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PubMed2006

Medical error management and the role of information technology--a new approach to investigating medical handover in acute care settings.

While identifying reasons why medical errors occur and constructing models of how to manage them has proved relatively straightforward, implementing and meaningfully evaluating solutions in 'real-world' settings has proven considerably more difficult. From an information systems (IS) perspective, although the promise of technology remains powerful, the continuing high incidence of medical errors suggest that eHealth approaches are struggling to acquire a clear understanding of the complex, dynamic and multi-layered nature of acute care settings and clinical practices, and to respond effectively to address the range of errors that actually occur. Using medical handover as a field-site, this research-in-progress paper presents an adaptation of James Reason's 'Swiss Cheese Model' to conceptualize the complex factors at play in medical errors in terms of human, system and informational elements. This research paper then examines how drawing on this model it is possible to generate and implement a methodological approach that both enhances a holistic understanding of medical error management and illuminates criteria that can be used to meaningfully identify an appropriate role for information technology in medical error mitigation. This research-in-progress paper aims to make a significant contribution to research into medical error management in 'real-world' acute care settings. This research is part of a bigger project that aims to develop, implement and evaluate an information technology artefact as part of an holistic information systems approach to improving medical error management at medical handover.

Continuity of Patient Care↗
PubMedDate not supplied

Reducing medical errors through better documentation.

Preventable medical errors occur with alarming frequency in US hospitals. Questions to address include what is a medical error, what errors occur most often, and what solutions can health information technologies offer with better documentation. Preventable injuries caused by mismanagement of treatment happen in all areas of care. Some result from human fallibility and some from system failures. Most errors stem from a combination of the two. Examples of combination errors include wrong-site surgeries, scrambled laboratory results, medication mishaps, misidentification of patients, and equipment failures. Unavailable patient information and illegible handwriting lead to diagnosing and ordering errors. Recent technology offers viable solutions to many of these medical errors. Computer-based medical records, integration with the pharmacy, decision support software, Computerized Physician Order Entry Systems, and bar coding all offer ways to avoid tragic treatment outcomes. Persuading and training hospital staff to use the technology poses a problem, as does budgeting for the new equipment. However, the technology would prove its worth in time. The Institute of Medicine and coalition groups such as Leapfrog Group have recognized the problem that permeates the health care industry, manifests in many ways, and requires the many solutions that information technology offer.

Decision Support Techniques↗
PubMedDate not supplied

Medication errors: the problem and its scope.

Nurses can take an important lead role in protecting their patients, their peers, and themselves from the unfortunate consequences of medication errors. Medication errors occurs for a variety of reasons, including inaccurate communications and deficits in knowledge and performance by and among all health care professionals. These problems and deficits need to be addressed. USP stresses the importance of focusing on the process or system in which the error occurred, rather than focusing blame on an individual. By acknowledging all actual and potential errors, and by consistently assessing and reassessing systems, nurses can help reduce medication errors and contribute significantly to improve patient safety.

Humans↗
PubMed2001

Retrospective analysis of mortalities associated with medication errors.

The types, causes, contributing factors, and patient demographics of fatal medication errors were reviewed. Case reports of medication errors from hospitals, ambulatory care settings, and patients' homes that were entered in FDA's Adverse Event Reporting System during 1993-98 were the source of information on fatal medication errors. Each report was classified using predefined criteria and a taxonomy developed by the National Coordinating Council for Medication Error Reporting and Prevention. The types, causes, contributing factors, and patient demographics were identified, and the causality of each case was assessed to prevent future fatalities. The data indicated 5,366 medication error reports. Fifty-nine reports were excluded and classified as duplicate reports or intentional overdoses. Of the remaining medication error reports, 68.2% resulted in serious patient outcomes and 9.8% were fatal. Of the 469 fatal medication error reports, 48.6% occurred in patients over 60 years. The most common types of errors resulting in patient death involved administering an improper dose (40.9%), administering the wrong drug (16%), and using the wrong route of administration (9.5%). The most common causes of errors were performance and knowledge deficits (44%) and communication errors (15.8%). Fatal medication errors accounted for approximately 10% of medication errors reported to FDA and were most frequently the result of improper dosing of the intended drug and administration of an incorrect drug. A review of case reports of medication errors from 1993 to 1998 yielded information on the most frequent causes of and contributing factors involved in fatal medication errors.

Adolescent↗
PubMedDate not supplied

Managing the aftermath of medication errors: managed care's role.

