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PubMed2001

[Medication errors in a neonatal unit].

INTRODUCTION: Medication errors occur as a result of human mistakes or system flaws and could be prevented by studying and modifying the conditions that predispose to errors. In recent years, interest in medical errors has increased because of their health and economic implications. OBJECTIVES: To evaluate the frequency and types of prescribing errors in the Neonatology Unit of the Hospital 12 Octubre before and after an intervention to raise awareness of errors among the medical staff by comparing the frequency of error before and after the intervention. PATIENTS AND METHODS: We conducted a prospective pilot study in two phases. In the first phase, we studied prescribing errors by reviewing 100 prescriptions for newborns admitted to the Intensive or Intermediate Care Units. When the prescriptions were written, the neonatologists were unaware that the study would be performed. Legibility, dose, units used to express medications, route of administration, use of abbreviations, specification of dosage per kilogram of body weight and use of brand names were evaluated. The information was analyzed and an information-training intervention was performed in which the results were made known in a clinical session and recommendations for improving prescriptions were made. In the second phase, another 100 prescriptions were reviewed. The results were compared with those obtained before the intervention using the chi-squared test. RESULTS: In the first phase, 22 % of prescriptions were illegible or doubtful, 4 % contained dose errors and 28 % did not specify the route of administration. After the intervention, 8 % (p 0.005) of prescriptions were illegible, 4 % contained dose errors and 5 % (p 0.0001) did not specify the route of administration. Regarding other quality markers, the percentage of prescriptions specifying dosage per kilogram of body weight increased from 46 % to 78 %. Brand names were used in 21 %. Units were always expressed in abbreviations. All errors were severity index 0 or 1. CONCLUSIONS: The first step in prevention is recognition of mistakes. Increasing awareness among the medical staff of the consequences of errors improved the quality of prescriptions in our department. Awareness of the frequency and type of errors is the first step towards implementing strategies to reduce iatrogeny.

Humans↗
PubMed2004

A community survey of medical errors in New York.

OBJECTIVE: To assess factors related to experiences with medical errors by health care consumers in the community. DESIGN: Using a random telephone survey of New York State residents screened for knowledge of health care utilization, we gathered information about demographic factors, health care attitudes, experiences with the health care system, and use of information to make health care decisions. SETTING: The State of New York, USA. PARTICIPANTS: Adults living in the State of New York who possessed a telephone. INTERVENTIONS: None. RESULTS: Approximately one-fifth (21.1%) of New Yorkers reported that either they or someone in their household had experienced a medical error, with logistic regression models for ever experiencing a household medical error revealed that respondents who were divorced/separated/widowed, African American, and those from higher income households were less likely to report medical errors. Conversely, those between the ages of 30 and 65 years, those who had frequent doctor visits, and those who were better informed about health care were more likely to report them. The results were similar for household medical errors in the past 5 years. In all multivariate models, greater use of medical information was consistently related to experiencing household medical errors. Having a regular doctor, having health insurance, and concern about health care delivery were not related to either of these outcomes. CONCLUSIONS: Our study indicated that one-fifth of New York State households had experienced a medical error, with one in 10 reporting experiencing a household medical error within the past 5 years. Greater knowledge about health care increased the likelihood of reporting a household medical error. Thus, a greater consumer orientation in health care and provision of more medical information may increase rather than reduce the reporting of medical errors by the public.

Adolescent↗
PubMed2002

Evaluating a medical error taxonomy.

Healthcare has been slow in using human factors principles to reduce medical errors. The Center for Devices and Radiological Health (CDRH) recognizes that a lack of attention to human factors during product development may lead to errors that have the potential for patient injury, or even death. In response to the need for reducing medication errors, the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) released the NCC MERP taxonomy that provides a standard language for reporting medication errors. This project maps the NCC MERP taxonomy of medication error to MedWatch medical errors involving infusion pumps. Of particular interest are human factors associated with medical device errors. The NCC MERP taxonomy of medication errors is limited in mapping information from MEDWATCH because of the focus on the medical device and the format of reporting.

