Sample records for prevent medication errors

  1. [Medical errors: inevitable but preventable]. (United States)

    Giard, R W


    Medical errors are increasingly reported in the lay press. Studies have shown dramatic error rates of 10 percent or even higher. From a methodological point of view, studying the frequency and causes of medical errors is far from simple. Clinical decisions on diagnostic or therapeutic interventions are always taken within a clinical context. Reviewing outcomes of interventions without taking into account both the intentions and the arguments for a particular action will limit the conclusions from a study on the rate and preventability of errors. The interpretation of the preventability of medical errors is fraught with difficulties and probably highly subjective. Blaming the doctor personally does not do justice to the actual situation and especially the organisational framework. Attention for and improvement of the organisational aspects of error are far more important then litigating the person. To err is and will remain human and if we want to reduce the incidence of faults we must be able to learn from our mistakes. That requires an open attitude towards medical mistakes, a continuous effort in their detection, a sound analysis and, where feasible, the institution of preventive measures.

  2. Preventing Medication Error Based on Knowledge Management Against Adverse Event


    Hastuti, Apriyani Puji; Nursalam, Nursalam; Triharini, Mira


    Introductions: Medication error is one of many types of errors that could decrease the quality and safety of healthcare. Increasing number of adverse events (AE) reflects the number of medication errors. This study aimed to develop a model of medication error prevention based on knowledge management. This model is expected to improve knowledge and skill of nurses to prevent medication error which is characterized by the decrease of adverse events (AE). Methods: This study consisted of two sta...

  3. Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention. (United States)

    Goedecke, Thomas; Ord, Kathryn; Newbould, Victoria; Brosch, Sabine; Arlett, Peter


    A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Reducing the risk of medication errors is a shared responsibility between patients, healthcare professionals, regulators and the pharmaceutical industry at all levels of healthcare delivery. In 2015, the EU regulatory network released a two-part good practice guide on medication errors to support both the pharmaceutical industry and regulators in the implementation of the changes introduced with the EU pharmacovigilance legislation. These changes included a modification of the 'adverse reaction' definition to include events associated with medication errors, and the requirement for national competent authorities responsible for pharmacovigilance in EU Member States to collaborate and exchange information on medication errors resulting in harm with national patient safety organisations. To facilitate reporting and learning from medication errors, a clear distinction has been made in the guidance between medication errors resulting in adverse reactions, medication errors without harm, intercepted medication errors and potential errors. This distinction is supported by an enhanced MedDRA(®) terminology that allows for coding all stages of the medication use process where the error occurred in addition to any clinical consequences. To better understand the causes and contributing factors, individual case safety reports involving an error should be followed-up with the primary reporter to gather information relevant for the conduct of root cause analysis where this may be appropriate. Such reports should also be summarised in periodic safety update reports and addressed in risk management plans. Any risk minimisation and prevention strategy for medication errors should consider all stages of a medicinal product's life-cycle, particularly the main sources and types of medication errors during product development. This article

  4. Medication Errors - A Review


    Vinay BC; Nikhitha MK; Patel Sunil B


    In this present review article, regarding medication errors its definition, medication error problem, types of medication errors, common causes of medication errors, monitoring medication errors, consequences of medication errors, prevention of medication error and managing medication errors have been explained neatly and legibly with proper tables which is easy to understand.

  5. Medication errors : the impact of prescribing and transcribing errors on preventable harm in hospitalised patients

    NARCIS (Netherlands)

    van Doormaal, J.E.; van der Bemt, P.M.L.A.; Mol, P.G.M.; Egberts, A.C.G.; Haaijer-Ruskamp, F.M.; Kosterink, J.G.W.; Zaal, Rianne J.

