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PubMed2001

How can information technology improve patient safety and reduce medication errors in children's health care?

BACKGROUND: Medication errors are common, costly, and injurious to patients. OBJECTIVE: To review the role of information technology in decreasing pediatric medication errors in both inpatient and outpatient settings. DESIGN: We performed a literature review of current information technology interventions. RESULTS: Several types of information technology will likely reduce the frequency of medication errors, although insufficient data exists for many technologies, and most available data come from adult settings. Computerized physician order entry with decision support substantially decreases the frequency of serious inpatient medication errors in adults. Certain other inpatient information technologies may be beneficial even though less evidence is currently available. These include computerized medication administration records, robots, automated pharmacy systems, bar coding, "smart" intravenous devices, and computerized discharge prescriptions and instructions. In the outpatient setting, where adherence is especially important, personalized Web pages and World Wide Web-based information have substantial potential. CONCLUSIONS: Medication errors are an important problem in pediatrics. Information technology interventions have great potential for reducing the frequency of errors. The magnitude of benefits may be even greater in pediatrics than in adult medicine because of the need for weight-based dosing. Further development, application, evaluation, and dissemination of pediatric-specific information technology interventions are essential.

Adolescent↗

PubMed2004

Use of incident reports by physicians and nurses to document medical errors in pediatric patients.

OBJECTIVES: To describe the proportion and types of medical errors that are stated to be reported via incident report systems by physicians and nurses who care for pediatric patients and to determine attitudes about potential interventions for increasing error reports. METHODS: A survey on use of incident reports to document medical errors was sent to a random sample of 200 physicians and nurses at a large children's hospital. Items on the survey included proportion of medical errors that were reported, reasons for underreporting medical errors, and attitudes about potential interventions for increasing error reports. In addition, the survey contained scenarios about hypothetical medical errors; the physicians and nurses were asked how likely they were to report each of the events described. Differences in use of incident reports for documenting medical errors between nurses and physicians were assessed with chi(2) tests. Logistic regression was used to determine the association between health care profession type and likelihood of reporting medical errors. RESULTS: A total of 140 surveys were returned, including 74 from physicians and 66 by nurses. Overall, 34.8% of respondents indicated that they had reported <20% of their perceived medical errors in the previous 12 months, and 32.6% had reported <40% of perceived errors committed by colleagues. After controlling for potentially confounding variables, nurses were significantly more likely to report >or=80% of their own medical errors than physicians (odds ratio: 2.8; 95% confidence interval: 1.3-6.0). Commonly listed reasons for underreporting included lack of certainty about what is considered an error (indicated by 40.7% of respondents) and concerns about implicating others (37%). Potential interventions that would lead to increased reporting included education about which errors should be reported (listed by 65.4% of respondents), feedback on a regular basis about the errors reported (63.8%) and about individual events (51.2%), evidence of system changes because of reports of errors (55.4%), and an electronic format for reports (44.9%). Although virtually all respondents would likely report a 10-fold overdose of morphine leading to respiratory depression in a child, only 31.7% would report an event in which a supply of breast milk is inadvertently connected to a venous catheter but is discovered before any breast milk goes into the catheter. CONCLUSIONS: Medical errors in pediatric patients are significantly underreported in incident report systems, particularly by physicians. Some types of errors are less likely to be reported than others. Information in incident reports is not a representative sample of errors committed in a children's hospital. Specific changes in the incident report system could lead to more reporting by physicians and nurses who care for pediatric patients.

Attitude of Health Personnel↗

PubMed2004

Medical errors: overcoming the challenges.

The issue of medical errors has received substantial attention in recent years. The Institute of Medicine (IOM) report released in 1999 has several implications for health care systems in all disciplines of medicine. Notwithstanding the plethora of available information on the subject, little, by way of substantive action, is done toward medical error reduction. A principal reason for this may be the stigma associated with medical errors. An educational program with a practical, informed, and longitudinal approach offers realistic solutions toward this end. Effective reporting systems need to be developed as a medium of learning from the errors and modifying behaviors appropriately. The presence of a strong leadership supported by organizational commitment is essential in driving these changes. A national, provincial or territorial quality care council dedicated solely for the purpose of enhancing patient safety and medical error reduction may be formed to oversee these efforts. The bioethical and emotional components associated with medical errors also deserve attention and focus.

Health Education↗

PubMed1986

Evaluating medication errors.

