Frequency Of Medication Errors Research Articles

Medication errors: prevention using information technology systems

1. Given the high frequency of medication errors with resultant patient harm and cost, their prevention is a worldwide priority for health systems. 2. Systems that use information technology (IT), such as computerized physician order entry, automated dispensing, barcode medication administration, electronic medication reconciliation, and personal health records, are vital components of strategies to prevent medication errors, and a growing body of evidence calls for their widespread implementation. 3. However, important barriers, such as the high costs of such systems, must be addressed through economic incentives and government policies. 4. This paper provides a review of the current state of IT systems in preventing medication errors.

Medical error prevention: The role of oncological nursing

6591 Background: The medical care of oncological patients is a multidisciplinary task. The nurse is a key member of the team. The aim of this study is to analyze the incidence rate and the type of intravenous chemotherapy prescription errors detected by the nurses in the the ambulatory setting at the IOHM in a 3 months period. Methods: The intravenous chemotherapy treatments (tx) prescribed by the IOHM's staff (14 oncologists and 4 onco-hematologists) between Aug 1, 2008 and Nov 1, 2008, were analyzed. A database was prospectively built with the following variables: attending physician, diagnosis, treatment cycle, drug, dosage, time of perfusion, type of error detected, and potential harm from it. Frequency tables were established for the type of error. The correlation between the rate of errors by prescribing physician and his expertise, weekly hours of work at the institution, number of patients under his care and number of consults were also studied. Results: A total of 5,015 tx administered to 2,492 pt were evaluated (mean of 2.1 tx per pt, range 1–5). The most common cancer diagnoses were breast (20%), colon (16%), lung (10%), and lymphoma (7%). Forty-five medical prescription errors before administration of treatment were found. There were no errors found in the preparation and administration of treatment. Of the 45 errors detected, 18 were related to drug selection (in 2 cases the error could lead to serious complications). Twenty seven errors were related to a dosage mistake (3 cases with serious potential harm). The frequency of medical errors between the attending physicians did not differ statistically (Fisher Exact Test 0.082) and due to the low error rate, none of the other variables could be properly studied. Conclusions: 1. Specialized nursing is a key element in the safety of the patient and the prevention of malpractice, 2. The rate of errors in this population is 0.9% (45 errors out of 5,015) and the rate of potentially serious harm to the patient is 1/1000 tx.; 3) All errors were corrected before drug administration. No significant financial relationships to disclose.

Comment: Frequency of Medication Errors with Intravenous Acetylcysteine for Acetaminophen Overdose

Comment: Frequency of Medication Errors with Intravenous Acetylcysteine for Acetaminophen Overdose

Comment: Frequency of Medication Errors with Intravenous Acetylcysteine for Acetaminophen Overdose

Comment: Frequency of Medication Errors with Intravenous Acetylcysteine for Acetaminophen Overdose

Medication errors in anesthesia: an 8-year retrospective analysis at an urban university hospital

The Japanese Society of Anesthesiologists (JSA) has investigated critical events in several fields of anesthesiology. However, the types, frequency, and characteristics of medication errors related to anesthesia have not been investigated. By analyzing incident reports retrospectively, we investigated medication errors that occurred during anesthetic practice over the past 8 years at our institution. Incident reports related to medication errors that occurred between May 1999 and March 2007 were analyzed retrospectively using a questionnaire published by the JSA in the "Survey of medication errors related to anesthesia". During these 8 years, 233 incidents were reported, in a total of 27454 anesthesia cases conducted during this period. Of these incidents, 61 (26.2%) were anesthetic drug administration errors. In these 61 incidents, clerical error (e.g., erroneous prescription writing), and pre-error (defined as any incident with the potential to become an error) were excluded from the analysis. Consequently, 13 incidents were excluded and 48 incidents were analyzed. Medication errors due to overdose were the most frequent kind of error (25%), followed by substitution (23%), and omission (21%). Errors due to an incorrect route of administration were rare. The drugs most frequently involved in these errors were antibiotics and muscle relaxants. Most of the patients involved in the incidents were, fortunately, not harmed seriously. The total frequency of medication errors in the survey period was 0.175% (48 incidents in 27 454 total anesthesia cases). We found that overdose, substitution, and omission were the main causes of anesthesia-related medication errors in our department.

