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PubMed1989

Medication errors and nursing responsibility.

Medication errors could effectively be reduced by systematically identifying, eliminating, or minimizing human and system risks. However, errors associated with random events may never be controlled by risk reduction efforts because of the unpredictability of the events preceding the error. Identifying and reducing risks is as important as acknowledging medication errors after they occur. A preliminary model including risks and types of medication errors is presented in Fig 1. Additional classification and explanation is needed in order to identify strategies to reduce medication errors. Medication administration is a nursing function that incorporates scientific knowledge, technical skill, and ritualistic practice. When nurses give medications and make medication errors, they remember their responsibility to do good and avoid harm. Nurses can better exert this responsibility by taking a more prospective, risk-reduction approach to medication errors.

Humans↗
PubMed2004

Occurrence of dispensing errors and efforts to reduce medication errors at the Central Arkansas Veteran's Healthcare System.

BACKGROUND: Medical errors have received national attention in the past few years, largely due to the Institute of Medicine's (IOM) 1999 report, which found that over one million injuries and nearly 100,000 deaths occur annually in the US as a result of medical errors. PURPOSE: The purpose of this study was to examine the type and severity of dispensing errors reported by pharmacy services at the Central Arkansas Veteran's Healthcare System from October 1997 through September 2001 and to examine the efforts implemented by the Central Arkansas Veteran's Healthcare System to reduce overall medication-related errors. METHODS: Dispensing error reports for the Central Arkansas Veteran's Healthcare System were obtained for October 1997 to September 2001. Dispensing errors were tabulated in the Statistical Package for the Social Sciences (SPSS) according to the pharmacy section, type of error (wrong drug, wrong dose, wrong patient and 'other') and severity of error (minor, significant, major and unrated). Data were explored using descriptive statistics, chi2, independent sample t-tests and Pearson's correlation. Information on error reduction efforts was obtained from pharmacy administrative services. RESULTS: A total of 82 dispensing errors were reported from eight different pharmacy sections for the time period examined. Errors included 31 wrong drugs, 21 wrong doses, 24 wrong patients and six 'other' errors. The number of errors, according to severity, included 29 unrated, 30 minor, 21 significant and two major errors. Both major errors were due to wrong drug selection. In total, the highest number of errors occurred at the North Little Rock Ambulatory Care Pharmacy (39 errors) and the Little Rock Ambulatory Care Pharmacy (24 errors). Wrong drug and wrong dose dispensing errors were not significantly different among the pharmacy sections. Wrong patient selection was significantly different among pharmacy service sections. Wrong patient selection, wrong drug, and wrong dose were all significantly correlated with unrated severity, minor severity, and significant severity. Significant correlations were also found between wrong drug, wrong dose and wrong patient selection. There were no significant correlations between wrong patient selection and major severity, or other errors. chi2 analysis found significant differences in expected frequency among errors for wrong drug, wrong dosage, wrong patient and other errors. Significant differences were also found in expected frequencies between unrated, minor, significant and major errors. DISCUSSION: Although the major dispensing errors were not statistically different according to pharmacy services sections and not significantly correlated with any other categories, they both involved the selection of the wrong drug, which was also the most common error. In contrast, the selection of the wrong patient, the second most common error, was statistically different among pharmacy sections and was significantly correlated with all other dispensing type and severity of error except major severity and other errors. CONCLUSION: Focusing error reduction efforts on selection of the correct drug and correct patient would likely yield the best results in reducing dispensing errors since these errors combined accounted for 55 (67.1%) of the 82 reported errors.

Hospitals, Veterans↗
PubMed1990

Fundamentals of medication error research.

Types of medication errors are defined, error detection techniques are described, and the validity of several medication error studies is evaluated. A medication error is generally defined as a deviation from the physician's medication order as written on the patient's chart. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Categories of medication errors should be operationally defined before an investigation, and any allowable deviations from the physician's order should be clearly stated. Fourteen error category definitions are presented. Methods for detecting medication errors include anonymous self-reports (questionnaires), incident reports, the critical-incident technique (analyses of a large number of individual errors to identify common causal factors), and direct observation (including the disguised-observation and participant observer techniques). Observation is the best error detection method in terms of accuracy. Results of medication error studies were examined for validity and classified into one of four categories: (A) results should be accepted as reported, (B) results overestimate or underestimate the truth by a known amount, (C) results overestimate the truth by an unknown amount, and (D) results should not be accepted. All studies examined for validity used observation as the error detection technique. The following guidelines for observation-based medication error studies were established: The observer should follow the subject to the patient's bedside, the observer should witness patient consumption of each dose, the observer should not be familiar with patient drug regimens before observation, operational definitions must be used, and having an error validation committee can be advantageous. Future studies are needed that focus on the identification and testing of new error prevention methods that use the techniques described.

Data Collection↗
PubMedDate not supplied

[Medication errors: prevention strategies].