    Background: Medication errors (MEs) affect patient safety to a significant extent. Because these errors can lead to preventable adverse drug events (pADEs), it is important to know what type of ME is the most prevalent cause of these pADEs. This study determined the impact of the various types of

  6. Checklists in Neurosurgery to Decrease Preventable Medical Errors: A Review (United States)

    Enchev, Yavor


    Neurosurgery represents a zero tolerance environment for medical errors, especially preventable ones like all types of wrong site surgery, complications due to the incorrect positioning of patients for neurosurgical interventions and complications due to failure of the devices required for the specific procedure. Following the excellent and encouraging results of the safety checklists in intensive care medicine and in other surgical areas, the checklist was naturally introduced in neurosurgery. To date, the reported world experience with neurosurgical checklists is limited to 15 series with fewer than 20,000 cases in various neurosurgical areas. The purpose of this review was to study the reported neurosurgical checklists according to the following parameters: year of publication; country of origin; area of neurosurgery; type of neurosurgical procedure-elective or emergency; person in charge of the checklist completion; participants involved in completion; whether they prevented incorrect site surgery; whether they prevented complications due to incorrect positioning of the patients for neurosurgical interventions; whether they prevented complications due to failure of the devices required for the specific procedure; their specific aims; educational preparation and training; the time needed for checklist completion; study duration and phases; number of cases included; barriers to implementation; efforts to implementation; team appreciation; and safety outcomes. Based on this analysis, it could be concluded that neurosurgical checklists represent an efficient, reliable, cost-effective and time-saving tool for increasing patient safety and elevating the neurosurgeons’ self-confidence. Every neurosurgical department must develop its own neurosurgical checklist or adopt and modify an existing one according to its specific features and needs in an attempt to establish or develop its safety culture. The world, continental, regional and national neurosurgical societies

  7. [Medication error management climate and perception for system use according to construction of medication error prevention system]. (United States)

    Kim, Myoung Soo


    The purpose of this cross-sectional study was to examine current status of IT-based medication error prevention system construction and the relationships among system construction, medication error management climate and perception for system use. The participants were 124 patient safety chief managers working for 124 hospitals with over 300 beds in Korea. The characteristics of the participants, construction status and perception of systems (electric pharmacopoeia, electric drug dosage calculation system, computer-based patient safety reporting and bar-code system) and medication error management climate were measured in this study. The data were collected between June and August 2011. Descriptive statistics, partial Pearson correlation and MANCOVA were used for data analysis. Electric pharmacopoeia were constructed in 67.7% of participating hospitals, computer-based patient safety reporting systems were constructed in 50.8%, electric drug dosage calculation systems were in use in 32.3%. Bar-code systems showed up the lowest construction rate at 16.1% of Korean hospitals. Higher rates of construction of IT-based medication error prevention systems resulted in greater safety and a more positive error management climate prevailed. The supportive strategies for improving perception for use of IT-based systems would add to system construction, and positive error management climate would be more easily promoted.

  8. Using incident reports to inform the prevention of medication administration errors. (United States)

    Härkänen, Marja; Saano, Susanna; Vehviläinen-Julkunen, Katri


    To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports. Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed. This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health

  9. The Institute for Safe Medication Practices and Poison Control Centers: Collaborating to Prevent Medication Errors and Unintentional Poisonings. (United States)

    Vaida, Allen J


    This article provides an overview on the Institute for Safe Medication Practices (ISMP), the only independent nonprofit organization in the USA devoted to the prevention of medication errors. ISMP developed the national Medication Errors Reporting Program (MERP) and investigates and analyzes errors in order to formulate recommendations to prevent further occurrences. ISMP works closely with the US Food and Drug Administration (FDA), drug manufacturers, professional organizations, and others to promote changes in package design, practice standards, and healthcare practitioner and consumer education. By collaborating with ISMP to share and disseminate information, Poison Control centers, emergency departments, and toxicologists can help decrease unintentional and accidental poisonings.

  10. Preventing Errors in Laterality


    Landau, Elliot; Hirschorn, David; Koutras, Iakovos; Malek, Alexander; Demissie, Seleshie


    An error in laterality is the reporting of a finding that is present on the right side as on the left or vice versa. While different medical and surgical specialties have implemented protocols to help prevent such errors, very few studies have been published that describe these errors in radiology reports and ways to prevent them. We devised a system that allows the radiologist to view reports in a separate window, displayed in a simple font and with all terms of laterality highlighted in sep...

  11. Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors. (United States)

    Huynh, Chi; Wong, Ian C K; Correa-West, Jo; Terry, David; McCarthy, Suzanne


    Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.

