Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects. Twenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors
According to a report by The Institute of Medicine, medical errors were associated with up to 98,000 deaths and more than 1 million injuries each year in the United States. These errors can result in poor outcomes, which increase harm or death. According to the Pennsylvania Patient Safety Reporting System, up to 15% of errors reported cite automated dispensing cabinets as the source of the drug involved in the error.Nearly 58% to 70% of hospitals nationwide use automated dispensing cabinets. Nurses play a critical role in promoting patient safety by surveilling and intercepting any possible errors that could occur during patient care, especially with medication administration. The purpose of this integrative literature review was aimed at exploring and analyzing research on various ways to decrease medication administration errors associated with automated dispensing system usage. The methods used to conduct this literature review included a search of the following databases: CINAHL Complete, PubMed,
To examine characteristics of verbal consultation about medication within social networks of hospital inpatient medication system, and their associations with medication error reporting. The setting was a 90-bed provincial district hospital with 4 wards, 7 physicians, 5 pharmacists, 44 nurses, 5 pharmacist assistants, and 4 unskilled ancillary workers. A mixed method comprising (i) a prospective observational study for investigating incidences and the nature of reporting medication errors, and (ii) a social network analysis for patterns of interaction. Out of 5296 prescriptions, 132 medication errors were reported during the one month study period: an incidence rate of 2.5%. Every incident of medication errors was formally documented through pharmacists. The most frequent medication errors were in pre-transcribing (n = 54; 40.9%). The pharmacists were central in the whole network of consultation on medication with the mean in-degree centrality of 35 (SD 14.9) and mean out-degree centrality of 15.4 (SD
Session presented on Sunday, July 24, 2016: Purpose: To assess senior baccalaureate nursing students self-rated competence of safe medication administration and their actual competence to do so by using simulation scenario. Methods: This is a cross-sectional, descriptive study. A self-rated questionnaire of safe medication administration was developed. Participants were asked to rate levels of their knowledge, confidence, competence, and experience in safe medication administration by 5-point Likert scale (0 is none, and 5 is always) before the simulation scenario. The higher points the participants give, the higher levels of confidence the participants think that they have. A simulation scenario was developed to assess participants competence in applying the six rights (right patient, right medication, right dose, right time, right route, and right reason) at the medication administration phase. Participants were expected to identify nine errors, including: 1). Use two-identifiers to identify ...
TY - JOUR. T1 - Computer calculated dose in paediatric prescribing. AU - Kirk, Richard C.. AU - Goh, Denise Li Meng. AU - Packia, Jeya. AU - Kam, Huey Min. AU - Ong, Benjamin K C. PY - 2005/10/17. Y1 - 2005/10/17. N2 - Background and objective: Medication errors are an important cause of hospital-based morbidity and mortality. However, only a few medication error studies have been conducted in children. These have mainly quantified errors in the inpatient setting; there is very little data available on paediatric outpatient and emergency department medication errors and none on discharge medication. This deficiency is of concern because medication errors are more common in children and it has been suggested that the risk of an adverse drug event as a consequence of a medication error is higher in children than in adults. Objective: The aims of this study were to assess the rate of medication errors in predominantly ambulatory paediatric patients and the effect of computer calculated doses on ...
Developed by the hospital and the Cerner Corp. Bonuses Facilities are cutting staff to the bone for the sake of the almighty dollar. Preventing Medication Errors In Nursing Central cord syndromeName* First Last Email address* Zip/Postal Code* ZIP / Postal Code This iframe contains the logic required to handle AJAX powered Gravity Forms. Reducing Medication Errors In Nursing Practice The solution was to have pharmacy technicians record complete medication histories on a form. Graham, PharmD Cynthia Chan Huang, PharmD, MBA Fred Plageman, PharmD Editorial Advisor and Clinical Practice Consultant for Nurse Practitioners Emily K. news PharmacopeiaThe Medication Errors Reporting (MER) Program, in cooperation with the Institute for Safe Medication Practices, is a voluntary national medication error reporting program.12601 Twinbrook ParkwayRockville, MD 20852 (800) 23-ERROR (233-7767)www.usp.orgMedMARXUSPs anonymous An untrained prescriber may not be aware of the drug-drug interaction. in Kansas City, ...