Medication errors are an important aspect of health care. The American Institute of Medicine informs that 44,000 to 98,000 Americans die annually as a result of medication errors and that such errors affect 2 to 14% of hospitalized patients. The American Society of Hospital Pharmacists presents strategies that, if implemented, can prevent or reduce medication errors. This review discusses four strategies: electronic prescription, the pharmacist's role, the report of errors and the patient's role. A non-punitive culture that prioritizes patient's safety should be stimulated in institutions.

Computer Communication Networks↗
PubMedDate not supplied

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 teamwork. Measuring and reporting performance outcomes.

Efficiency, Organizational↗
PubMed2003

A pilot study in ophthalmology of inter-rater reliability in classifying diagnostic errors: an underinvestigated area of medical error.

BACKGROUND: Misdiagnosis is the least studied form of medical error. Before effective strategies to reduce misdiagnosis can be developed, there needs to be a better understanding of the factors that lead to these errors. AIM: To evaluate the applicability and reliability of three classification systems for misdiagnosis. DESIGN: Retrospective independent analysis of five cases by clinical experts. PARTICIPANTS: Three ophthalmologists trained in ocular oncology who devote at least 75% of their practice to ocular oncology. MAIN OUTCOME MEASURES: Percentage agreement in determining cause of misdiagnosis. RESULTS: Participants agreed a misdiagnosis occurred in all cases and the error was graded as serious 14 of 15 times (93%). Inter-rater agreement for root cause varied among the three classification systems from 47% to zero. CONCLUSIONS: Although there was excellent agreement among clinical experts of what constitutes serious misdiagnosis under idealized conditions, there is not a reliable method for categorizing the primary or root cause for these errors. The origins of misdiagnosis are complex, often multifactorial, and more difficult to categorize than other types of medical error. Misdiagnosis is a professional and public healthcare challenge that will require novel strategies to enable it to be successfully studied.

Diagnostic Errors↗
PubMed2004

Strategies to reduce medication errors in ambulatory practice.

Medication errors generally refer to mistakes made in the processes of ordering, transcribing, dispensing, administering or monitoring of pharmaceutical agents used in clinical practice. The Institute of Medicine report, To Err Is Human: Building a Safer Health System, has helped raise public awareness surrounding the issue of patient safety within our hospitals. A number of legislative and regulatory steps have resulted in hospital authorities putting in place various systems to allow for error reporting and prevention. Medication errors are being closely scrutinized as part of these hospital-based efforts. Most Americans, however, receive their healthcare in the ambulatory primary care setting. Primary care physicians are involved in the writing of several million prescriptions annually. The steps underway in our hospitals to reduce medication errors should occur concurrently with steps to increase awareness of this problem in the out-patient setting. This article provides an overview of strategies that can be adopted by primary care physicians to decrease medication errors in ambulatory practice.

Ambulatory Care↗
PubMedDate not supplied

Medical errors in psychiatry.

Medical errors in the general medical sector result in significant patient deaths and injuries, as well as high costs to the health care system. Despite the growing literature on errors in medical and surgical specialties, few studies have examined the incidence, nature, predictors, and prevention of errors that may occur in mental health treatment settings. The purpose of the current review is to examine the lessons learned from patient-safety research in the general medical sector, provide examples of types of errors in psychiatry, review the errors identified in the literature, offer a discussion of error-reduction strategies for improving patient safety, and provide recommendations for future research. Increased attention to medical errors in psychiatry is necessary in order to build safer health systems and promote a culture of safety among providers, thereby producing better care for patients with mental disorders.

Cost Control↗
PubMed2002

Trends of medication errors in hospitalized children.

Medication errors are a major cause of morbidity and mortality among hospitalized children. Due to the small volumes of stock solution involved, even a large error may look as an unsuspiciously small dose. Strategies were implemented to reduce medication errors in a large tertiary pediatric hospital in Toronto. Starting in 1993, several initiatives were taken, including a new hospital computer system for medication ordering, a review process to remove hazardous drugs from wards where they are not needed immediately, and in the training of pediatric residents. The rates of reported medication errors were compared before and after these initiatives were taken. Compared to baseline, there was a steady and a statistically significant decrease in medication errors through the decade. Total errors (actual and potential) decreased for nurses and physicians by half and for pharmacists by 75%. Actual incidents decreased by half. Moderate and severe errors decreased by more than 70%. It was concluded that a combination of several initiatives to decrease system and human errors has resulted in more than a 50% reduction of medication errors reaching the pediatric patient.

Canada↗
PubMed2004

Medication error reporting in long term care.

