PubMed Health⌕ Search

SEARCH · PubMed Health

Results for “Medication Errors”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 91 records · Page 5Linked to original sources
PubMed1997

Predicting look-alike and sound-alike medication errors.

A model for predicting medication name confusion is described. Many medication errors are caused by look-alike and sound-alike medication names, yet few procedures exist to ensure the safety of new drug nomenclature or to identify confusingly similar names from within existing databases. In this study, three automated, quantitative measures of orthographic similarity (i.e., similarity in spelling) were identified (bigram similarity, trigram similarity, and Levenshtein distance). The relationship between orthographic similarity and the likelihood of a medication error was examined. For each measure of similarity, the frequency distribution of similarity scores for pairs of drug names previously reported to cause confusion (error pairs) was compared with the distribution of similarity scores for control pairs randomly selected from the general index of USP DI-Volume I: Drug Information for the Health Care Professional. Then, three parallel, unmatched case-control studies were conducted to discover whether similarity was a significant risk factor for medication errors. Finally, on the basis of the three similarity measures, tests for predicting confusion were developed and evaluated. For each similarity measure, the frequency distribution of error pairs was significantly different from that for control pairs, and orthographic similarity was a significant risk factor for medication errors. Pairs of names whose measures of similarity exceeded present thresholds were between 25 and 523 times more likely to be involved in a medication error than pairs whose similarity did not exceed these thresholds. A prognostic test that correctly identified 91% of all pairs as either errors or controls was developed. This test had a sensitivity of 84% and a specificity of 99%. Automated measures of similarities between medication names can form the basis of highly accurate, sensitive, and specific tests of the potential for errors with look-alike and sound-alike medication names.

Humans↗
PubMed2006

Why worry? Worry, risk perceptions, and willingness to act to reduce medical errors.

Through the domain of medical errors, the role of worry and perceived risk in precautionary behaviors was examined in a convenience sample (N = 195, mean age = 42 years, 71% female). Worry was linked to fatality estimates. A model of the antecedents and consequences of worry also was tested. Risk characteristics such as dread and preventability, negative reactivity, and vulnerability to medical errors appeared to motivate worry about medical errors. Worry about medical errors was a better predictor of intentions to take precautionary actions than were risk perceptions. An understanding of how worry influences preventive efforts will help in building communication strategies to the public and in effectively engaging patients in the role of vigilant partner in care.

Adult↗
PubMed2005

Health plan members' views on forgiving medical errors.

BACKGROUND: How patients respond to medical errors may influence how physicians approach disclosure of medical errors, but information on patients' responses is limited. Research is needed on how the circumstances that surround a medical error affect how patients respond. OBJECTIVE: To investigate whether patients' tendency to forgive a physician following a medical error varied under different circumstances. STUDY DESIGN: Cross-sectional survey. METHODS: We mailed a questionnaire to 1500 randomly selected health plan members; the response rate was 66%. Questionnaire items assessed the likelihood of forgiveness following a medical error under 12 circumstances drawn from a review of the literature. RESULTS: Respondents were most likely to forgive a physician if the patient failed to provide complete information (93% would or might forgive) and least likely to forgive if the error was due to efforts to keep costs down (11% would or might forgive). Most respondents would not forgive a physician when the physician was tired or distracted (68%), was incomplete in data collection (76%), lacked knowledge (78%), or failed to follow up (85%). Men were more likely to forgive than women; the most educated respondents were most likely to forgive. CONCLUSIONS: Our findings suggest that patients are not likely to forgive a physician in circumstances in which they suspect incompetence, inattention, or a lack of caring on the part of the physician involved. A more comprehensive understanding of forgiveness and the effect of forgiveness on the physician-patient relationship following a medical error is needed.

Cross-Sectional Studies↗
PubMed1994

Experience with a national medication error reporting program.

Actual or potential medication errors reported to a national medication error database from August 1991 through April 1993 are summarized. The United States Pharmacopeial Convention (USP) and the Institute for Safe Medication Practices (ISMP) collect medication error reports and study them in an effort to provide feedback to practitioners, the FDA, and product manufacturers. Reports are voluntary and are most often received by telephone or submission of a standard form. Five hundred sixty-eight such reports were received by the USP between August 1991 and April 1993; the majority of these were from pharmacists. Medication errors were classified as potential, actual-intercepted, or actual-transpired; 406 actual errors occurred in the prescribing, transcribing, communication, dispensing, or administration of medications, and 162 incidents involved potential errors in these areas. Nurses, pharmacists, and physicians were implicated in the greatest number of triggering incidents. The drugs most commonly involved in errors were heparin, lidocaine, epinephrine, and potassium chloride; lidocaine was implicated in the largest number of fatalities. Product problems (e.g., similar packaging, incomplete labeling) played the largest role overall, whereas cognitive error was the most important factor in fatalities. A national medication error reporting program can provide valuable feedback to practitioners and manufacturers.