OBJECTIVE: To discuss managed care's role in managing an organization's response to a medication error and to provide specific recommendations for that response. DATA SOURCES: Published articles and reports related to crisis management, service failure, public relations, ethics, psychology, management, marketing, health care, and law. Review of the literature on crisis management and service failure was extensive. ProQuest and MEDLINE databases were searched. Search terms were medication error, medical error, and organizational crisis. STUDY SELECTION: Studies were selected on the basis of their relevance to practitioners. DATA SYNTHESIS: Medication errors place practitioners, pharmacies, and health care organizations under severe emotional, physical, and financial stress. Managed poorly, a medication error can have disastrous consequences for all involved. When the response is managed correctly, a medication error presents a challenge, but one that is survivable and potentially instructive. Managed care should develop and disseminate best practices for responding to errors and lead the development and adoption of technologies and systems designed to curtail the number of errors and reduce the costs associated with those errors. Effectively responding to a medication error allows the pharmacy organization to maintain or resume its core activities while minimizing stakeholders' losses. The lessons learned in the process of managing the aftermath of a medication error should be incorporated into ongoing quality improvement programs. CONCLUSION: Based on the literature review and the ideas presented, specific recommendations for responding to catastrophic medication errors are made. Following those recommendations would allow those in the health care system--managed care organizations and individual practitioners--to improve their image and do good at the same time.

Attitude of Health Personnel↗
PubMedDate not supplied

The role of managed care pharmacy in reducing medication errors.

OBJECTIVE: To outline some of the causes of medication errors and recommend ways that managed care pharmacy organizations and managed care pharmacists can prevent some of these errors through practitioner and patient education. BACKGROUND: 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 7,000 American deaths per year and the financial costs of drug-related morbidity and mortality may cost nearly $77 billion US dollars a year. The Institute for Safe Medication Practices (ISMP) collects and analyzes voluntary confidential medication error reports and makes recommendations on the prevention of these errors. This article uses the expertise of ISMP in medication error prevention to make recommendations on educational programs for patients and managed care and community pharmacists to reduce medication errors in the outpatient (community) setting. These educational areas focus on patient education, compliance, and health care literacy. CONCLUSION: Managed care pharmacy is well positioned to affect change in the health care system. Through information dissemination and education, managed care pharmacists should play a more active role in medication error-reduction activities by improving the patient education process and in assisting the pharmacy community in its goal of improving patient safety.

Adolescent↗
PubMed2004

Reducing medication errors in the neonatal intensive care unit.

BACKGROUND: Medication errors are common in the neonatal intensive care unit (NICU). Various strategies to reduce errors have been described in adult and paediatric patients but there are few published data on their effect in the NICU. AIM: To describe the medication errors occurring within an NICU, and assess the impact of a combined risk management/clinical pharmacist led education programme on these errors. METHODS: Medication errors were identified prospectively over one year by critical incident reporting. Four months into the study, a pharmacist led education programme was instituted. This involved a daily, cot side, pharmacist led review of medication orders. Each new member of pharmacy, nursing, or medical staff was also required to successfully complete a series of dose calculations. In addition, a risk management approach was used to make several changes in practice during the study period. RESULTS: A total of 105 errors were identified, four serious, 45 potentially serious, and 56 minor. The four serious errors included two tenfold dose miscalculations. Most (71%) of the errors were due to poor prescribing. After the introduction of our interventions, monthly medication errors fell from a mean (SD) of 24.1 (1.7) per 1000 neonatal activity days to 5.1 (3.6) per 1000 days (p < 0.001) in the following three months. The subsequent change over of junior medical staff was associated with a significant increase in medication errors to 12.2 (3.6) per 1000 neonatal activity days (p = 0.037). However, the number remained significantly less than before our interventions (p < 0.001). Three serious errors occurred in the first four months compared with one in the second eight month period, the latter corresponding to the six monthly change over of junior medical staff. CONCLUSIONS: Medication errors are common in NICUs. Fortunately, actual harm to an infant is rare. Interventions to reduce errors, particularly within the context of a risk management programme, are effective.

Drug Prescriptions↗
PubMed2006

Medication errors: professional issues and concerns.

In the UK, medication errors are a growing problem. Dobrzanski et al (2002) estimated that in one trust the incidence of medication error ranged between 35 to 70 per cent. Such high estimations are a cause for concern, particularly when the administration and supply of medicines, which directly involves nurses, can contribute to the cause of medication error. Part of the National Patient Safety Agency's (NPSA) role is monitoring medication errors in hospitals. Although the NPSA can provide information on drug alerts that target primary care organisations, obtaining accurate figures for medication errors is more difficult. Medication errors can be extremely harmful for older people, therefore nurses who prescribe or administer medicines should be assessed for mathematical competence, but also be aware of the potential problems that can arise from medication errors (Banning 2005).

