implemented on 2 medical wards and compared with 1 medical and 2 surgical wards that continued to use hand written orders. OUTCOME MEASURES: Rate of medication error and ADEs before and after CPOE implementation. RESULTS: In 6 years, a total of 804 medication errors were identified with 18 ADEs, resulting in patient injury among 36 103 discharges and 179 183 patient days. The overall medication error rate (MER) was 4.49 per 1000 patient days. Before the introduction of CPOE, the MERs of the intervention versus control wards were indistinguishable (ratio = 0.93; 95% confidence interval [CI] = 0.76, 1.13). After the introduction of CPOE, the MER was 40% lower on the intervention than on the control wards (ratio = 0.60; 95% CI = 0.48, 0.74). On average, 490 patient days are required to see the benefit of one less medication error using CPOE. We did not demonstrate a similar effect of CPOE for ADEs (ratio of rate ratios = 1.30; 95% CI 0.47, 3.52). CONCLUSIONS: The introduction of a commercially available physician computer order entry system was associated with a significant decrease in the rate of medication errors but not ADEs in an inpatient pediatric population.

Child↗
PubMed2001

Assessing professional behaviour and medical error.

The mission of medical schools underwent significant change in the post-Second World War period, which resulted in a de-evaluation of teaching, which in turn impacted on the type of assessment methods that emerged in the latter part of the twentieth century. Assessment based on direct observation did not receive the same degree of attention as methods such as multiple choice question and the objective structured clinical examination. During the past two decades medical educators have begun to emphasize the importance of teaching and assessing professional behaviour. It is suggested in this paper that assessment of professional behaviour can best be achieved by means of direct observation. A review of the area of assessment of clinical competence over the past 50 years reveals that it has been dominated by assessment methods that for the most part have been removed from the clinical setting in which medical students work and learn. In this paper it is proposed that there is a need to focus attention on methods of assessment which are based on the direct observation of performance that can be used in the clinical setting. Specifically, more attention needs to be directed at two areas of performance: (1) professionalism, and (2) medical error, both of which have given rise to increasing concern in the medical profession, healthcare agencies and the public at large.

Journal Article↗
PubMed2004

Medical errors and the trainee: ethical concerns.

How medical errors are handled by individual physicians and hospital systems is a topic of considerable interest. In teaching hospitals, medical students and house officers often observe and commit mistakes. Commission of a mistake is associated with serious emotional turmoil and uncertainty among trainees as well as experienced physicians. Although disclosure is the ethical standard, the consequences of disclosure are feared by many. This article focuses on the issues that surround medical errors as they pertain to medical students and residents. It is important that this group of future physicians has appropriate training, mentoring, and support when dealing with errors.

Aged↗
PubMed2004

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

Academic Medical Centers↗
PubMed2005

Medical errors and clinical risk management: state of the art.

Medical errors represent a serious public health problem and pose a threat to patient safety. All patients are potentially vulnerable, therefore medical errors are costly from a human, economic, and social viewpoint. The present report aims not only to provide an overview of the problem on the basis of the published literature, but also to stress the importance of adopting standard terminology and classifications, fundamental tools for researchers to obtain valid and reliable methods for error identification and reporting. In fact, agreement on standard definitions allows comparison of data in different contexts. Errors can be classified according to their outcome, the setting where they take place (inpatient, outpatient), the kind of procedure involved (medication, surgery, etc.) or the probability of occurring (high, low). Error categories are analysed taking into consideration their prevalence, avoidance and associated factors as well as the different strategies for detecting medical errors. Incident reporting and documentation of near-misses are described as useful sources of information, and Healthcare Failure Mode Effect Analysis (HFMEA) and Root Cause Analysis (RCA) are seen as powerful methods for process analysis. Furthermore, means to increase patient safety are considered in the broader context of clinical risk management. New approaches in the field of medical errors are aimed at minimizing the recurrence of avoidable patterns associated with higher error rate. A system approach and a blame-free environment, aimed at better organizational performances, lead to much better results than focusing on individuals. Furthermore, use of technology, information accessibility, communication, patient collaboration and multi-professional team-work are successful strategies to reach the goal of patient safety within healthcare organizations.

Humans↗
PubMed2004

Medication errors in the PACU: a secondary analysis of MEDMARX findings.

Medication errors commonly occur in many health care settings. This review of medication errors illustrates that complex, fast-paced care delivered in PACUs often occurs in an environment where patients encounter numerous processes as they move from preadmission, to preop holding, to the operating room, to PACU, and then back to a clinical unit or discharge. Using a nationally recognized framework, 645 PACU medication error records were analyzed. The errors resulted in a higher than expected threshold of harm (6.8%), with most errors occurring during the administration phase (59%) of the medication use process. Nearly one quarter of the errors involved an improper dose of a medication. Three quarters of the errors were influenced by distractions. More than 130 different products were present in the sample of cases reviewed. Problem areas identified involved epidural analgesia, patient-controlled analgesia, and duplicate doses.