There is no "typical" medication error, and health professionals, patients, and their families are all involved. Heres an example: While caring for Morris Wilson, age 72, Nurse Jessica notices his heart rhythm has suddenly changed to ventricular tachycardia. One recent critique (Berger and Kichak, 2004) of two key studies on the medication-related safety benefits of CPOE (Bates et al., 1998, 1999) suggested that while CPOE (with decision support) has Medication Errors Articles Rather than simply letting the doctor write you a prescription and send you on your way, be sure to ask the name of the drug. Consider having a drug guide available at all times. Have the physician (or another nurse) read it back. Preventing Medication Errors: Quality Chasm Series. check my blog The American Society of Health-System Pharmacists has produced guidelines on how to improve the antineoplastic medication-use system and error prevention programs for all care settings (ASHP, 2002). line, she realizes her mistake. ...
According to a new research study, computerized provider order entry (CPOE) systems are effective in reducing the frequency of medication errors in inpatient acute-care settings. The researchers conducted a systematic literature review and applied random-effects meta-analytic techniques to derive a summary estimate of the effect of CPOE on medication errors using data from the American Hospital Association (AHA) Annual Survey and the Electronic Health Record Adoption Database.. The researchers, led by David C. Radley, Ph.D., who is a senior analyst and project director for The Commonwealth Fund Health System Scorecard and Research Project, a grant-funded position located at the Institute for Healthcare Improvement, discovered that processing a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48 percent. "Given this effect size, and the degree of CPOE adoption and use in hospitals in 2008, we estimate a 12.5 percent reduction in medication errors, ...
In a medication error report that the Food and Drug Administration (FDA) published last Fall, it estimated that over a million US citizens are injured each year from various medication errors and that one person dies each day from a medication error. A medication error can occur at any place along the prescription drug distribution…
To the Editor:-This correspondence is to inform the reader of a potential for drug administration error. An adult patient underwent general endotracheal anesthesia for laparoscopic cholecystectomy. The anesthetic consisted of isoflurane, oxygen, and intravenous narcotic. Neuromuscular blockade for intubation was achieved using rocuronium. At the conclusion of the operation, the patient was breathing spontaneously and had three twitches on train-of-four stimulation. The neuromuscular blockade was reversed using glycopyrrolate and neostigmine. Shortly thereafter, the patients respiratory efforts ceased. At this point, no twitches could be elicited by train-of-four stimulation. We discovered that rocuronium, rather than glycopyrrolate, had been used for reversal of the muscle relaxant. The patient remained intubated during general anesthesia until reversal of neuromuscular blockade was possible. The patient was then extubated and had an uneventful recovery ...
This prospective, direct-observation study examined medication administration accuracy of medications dispensed by nurses and caregivers in long-term care facilities. Investigators compared medication administration from original medication packaging to administration from multicompartment medication devices. The team observed nearly 2500 doses.
OBJECTIVE. Although initial research suggests that computerized physician order entry reduces pediatric medication errors, no comprehensive error surveillance studies have evaluated the effect of computerized physician order entry on children. Our objective was to evaluate comprehensively the effect of computerized physician order entry on the rate of inpatient pediatric medication errors. METHODS. Using interrupted time-series regression analysis, we reviewed all charts, orders, and incident reports for 40 admissions per month to the NICU, PICU, and inpatient pediatric wards for 7 months before and 9 months after implementation of commercial computerized physician order entry in a general hospital. Nurse data extractors, who were unaware of study objectives, used an established error surveillance method to detect possible errors. Two physicians who were unaware of when the possible error occurred rated each possible error. RESULTS. In 627 pediatric admissions, with 12 672 medication orders ...