Classification↗
PubMed2002

A system of medical error disclosure.

External mandates for medical error disclosure are often justified by potential cost savings, the belief in individual moral obligations in health care, and the concept that patients have rights and providers have responsibilities. Such an approach does not recognise the systems nature of error and outcomes and the important quality role disclosure can play in a system of medical error disclosure. Systems concepts, the patient-provider partnership, and overall quality of care can be enhanced using a system of disclosure that provides for education about the systems nature of error, fulfills the delivery system philosophy of mutual respect, and integrates the patient and his/her family as a partner in the error reduction enterprise. Such a system can result using clear disclosure policies and procedures sensitive to patient and family needs, open communications with concerned, committed, and compassionate system representatives, and use of mediation methods that foster communication, allow for venting, and are flexible in their approach to resolving conflict, including using apology. Although a system may also result in conflict resolution costs, more importantly it may foster and solidify a team approach to reducing errors and promoting patient safety.

Humans↗
PubMedDate not supplied

Pediatric resident education about medical errors.

BACKGROUND: National organizations have called for patient safety curricula to help reduce the incidence of errors. Little is known about what trainees are taught about medical errors. OBJECTIVE: 1) To determine the amount and type of training that pediatric residents have about medical errors and 2) to assess pediatric chief resident knowledge about medical errors. METHODS: We surveyed chief residents from a national sample of 51 pediatric training programs by selecting every fourth program from the American Council on Graduate Medical Education list of accredited programs. The 21-item telephone survey was developed with patient safety specialists and piloted on several chief residents. It asked about patient-safety training sessions and awareness and knowledge about medical errors. RESULTS: The 51 chief residents helped teach 2176 residents, approximately one third of all pediatric residents. One third of programs had no lectures about medical errors and 23% did not have morbidity and mortality rounds. Sixty-one percent of respondents stated that outpatient medical errors were rarely discussed. Informal teaching was most often reported as the primary method for educating residents about medical errors. Although 58% of respondents did not know that a systemic change should be made in response to a medical error, 83% felt that residents are adequately trained to deal with a medical error. DISCUSSION: Pediatric resident education about medical errors varies widely. Attention by pediatric residency training programs to this important issue seems limited.

Analysis of Variance↗
PubMed2006

Reconcilable differences: correcting medication errors at hospital admission and discharge.

BACKGROUND: Medication errors at the time of hospital admission and discharge are common and can lead to preventable adverse drug events. The objective of this study was to describe the potential impact of a medication reconciliation process to identify and rectify medication errors at the time of hospital admission and discharge. METHODS: Sixty randomly selected patients were prospectively enrolled at the time of admission to a Canadian community hospital. At admission, patients' medication orders were compared with pre-admission medication use based on medication vials and interviews with patients, caregivers, and/or outpatient healthcare providers. At discharge, pre-admission and in-patient medications were compared with discharge orders and written instructions. All variances were discussed with the prescribing physician and classified as intended or unintended; unintended variances were considered to be medication errors. An internist classified the clinical importance of each unintended variance. RESULTS: Overall, 60% (95% CI 48 to 72) of patients had at least one unintended variance and 18% (95% CI 9 to 28) had at least one clinically important unintended variance. None of the variances had been detected by usual clinical practice before reconciliation was conducted. Of the 20 clinically important variances, 75% (95% CI 56 to 94) were intercepted by medication reconciliation before patients were harmed. DISCUSSION: Unintended medication variances at the time of hospital admission and discharge are common and clinically important. The medication reconciliation process identified and addressed most of these unintended variances before harm occurred. In this small study, medication reconciliation was a useful method for identifying and rectifying medication errors at times of transition. Reconciliation warrants broader evaluation.

Analysis of Variance↗
PubMedDate not supplied

Nurses' perceptions of causes of medication errors and barriers to reporting.