The Effect of Nurse Staffing Patterns on Medical Errors and Nurse Burnout

Hospital administrators frequently rely on the use of mandatory or voluntary overtime to cover staff nurse vacancies. This practice is common in the perioperative setting, but it can lead to staff-member fatigue that may adversely affect patient safety. This literature review explores the effect that nurse staffing patterns have on the frequency of medical errors, fatigue, and nurse burnout. The evidence indicates that inadequate nurse staffing leads to adverse patient outcomes and increased nurse burnout. Hospital administrators should invest in adequate nurse staffing to improve patient safety and increase nurse retention.

Frequency of Medication Errors with Intravenous Acetylcysteine for Acetaminophen Overdose

Acetadote, an intravenous preparation of acetylcysteine, became commercially available in the US in June 2004 for the treatment of acetaminophen poisoning. The dosing regimen is complex, consisting of a loading dose followed by 2 maintenance doses, each with different infusion rates. To analyze the frequency of medication errors related to the complex dosing regimen for intravenous acetylcysteine. A retrospective chart review of a regional poison center's records was performed for all patients treated with intravenous acetylcysteine from August 1, 2006, to August 31, 2007. Data collected included acetylcysteine dose, infusion rate, interruptions in therapy, unnecessary administration, and medical outcome. Records that revealed medication errors were further examined for the time and location of the errors. There were 221 acetaminophen overdose cases treated with intravenous acetylcysteine that met inclusion criteria. Of these, 84 medication errors occurred in 74 (33%) patients. The frequency and types of errors were 1.4% incorrect dose, 5% incorrect infusion rate, 18.6% more than 1 hour of interruption in therapy, and 13.1% unnecessary administration. The frequency and types of medication errors in pediatric patients were similar to those in the total patient population. Errors occurred most frequently in the emergency department compared with intensive care units or general medical floors. In addition, errors occurred most frequently on third shift, compared with first or second shift. Evaluation of medical outcomes in cases involving acetaminophen only found that medication errors did not have an impact on coded outcomes. Medication administration errors occur frequently with intravenous acetylcysteine. Awareness of this problem, coupled with increased vigilance in identifying factors associated with errors, should decrease medication errors with intravenous acetylcysteine therapy for acetaminophen poisoning.

Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: An observational study

To determine the frequency of medication errors that occurred during the preparation and administration of IV drugs in an intensive care unit. The study was conducted in a 12-bed intensive care unit of one of the largest teaching hospitals in Tehran. Data were collected over 16 randomly selected days at different medication round times, between July and September 2006. A trained observer accompanied nurses during intravenous (IV) drug rounds. Medication errors were recorded during the observation times of IV drug administration and preparation. Drugs with the highest rate of use in the intensive care unit (ICU) were selected. Details of the process of preparation and administration of the selected drugs were compared to an informed checklist which was prepared using reference books and manufacturers' instructions. We observed a total of 524 preparations and administrations. The calculated number of opportunities for error was 4040. The number of errors identified were 380/4040 (9.4%). Of those, 33.6% were related to the preparation process and 66.4% to the administration process. The most common type of error (43.4%) was the injection of bolus doses faster than the recommended rate. Amikacin was involved in the highest rate of error (11%) among all the selected medications. It was found that the IV rounds conducted at 9:a.m. had the highest rate of error (19.8%). No significant correlation was found between the rate of error and the nurses' age, sex, qualification, work experience, marital status, and type of working contract (permanent or temporary). Since our system is devoid of a well-organized reporting system, errors are not detected and consequently not prevented. Administrators need to take the initiative of developing systems that guarantee safe medication administration.