Health,...Two reports show promise of computers pharmacists for proper prescrib...MONDAY April 27 (HealthDay News) -- Medication errors and adverse dru...Medication errors are one of the most common medical errors affecting...In the first report researchers led by Dr. Jeffrey L. Schnipper of B...,Medication,Errors,Could,Be,Cut:,Experts,medicine,medical news today,latest medical news,medical newsletters,current medical news,latest medicine news
The Institute for Safe Medication Practices (ISMP) is devoted entirely to medication error prevention and safe medication use. ISMP represents over 30 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. The organization is known and respected worldwide as the premier resource for impartial, timely, and accurate medication safety information.
However, the health care system as a whole and on an individual institute basis has been working to create a safer environment for patients. The patient was placed on supplemental oxygen and a 0.5 mg (1:1000) dose of epinephrine was ordered. Medication Error Case Report To fix this, set the correct time and date on your computer. Real Life Case Study Involving Medication Error Institute of Medicine: Washington, DC; 2000. A subsequent ECG indicated her ST levels had returned to baseline. http://dlldesigner.com/medication-error/nurse-error-medication.php References Kohn LT, Corrigan JM, Donaldson MS (eds). In: Cohen RM, ed. Medical errors are responsible for injury in 1 out of every 25 hospital patients and result in more deaths than those caused by car accidents, breast cancer, or AIDS individually.1 Consequences Medication Errors Case Reports Allowing a website to create a cookie does not give that or any other site access to the rest of your computer, and only the site that created the cookie ...
Whats more, not all electronic medication J Am Med if clinicians arent familiar with the specific medication. Now Altocor is called Altoprev, and the agencyPract. 2016;20:139-146.These medications include antidiabetic agents (e.g., insulin), oral anticoagulantspatients suffered loss of function.. For example, the intravenous anticoagulant heparin is considered one BMJ Qual error policy Reporting Medication Errors In Nursing The investigators found that error reports increased as well as intercepted error notes, safety committee reports, patient care rounds, and change-of-shift reports. error 2014;44(4):65-7.. be taught to withdraw 0.3 mL insulin in a tuberculin syringe. Transitions in care are also a well-documented medication illustrated in Figure 1.Journal Article › Study day, does that mean eight hours apart exactly or at mealtimes? Are there any medications, beverages, 1995;274:29-34. ISMP Medicationone in three vaccine errors associated with age-related factors. Medication Error Policy ...
Medication errors are one of the most common incidents leading to adverse events in healthcare worldwide. Tackling these major problems requires the implementation of a systems approach to healthcare, stating that risks should be managed proactively by improving the healthcare system. One of the recommended key strategies for learning from medication errors and risk prone processes is the establishment of local and national medication error reporting (MER) systems in healthcare. This study explored national and local MER systems in different countries and what makes them work in learning from medication errors. The study also explored how continuing education in medication safety could be organised for practicing healthcare professionals. The study applied both qualitative and quantitative research methods and utilized various data sources. The study was based on the theory of Human Error and the systems approach to risk management. The study comprised of three phases. Phase I explored the ...
Who reviews medical error reports for human drugs? Meet FDAs Division of Medication Error Prevention and Analysis. According to the National Coordinating Council for Medication Error Reporting and Prevention,
The genome provides a precise biological blueprint of life. To implement this blueprint correctly, the genome must be transcribed with great precision. Here, we demonstrate that this process is inherently error-prone and that transcription errors can occur in any gene, at any location, and affect every aspect of protein structure and function. In addition, we describe how numerous proteins maintain the fidelity of transcription, including proteins associated with RNAPI, RNAPII, and the NMD. These observations provide the first comprehensive analysis of the fidelity of transcription in eukaryotic cells. Furthermore, with the modified protocol of the circle-sequencing assay we describe here, it will be possible to examine transcriptional fidelity in an even greater detail. For example, by mimicking our analysis of Rpa12Δ, Rpb1E1103G, Rpb9Δ, and Dst1Δ cells, it will be possible to identify every gene that controls the fidelity of transcription-for all four major RNA polymerases in eukaryotic ...
The extent to which healthcare students are involved in medication errors is relatively unexplored. Professional organizations, healthcare facilities, and professional schools can help reduce the risk of student-involved errors by implementing key strategies, including incorporation of didactic and experiential medication safety content into school curricula and on-site training programs.