Adverse Drug Reaction Reporting Systems↗
PubMed1995

Comparison of medication errors in an American and a British hospital.

Medication errors in a hospital in the United States and a hospital in the United Kingdom were compared. The study was conducted in wards with a high oral-drug-related workload in two large university hospitals. The U.S. hospital was studied in August 1993 and the U.K. hospital in May and June 1993. The U.S. hospital had a typical unit dose drug distribution system, and the U.K. hospital had the ward-based system commonly used in that country, in which a pharmacist visits each ward several times daily and reviews each patient's medication chart. The medication chart is used by the physician to order drugs and obviates the need for transcription of orders. A disguised-observation technique was used to determine frequencies and types of medication errors. Medication errors were identified retrospectively in the U.S. hospital by comparing the observer's notes with the original drug orders made in the patient's chart by the physician. In the U.K. hospital, identification of errors took place concurrently; as doses were administered, they were compared with the orders on the medication chart. In the U.S. and U.K. hospitals, 919 and 2756 opportunities for error were observed, respectively. The medication error rate in the U.S. hospital was 6.9% (95% confidence interval [CI], 5.2% to 8.5%), significantly higher than the 3.0% rate observed in the U.K. hospital (95% CI, 2.4% to 3.7%) (95% CI for the difference, 2.1% to 5.7%). Omitted doses and incorrect doses were the most common types of errors in the U.K. hospital; incorrect doses and unordered doses were the most common types in the U.S. hospital. An American hospital with a unit dose distribution system had a significantly higher medication error rate than a British hospital with a ward-based supply system.

Hospitals, University↗
PubMed2006

Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia.

BACKGROUND: Although medication errors are 1 of the most common types of medical errors, their frequency in pediatric patients receiving oral outpatient chemotherapeutic agents is unknown. The prescribing, dispensing, and parental administration of these medications to children receiving treatment for acute lymphoblastic leukemia (ALL) were systematically reviewed to determine the rate and types of medication errors occurring in these patients. METHODS: During a 2-month study period, parents of children with ALL were contacted and asked to participate in the study before a regularly scheduled clinic appointment. At the visit, the parent demonstrated how each medication was administered. A pediatric oncologist reviewed the medical record to determine the correct treatment regimen for study patients. After comparing the correct treatment regimen with what was administered, a classification of "no medication error," "medication error," or "cannot determine" due to insufficient information was made for each indicated drug. Identified medication errors were subclassified as prescribing, dispensing, or administration errors. RESULTS: Data on 172 chemotherapeutic medications for 69 patients were analyzed. One or more errors occurred with 17 of the 172 (9.9%) medications; a classification of "cannot determine" was made for 12 (7.0%) medications. Among the 17 medication errors there were 12 (7.0%) administration errors and 5 (2.9%) prescribing errors. There were no pharmacy dispensing errors. All errors were due to incorrect dosing or failure to administer an indicated medication. At least 1 medication error occurred in 13 of the 69 (18.8%) study patients. CONCLUSIONS: Prescribing and administration medication errors occurred with nearly 10% of chemotherapeutic drugs administered to outpatient children with ALL. Systematic changes, including computerized physician order entry and simplification of treatment protocols, should be considered.

Administration, Oral↗
PubMed2002

Moving toward safer practice: reducing medication errors in neonatal care.

Medication errors are a concern in all areas of health care, including neonatal units. In order to reduce errors and move toward safer practice, it is essential for clinicians to focus less on assigning blame to individuals and more on how these problems occurred. Only then will we fully understand the contributing factors and comprehensively address the reduction of medication errors. This article examines historical perspectives, contributing factors, and strategies for developing safer practice in neonatal care.

Humans↗
PubMed2004

A cognitive taxonomy of medical errors.

OBJECTIVE: Propose a cognitive taxonomy of medical errors at the level of individuals and their interactions with technology. DESIGN: Use cognitive theories of human error and human action to develop the theoretical foundations of the taxonomy, develop the structure of the taxonomy, populate the taxonomy with examples of medical error cases, identify cognitive mechanisms for each category of medical error under the taxonomy, and apply the taxonomy to practical problems. MEASUREMENTS: Four criteria were used to evaluate the cognitive taxonomy. The taxonomy should be able (1) to categorize major types of errors at the individual level along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to describe how and explain why a specific error occurs, and (4) to generate intervention strategies for each type of error. RESULTS: The proposed cognitive taxonomy largely satisfies the four criteria at a theoretical and conceptual level. CONCLUSION: Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies.

Cognition↗
PubMed2004

What makes an error unacceptable? A factorial survey on the disclosure of medical errors.