Causality↗
PubMedDate not supplied

Communicating with patients about medical errors: a review of the literature.

BACKGROUND: Ethical and professional guidelines recommend disclosure of medical errors to patients. The objective of this study was to review the empirical literature on disclosure of medical errors with respect to (1) the decision to disclose, (2) the process of informing the patient and family, and (3) the consequences of disclosure or nondisclosure. METHODS: We searched 4 electronic databases (MEDLINE, CINAHL, PsycINFO, and Social Sciences Citations Index) and the reference lists of relevant articles for English-language studies on disclosure of medical errors. From more than 800 titles reviewed, we identified 17 articles reporting original empirical data on disclosure of medical errors to patients and families. We examined methods and results of the articles and extracted study designs, data collection procedures, populations sampled, response rates, and definitions of error. RESULTS: Available research findings suggest that patients and the public support disclosure. Physicians also indicate support for disclosure, but often do not disclose. We found insufficient empirical evidence to support conclusions about the disclosure process or its consequences. CONCLUSIONS: Empirical research on disclosure of medical errors to patients and families has been limited, and studies have focused primarily on the decision stage of disclosure. Fewer have considered the disclosure process, the consequences of disclosure, or the relationship between the two. Additional research is needed to understand how disclosure decisions are made, to provide guidance to physicians on the process, and to help all involved anticipate the consequences of disclosure.

Attitude to Health↗
PubMed1996

How nurses perceive medication errors.

It is widely believed that the number of medication errors reported at each hospital represents only the tip of the iceberg. The reported data rarely address issues beyond the number of incidents that occur. A study conducted at an urban community hospital found that medication errors are under-reported and that nurses view medication errors as multiple cause incidents.

Attitude of Health Personnel↗
PubMed2005

Medication errors and professional practice of registered nurses.

This Australian study identified and described the incidence of medication errors among registered nurses, the type and causes of these errors and the impact that administration of medications has on the professional practice of registered nurses. Mostly, medication errors were attributed to documentation issues, including: illegible handwriting, misunderstanding abbreviations, misplaced decimal point, misreading and misinterpreting written orders. Several human factors were attributed to potential causes of medication errors, including: stress, fatigue, knowledge and skill deficits. Environmental factors, namely, interruptions and distractions during the administration of medications, were also attributed to potential errors. The study found professional nursing practice involving administration of medications had a strong education, patient and ethical focus. Over a quarter of the respondents indicated that further training in medication administration would positively impact on their nursing practice. The registered nurses also highlighted they would appreciate more time to spend with patients when administering medications. Medication errors are not the sole responsibility of any single professional group, therefore, collaboration with other health professionals is central to establishing processes, policies, strategies and systems that will reduce their occurrence. The organisation and those nurses employed within it share an accountability to ensure safe administration of medications to patients. Based on study results, several recommendations are directed towards preventing or reducing medication errors and supporting nurses in providing best practice.

Attitude of Health Personnel↗
PubMed2005

Adverse drug reaction and medication error reporting by pharmacy students.

BACKGROUND: The reporting of adverse drug reactions (ADRs) and medication errors is the responsibility of all who are involved, particularly pharmacists. Since pharmacists are often privy to information surrounding ADRs and medication errors, it is of utmost importance that they are educated regarding the procedures of reporting. OBJECTIVE: To determine pharmacy students' knowledge of and ability to report ADRs and medication errors. METHODS: A total of 1322 students from 9 colleges of pharmacy were surveyed. RESULTS: The largest group of respondents was fifth-year pharmacy students (38%) followed by third-, fourth-, and sixth-year students (28%, 26%, and 8%, respectively). The majority of students reported learning about ADR and medication error reporting programs via didactic experiences. In comparison, fewer students cited alternative mechanisms of learning, including experiential rotations and work experience. Overall, respondents demonstrated the most experience with MedWatch and the least experience with the Vaccine Adverse Event Reporting System (VAERS). As students progressed through pharmacy curricula, there was a positive trend in the ability to locate and complete MedWatch forms. For VAERS and Medication Error Reporting (MER) program forms, however, this positive trend was broken at year 4. For all programs, significantly fewer students demonstrated appropriate use of the forms compared with those indicating familiarity with the programs. CONCLUSIONS: This study demonstrated that students are becoming familiar with ADR and MER programs via the college curriculum; however, there is opportunity for greater exposure and understanding. Colleges of pharmacy should continually seek methods to strengthen the education provided to pharmacy students regarding these programs.

Adverse Drug Reaction Reporting Systems↗