Adverse Drug Reaction Reporting Systems↗
PubMed2004

Voluntary anonymous reporting of medical errors for neonatal intensive care.

OBJECTIVES: Medical errors cause significant morbidity and mortality in hospitalized patients. Specialty-based, voluntary reporting of medical errors by health care providers is an important strategy that may enhance patient safety. We developed a voluntary, anonymous, Internet-based reporting system for medical errors in neonatal intensive care, evaluated its feasibility, and identified errors that affect high-risk neonates and their families. METHODS: Health professionals (n = 739) from 54 hospitals in the Vermont Oxford Network received access to a secure Internet site for anonymous reporting of errors, near-miss errors, and adverse events. Reports used free-text entry in phase 1 (17 months) and a structured form in phase 2 (10 months). The number and types of reported events and factors that contributed to the events were measured. RESULTS: Of 1230 reports--522 in phase 1 (17 months) and 708 in phase 2 (10 months)--the most frequent event categories were wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products; 47%); error in administration or method of using a treatment (14%); patient misidentification (11%); other system failure (9%); error or delay in diagnosis (7%); and error in the performance of an operation, procedure, or test (4%). The most frequent contributory factors were failure to follow policy or protocol (47%), inattention (27%), communications problem (22%), error in charting or documentation (13%), distraction (12%), inexperience (10%), labeling error (10%), and poor teamwork (9%). In 24 reports, family members assisted in discovery, contributed to the cause, or themselves were victims of the error. Serious patient harm was reported in 2% and minor harm in 25% of phase 2 events. CONCLUSIONS: Specialty-based, voluntary, anonymous Internet reporting by health care professionals identified a broad range of medical errors in neonatal intensive care and promoted multidisciplinary collaborative learning. Similar specialty-based systems have the potential to enhance patient safety in a variety of clinical settings.

Adverse Drug Reaction Reporting Systems↗
PubMed2005

Is consent required for publication of medical errors?

Publication of information about medical errors is critical to error prevention and shared learning among health professionals and institutions. While some countries have error reporting systems in place, journal publications are still essential reference tools for learning about error, and editorial policies about when to publish errors are needed, as these provide important guidance to journal editorial boards. While there is a prima facie moral requirement to obtain consent to publish patient information, publication without patient consent may be justified if certain criteria are met. Justification will involve consideration of a variety of principles, rules and conditions grounded in ethics, law and policy. Except in exceptional circumstances of overriding importance to public health, a patient's personal information should not be published over the patient's refusal. But what constitutes "exceptional circumstances of overriding importance to public health"? We argue that medical error is one such circumstance and present an argument in favour of a specific policy stance on publication of medical errors.

Canada↗
PubMed1995

Relationship between medication errors and adverse drug events.

OBJECTIVE: To evaluate the frequency of medication errors using a multidisciplinary approach, to classify these errors by type, and to determine how often medication errors are associated with adverse drug events (ADEs) and potential ADEs. DESIGN: Medication errors were detected using self-report by pharmacists, nurse review of all patient charts, and review of all medication sheets. Incidents that were thought to represent ADEs or potential ADEs were identified through spontaneous reporting from nursing or pharmacy personnel, solicited reporting from nurses, and daily chart review by the study nurse. Incidents were subsequently classified by two independent reviewers as ADEs or potential ADEs. SETTING: Three medical units at an urban tertiary care hospital. PATIENTS: A cohort of 379 consecutive admissions during a 51-day period (1,704 patient-days). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Over the study period, 10,070 medication orders were written, and 530 medications errors were identified (5.3 errors/100 orders), for a mean of 0.3 medication errors per patient-day, or 1.4 per admission. Of the medication errors, 53% involved at least one missing dose of a medication; 15% involved other dose errors, 8% frequency errors, and 5% route errors. During the same period, 25 ADEs and 35 potential ADEs were found. Of the 25 ADEs, five (20%) were associated with medication errors; all were judged preventable. Thus, five of 530 medication errors (0.9%) resulted in ADEs. Physician computer order entry could have prevented 84% of non-missing dose medication errors, 86% of potential ADEs, and 60% of preventable ADEs. CONCLUSIONS: Medication errors are common, although relatively few result in ADEs. However, those that do are preventable, many through physician computer order entry.

Boston↗
PubMed2004

Medication errors in pediatrics--the octopus evading defeat.