A confidential, self-reporting survey was sent out to all 65 anaesthetists (25 specialists and 40 registrars) in the Department of Anaesthesia at the University of Cape Town with the aim of determining the incidence and possible causes of wrong drug administrations. The response rate was 95%. 93.5 % of respondents admitted to having administered the wrong drug at some stage of their anaesthetic career. 19/62 (30.6%) have injected the wrong drug or the correct drug into the wrong site on at least three occasions. 56.9 % of incidents involved muscle relaxants with suxamethonium chloride administered instead of fentanyl accounting for nearly a third of cases. 17.6 % of reported incidents were classified as being dangerous, with the potential to cause either severe haemodynamic instability and / or neurological damage or seizures.
A new analysis points to surprisingly low rates of serious impacts from medication errors affecting nursing home residents, despite the fact that these errors remain fairly common. The investigators noted that its unclear whether medication errors resulting in serious outcomes are truly infrequent or are under-reported due to the difficulty in ascertaining them. The findings are published in the Journal of the American Geriatrics Society.
Of 14,041 medication administrations and 3,082 order transcriptions reviewed, approximately 30, 52, and 17% were observed in medical, surgical, and intensive care units, respectively. There was a 41.4% relative reduction in nontiming errors in units that used the bar-code eMAR (P , 0.001). The most common types of errors in units that did versus those that did not use the system included errors in oral versus nasogastric tube administration (4.4% vs . 3.6%), administration documentation (2.9 vs . 0.6%), dose (2.0 vs . 1.1%), and wrong medication (1.0 vs . 0.4%). Errors occurred more frequently in surgical and intensive care units compared with medical units. There was a 50.8% relative reduction in the rate of potential adverse drug events (other than those associated with timing errors) in units that used the bar-code eMAR (P , 0.001). The rate of timing errors in medication administration was reduced by 27.3% (P , 0.001). Transcription errors occurred at a rate of 6.1% on units that did not use ...
Innovations in Medication Safety in the OR" was the subject for the annual APSF Board of Directors Workshop held October 17 in Orlando, prior to the ASA annual meeting. Over 100 attendees included APSF directors, academic anesthesiologists, regulators, and industry representatives from several companies offering products intended to enhance the safety of medication administration during anesthesia care.. As introduced by Robert K. Stoelting, MD, APSF president, the vision of the activity was to help achieve a "six-sigma" or vanishingly small medication error rate in the OR. The proposed means to achieve this were identification of current possible solutions to OR drug errors as well as promotion of the exploration and development of new medication safety processes for anesthesia professionals.. Kick-off of the meaty presentations was by the workshop organizer/moderator, Jeffrey B. Cooper, PhD, of the Massachusetts General Hospital and APSF executive vice president, who fittingly harkened back ...
Prescription errors may seem relatively minor when youre dealing with over-the-counter drugs. If you take the wrong pill then you get a stomach ache or headache and no big loss occurs, right? However when prescription medication is involved, the effects can be critical.
Methods A descriptive, cross-sectional study was conducted in the High Risk Newborn Follow-up Clinic of our institute, on a sample of 166 children, ,3 months old. The medications prescribed (syrup preparations of vitamin D, multivitamins, calcium, iron and levetiracetam, tablet L-thyroxine and ursodeoxycholic acid and human milk fortifier powder) were noted from the discharge summary. The caregiver who usually administered the medicines to the child at home was asked the names of the medications, frequency of their administration and to show in a measuring cup/syringe/dropper the dose of the medication. The names, doses and frequency of the drugs as reported were matched against those actually prescribed in the discharge summary. Various risk factors probably associated with medication errors, were noted. ...