What is appropriate disciplinary action for medication errors? Believing the severity of the error is a critical factor in determining disciplinary actions, we developed a tool to assess medication error severity. The El Dorado Medication Error Tool (EDMET) is objective and simple to use. It ensures objectivity, fairness, and clarity of expectations for the staff nurse and ensures consistency of scoring medication errors and disciplinary actions among nurse administrators.

Arizona↗

PubMed1986

Evaluating medication errors.

Arizona↗

PubMed2002

Medication errors observed in 36 health care facilities.

BACKGROUND: Medication errors are a national concern. OBJECTIVE: To identify the prevalence of medication errors (doses administered differently than ordered). DESIGN: A prospective cohort study. SETTING: Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado. PARTICIPANTS: A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication-volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered. METHODS: Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians. MAIN OUTCOME MEASURE: Medication errors reaching patients. RESULTS: In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P =.82) or by size (P =.39). Error rates were higher in Colorado than in Georgia (P =.04) CONCLUSIONS: Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.

Accreditation↗

PubMed2006

Standardizing IV infusion medication concentrations to reduce variability in medication errors.

Practical strategies for preventing medication errors in pediatric patients are needed. Medication safety can be improved by assessing current practices, developing evidence-based interventions to improve such practices, evaluating the impact of new evidence-based innovations, and providing feedback to clinicians [20]. Nurses at the point of care are well positioned to identify and implement structures and processes to address medication errors so that the most preventable errors become a thing of the past.

Adverse Drug Reaction Reporting Systems↗

PubMed2002

Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals.

The direct relationships and associations among clinical pharmacy services, pharmacist staffing, and medication errors in United States hospitals were evaluated. A database was constructed from the 1992 National Clinical Pharmacy Services database. Both simple and multiple regression analyses were employed to determine relationships and associations. A total of 429,827 medication errors were evaluated from 1081 hospitals (study population). Medication errors occurred in 5.22% of patients admitted to these hospitals each year. Hospitals experienced a medication error every 22.04 hours (every 19.13 admissions). These findings suggest that at minimum, 90,895 patients annually were harmed by medication errors in our nation's general medical-surgical hospitals. Factors associated with increased medication errors/occupied bed/year were drug-use evaluation (slope = 0.0023476, p=0.006), increased staffing of hospital pharmacy administrators/occupied bed (slope = 29.1972932, p<0.001), and increased staffing of dispensing pharmacists/occupied bed (slope = 19.3784148, p<0.001). Factors associated with decreased medication errors/occupied bed/year were presence of a drug information service (slope = -0.1279301, p<0.001), pharmacist-provided adverse drug reaction management (slope = -0.3409332, p<0.001), pharmacist-provided drug protocol management (slope = -0.3981472, p=0.013), pharmacist participation on medical rounds (slope = -0.6974303, p<0.001), pharmacist-provided admission histories (slope = -1.6021493, p<0.001), and increased staffing of clinical pharmacists/occupied bed (slope = -9.5483813, p<0.001). As staffing increased for clinical pharmacists/occupied bed from the 10th percentile to the 90th percentile, medication errors decreased from 700.98 +/- 601.42 to 245.09 +/- 197.38/hospital/year, a decrease of 286%. Specific increases or decreases in yearly medication errors associated with these clinical pharmacy services in the 1081 study hospitals were drug-use evaluation (21,372 more medication errors), drug information services (26,738 fewer medication errors), adverse drug reaction management (44,803 fewer medication errors), drug protocol management (90,019 fewer medication errors), medical round participation (42,859 fewer medication errors), and medication admission histories (17,638 fewer medication errors). Overall, clinical pharmacy services and hospital pharmacy staffing variables were associated with medication error rates. The results of this study should help hospitals reduce the number of medication errors that occur each year.

Adverse Drug Reaction Reporting Systems↗

PubMed2005

[Pediatric medication errors and their prevention].

Two investigations, one carried out throughout France (PediAD) and the other exclusively in Robert Debré pediatric hospital (PediEM), focus on the difficulties encountered by nursing staff when administering drugs to children, and the risk of medication errors. Medication errors can arise from dysfunctions at all stages of the drugs circuit, and may involve doctors, pharmacists or nursing staff. In pediatric hospitals they are mainly related to the lack of commercial products specifically designed Jor children. In Robert Debré Hospital, only one-third of commercial products in stock are authorized for pediatric use with no age limit. Thus, even in a hospital where drug distribution is entirely computerized (PCS Patient Care System software), where dispensing is based on the DIP system (daily, individual, and personal) but is not con trolled, and where almost all requirements for sterile and non sterile preparations are met but where validation is only partial, the system is far from being error-free. Two major improvements are planned. First, dispensing will be automated in 2006. With the current shortage of pharmacy technicians, this will securitize drug dispensing and provide for therapeutic and economic traceability. Second, integration of a pharmacist within each medical team is being compared with validation of prescriptions by a pharmacist in the hospital pharmacy.