Effect of pharmacists on medication errors in an emergency department

The frequency of medication errors in an emergency department (ED) before and after an ED pharmacist was assigned to check medication orders was studied. A retrospective chart review was conducted for any patient admitted to the ED of a large rural hospital between November 6, 2005, and December 6, 2005 (control group), or between November 6, 2006, and December 6, 2006 (intervention group). For the control group, no pharmacist was present in the ED to check drug orders; for the intervention group, a pharmacist was present. Potential errors in medication orders were identified and validated. A total of 490 medication orders written for 198 patients were evaluated for errors. The control group (n = 94) and the intervention group (n = 104) did not differ significantly with respect to age, sex, race, or number of medication orders. A total of 37 and 14 medication errors were identified for the control and intervention groups, respectively. The rate of errors was 16.09 per 100 medication orders for the control group compared with 5.38 per 100 orders for the intervention group, a 66.6% difference (p = 0.0001). The ED pharmacists made 183 recommendations, of which 98.6% were accepted. The rate of medication errors in the ED decreased significantly when pharmacists prospectively reviewed ED medication orders.

Medication Error: A Leading Cause of Anesthesia-related Morbidity and Mortality

We read with great interest the analysis of anesthesia-related deaths registered by the Danish Patient Insurance Association.1Hove et al. 1are to be congratulated for reporting these important results. The authors categorized 24 fatal cases by their underlying causes: airway management, ventilation management, placement of a central venous catheter, medication errors, transfusion error, infusion pump problems, and regional blockade. We noted that 8 of the 24 anesthesia-related deaths described were most likely attributable to a drug error: 4 overdoses (benzodiazepines, methohexital, thiopental, nitroglycerine), 3 infusion pump errors, and 1 patient likely received a large intrathecal dose of mepivacaine. Therefore, the frequency of medication-related incidents exceeded the 4 deaths that resulted from loss of the airway and 4 from complications related to central venous line insertion. It seems that the single most common cause of anesthetic-related death was a drug error.These findings are consistent with an analysis from the Canadian Medical Protective Association of closed medicolegal claims against anesthesiologists.2The Canadian Medical Protective Association provides malpractice insurance for most physicians in Canada. From 1998 to 2002, there were 232 closed legal actions against anesthesiologists. Medication error was the most common cause involving 52% of the claims. It is noteworthy that the American Society of Anesthesiologists Closed Claims Project reports the proportion of drug errors as 4%.2This number has been consistent throughout the 1980s and 1990s. Reasons for the discrepancy in the relative frequency of medication errors reported in the American Society of Anesthesiologists Closed Claims Database from those in Demark and Canada requires further exploration but may be attributed, in part, to differences in the categorization of root causes.The impact of drug error in anesthetic practice is not new and will not surprise experienced anesthesiologists. A survey by the Canadian Anesthesiologists' Society found that 85% of participants had experienced at least one drug error or “near miss.”3Most of these errors were of minor consequence; however, 1.8% resulted in major morbidity (cardiac arrest, stroke, permanent injury) or death. The misidentification of a syringe was the most common cause. In 1984, Cooper et al. 4published a classic analysis of critical incidents in anesthesia management. Breathing circuit disconnect was the most common identified factor; however, reanalyzing their data set indicates that medication-related events far exceeded airway and ventilation problems. Of a total of 507 incidents, 169 were attributed to errors or problems in drug administration. Equally important, when incidents with “substantive negative outcomes” were further analyzed (defined as mortality, cardiac arrest, cancelled operative procedure, or extended recovery room, intensive care unit, or hospital stay) approximately 25% of them resulted from a drug error.Together, these studies suggest that the impact of medication error has been underestimated by the lack of a common taxonomy for anesthesia-related adverse events. More importantly, the data beseech us to acknowledge the problem and develop innovative strategies to reduce the likelihood of a drug error in anesthetic practice.*University of Toronto, Toronto, Ontario, Canada. rachel.meyer@utoronto.ca