The drastic differences in concentrations patients could receive depending on which pharmacy compounded their prescriptions were deeply concerning, and these uniform standards are essential for patient safety. We are urging all prescribers and pharmacies to follow our recommended standards to avoid potentially harmful medication errors.". Children are often prescribed oral liquid prescriptions instead of hard-to-swallow pills, and medications that are not commercially available must be compounded by a pharmacist. Before the new recommendations, pharmacists were using different concentrations when compounding more than 100 drugs.. "Transitions in sites of care, including movement between the home and the hospital as well as between pharmacies, are associated with patient safety risks and this may be especially true in the pediatric population because of the number of liquid medicines that must be compounded," says UMHS Pediatric Associate Chief Medical Officer Chris Dickinson, M.D., a ...
The National Alert Network (NAN) is a coalition of members of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). The Institute for Safe Medication Practices (ISMP) and the American Society of Health-System Pharmacists (ASHP) publish the alerts from the National Medication Errors Reporting Program, operated by ISMP. The alerts are incident driven. The NCC MERP, ISMP and the ASHP encourage the sharing and reporting of medication errors, so that lessons learned can be used to increase the safety of the medication use system.. ...
An automated drug dispensing system reduced medication errors at both the dispensing and administration steps in an adult intensive care unit.
Most medication errors in primary care practices are prescribing errors and, while a majority of those reach the patient, pharmacists are most likely to intercept the mistakes, according to a new study by the Agency for Healthcare Research and Quality.
At Kishwaukee and Valley West Hospitals, many precautions are taken each time a medication is administered to a patient in order to prevent medication errors.
There are special risks associated with liquids that are placed in syringes, basins or cups. Using unlabeled solutions may cause medication errors.
The pediatric population is more susceptible to medication errors due to factors such as weight, body surface, immaturity of the enzymatic system to m..
Seven nursing homes -- including one in Stamford and another in Milford -- have been fined by the state Department of Public Health in connection with medication errors or residents who fell or sustained broken bones. The home was also cited in connection with a May 12 incident in which a resident suffered a broken toe when a shower door inadvertently closed on the residents foot, DPH records show. Regency Heights was also cited in connection with an incident Oct. 20 when a resident fell out of a lift sling and hit his or her head while being moved from a bed to a wheelchair, records show. DPH found that two aides had transferred the resident out of bed using a lift without the consent of a licensed staff member, records show. The state found that the home had failed to notify a physician for eight hours after the staff noticed the resident moaning and crying. The home was also cited in connection with the same incident when DPH found that a nurses note failed to document that the resident was
Nearly half of heart patients will make a major medication error after they are discharged from the hospital, even when under a pharmacists care.. ...
In the first six months of 2016, Pennsylvania hospitals reported 889 medication errors or close calls that were attributed, at least in part, to electronic ...
Dr. Kim Sears is an Assistant Professor at Queens University. She is the Co-Director, Master of Science in Healthcare Quality program and the Deputy Director/ Healthcare Quality, Queens Joanna Briggs Collaboration. Dr. Sears has over twenty years experience as a nurse, primarily focused in neonatal intensive care units. Dr. Sears conducts an active program of research in health services with a focus on advancing quality care, reducing risk and improving patient safety. The majority of her work focuses on furthering the quality and safety of medication delivery. Dr. Sears explores the advancement of medication delivery in Canada and internationally including both the community and hospital settings for children and adults. Her doctoral work focused on medication administration in childrens hospitals and the link the work environment has on the occurrence of reported peaditric medication administration errors. To further her knowledge of the medication delivery system, she was awarded a ...
Medication errors in Illinois nursing homes are leading to hospitalizations for dangerously low blood sugar, visual hallucinations and labored breathing, according to information obtained by NBC 5 Investigates...
Learn the medication error definition used by NCC MERP, and encouraged for use by researchers, software developers, and institutions.
Medication prescribing for 158 neonates was studied. The rate of nonintercepted medication errors during the NOE period was 40% lower than during the POE period (rate ratio 0.60; 95% confidence interval [CI] .50, .71; P less than .001). During the POE period, 80% of nonintercepted errors occurred at the prescription stage, while during the NOE period, 60% of nonintercepted errors occurred in that stage. Prescription errors decreased from 10.3% during the POE period to 4.6% during the NOE period (P less than .001), and the number of warnings with which physicians complied increased from 44% to 68% respectively (P less than .001). Meanwhile, transcription errors showed a nonsignificant increase from the POE period to the NOE period. The median error per patient was reduced from 2 during the POE period to 0 during the NOE period (P= .005). Underdose and curtailed and prolonged interval errors were significantly reduced from the POE period to the NOE period. The rate of nonintercepted overdose ...