BACKGROUND: Medication errors are common causes of medical error in the long-term care (LTC) setting. Despite their frequency and potential clinical impact, most medication errors in LTC facilities remain unreported. Before better reporting systems can be developed to reduce clinically significant medication errors, it is necessary to understand how current medication error reporting systems function. OBJECTIVE: This study describes the medication use and medication error reporting processes, and characterizes the knowledge, attitudes, and beliefs about medication errors of the nursing staff at a single LTC facility. METHODS: Three methods were used to characterize the medication use and medication error reporting processes and the nursing staff's perceptions about such errors. First, key elements and basic processes were defined through observation and semi-structured interviews. Second, medication error reports were reviewed and summarized over a 21-month period. Third, nursing facility staff were surveyed about their knowledge, attitudes, and beliefs concerning medication errors. RESULTS: The medication use process in the LTC setting is similar to that employed in the acute care setting, consisting of 5 steps: prescribing, documenting, dispensing, administering, and monitoring. In the facility studied, an average of 4.7 medication error reports were submitted per month. Staff felt that half of all medication errors were identified and communicated informally through change-of-shift reports rather than through medication error reports. Most staff (85%) believed that disciplinary action was taken against the person who committed an error. CONCLUSIONS: The medication error policies and processes of the LTC facility studied were associated with a low frequency of formal reporting, a narrow perspective on the sources of error, and concerns about disciplinary action. Research is needed to better identify errors, develop interventions that broaden the monitoring perspective to include all health care professionals, reduce the work of reporting, standardize the information collected, and create an institutional atmosphere of participation rather than punishment.

Data Collection↗
PubMed2006

Learning from mistakes. Factors that influence how students and residents learn from medical errors.

CONTEXT: Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. OBJECTIVE: To identify major factors and areas of tension in trainees' learning from medical errors. DESIGN, SETTING, AND PARTICIPANTS: Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. RESULTS: Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. CONCLUSIONS: Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.

Attitude of Health Personnel↗
PubMed2000

Disclosure and prevention of medical errors. Committee on Bioethical Issues of the Medical Society of the State of New York.

Medical errors occur and are sometimes unavoidable. Physicians generally, but not always, have ethical and moral obligations to disclose their errors to the patient. Because common medical errors can be expected, physicians are obligated to work within health systems toward reducing systems flaws that promote errors. However, the obligations of physicians to disclose errors made by others are less clear. This article discusses the professional ethics involved in disclosing and preventing medical errors.

Ethics, Medical↗
PubMed2003

Systems factors in the reporting of serious medication errors in hospitals.

Underreporting of medication errors poses a threat to quality improvement initiatives. Hospital risk management programs encourage medication error reporting for effective management of systems failures. This study involved a survey of 156 medical-surgical hospitals in the United States to evaluate systems factors associated with the reporting of serious medication errors. Prior to controlling for bed size, a multivariate logistic regression model showed increased reporting of medication errors in hospitals with 24-h pharmacy services, presumably because of better error reporting systems. When number of occupied beds was included, the final model demonstrated bed size to be the only statistically significant factor. Increased reporting rates for serious medication errors warrant further evaluation, but higher error reporting may paradoxically indicate improved error surveillance. Results suggest that increased availability of pharmacist services results in opportunities for more diligent systematic efforts in detecting and reporting medication errors, which should lead to improved patient safety.

Computer Systems↗
PubMedDate not supplied

Medication errors: analysis not blame.

This article summarizes current knowledge regarding neonatal medication errors and explicates the key concepts of human error and system error. A case report illustrates the sources of error. Medication error analysis must go beyond the blaming of individuals for active errors and explore the latent errors that exist in a complex health care environment. Using correct language to describe and define medication error may facilitate the development of a nonpunitive culture and enable effective evaluation of the causes of error.

Female↗
PubMed2001

[Medical errors: inevitable but preventable].

Medical errors are increasingly reported in the lay press. Studies have shown dramatic error rates of 10 percent or even higher. From a methodological point of view, studying the frequency and causes of medical errors is far from simple. Clinical decisions on diagnostic or therapeutic interventions are always taken within a clinical context. Reviewing outcomes of interventions without taking into account both the intentions and the arguments for a particular action will limit the conclusions from a study on the rate and preventability of errors. The interpretation of the preventability of medical errors is fraught with difficulties and probably highly subjective. Blaming the doctor personally does not do justice to the actual situation and especially the organisational framework. Attention for and improvement of the organisational aspects of error are far more important then litigating the person. To err is and will remain human and if we want to reduce the incidence of faults we must be able to learn from our mistakes. That requires an open attitude towards medical mistakes, a continuous effort in their detection, a sound analysis and, where feasible, the institution of preventive measures.

Humans↗
PubMed2004

Reporting of medication errors by pediatric nurses.

Medication administration errors can threaten patient outcomes and are a dimension of patient safety directly linked to nursing care. Children are particularly vulnerable to medication errors because of their unique physiology and developmental needs. This descriptive study surveyed a convenience sample of 57 pediatric and 227 adult hospital nurses regarding their perceptions of the proportion of medication errors reported on their units, why medication errors occur, and why medication errors are not always reported. In this study, which focuses on pediatric data, pediatric nurses indicated that a higher proportion of errors were reported (67%) than adult nurses indicated (56%). The medication error rates per 1,000 patient-days computed from actual occurrence reports were also higher on pediatric (14.80) as compared with adult units (5.66). Pediatric nurses selected distractions/interruptions and RN-to-patient ratios as major reasons medication errors occurred. Nursing administration's focus on the person rather than the system and the fear of adverse consequences (reprimand) were primary reasons selected for not reporting medication errors. Results suggest the need to explore both individual and systematic safeguards to focus on the reported causes and underreporting of medication errors.

Adult↗