Reducing pediatric medication errors: children are especially at risk for medication errors.
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Adolescent↗
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Results for “Medication Errors”
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[An exploratory approach on teaching for prevention of medical error].
INTRODUCTION: Medical error is prevalent in the contemporary practice of medicine. Prevention and solution of the majority of medical errors can be focused upon from the early stages of physician formation by improving knowledge and abilities with regard to human communication. Despite its importance, information systematized with empirical bases on the teaching of human communication in Mexico is non-existent. PURPOSE: Our purpose was to highlight the experience of an exploratory nature on the educative intervention on human communication in medicine in medical residents of different medical specialties. METHODS: A study of educational intervention was presented 216 medical residents of the National Institutes of Health in Mexico City on the topic of human communication in medical practice. Chi square distribution was employed to find associations among variables. RESULTS: Eighty percent of students presented deficiencies in knowledge and thinking abilities for clinical communication. As a result of the educational intervention, 70 percent of medical resident students reached acceptable significant learning on the topic. There were no appreciable differences between the men and women in response patterns. Data indicated necessity of incorporating this topic pre-and postgraduate studies, to achieve improvement of quality of medical care and prevention of conflicts in medicine.
Communication↗
Reducing error, improving safety. Medical errors must be discussed during medical education.
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Curriculum↗
Avoiding and fixing medical errors in general practice: prevention strategies reported in the Linnaeus Collaboration's Primary Care International Study of Medical Errors.
AIM: To report tactics for avoiding and remedying medical errors observed by general practitioners in New Zealand and five other countries. METHODS: The Primary Care International Study of Medical Errors collected 66 reports of medical errors in New Zealand and 363 reports from general practitioners in Australia, Canada, England, the Netherlands, and the United States. Strategies for avoiding and overcoming errors were grouped by themes, for New Zealand and the five other countries combined. RESULTS: In all New Zealand reports and 336 (92.6%) reports from other countries, doctors offered at least one error prevention idea. The largest category of suggestions was 'more diligence' (New Zealand: 69.7% of reports, other countries: 55.3%). Other strategies were: 'provide care differently' (New Zealand 22.7%, other countries 36.4%); 'improve communication' (19.7% and 17.8% of reports); 'education' (7.8% and 11.0% of reports); and 'more resources' (12.1% and 14.0% of reports). CONCLUSIONS: In general practitioners' medical errors reports, a culture of individual blame is more evident than recognised need for systems design. A minority of reports contained specific, pragmatic suggestions for changing healthcare systems to protect patients' safety. Error reporting systems may be a practical way to generate innovative solutions to potentially harmful problems facing general practice patients.
Australia↗
[Erroneous and unsatisfactory filling in of drug charts--a potential source of medication error].
BACKGROUND: Medication errors may have serious consequences for patients and erroneous drug charts represent one of several causes of error. As part of a quality assurance survey, we studied whether user documentation on the charts was in accordance with the guidelines for chart keeping. MATERIAL AND METHODS: On the same day, the drug charts of all hospitalized patients (n = 401) were copied and a representative sample of 207 charts was reviewed. RESULTS: 15 charts had no prescriptions; 14 of the remaining 192 charts (7 %) were correctly filled in. 152 charts (79 %) had deviations that we considered might pose only minor potential health risk; 26 (14 %) had deviations implying potential risk. No charts had deviations considered to pose major risk. INTERPRETATION: Several deviations from the guidelines were found and better training is needed; we recommend standardisation of drug charts and guidelines.
Documentation↗
Medication errors involving continuously infused medications in a surgical intensive care unit.
OBJECTIVE: To document the incidence of medication errors related to medications administered by continuous infusion. DESIGN: Observational study. SETTING: Sixteen-bed surgical intensive care unit. MEASUREMENTS AND MAIN RESULTS: All continuous infusions in the surgical intensive care unit were evaluated at least once daily for correct flow-sheet charting, concentration, infusion rate, and dose administered, as well as patients' heights and weights (actual, ideal, and "dry"). Collected information was examined to determine the error rate, types of errors occurring, and weight used for dose calculation. Variations inpatient weight measures were compared. Seventy-one patients with 202 total infusions were observed. Errors involving continuously infused medications in our surgical intensive care unit occurred at a rate of 105.9 per 1,000 patient days. For nonweight-based infusions, 94% of doses were delivered correctly. Slightly >10% of the doses administered for weight-based infusions (dose based on dry body weight) were incorrect. Significant differences were found between the weight measurements recorded, but this did not translate into statistically significant differences in the apparent calculated doses delivered. CONCLUSIONS: Medications delivered by continuous infusion, particularly those that are weight based, can contribute to medication errors in the intensive care unit. A large proportion (87.6%) of doses for weight-based infusions was calculated based on estimated or unreliable admission weights. There were no severe consequences resulting from the errors observed in this 1 month investigation; however, depending on the pharmacokinetic characteristics of the drug being administered, there is a potential to deliver artificially low or high doses resulting in subtherapeutic or adverse effects.
