Medication Errors Recovered by Emergency Department Pharmacists
Division of General Medicine, Brigham and Women's Hospital, Boston, MA, USA. Annals of emergency medicine
(Impact Factor: 4.68).
12/2009; 55(6):513-21. DOI: 10.1016/j.annemergmed.2009.10.012
We assess the impact of emergency department (ED) pharmacists on reducing potentially harmful medication errors.
We conducted this observational study in 4 academic EDs. Trained pharmacy residents observed a convenience sample of ED pharmacists' activities. The primary outcome was medication errors recovered by pharmacists, including errors intercepted before reaching the patient (near miss or potential adverse drug event), caught after reaching the patient but before causing harm (mitigated adverse drug event), or caught after some harm but before further or worsening harm (ameliorated adverse drug event). Pairs of physician and pharmacist reviewers confirmed recovered medication errors and assessed their potential for harm. Observers were unblinded and clinical outcomes were not evaluated.
We conducted 226 observation sessions spanning 787 hours and observed pharmacists reviewing 17,320 medications ordered or administered to 6,471 patients. We identified 504 recovered medication errors, or 7.8 per 100 patients and 2.9 per 100 medications. Most of the recovered medication errors were intercepted potential adverse drug events (90.3%), with fewer mitigated adverse drug events (3.9%) and ameliorated adverse drug events (0.2%). The potential severities of the recovered errors were most often serious (47.8%) or significant (36.2%). The most common medication classes associated with recovered medication errors were antimicrobial agents (32.1%), central nervous system agents (16.2%), and anticoagulant and thrombolytic agents (14.1%). The most common error types were dosing errors, drug omission, and wrong frequency errors.
ED pharmacists can identify and prevent potentially harmful medication errors. Controlled trials are necessary to determine the net costs and benefits of ED pharmacist staffing on safety, quality, and costs, especially important considerations for smaller EDs and pharmacy departments.
Available from: Hussain T. Bakhsh
- "The majority of errors were due to drug omissions. However, previous studies primarily identified errors related to dosing and drug selection   . This supports the idea that boarded psychiatric patients have different needs than those of the general ED patient. "
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ABSTRACT: Patients boarded in the emergency department (ED) with psychiatric complaints may be at risk for medication errors. However, no studies exist to characterize the types of errors and risk factors for errors in these patients.
To characterize medication errors in psychiatric patients boarded in ED, and to identify risk factors associated with these errors.
A prospective observational study conducted in a community ED included all patients seen in the ED for primary psychiatric complaints and remained in the ED pending transfer to a psychiatric facility. An investigator recorded all medication errors requiring an intervention by an emergency pharmacist.
A total of 288 medication errors in 100 patients were observed. Overall, 65 patients had one or more medication errors. The majority of errors (n = 256, 89%) were due to errors of omission. The final severity classification of the medication errors was: Insignificant (n = 77), significant (n = 152), and serious (n = 3). In the multivariate analysis (R-squared 19.6%), increasing number of home medications (OR 1.17, 95% CI 1.01 to 1.36; p = 0.035), and increasing number of comorbidities (OR 1.89, 95% CI 1.10 to 3.27; p = 0.022) were associated with the occurrence of medication errors.
Psychiatric patients boarded in the ED commonly have medication errors that require intervention.
Available from: Anping Xie
- "Strategies for error detection and recovery have been explored among nurses,26 in particular critical care nurses,27 and among pharmacists.28 29 Resilience engineering builds on and extends the work done by high-reliability organisation (HRO) researchers, in particular the HRO concept of mindfulness, that is, the ability to prepare for the unexpected and to be vigilant about hazards.30 "
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ABSTRACT: Human factors and ergonomics (HFE) approaches to patient safety have addressed five different domains: usability of technology; human error and its role in patient safety; the role of healthcare worker performance in patient safety; system resilience; and HFE systems approaches to patient safety.
A review of various HFE approaches to patient safety and studies on HFE interventions was conducted.
This paper describes specific examples of HFE-based interventions for patient safety. Studies show that HFE can be used in a variety of domains.
HFE is a core element of patient safety improvement. Therefore, every effort should be made to support HFE applications in patient safety.
Available from: Jan Horsky
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ABSTRACT: Electronic patient tracking and records systems in emergency departments often connect to hospital information systems, ambulatory patient records and ancillary systems. The networked systems may not be fully interoperable and clinicians need to access data through different interfaces. This study was conducted to describe the interactive behavior of clinicians working with partially interoperable clinical information systems. We performed 78 hours of observation at two emergency departments, shadowing five physicians, ten nurses and four administrative staff. Actions related to viewing or recording data in any system or on paper were recorded. Collected data were compared along clinical roles and contrasted with findings across the two hospital sites. The findings suggest that differences in the levels of interoperability may affect the ways physicians and nurses interact with the systems. When tradeoffs in functionality are necessary for connecting ancillary systems, the effects on clinicians and staff need to be considered.
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