  12. A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care. (United States)

    Niemann, Dorothee; Bertsche, Astrid; Meyrath, David; Koepf, Ellen D; Traiser, Carolin; Seebald, Katja; Schmitt, Claus P; Hoffmann, Georg F; Haefeli, Walter E; Bertsche, Thilo


    To prevent medication errors in drug handling in a paediatric ward. One in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce. A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling. After approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors. The number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct 'volume of solvent for IV drugs' from 49-25%. Paediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes. Worldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings. © 2014 John Wiley & Sons Ltd.

  13. Human-simulation-based learning to prevent medication error: A systematic review. (United States)

    Sarfati, Laura; Ranchon, Florence; Vantard, Nicolas; Schwiertz, Vérane; Larbre, Virginie; Parat, Stéphanie; Faudel, Amélie; Rioufol, Catherine


    In the past 2 decades, there has been an increasing interest in simulation-based learning programs to prevent medication error (ME). To improve knowledge, skills, and attitudes in prescribers, nurses, and pharmaceutical staff, these methods enable training without directly involving patients. However, best practices for simulation for healthcare providers are as yet undefined. By analysing the current state of experience in the field, the present review aims to assess whether human simulation in healthcare helps to reduce ME. A systematic review was conducted on Medline from 2000 to June 2015, associating the terms "Patient Simulation," "Medication Errors," and "Simulation Healthcare." Reports of technology-based simulation were excluded, to focus exclusively on human simulation in nontechnical skills learning. Twenty-one studies assessing simulation-based learning programs were selected, focusing on pharmacy, medicine or nursing students, or concerning programs aimed at reducing administration or preparation errors, managing crises, or learning communication skills for healthcare professionals. The studies varied in design, methodology, and assessment criteria. Few demonstrated that simulation was more effective than didactic learning in reducing ME. This review highlights a lack of long-term assessment and real-life extrapolation, with limited scenarios and participant samples. These various experiences, however, help in identifying the key elements required for an effective human simulation-based learning program for ME prevention: ie, scenario design, debriefing, and perception assessment. The performance of these programs depends on their ability to reflect reality and on professional guidance. Properly regulated simulation is a good way to train staff in events that happen only exceptionally, as well as in standard daily activities. By integrating human factors, simulation seems to be effective in preventing iatrogenic risk related to ME, if the program is

  14. Evaluating a medical error taxonomy.


    Brixey, Juliana; Johnson, Todd R.; Zhang, Jiajie


    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 stand...

  15. Using total quality management approach to improve patient safety by preventing medication error incidences*. (United States)

    Yousef, Nadin; Yousef, Farah


    Whereas one of the predominant causes of medication errors is a drug administration error, a previous study related to our investigations and reviews estimated that the incidences of medication errors constituted 6.7 out of 100 administrated medication doses. Therefore, we aimed by using six sigma approach to propose a way that reduces these errors to become less than 1 out of 100 administrated medication doses by improving healthcare professional education and clearer handwritten prescriptions. The study was held in a General Government Hospital. First, we systematically studied the current medication use process. Second, we used six sigma approach by utilizing the five-step DMAIC process (Define, Measure, Analyze, Implement, Control) to find out the real reasons behind such errors. This was to figure out a useful solution to avoid medication error incidences in daily healthcare professional practice. Data sheet was used in Data tool and Pareto diagrams were used in Analyzing tool. In our investigation, we reached out the real cause behind administrated medication errors. As Pareto diagrams used in our study showed that the fault percentage in administrated phase was 24.8%, while the percentage of errors related to prescribing phase was 42.8%, 1.7 folds. This means that the mistakes in prescribing phase, especially because of the poor handwritten prescriptions whose percentage in this phase was 17.6%, are responsible for the consequent) mistakes in this treatment process later on. Therefore, we proposed in this study an effective low cost strategy based on the behavior of healthcare workers as Guideline Recommendations to be followed by the physicians. This method can be a prior caution to decrease errors in prescribing phase which may lead to decrease the administrated medication error incidences to less than 1%. This improvement way of behavior can be efficient to improve hand written prescriptions and decrease the consequent errors related to administrated

  16. Medical Errors Reduction Initiative

    National Research Council Canada - National Science Library

    Mutter, Michael L


    The Valley Hospital of Ridgewood, New Jersey, is proposing to extend a limited but highly successful specimen management and medication administration medical errors reduction initiative on a hospital-wide basis...