Female↗
Medication errors when transferring elderly patients between primary health care and hospital care.
OBJECTIVE: The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care. METHOD: Elderly primary health care patients (> 65 years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital. MAIN OUTCOME MEASURE: Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not. RESULTS: There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specific medication dispensing system constituted a significant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added. CONCLUSION: Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients' medications could reduce these errors. The specific medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication.
Aged↗
Medical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error.
INTRODUCTION: There is a growing public perception that serious medical error is commonplace and largely tolerated by the medical profession. The Government and medical establishment's response to this perceived epidemic of error has included tighter controls over practising doctors and individual stick-and-carrot reforms of medical practice. DISCUSSION: This paper critically reviews the literature on medical error, professional socialization and medical student education, and suggests that common themes such as uncertainty, necessary fallibility, exclusivity of professional judgement and extensive use of medical networks find their genesis, in part, in aspects of medical education and socialization into medicine. The nature and comparative failure of recent reforms of medical practice and the tension between the individualistic nature of the reforms and the collegiate nature of the medical profession are discussed. CONCLUSION: A more theoretically informed and longitudinal approach to decreasing medical error might be to address the genesis of medical thinking about error through reforms to the aspects of medical education and professional socialization that help to create and perpetuate the existence of avoidable error, and reinforce medical collusion concerning error. Further changes in the curriculum to emphasize team working, communication skills, evidence-based practice and strategies for managing uncertainty are therefore potentially key components in helping tomorrow's doctors to discuss, cope with and commit fewer medical errors.
Education, Medical↗
The impact of computerized physician order entry on medication error prevention.
BACKGROUND: Medication errors are common, and while most such errors have little potential for harm they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events. OBJECTIVE: To evaluate the impact of computerized physician order entry (POE) with decision support in reducing the number of medication errors. DESIGN: Prospective time series analysis, with four periods. SETTING AND PARTICIPANTS: All patients admitted to three medical units were studied for seven to ten-week periods in four different years. The baseline period was before implementation of POE, and the remaining three were after. Sophistication of POE increased with each successive period. INTERVENTION: Physician order entry with decision support features such as drug allergy and drug-drug interaction warnings. MAIN OUTCOME MEASURE: Medication errors, excluding missed dose errors. RESULTS: During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001). CONCLUSIONS: Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.
Clinical Pharmacy Information Systems↗
The organizational costs of preventable medical errors.
BACKGROUND: Preventable medical errors are associated with additional costs that tend to be borne by patients, but little is known about organizational costs associated with such errors. Two composite case studies (a fall and a delay in diagnosis) were used to identify the organizational costs of preventable medical errors. ANALYSIS: Legal, marketing, and organizational costs--direct, indirect, and long term--were associated with each of the preventable medical errors. A model was generated to examine the theoretical relationship between the costs and four determinants of corporate performance--price, wages, cost of capital, and efficiency. DISCUSSION: Organizations may also have a financial incentive to improve patient safety, for beyond patient and societal costs, preventable medical errors appear to account for significant legal, marketing, and operational costs for the organizations that deliver health care. Some of these costs are not so much the cost of the error but the costs of organizational responses to the error. Three broad areas of inquiry could be used to test the model and improve our understanding of the organizational costs of errors: market response to patient safety interventions, before/after studies of interventions, and case-control studies. SUMMARY AND CONCLUSION: Health care leaders have a moral imperative to implement systems that reduce medical errors and improve patient safety. An understanding of the costs associated with medical errors may help leaders understand the importance of patient safety from a financial perspective, develop measures to evaluate the impact of patient safety initiatives, and efficiently allocate resources to address this important health concern.
Female↗
Medication errors in nursing homes: Part II. Surveyor methodology for detecting medication errors.
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Centers for Medicare and Medicaid Services, U.S.↗
Medication errors in children.
Medication error is a major source of iatrogenic injuries in children. Dosing errors are the most common type of medication errors in pediatrics. Sicker patients in intensive care units and emergency departments are more often harmed by such errors. Strategies that have been found to be effective in reducing medication errors include the use of computerized physician order entry systems, preprinted order forms, and color-coded systems. Adopting the "systems approach" to medication errors is crucial to every health system where practitioners seek to enhance patient safety.
Child↗
Hospital-reported medical errors in children.