BACKGROUND: Although the importance of disclosing medical errors to patients has been argued, little is known about the relative effect of different attributes of error handling and communication on patients' judgments about errors. OBJECTIVES: This study investigates how different characteristics of medical errors and of physicians' subsequent handling of errors contribute to patients' evaluations of the incident and their attitudes towards potential consequences and sanctions for the physician. MATERIALS AND METHODS: A factorial survey using the vignette technique presented hypothetical scenarios involving medical errors to members of the general public in an Internet-based study. Members of a German Internet survey panel participated (n = 1017). Multiple ordered logistic regression models were estimated to explain citizens' judgments of error severity and their attitudes towards reporting of errors, wishing for referral to another physician, and supporting sanctions against the health professional involved as a response to characteristics of the presented errors. RESULTS: While the severity of the outcomes of errors remains the most important single factor in the choice of actions to be taken, the professional's approach to the error is regarded as essential in the overall evaluation of errors and the consideration of consequences. In errors with a severe outcome, an honest, empathic, and accountable approach to the error decreases the probability of participants' support for strong sanctions against the physician involved by 59%. Judgments were only marginally affected by respondents' characteristics. CONCLUSIONS: The handling of errors strongly contributes to citizens' choice of actions to be taken, and they are sensitive to failures to name the incident as an 'error'. For the success of de-individualized, systems-oriented approaches to errors, communication of clear accountability to patients will be crucial.

Adolescent↗
PubMedDate not supplied

Reducing the risk of medication errors in women.

We outline some of the causes of medication errors involving women and recommend ways that healthcare practitioners can prevent some of these errors. Patient safety has become a major concern since the November 1999 release of the Institute of Medicine (IOM) report, "To Err Is Human." Errors involving prescription medications are responsible for up to 7000 American deaths per year, and the financial costs of drug-related morbidity and mortality may be nearly $77 billion a year. The Institute for Safe Medication Practices (ISMP) collects and analyzes voluntary confidential medication error reports and makes recommendations on the prevention of such errors. This paper uses the expertise of ISMP in medication error prevention to make recommendations to prevent medication errors involving women. Healthcare practitioners should focus on areas of the medication use process that would have the greatest impact, including obtaining complete patient information, accurately communicating drug information, and properly educating patients. Although medication errors are not more common in women, there are some unique concerns with medications used for treating women. In addition, sharing of information about medication use and compliance with medication regimens have been identified as concerns. Through the sharing of information and improving the patient education process, healthcare practitioners should play a more active role in medication error reduction activities by working together toward the goal of improving medication safety and encouraging women to become active in their own care.

Attitude to Health↗
PubMed2005

Managing medication errors--a qualitative study.

Medication errors continue to be a significant issue affecting patient safety in United States hospitals. The researchers conducted a qualitative study to explore the understanding and management of medication errors by practicing nurses. The results indicated a belief that late medication administration does not always constitute an error, the use of nursing judgment helps determine when and if medication should be given, and an increased reliance upon computerized and systematic checks put into place in health care systems.

Attitude of Health Personnel↗
PubMed2006

An individual-based framework for the study of medical error.

BACKGROUND: In the late 1990s, medical error came into focus as a problem to be explicitly acknowledged and addressed. Research on this topic is amassing in the epidemiology of medical error and the system and human factors that contribute to error. In addition, however, an understanding of medical errors in terms of the underlying decision process is needed. OBJECTIVE: To present an individual-based framework for the study of medical errors in the context of the decision maker. RESULTS: A framework is developed in terms of four state spaces: the decision environment, problem, goal, and action spaces. The role of information uncertainty is discussed. The framework is purposefully simple to provide flexibility and options for research-specific extensions, but sufficient structure is imposed to guide understanding and investigation. CONCLUSION: Understanding medical error in terms of the proposed framework can guide research and subsequent interventions by illuminating where in the decision process such errors are generated.

Decision Making↗
PubMed1992

What should a pharmacy manager do when a serious medication error occurs? A panel discussion.

Questions related to medication errors were discussed by a panel of hospital department managers. When a serious medication error occurs, the manager has a responsibility to help the employee, the patient, and the patient's family cope with its effects, as well as a responsibility to prevent such errors from recurring. The difficulty of dealing with medication errors may be compounded when the legal system and the news media get involved. Therefore, a system for handling a serious error should be in place before that error occurs. It is also necessary to decide whether to use medication error reports in the employee evaluation process; this could make employees reluctant to report their errors. Ultimately, pharmacy managers are responsible for medication errors that occur, and repercussions have varied from nothing to reprimands to termination. Past errors, if they are reported, can be used to improve the system in which they occurred and to educate other health-care professionals. Therefore, pharmacists need to cooperate with other health-care professionals in documenting medication error reports. A national reporting system is needed so that medication error information can be shared on a large scale without placing the people involved in legal jeopardy. Sharing information about medication errors is necessary to prevent future occurrences; mechanisms are needed to facilitate such sharing.