  17. Help prevent hospital errors (United States)

    ... this page: // Help prevent hospital errors To use the sharing features ... in the hospital. If You Are Having Surgery, Help Keep Yourself Safe Go to a hospital you ...

  18. Development of case-based medication alerting and recommender system: a new approach to prevention for medication error. (United States)

    Miyo, Kengo; Nittami, Yuki S; Kitagawa, Yoichiro; Ohe, Kazuhiko


    The purpose of this study was to develop a new alerting and recommender system for preventing medication errors. In recent years, alerting systems have been widely implemented, but because these systems apply a same static threshold for all patients in all cases, they produce excessive alerts and subject physicians to "alert fatigue". We believe that the most commonly-written prescription for a patient's status is the safest one. From this standpoint, we developed a real-time case-based medication alerting and recommender system linked to a database of past prescriptions. When a physician issues his or her prescription, our system dynamically compares it with past ones for similar patients in the database. An analysis of the 10 most frequently-used drugs in the University of Tokyo Hospital revealed that our system reduced the number of false alerts compared to the traditional static alert method. Our system contributes to the creation of alerts that are appropriate for patients' clinical conditions and based on physicians' empirical discretion.

  19. Apologies and Medical Error (United States)


    One way in which physicians can respond to a medical error is to apologize. Apologies—statements that acknowledge an error and its consequences, take responsibility, and communicate regret for having caused harm—can decrease blame, decrease anger, increase trust, and improve relationships. Importantly, apologies also have the potential to decrease the risk of a medical malpractice lawsuit and can help settle claims by patients. Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologize. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologizing after medical error, the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologizing for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error. PMID:18972177

  20. Eliminating US hospital medical errors. (United States)

    Kumar, Sameer; Steinebach, Marc


    Healthcare costs in the USA have continued to rise steadily since the 1980s. Medical errors are one of the major causes of deaths and injuries of thousands of patients every year, contributing to soaring healthcare costs. The purpose of this study is to examine what has been done to deal with the medical-error problem in the last two decades and present a closed-loop mistake-proof operation system for surgery processes that would likely eliminate preventable medical errors. The design method used is a combination of creating a service blueprint, implementing the six sigma DMAIC cycle, developing cause-and-effect diagrams as well as devising poka-yokes in order to develop a robust surgery operation process for a typical US hospital. In the improve phase of the six sigma DMAIC cycle, a number of poka-yoke techniques are introduced to prevent typical medical errors (identified through cause-and-effect diagrams) that may occur in surgery operation processes in US hospitals. It is the authors' assertion that implementing the new service blueprint along with the poka-yokes, will likely result in the current medical error rate to significantly improve to the six-sigma level. Additionally, designing as many redundancies as possible in the delivery of care will help reduce medical errors. Primary healthcare providers should strongly consider investing in adequate doctor and nurse staffing, and improving their education related to the quality of service delivery to minimize clinical errors. This will lead to an increase in higher fixed costs, especially in the shorter time frame. This paper focuses additional attention needed to make a sound technical and business case for implementing six sigma tools to eliminate medical errors that will enable hospital managers to increase their hospital's profitability in the long run and also ensure patient safety.

  1. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. (United States)

    Starmer, Amy J; Sectish, Theodore C; Simon, Dennis W; Keohane, Carol; McSweeney, Maireade E; Chung, Erica Y; Yoon, Catherine S; Lipsitz, Stuart R; Wassner, Ari J; Harper, Marvin B; Landrigan, Christopher P


    Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children's Hospital. Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal

  2. Medical Error and Moral Luck. (United States)

    Hubbeling, Dieneke


    This paper addresses the concept of moral luck. Moral luck is discussed in the context of medical error, especially an error of omission that occurs frequently, but only rarely has adverse consequences. As an example, a failure to compare the label on a syringe with the drug chart results in the wrong medication being administered and the patient dies. However, this error may have previously occurred many times with no tragic consequences. Discussions on moral luck can highlight conflicting intuitions. Should perpetrators receive a harsher punishment because of an adverse outcome, or should they be dealt with in the same way as colleagues who have acted similarly, but with no adverse effects? An additional element to the discussion, specifically with medical errors, is that according to the evidence currently available, punishing individual practitioners does not seem to be effective in preventing future errors. The following discussion, using relevant philosophical and empirical evidence, posits a possible solution for the moral luck conundrum in the context of medical error: namely, making a distinction between the duty to make amends and assigning blame. Blame should be assigned on the basis of actual behavior, while the duty to make amends is dependent on the outcome.