Uncertainties in the selection of applicants for medical school

Decisions about admissions to medical school are based on assessments of the applicants' cognitive achievements and non-cognitive traits. Admission criteria are expected to be fair, transparent, evidence-based and legally defensible. However, unlike cognitive criteria, which are highly reliable and moderately valid, the reliability and validity of the non-cognitive criteria are low or uncertain. Their uncertain predictive value is due not only to their limited validity, but also to the unknown prevalence of the desirable non-cognitive traits in the applicants' pool. Consequently, the use of non-cognitive admission criteria inevitably leads to rejection of an unknown proportion of applicants who have a desirable trait and selection of applicants who lack this trait. We propose that, rather than using non-cognitive admission criteria, admission officers should assist prospective applicants to make informed decisions based on a reflective self-appraisal whether or not to apply to medical school. To this end, medical schools should disseminate information on the strains of medical training and practice, the frequency of medical errors and the most common causes of dissatisfaction and burn-out among practicing physicians. Such information may improve the self-selection process and thereby enrich the applicants' pool for individuals with appropriate motivation. The final selection of medical students may then be based either on past academic achievements, or on a lottery, or on various combinations thereof.

Improving Medication Safety in the ICU: The Pharmacist's Role

Purpose The clinical impact of a critical care pharmacist in reducing medication errors in the intensive care unit (ICU) setting was evaluated. Methods The study was divided into two 8-week phases: control phase without a critical care pharmacist and an ICU pharmacist phase with a critical care pharmacist. During both phases, pharmacy staff documented interventions using an electronic documentation system. Interventions that could be classified as medication errors were categorized by type of error and whether they were “averted” (intervention accepted) or “not averted” (intervention not accepted). The type and frequency of medication errors, number of medication errors “averted,” and clinical outcomes associated with the medication errors were compared between the control and ICU pharmacist phases. Results There was no significant difference between the groups for gender and mean age. Of the 267 interventions included in the ICU pharmacist phase, 256 were classified as medication errors compared with 54 of 58 interventions for the control phase. The average number of medication errors per day was significantly higher during the ICU pharmacist phase (4.27 ± 5.2) compared with the control phase (0.92 ± 1.29, P < 0.0001). The number of medication errors “averted” was higher in the ICU pharmacist phase compared with the control phase (212 vs 50). The “averted” medication errors during the ICU pharmacist phase were related to a higher percentage of improved or resolved clinical outcomes compared with the control phase (66/194 [34%] vs 7/46 [15.2%], P = 0.013). Conclusion A critical care pharmacist improves medication safety by identifying and preventing medication errors and improving outcomes.

Incidence and Nature of Medication Errors in Neonatal Intensive Care with Strategies to Improve Safety

Neonates are highly vulnerable to medication errors because of their extensive exposure to medications in the neonatal intensive care unit (NICU), the general lack of evidence on pharmacotherapeutic interventions in neonates and the lack of neonate-specific formulations. We searched PubMed and EMBASE to identify relevant original studies published in the English language. Eleven studies were identified on the frequency of medication errors in the NICU. The highest rate was 5.5 medication errors per 100 prescriptions; however, medication error rates varied widely between studies, partly due to differences in the definition of an error and the rigor of the method used to identify medication errors. Furthermore, studies were difficult to compare because medication error rates were calculated differently. Most studies did not assess the potential clinical impact of the errors. The majority of studies identified dose errors as the most common type of error. Computerised physician order entry and interventions by clinical pharmacists (e.g. the participation of pharmacists in ward rounds and review of patients' prescriptions prior to dispensing) were the most common interventions suggested to improve medication safety in the NICU. However, only very limited data were available on evaluation of the effects of such interventions in NICUs. More research is needed to determine the frequency and types of medication errors in NICUs and to develop evidence-based interventions to improve medication safety in the NICU setting. Some of these research efforts need to be directed to the establishment of clear definitions of medication errors and agreement on the methods that should be used to measure medication error rates and their potential clinical impact.

