Errors in the medication process: frequency, type, and potential clinical consequences.
ABSTRACT 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.
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ABSTRACT: To investigate the frequency, type, and potential severity of errors in several stages of the medication process in an inpatient psychiatric setting. A cross-sectional study using three methods for detecting errors: (1) direct observation; (2) unannounced control visits in the wards collecting dispensed drugs; and (3) chart reviews. All errors, except errors in discharge summaries, were assessed for potential consequences by two clinical pharmacologists. Three psychiatric wards with adult patients at Aalborg University Hospital, Denmark, from January 2010-April 2010. The individual handling of medication (prescribing, dispensing, and administering). In total, 189 errors were detected in 1,082 opportunities for error (17%) of which 84/998 (8%) were assessed as potentially harmful. The frequency of errors was: prescribing, 10/189 (5%); dispensing, 18/189 (10%); administration, 142/189 (75%); and discharge summaries, 19/189 (10%). The most common errors were omission of pro re nata dosing regime in computerized physician order entry, omission of dose, lack of identity control, and omission of drug. Errors throughout the medication process are common in psychiatric wards to an extent which resembles error rates in somatic care. Despite a substantial proportion of errors with potential to harm patients, very few errors were considered potentially fatal. Medical staff needs greater awareness of medication safety and guidelines related to the medication process. Many errors in this study might potentially be prevented by nursing staff when handling medication and observing patients for effect and side effects of medication. The nurses' role in psychiatric medication safety should be further explored as nurses appear to be in the unique position to intercept errors before they reach the patient.Risk Management and Healthcare Policy 01/2013; 6:23-31.
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ABSTRACT: To determine the nature and frequency of medication errors during medication delivery processes in a public teaching hospital geriatric ward in Bali, Indonesia.Therapeutics and Clinical Risk Management 01/2014; 10:413-21.
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ABSTRACT: Quality of care is important in health care systems, and reducing medication errors is an effective approach to improve health care quality because medication errors are not rare and can cause adverse patient outcomes. Current researchers have adopted contextual, macro level methods to study the medication administration process, but the association between cognitive factors and the nurses' abilities to identify medication errors remains unclear. We used visual scanning patterns to study how nurses complete the medication administration process. In our study, we focused on a specific type of visual scanning pattern: nurses' two fixation scanpaths. We sought to find links between whether nurses identifies a patient identification error while administering a medication and their two fixation scanpaths. The data used in this study was collected in an experiment conducted at a Western Massachusetts hospital. Nurse participants wore an eye tracking device to record their eye movements while they performed a simulated medication administration process. We coded the eye tracking videos and analyzed the generated sequence data based on whether nurses identified a patient identification error during the process. We found that two fixation scanpaths are different between the two groups of nurses, those who identified the error and who did not. This finding may have implications for the design of medication administration protocol development.Systems and Information Engineering Design Symposium (SIEDS), 2011 IEEE; 01/2011