Unfortunately, you are not immune to getting sick while breastfeeding. So when it comes to finding relief, rely only on safe medications while breastfeeding.
Recently, the subject of medical errors became front page news with the release of the Institute of Medicine (IOM) report: To Err is Human: Building a Safer Health System. According to two studies referenced in the report, medical errors may lead to somewhere between 44,000 and 98,000 hospital deaths per year. The majority of these errors, the report maintains, derive from basic flaws in the organization of the health care system, not from "individual recklessness." I think all of us would agree intuitively with the premise that we try to do our best in an imperfect system. In spite of the tremendous technological advances in recent decades, we often still function with inadequate information in an incompletely monitored environment. We make mistakes, some of which might be avoided if better controls were available. Medication errors are illustrative of this problem. They account for an estimated 7,000 deaths per year. Complications result from illegible prescriptions being misinterpreted, drug ...
medication errors published in the ISMP Medication Safety Alert!® The errors sound-alike drugs used in the organization. Those names that appear on involving these medications were reported to ISMP through the USP-ISMP TJCs list of look-alike or sound-alike names have been noted with a Medication Errors Reporting Program (MERP). ISMP Medication Safety Alert! Acute Care Edition ** These drug names are included on TJCs list of look-alike or sound-alike drug names from which an accredited organizationcreates its own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this TJC requirement ...
Medication record - free printable medical forms, A simple form on which to log medications prescribed and frequency and time of taking them. free to download and print. medication record. charts, and other. Maintaining a medication list in the chart -- fpm, With consistent and proper use, a simple medication list can become a very powerful part of the chart providing countless benefits, such as the following: efficient charting. because the medication list can be updated via a few check marks, it makes documentation quicker and easier.. Oral diabetes medications chart , joslin diabetes center, Our oral diabetes medications chart lists the names of different diabetes pills & explains how they are taken, how they work, side effects and more.. ...
A pharmacist-led program utilizing information technology successfully reduced medication errors in primary care, a randomized British study found.
... failure to follow Std. Guidelines in ERCP procedure = Rs. 47 lakhs of Compensation
29 MARCH 2017 , GENEVA/BONN - WHO today launched a global initiative to reduce severe, avoidable medication-associated harm in all countries by 50% over the next 5 years. The Global Patient Safety Challenge on Medication Safety aims to address the weaknesses in health systems that lead to medication errors and the severe harm that results. It lays out ways to improve the way medicines are prescribed, distributed and consumed, and increase awareness among patients about the risks associated with the improper use of medication. Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States of America alone. While low- and middle-income countries are estimated to have similar rates of medication-related adverse events to high-income countries, the impact is about twice as much in terms of the number of years of healthy life lost. Many countries lack good data, which will be gathered as part of the initiative. Globally, the cost ...
But theres another type of med error that you might expect to increase, which is judgment based medication error. So maybe the intern wrings the heart failure patient out with lasix without paying attention to her potassium, and she suffers cardiac arrest from ventricular arrhythmia. Maybe, in the tachycardic septic patient, dopamine is chosen, resulting in a serious arrhythmia, when norepinephrine would have been a better choice according to most literature. Or maybe heparin is given for a weak indication and the patient bleeds. The systems we have in place now are not very good at intercepting these types of judgment errors. One might argue that these arent really medication errors. I dont know how errors were adjudicated in this paper, but I wonder if such judgment errors were considered medication errors ...
Webster CS, Merry AF, Larson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesthesia and Intensive Care 2001; 29: 494-500 ...
Medication Safety in ABMU Health Board Roger Williams Head of Pharmacy Acute Services June 2014 Aims of presentation To consider: 1. Governance arrangements to provide assurances for medication safety