Legislation, Medical↗
PubMed2003

Prevention of medication errors in the pediatric inpatient setting.

Although medication errors in hospitals are common, medication errors that result in death or serious injury occur rarely. Even before the Institute of Medicine reported on medical errors in 1999, the American Academy of Pediatrics and its members had been committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults. This commitment includes designing health care systems to prevent errors and emphasizing the pediatrician's role in this system. Human and device errors can lead to preventable morbidity and mortality. National and state legislative actions have heightened public awareness of these events. All involved persons, beginning with the physician and including every member of the health care team, must be better educated about and engaged in the several steps recommended to decrease these errors. The safe administration of medications to hospitalized infants and children requires additional specific safeguards that are above and beyond those for adult patients. Pediatricians should help hospitals develop effective programs for safely providing medications, reporting medication errors, and creating an environment of medication safety for all hospitalized pediatric patients.

Child↗
PubMed2004

Reported medication errors associated with methotrexate.

PURPOSE: Medication errors reported to FDA as adverse events in which methotrexate was identified as a possible contributor were studied. METHODS: All adverse-event reports submitted to FDA between November 1997 and December 2001 indicating potential medication errors involving methotrexate were analyzed to determine the indication for use, the type of error, and the point in the medication-use process where the error occurred. RESULTS: A total of 106 cases of reported medication errors associated with methotrexate were identified, including errors resuiting in 25 deaths (24%) and 48 other serious outcomes (45%). The most common types of errors involved confusion about the once-weekly dosage schedule (30%) and other dosage errors (22%). The most frequently involved indication for use was rheumatoid arthritis (42%). Of the errors, 39 (37%) were attributable to the prescriber, 21 (20%) to the patient, 20 (19%) to dispensing, and 18 (17%) to administration by a health care professional. CONCLUSION: A review of medication errors involving methotrexate revealed that errors occurred during all phases of use, often resulted from confusion about dosage, and often caused death or other serious adverse effects.

Adult↗
PubMed1990

Medication errors: 1977 to 1988. Experience in medical malpractice claims.

MIIENJ has paid $30,144,636 in indemnity from 1977 through 1988 for medical malpractice suits arising from medication errors. A review of these files revealed that patients incurred death and serious morbidity, and that several specific behavior errors accounted for the majority of patient injury. Among the damages that occurred during that time period were 88 deaths, 15 patients with profound brain damage, 15 patients who alleged that they had become addicted to medications prescribed for pain, 10 patients who required amputations of limbs, and 12 patients who suffered some degree of hearing loss or decreased visual acuity. The predominant categories where insureds incurred difficulty were in disregarding patient allergies to specific drugs (acetylsalicylic acid (aspirin), penicillin and its derivatives); prescribing drugs without consideration of the patient's medical history; failing to monitor therapy with anticoagulants, nonsteroidal anti-inflammatory drugs, digitalis derivatives, theophylline, and aminoglycoside antibiotics; antibiotic therapy; and errors in the writing of prescriptions. In order to reduce the number of patient injuries and accompanying medical malpractice suits from medication errors, the following suggestions are offered: 1. Heed the patient's warning regarding drug allergies and prescribe a substitute drug, especially if the drug is aspirin or penicillin (and derivatives) or if the patient gives a history of having asthma. If the patient gives a history of aspirin sensitivity, make certain the drug you are prescribing does not contain aspirin as one of its components. Often physicians stated that they were not aware that aspirin was contained in the drug they prescribed for patients with a documented allergy to aspirin.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Perceived barriers to medical-error reporting: an exploratory investigation.

Medical-error reporting is an essential component for patient safety enhancement. Unfortunately, medical errors are largely underreported across healthcare institutions. This problem can be attributed to different factors and barriers present at organizational and individual levels that ultimately prevent individuals from generating the report. This study explored the factors that affect medical-error reporting among physicians and nurses at a large academic medical center located in the midwest United States. A nominal group session was conducted to identify the most relevant factors that act as barriers for error reporting. These factors were then used to design a questionnaire that explored the likelihood of the factors to act as barriers and their likelihood to be modified. Using these two parameters, the results were analyzed and combined into a Factor Relevance Matrix. The matrix identifies the factors for which immediate actions should be undertaken to improve medical-error reporting (immediate action factors). It also identifies factors that require long-term strategies (long-term strategy factors) as well as factors that the organization should be aware of but that are of lower priority (awareness factors). The strategies outlined in this study may assist healthcare organizations in improving medical-error reporting, as part of the efforts toward patient-safety enhancement. Although factors affecting medical-error reporting may vary between different organizations, the process used in identifying the factors and the Factor Relevance Matrix developed in this study are easily adaptable to any organizational setting.

Academic Medical Centers↗