Medication errors have come to the forefront in healthcare and oversight organizations as well as to the public over the past several years. There has been an increasing focus on this area of patient care requiring more intensive evaluation and intervention to prevent these errors. Although it is difficult to ascertain the true occurrence of medication errors, they may occur as frequently as once in every 20 orders. Children are at higher risk for medication errors and adverse drug events for numerous reasons. Not only is there great variability in weight and body surface area in this population, there is also significant differences in the pharmacokinetics and pharmacodynamics of many medications when compared to adults. In addition, our knowledge of pharmacogenetics and phenotypic ontogeny must be applied. Sources of medication errors are identified, and specific examples and solutions to improve medication use in children are provided. It is critical to have 1) personnel trained in pediatrics to prescribe, prepare, dispense and administer medications, 2) a quality review system in place to review drug use and medication errors, and 3) to implement computerized physician order entry with decision support and other tools in the next decade to improve pharmacologic therapy for pediatric patients.

Child↗
PubMed2005

[Hospital drug safety: medication errors and adverse drug reactions].

BACKGROUND: Drug related problems (medication errors and adverse drug reactions) are frequent and cause increased costs. AIMS: Evaluation of the original articles published between 1991-2001 reporting frequencies of medication errors and/or METHODS: Medline search with the expressions "medication error", "adverse drug reaction", "adverse drug event", "hospital" and completion of the retrieved articles by evaluating the references and by checking review articles about this subject. RESULTS: Medication errors occur with a frequency of 5-10% of all applications, studies retrieved. This variability can be explained by the way the frequencies are expressed (per application, per patient days or per hospitalization), the reporting system (systematic acquisition vs. spontaneous reports) and the wards investigated, but not by the distribution system. Application errors are more frequent than prescription errors. Risk factors are insufficient education in pharmacology, overworked nursing personnel, non-computerized transmission of the prescriptions and lacking pharmaceutical support on the wards. Adverse drug reactions appear in about 8% of the hospitalized patients, also with a high variability among the 20 studies retrieved. This variability can be explained by differences between the wards studied and by the detection systems used. Risk factors are medication errors, female sex, age > 65 years, polypharmacy, impaired drug elimination and deviance of risk factors (e.g. previous allergic reactions). CONCLUSIONS: Computerizing the whole medication process and improving the pharmacological education of physicians and nurses could help to reduce medication errors. In addition, the adoption of clinical pharmacists on critical wards could also lower the medication error rate. For lowering the frequency of adverse drug reactions, medication errors should be avoided and the dosage of the drugs should be adapted strictly to the function of the eliminating organs. Risk factors such as drug allergies and familiar diseases should be screened for and drug therapies adapted accordingly. Severe and/or novel adverse drug reactions have to be reported to the regional pharmacovigilance centers.

Adverse Drug Reaction Reporting Systems↗
PubMed1986

Medication errors in a pharmacy-coordinated drug administration program.

The medication error rate in a pharmacy-coordinated drug administration program was determined. During a five-week study period, two pharmacy interns observed pharmacy technicians administering medications to patients on five nursing units. Observations were made from 0800 to 1200 and from 1700 to 2100, Monday through Friday. The ASHP Standard Definition of a Medication Error served as the basis for the classification of medication errors. A total of 2028 usable observations were made. The predominant type of error was wrong-time error. The overall medication error rate was 4.4%; excluding wrong-time errors yielded a medication error rate of 1.6%. Comparison of this medication error rate with those of other studies must be made cautiously, with consideration given to methods, study objectives, and definitions.

Humans↗
PubMed2004

Use of medical emergency team (MET) responses to detect medical errors.

BACKGROUND: No previous studies have investigated whether medical emergency team (MET) responses can be used to detect medical errors. OBJECTIVES: To determine whether review of MET responses can be used as a surveillance method for detecting medical errors. METHODS: Charts of all patients receiving MET responses during an 8 month period were reviewed by a hospital based Quality Improvement Committee to establish if the clinical deterioration that prompted the MET response was associated with a medical error (defined as an adverse event that was preventable with the current state of medical knowledge). Medical errors were categorized as diagnostic, treatment, or preventive errors using a descriptive typology based on previous published reports. RESULTS: Three hundred and sixty four consecutive MET responses underwent chart review and 114 (31.3%) were associated with medical errors: 77 (67.5%) were categorized as diagnostic errors, 68 (59.6%) as treatment errors, and 30 (26.3%) as prevention errors. Eighteen separate hospital care processes were identified and modified as a result of this review, 10 of which involved standardization. CONCLUSIONS: MET review may be used for surveillance to detect medical errors and to identify and modify processes of care that underlie those errors.

Emergency Service, Hospital↗