CONTEXT: Medical errors are an important problem for hospitalized adult inpatients. However, medical errors in children remain comparatively understudied, and published research has been relatively limited. OBJECTIVES: To investigate the national rates of hospital-reported medical errors in pediatric inpatients over the period 1988-1997; and to determine the association of patient and hospital characteristics with the occurrence of hospital-reported medical errors in children. DESIGN, SETTING, AND PATIENTS: A nonconcurrent cohort study of hospitalized nonnewborn pediatric patients in the United States <or=18 years of age. Data from the Healthcare Cost and Utilization Project for the years 1988, 1991, 1994, and 1997 were used for these analyses. MAIN OUTCOME MEASURE: The occurrence of hospital-reported medical errors. RESULTS: The national rate of hospital-reported medical errors in hospitalized children ranged from 1.81 to 2.96 per 100 discharges. These medical error rates were statistically lower in 1988, with the years 1991, 1994, and 1997 not being statistically different from each other. There were no consistent differences in the rates of medical errors when stratified by gender, race, payor status, or median household income of the patient's zip code across years. There was, however, a statistically significant relationship between higher median household income and increasing medical error rates; this trend was consistent across all 4 years. Similarly, children with special medical needs or dependence on a medical technology also had significantly higher rates of hospital-reported medical errors. Although hospital size did not seem to be related to the rate of medical errors, private for-profit hospitals consistently reported lower rates, whereas urban teaching hospitals in all years but 1997 reported higher rates of medical errors. CONCLUSIONS: These data highlight both the strengths and limitations of administrative data in the investigation of medical errors. Substantively, they suggest fruitful areas for additional and more detailed study, notably children with special medical needs.
Adolescent↗
Using performance improvement strategies to reduce and prevent medication errors. 1.
The headlines feature tragic stories describing errors in medical practice. Medical literature reveals that errors in medical practice are common. In 1999, the Institute of Medicine released its report. "To Err is Human," that detailed an estimated 44,000 to 98,000 deaths annually due to medical errors. In September of 2002, the Archives of Internal Medicine released a study of medication errors observed in 36 healthcare facilities. Medication errors were commonly occurring in 19% or nearly one error out of every five doses administered in a typical hospital. It is imperative to analyze patient safety issues related to medication administration. This paper presents methods to improve the quality of care delivered by: Building effective structures through efficient use of technology. Establishing improved process through collaboration and team-work. Measuring and reporting performance outcomes. Using Performance improvement Strategies to Reduce and Prevent Medication Errors.
Efficiency, Organizational↗
Low-technology, cost-efficient strategies for reducing medication errors.
Medication-related errors are a common cause of patient morbidity and mortality. However, a number of strategies use the latest technology, such as computers and associated hardware and software, to reduce medication-related errors. In this era of reduced operating margins for most hospitals, strategies that employ physician order entry and bar code-labeled medication systems may be prohibitively expensive. Cost-efficient methods are available that can make simple changes in the way medications are mixed, stored, prescribed, and delivered, and they have the potential to have a major effect on medication safety. These methods do not rely on purchasing new hardware or expensive software. They include changing the culture within the hospital to one that focuses on patient safety, developing standardized protocols, developing an education program that provides direct feedback, and using protocols for high-risk medications. Coordinating hospital efforts with regional organizations may also be beneficial in reducing the occurrence of medication-related errors.
Clinical Protocols↗
A baseline study of medication error rates at Baylor University Medical Center in preparation for implementation of a computerized physician order entry system.
OBJECTIVE: To determine baseline levels of medication errors and their root causes so as to highlight areas of potential process improvements and serve as a ruler against which to measure future improvements. DESIGN: A prospective pharmacist intervention study determining errors in 1014 medication orders at Baylor University Medical Center. Only errors in the process of medication ordering were documented; errors in drug administration were not considered. Root causes of errors were examined. RESULTS: The baseline medication error rate was 111.4 per 1000 orders (n = 1014). Most common were dosing errors (43.4 per 1000 orders), followed by frequency errors (19.7 per 1000 orders) and unavailable drug errors (12.8 per 1000 orders). Of the 113 total errors found, 52 (46%) had a transcription-based cause, i.e., an error in inputting the handwritten physician order into a computer system. System- or process-related root causes (such as duplicate orders or lack of crossover from one information system to another) accounted for 35.4% of the errors, and prescribing based causes (such as wrong dosage or nonformulary drugs) accounted for 18.6% of errors. CONCLUSIONS: Implementing a computerized physician order entry (CPOE) system would eliminate order-entry transcription-based errors. Its ability to resolve system/process-based and prescribing-based root causes of error is not as clear. Furthermore, the modification of processes due to implementation of CPOE could lead to new types of errors. Present processes must be redesigned according to evidence-based medicine, and future processes must be anticipated as technological changes occur. Such efforts-rather than outright reliance on technology--are more likely to lead to an error-free environment after CPOE is implemented.
Journal Article↗
Medication errors: never borrow medications.
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Anxiety↗
ASHP Standard definition of a medication error.
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Medication Errors↗