This study describes nurses' perceptions about medication errors and the effects of physician order entry and barcode medication administration on medication errors. A convenience sample of 61 medical-surgical nurses was surveyed. All nurses surveyed perceived that information technology decreases medication errors. However, medication errors continue to occur despite the availability of sophisticated information technology systems.

Adverse Drug Reaction Reporting Systems↗
PubMed1999

Reported medication errors in community residences for individuals with mental retardation: a quality review.

Medication errors have long been a barometer of quality in the health care arena. A review of medication errors in community residences for individuals with mental retardation managed by one agency was performed. Medication errors were analyzed and compared to data in the literature. Although the frequency of medication errors in these residential settings was less than medication errors in hospital settings, there is concern about how common the medication error experience is: 85% of residents experienced at least one reported medication error. The number of medications administered to residents also doubled in one year. As this population ages, experiences more complex health problems, and takes more medication, medication administration practices will require systematic monitoring.

Adult↗
PubMed2005

Utility of an online medication-error-reporting system.

PURPOSE: The utility of an online medication-error-reporting program was evaluated. METHODS: A survey regarding the utility of Medmarx was developed and mailed to 550 hospitals and health systems that used the medication-error-reporting program. Primary contact persons were identified and asked to gather and report the necessary information to adequately characterize medication-error reporting in their institution before and after implementing the Medmarx system. Potential respondents were contacted four times during the survey period by the United States Pharmacopeia. RESULTS: Of the 550 surveys sent, 200 were returned and 25 were undeliverable, resulting in a response rate of 38%. The average number of medication errors reported internally increased twofold after the adoption of the Medmarx system. Pharmacy departments were most often reported as responsible for medication-safety oversight activities after Medmarx implementation. Most facilities (94%) generated reports from the medication-error database, and 75% used this information to identify 7.0+/-8.1 opportunities to improve their medication-use system annually. Most respondents believed that Medmarx played an integral role in preparing their facility for Joint Commission accreditation surveys (65%), provided a tool for root-cause analysis (71%), and helped identify problems in the medication-use process (85%). The annual costs of the subscription and staff time required to use the system was estimated to be 16,756 dollars+/-21,108 dollars. Sixty-six percent of users were satisfied with the impact the system has had on improving the medication-use process. CONCLUSION: Implementation of the Medmarx system led to an increase in the number of reported medication errors and improvements in the medication-use process.

Adverse Drug Reaction Reporting Systems↗
PubMed2001

[The approaches to factors which cause medication error--from the analyses of many near-miss cases related to intravenous medication which nurses experienced].

Given the complexity of the intravenous medication process, systematic thinking is essential to reduce medication errors. Two thousand eight hundred cases of 'Hiyari-Hatto' were analyzed. Eight important factors which cause intravenous medication error were clarified as a result. In the following I summarize the systematic approach for each factor. 1. Failed communication of information: illegible handwritten orders, and inaccurate verbal orders and copying cause medication error. Rules must be established to prevent miscommunication. 2. Error-prone design of the hardware: Look-alike packaging and labeling of drugs and the poor design of infusion pumps cause errors. The human-hardware interface should be improved by error-resistant design by manufacturers. 3. Patient names similar to simultaneously operating surgical procedures and interventions: This factor causes patient misidentification. Automated identification devices should be introduced into health care settings. 4. Interruption in the middle of tasks: The efficient assignment of medical work and business work should be made. 5. Inaccurate mixing procedure and insufficient mixing space: Mixing procedures must be standardized and the layout of the working space must be examined. 6. Time pressure: Mismatch between workload and manpower should be improved by reconsidering the work to be done. 7. Lack of information about high alert medications: The pharmacist should play a greater role in the medication process overall. 8. Poor knowledge and skill of recent graduates: Training methods and tools to prevent medication errors must be developed.

Communication↗
PubMed1985

A retrospective-prospective study of medication errors: basis for an ongoing monitoring program.