Health care work environments, employee satisfaction, and patient safety

Experts continue to decry the lack of progress made in decreasing the alarming frequency of medical errors in health care organizations (Leape, L. L., & Berwick, D. M. (2005). Five years after to err is human: What have we learned?. Journal of the American Medical Association, 293(19), 2384-2390). At the same time, other experts are concerned about the lack of job satisfaction and turnover among nurses (. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press). Research and theory suggest that a work environment that facilitates patient-centered care should increase patient safety and nurse satisfaction. The present study began with a conceptual model that specifies how work environment variables should be related to both nurse and patient outcomes. Specifically, we proposed that health care work units with climates for patient-centered care should have nurses who are more satisfied with their jobs. Such units should also have higher levels of patient safety, with fewer medication errors. We examined perceptions of nurses from three acute care hospitals in the eastern United States. Nurses who perceived their work units as more patient centered were significantly more satisfied with their jobs than were those whose units were perceived as less patient centered. Those whose work units were more patient centered reported that medication errors occurred less frequently in their units and said that they felt more comfortable reporting errors and near-misses than those in less patient-centered units. Patients and quality leaders continue to call for delivery of patient-centered care. If climates that facilitate such care are also related to improved patient safety and nurse satisfaction, proactive, patient-centered management of the work environment could result in improved patient, employee, and organizational outcomes.

Errors Associated With Applying Decision Support by Suggesting Default Doses for Aminoglycosides

Medication errors, and the resultant adverse drug events (ADEs), are one of the main preventable causes of morbidity and mortality. Computerised physician order entry (CPOE) is reported to reduce the frequency of these errors. However, CPOE systems themselves may be associated with errors. The aim of this study was to investigate the effects of a CPOE system that displays an initial default dose for gentamycin and tobramycin administration on the frequency of medication errors and potential ADEs in patients with renal insufficiency. Gentamycin and tobramycin prescriptions from the CPOE records of a Dutch tertiary adult intensive care unit were retrospectively compared with doses recommended by a locally developed guideline. The default dose for gentamycin and tobramycin in the CPOE system is 240 mg/day. A dose prescribing error was defined as an administered dose that exceeded the recommended dose by >10%. Three hundred and ninty two prescriptions, relating to 253 patients (of whom 184 had renal insufficiency), were analysed. There was a high frequency (58%, 227 of 392) of prescriptions that used the CPOE system's default dose of 240 mg/day. The dose was wrong in 73% (165) of these orders. Default orders for patients with renal insufficiency amounted to 52% (132 of 259). A total of 86% (113 of 132) of these resulted in potential ADEs compared with 53% (66 of 124) for the rest of orders (p < 0.0001). A markedly high frequency of prescriptions followed the default dose value and, in patients with renal insufficiency, there was a high frequency of doses exceeding the guideline recommendation (+10%), amounting to potential ADEs. Initial CPOE dose values for prescribing gentamycin and tobramycin, which are based on a fixed default value, form a source of potential ADEs for patients with renal insufficiency.

Errors in the medication process: frequency, type, and potential clinical consequences

To investigate the frequency, type, and consequences of medication errors in more stages of the medication process, including discharge summaries. A cross-sectional study using three methods to detect errors in the medication process: direct observations, unannounced control visits, and chart reviews. With the exception of errors in discharge summaries all potential medication error consequences were evaluated by physicians and pharmacists. A randomly selected medical and surgical department at Aarhus University Hospital, Denmark. Eligible in-hospital patients aged 18 or over (n = 64), physicians prescribing drugs and nurses dispensing and administering drugs. Frequency, type, and potential clinical consequences of all detected errors compared with the total number of opportunities for error. We detected a total of 1065 errors in 2467 opportunities for errors (43%). In worst case scenario 20-30% of all evaluated medication errors were assessed as potential adverse drug events. In each stage the frequency of medication errors were-ordering: 167/433 (39%), transcription: 310/558 (56%), dispensing: 22/538 (4%), administration: 166/412 (41%), and finally discharge summaries: 401/526 (76%). The most common types of error throughout the medication process were: lack of drug form, unordered drug, omission of drug/dose, and lack of identity control. There is a need for quality improvement, as almost 50% of all errors in doses and prescriptions in the medication process were caused by missing actions. We assume that the number of errors could be reduced by simple changes of existing procedures or by implementing automated technologies in the medication process.