Automation↗

PubMed2001

Development of an ontology to model medical errors, information needs, and the clinical communication space.

Medical errors are common, costly and often preventable. Work in understanding the proximal causes of medical errors demonstrates that systems failures predispose to adverse clinical events. Most of these systems failures are due to lack of appropriate information at the appropriate time during the course of clinical care. Problems with clinical communication are common proximal causes of medical errors. We have begun a project designed to measure the impact of wireless computing on medical errors. We report here on our efforts to develop an ontology representing the intersection of medical errors, information needs and the communication space. We will use this ontology to support the collection, storage and interpretation of project data. The ontology's formal representation of the concepts in this novel domain will help guide the rational deployment of our informatics interventions. A real-life scenario is evaluated using the ontology in order to demonstrate its utility.

Clinical Medicine↗

PubMed2002

Variables associated with medication errors in pediatric emergency medicine.

OBJECTIVE: Medication errors are a common cause of iatrogenic morbidity and mortality. The incidence of medication errors in pediatric emergency departments (EDs) has not been described. The objective of this study was to describe the incidence and type of drug errors in a pediatric ED and determine factors associated with risk of errors. METHODS: A retrospective cohort study was conducted of the charts of 1532 children who were treated in the ED of a pediatric tertiary care hospital during 12 randomly selected days from the summer of 2000. Two pediatricians, blinded to other study variables, independently decided whether a medication error occurred and ranked it according to a severity score. Disagreement was resolved by consensus. RESULTS: Prescribing errors were identified in 10.1% of the charts. The following variables were associated in univariate analysis with an increased proportion of errors: patients seen between 4 AM and 8 AM (odds ratio [OR]: 2.45; 95% confidence interval [CI]: 1.10-5.50), patients with severe disease (OR: 2.53; 95% CI: 1.18-5.41), medication ordered by a trainee (OR: 1.48; 95% CI: 1.03-2.11), and patients seen during weekends (OR: 1.48; 95% CI: 1.04-2.11). Among trainees, there was a higher rate of errors at the beginning of the academic year (OR: 1.67; 95% CI: 1.06-2.64). Logistic regression revealed increased risk for errors when a medication was ordered by a trainee (OR: 1.64; 95% CI: 1.06-2.52) and in seriously ill patients (OR: 1.55; 95% CI: 1.06-2.26). CONCLUSIONS: In the pediatric ED, trainees are more likely to commit prescribing errors, and the most seriously ill patients are more likely to be subjected to prescribing errors.

Child↗

PubMed1995

Nurses' perceptions of harmful outcomes from medication errors.

To determine if factors associated with medication errors explained perceived harmful outcome from such errors, perceptions of vividly recollected medication errors were reported by a convenience sample of 206 hospital-employed RNs and LPNs who completed the Medication Error Risk Profile (MERP). Symptoms related to the error, radiology studies performed, the toxicity of the medication given, adverse drug reaction unrecognized at first, and transfer of the patient to another unit explained 38% of the variance in perceived harmful outcome. The implications of the this study for medical-surgical nurses are explored.

Adult↗

PubMedDate not supplied

[Detection and classification of medication errors at Joan XXIII University Hospital].

INTRODUCTION: Medication errors are multifactorial and multidisciplinary, and may originate in processes such as drug prescription, transcription, dispensation, preparation and administration. The goal of this work was to measure the incidence of detectable medication errors that arise within a unit dose drug distribution and control system, from drug prescription to drug administration, by means of an observational method confined to the Pharmacy Department, as well as a voluntary, anonymous report system. The acceptance of this voluntary report system's implementation was also assessed. MATERIAL AND METHODS: A prospective descriptive study was conducted. Data collection was performed at the Pharmacy Department from a review of prescribed medical orders, a review of pharmaceutical transcriptions, a review of dispensed medication and a review of medication returned in unit dose medication carts. A voluntary, anonymous report system centralized in the Pharmacy Department was also set up to detect medication errors. RESULTS: Prescription errors were the most frequent (1.12%), closely followed by dispensation errors (1.04%). Transcription errors (0.42%) and administration errors (0.69%) had the lowest overall incidence. Voluntary report involved only 4.25% of all detected errors, whereas unit dose medication cart review contributed the most to error detection. CONCLUSIONS: Recognizing the incidence and types of medication errors that occur in a health-care setting allows us to analyze their causes and effect changes in different stages of the process in order to ensure maximal patient safety.