Medication error surveillance is an important component of the quality assurance program of any hospital. The present study was undertaken in an attempt to determine the reliability of data collected retrospectively on medication error forms, as compared to data obtained from a prospective observational study within the same hospital. The results indicate that for many parameters reasonably reliable information can be obtained from voluntarily submitted error reports. Other observations made during the study were also useful to both the nursing and pharmacy departments in their efforts to minimize the occurrence of errors. Based on the information provided by this study, a more formalized medication error surveillance program has been established and a number of changes in the drug distribution and administration systems have been proposed.

Hospital Bed Capacity, 500 and over↗
PubMed2003

A patient empowerment model to prevent medication errors.

Each year, untold deaths occur because of medical and medication errors in the United States. In generally, most people have the naïve perception that the health-care enterprise is a fail-safe system and as such do not take proactive measures to prevent potential medication errors. This paper is timely in light of the proliferation of medication use in outpatient settings and thus warrants the education of patients to take the responsibility in proper drug use. Patients and the health-care professionals must understand the need to see patients as part of the health-care team to ensure quality of care and decrease medication errors. A patient empowerment model to prevent medication error is therefore proposed.

Humans↗
PubMed2006

Reconciliation failures lead to medication errors.

Poor communication of medical information at transition points of care--at admission, transfer, and discharge--often results in medication errors, but various strategies can reduce the likelihood of error.

Documentation↗
PubMed2006

Types of medication errors in North Carolina nursing homes: a target for quality improvement.

BACKGROUND: Medication errors are an important problem in nursing homes, but little is known about the types of medications involved in errors in this setting. Gaining a better understanding of the types of medications commonly involved in medication errors in nursing homes would be an important step toward quality improvement. OBJECTIVES: This study sought to describe the types of medication errors most frequently reported to a statewide repository by North Carolina nursing homes. We also examined whether nursing homes reporting an error involving a drug on the updated Beers list of medications considered potentially inappropriate for use in the elderly were likely to report a greater number of medication errors or more harmful medication errors compared with nursing homes that did not report such an error. METHODS: Medication errors were defined as preventable events that had the potential to cause/lead to or actually caused/led to inappropriate medication use or patient harm. We analyzed summary reports of medication errors submitted to the State of North Carolina by licensed nursing homes for the 9-month period from January 1, 2004, to September 30, 2004, using a Web-based reporting system. Drugs commonly involved in medication errors were summarized for all nursing homes in the state. Errors involving medications on the updated Beers list also were identified. Nursing homes were profiled and compared according to the type of medication error and whether the error reached the patient and/or caused harm. RESULTS: Among the 384 licensed nursing homes included in our analysis, 9272 medication errors were reported. The specific medication involved was documented for 5986 of these errors. The medications most commonly involved in an error were lorazepam (457 errors [8%]), warfarin (349 [6%]), insulin (332 [6%]), hydrocodone and hydrocodone combinations (233 [4%]), furosemide (173 [3%]), and the fentanyl patch (150 [3%]). The medication errors disproportionately included central nervous system agents (16%) and analgesics (11%). Medications considered potentially inappropriate in the elderly were frequently involved in the reported errors (10% of all reported errors), with the greatest number of such errors associated with lorazepam (457 [8%]), alprazolam (130 [2%]), and digoxin (74 [1%]). Nursing homes reporting potentially inappropriate drugs among their 10 most common medication errors also reported a significantly greater mean number of errors compared with nursing homes that did not report such errors (26.9 vs 17.6, respectively; P < 0.001), as well as a significantly greater number of errors that reached the patient (6148 vs 1393; P < 0.001). CONCLUSION: Based on the experience in North Carolina, quality improvement efforts in nursing homes should focus on the medications commonly involved in errors and should continue to discourage or closely monitor the use of medications considered potentially inappropriate in the elderly.

Adverse Drug Reaction Reporting Systems↗
PubMed2004

Nature and causes of clinically significant medication errors in a tertiary care hospital.