The psychology of error in relation to medical practice

There is a broad effort underway to reduce the frequency of medical error. This effort will be facilitated by understanding the causes of human error and the methods that serve to reduce it in settings comparable to medical practice. To serve this end, this article is a review of cognitive psychology as it relates to the origins of human error and an application of that material to issues that arise in medical practice.

The Real Cost of Process Safety—A Clear Case for Inherent Safety

This paper takes a deep look at the costs related to process safety. It is not confined to the costs of trips and alarms, compliance with regulations and worker training, but also takes into consideration many aspects considered standard process design practice. In reality, these practices have evolved due to process safety considerations, for example, use of a pressure vessel as a reactor instead of an open vat. The scenario considered is a simple process of making salt solution (sodium chloride dissolved in hydrogen monoxide, H2O). It is carried out in open vats. New tests indicate that hydrogen monoxide is indeed very hazardous, since it is made up of extremely hazardous hydrogen and a very active supporter of fire, oxygen. Hence, the company has to comply with all the applicable process safety regulations and modify the plant accordingly. Factors that affect the cost due to the hazardous nature of operation have been listed. While the exact cost would vary from one plant to another, this cost could, according to our thinking, amount up to one-third to one-half, or even more, of the capital and operating costs of the new plant handling the hazardous operations. The vision of the process industry globally is zero hazards and zero accidents. The costs of running the hazardous process mentioned in this paper would hopefully drive the industry to consider inherently safer systems, green chemistry, process intensification, and the like. Just imagine if process plants, at some later date, cost only one-third to one-half of their current counterparts, and are significantly safer too! How much cheaper would the cost of living become, since we use chemicals in one form or the other, throughout the day? Corporate profits would increase and process-related liabilities would (almost) disappear. The regulations too would be reduced to just a few, as would the number of regulators. Successful application of inherently safer concepts in the process industry will motivate other accident-prone industries such as construction, mining and transport. It may even decrease the frequency of medical errors by encouraging development of inherently safer medical equipment, techniques, and procedures.

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

Medication errors are common, costly, and injurious to patients. To review the role of information technology in decreasing pediatric medication errors in both inpatient and outpatient settings. We performed a literature review of current information technology interventions. 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. 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.

American College of Medical Informatics FELLOWS, 2000

David Bates is Chief, Division of General Medicine at Brigham and Women's Hospital, and Medical Director, Clinical and Quality Analysis at Partners HealthCare System, Inc. He is also an Associate Professor in Medicine at Harvard Medical School and has a joint appointment at Harvard School of Public Health in the Department of Health Policy and Management. Dr. Bates received his BS degree in Chemistry from Stanford University, his MD from Johns Hopkins School of Medicine, and his MSc from Harvard School of Public Health (Department of Health Policy and Management). He completed residency training in internal medicine at the Oregon Health Sciences University and a postdoctoral research fellowship in medicine at the Harvard Medical School. Dr. Bates' primary informatics interest has been the use of computerized decision support to improve safety and thereby reduce the costs of care. A particular focus has been on improving the systems by which drugs are given, to reduce the frequency of medication errors and adverse drug events. One study he led demonstrated that implementation of computerized physician order entry reduced the rate of serious medication errors by 55 percent. Other research interests include affecting physicians' decision making, particularly using computerized interventions; quality of care and cost-effectiveness in medical practice; and outcomes assessment. Dr. Bates has been the recipient of numerous awards, including a National Research Service Award; the Henry Christian Award for Excellence in Research; the Culpeper Award; the Young Investigator of the Year from the Society of General Internal Medicine, Northeast Region; Clinical Investigator of the Year, Center for Healthcare Information Management; the Partners in Excellence Award Quality Treatment and Service and Leadership and Innovation; and the Cheers Award for Outstanding Contribution to Medication Error Prevention from the Institute for Safe Medication Practices. Dr. Bates is a Scientific Advisor, SCRIPT Project, Health Care …