Hospital Units↗

PubMed2003

Database design to ensure anonymous study of medical errors: a report from the ASIPS Collaborative.

Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians.

Computer Security↗

PubMed2005

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.

Research in the last decade has identified medication errors as a more frequent cause of unintended harm than was previously thought. Inpatient medication errors and error-prone medication usage are detected internally by medication error reporting and externally through hospital licensing and accreditation surveys. A hospital's rate of medication errors is one of several measures of patient safety available to staff. However, prospective patients and other interested parties must rely upon licensing and accreditation scores, along with varying access to outcome data, as their sole measures of patient safety. We have previously reported that much higher rates of medication errors were found when an independent audit was used compared with rates determined by the usual process of self-report. In this study, we summarize these earlier findings and then compare the error detection sensitivity of licensing and accreditation surveys with that of an independent audit. When experienced surveyors fail to detect a highly error prone medication usage system, it raises questions about the validity of survey scores as a measure of safety (i.e., lack of medication errors). Replication of our findings in other hospital settings is needed. We also recommend measures for improving patient safety by reducing error rates and increasing error detection.

Cross-Sectional Studies↗

PubMed2006

Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.

CONTEXT: Medical errors are associated with feelings of distress in physicians, but little is known about the magnitude and direction of these associations. OBJECTIVE: To assess the frequency of self-perceived medical errors among resident physicians and to determine the association of self-perceived medical errors with resident quality of life, burnout, depression, and empathy using validated metrics. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic Rochester. Data were provided by 184 (84%) of 219 eligible residents. Participants began training in the 2003-2004, 2004-2005, and 2005-2006 academic years and completed surveys quarterly through May 2006. Surveys included self-assessment of medical errors and linear analog scale assessment of quality of life every 3 months, and the Maslach Burnout Inventory (depersonalization, emotional exhaustion, and personal accomplishment), Interpersonal Reactivity Index, and a validated depression screening tool every 6 months. MAIN OUTCOME MEASURES: Frequency of self-perceived medical errors was recorded. Associations of an error with quality of life, burnout, empathy, and symptoms of depression were determined using generalized estimating equations for repeated measures. RESULTS: Thirty-four percent of participants reported making at least 1 major medical error during the study period. Making a medical error in the previous 3 months was reported by a mean of 14.7% of participants at each quarter. Self-perceived medical errors were associated with a subsequent decrease in quality of life (P = .02) and worsened measures in all domains of burnout (P = .002 for each). Self-perceived errors were associated with an odds ratio of screening positive for depression at the subsequent time point of 3.29 (95% confidence interval, 1.90-5.64). In addition, increased burnout in all domains and reduced empathy were associated with increased odds of self-perceived error in the following 3 months (P=.001, P<.001, and P=.02 for depersonalization, emotional exhaustion, and lower personal accomplishment, respectively; P=.02 and P=.01 for emotive and cognitive empathy, respectively). CONCLUSIONS: Self-perceived medical errors are common among internal medicine residents and are associated with substantial subsequent personal distress. Personal distress and decreased empathy are also associated with increased odds of future self-perceived errors, suggesting that perceived errors and distress may be related in a reciprocal cycle.

Adult↗

PubMed1979

Joint nursing-pharmacy program helps reduce medication errors.

A hospital's nursing and pharmacy staffs have substantially reduced errors in medication administration, especially errors of omission. They have achieved the reductions partly through primary nursing, which demands greater accountability for total patient care, including medication, from each nurse. Other methods and aids include corrective action, special reports and audits, "remainder" cards, and a computer system.

California↗

PubMed1993

Prevention of medication errors. Developing a continuous-quality-improvement approach.

Medication errors can be a serious problem that exposes patients to preventable risks. Although medication errors are often considered primarily a nursing issue, every health care provider plays an important role in medication error prevention. A continuous quality improvement philosophy with involvement of a multidisciplinary team is the optimal method for identifying and correcting the causes of medication errors. Careful analysis of the medication distribution system and identification of system flaws is an integral part of the continuous quality improvement process.

Hospitals, Teaching↗