PURPOSE: Medication errors identified through solicited error reports in general medicine and specialty units of a major tertiary care teaching hospital were studied to identify prevalent patterns and causes. METHODS: Medication error reports by a multidisciplinary team of eight clinicians at adult medical and surgical, hematology and oncology, bone marrow transplantation, and medical and cardiac intensive care units were collected prospectively over a three-month period. The reports were validated in terms of clinical significance, causality, and true presence of an error by two independent reviewers. Cluster analysis of valid reports (reports accepted by both reviewers) was used to identify prominent error patterns. RESULTS: Of 321 medication error reports, 240 were included in the analysis. Of these, 95 represented manifested errors and the rest near misses (not manifested [94] or averted [51]). Most manifested errors involved uncontrolled infections associated with prescribed underdoses of antiinfectives (23%), renal failure associated with prescribed overdoses of antiinfectives (4%), central-nervous-system drug intoxication following prescribed overdoses (4%), or uncontrolled pain associated with prescribed underdoses (4%). Most errors were initiated during prescribing (72%) and were associated with deficits in pharmacotherapy knowledge (39%) or with failure to consider critical patient information (18%). Errors initiated during dispensing and administration were mostly associated with performance deficits (e.g., accidental slips and lapses). CONCLUSION: A limited number of prevalent medication-error patterns described more than half of all reported errors in a hospital and suggested excellent areas for quality improvement. Error causes varied with the node of the medication-use process where they arose and suggested the need for tailored interventions to improve clinicians' performance.

Anti-Infective Agents↗
PubMed2006

Multiple user considerations and their implications in medical error reporting system design.

OBJECTIVE: The study examined the differences between physicians and clinical assistants in their preferences for a statewide medical error reporting system. BACKGROUND: Medical error reporting systems have been proposed as a means for studying the causes of medical error. Knowledge of user similarities and differences is needed for the development of design guidelines for medical error reporting systems. METHOD: Separate focus groups composed of 8 physicians and 6 clinical assistants (physician clinical support staff) were conducted. One-hour focus group meetings were conducted via toll-free teleconference lines one to two times per month for 9 months. All conversations were audiotaped and transcribed for analysis. An inductive content analysis was conducted. RESULTS: Eighty-six major and minor themes emerged. Differences between physicians and clinical assistants included rules and regulations governing the use of the system, the medium of reporting, and aspects of the organization that may affect reporting levels. CONCLUSIONS: Although physicians and clinical assistants shared similar preferences and beliefs surrounding error reporting, there were differences that need to be considered if medical error reporting systems are to be effective. APPLICATION: To successfully deploy a medical error reporting system, the system itself must be designed for the potential users. This study uncovered previously underappreciated issues that should be incorporated into the design and implementation process. Actual or potential applications of this research include the improvement of the design and implementation of medical error reporting systems to account for the needs of different types of users.

Attitude of Health Personnel↗
PubMedDate not supplied

Nonpunitive medication error reporting: 3-year findings from one hospital's Primum Non Nocere initiative.

OBJECTIVE: To identify underlying practices and attitudes on medication error occurrences and reporting practices. BACKGROUND: In response to a hospital-wide quality improvement initiative, a task force was formed to facilitate a nonpunitive culture toward reporting medication errors. To identify underlying practices and attitudes on medication errors and medication error reporting, a baseline survey was conducted. Based on findings, an initiative that included modifications to clinical and administrative processes was developed and implemented. METHODS: A pre/post initiative questionnaire to measure staff practices and attitudes on medication error reporting was developed and administered. Findings from the presurvey were used to craft the Nonpunitive Patient Safety Policy and its implementation plan. Pre-post comparative analysis was performed following a baseline-postimplementation design. RESULTS: Conceptually, a medication error is qualified by its outcome severity. Medication errors with more serious outcomes are more likely to be reported than those with less serious ones. Staff perception that medication error reporting carries the risks of disciplinary action was identified as a primary barrier to the likelihood of reporting. CONCLUSION: Evaluation of the initiative suggests that a multicomponent approach facilitates positive movement in the direction of a nonpunitive culture toward reporting medication errors.

Attitude of Health Personnel↗