  3. Medication errors: an overview for clinicians. (United States)

    Wittich, Christopher M; Burkle, Christopher M; Lanier, William L


    Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for practicing physicians that focuses on medication error (1) terminology and definitions, (2) incidence, (3) risk factors, (4) avoidance strategies, and (5) disclosure and legal consequences. A medication error is any error that occurs at any point in the medication use process. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (eg, similar sounding names, low therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition, polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions and other communications, cognitive biases) can precipitate medication errors. Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. Methods to prevent medication errors from occurring (eg, use of information technology, better drug labeling, and medication reconciliation) have been used with varying success. When an error is discovered, patients expect disclosure that is timely, given in person, and accompanied with an apology and communication of efforts to prevent future errors. Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients. Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

  4. Qualitative exploration of practices to prevent medication errors in neonatal intensive care units

    DEFF Research Database (Denmark)

    Rishoej, Rikke Mie; Lai Nielsen, Henriette; Strzelec, Stina Maria


    to prevent MEs involved technology, procedures, education, skills and hospital pharmacy services. Potential future practices to prevent MEs included customizing the computerized physician order entry systems to support optimal prescribing, standardizing the double-check process, training of calculation...

  5. Medication errors: definitions and classification (United States)

    Aronson, Jeffrey K


    To understand medication errors and to identify preventive strategies, we need to classify them and define the terms that describe them. The four main approaches to defining technical terms consider etymology, usage, previous definitions, and the Ramsey–Lewis method (based on an understanding of theory and practice). A medication error is ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’. Prescribing faults, a subset of medication errors, should be distinguished from prescription errors. A prescribing fault is ‘a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient’. The converse of this, ‘balanced prescribing’ is ‘the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm’. This excludes all forms of prescribing faults, such as irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing. A prescription error is ‘a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription’. The ‘normal features’ include the identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency, and duration of administration. Medication errors can be classified, invoking psychological theory, as knowledge-based mistakes, rule-based mistakes, action-based slips, and memory-based lapses. This classification informs preventive strategies. PMID:19594526

  6. Medication errors in anesthesia: unacceptable or unavoidable?

    Directory of Open Access Journals (Sweden)

    Ira Dhawan

    Full Text Available Abstract Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to ‘treat' drug errors is to prevent them. Wrong medication (due to syringe swap, overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error, incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and ‘just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

  7. Benzodiazepine Use During Hospitalization: Automated Identification of Potential Medication Errors and Systematic Assessment of Preventable Adverse Events.

    Directory of Open Access Journals (Sweden)

    David Franklin Niedrig

    Full Text Available Benzodiazepines and "Z-drug" GABA-receptor modulators (BDZ are among the most frequently used drugs in hospitals. Adverse drug events (ADE associated with BDZ can be the result of preventable medication errors (ME related to dosing, drug interactions and comorbidities. The present study evaluated inpatient use of BDZ and related ME and ADE.We conducted an observational study within a pharmacoepidemiological database derived from the clinical information system of a tertiary care hospital. We developed algorithms that identified dosing errors and interacting comedication for all administered BDZ. Associated ADE and risk factors were validated in medical records.Among 53,081 patients contributing 495,813 patient-days BDZ were administered to 25,626 patients (48.3% on 115,150 patient-days (23.2%. We identified 3,372 patient-days (2.9% with comedication that inhibits BDZ metabolism, and 1,197 (1.0% with lorazepam administration in severe renal impairment. After validation we classified 134, 56, 12, and 3 cases involving lorazepam, zolpidem, midazolam and triazolam, respectively, as clinically relevant ME. Among those there were 23 cases with associated adverse drug events, including severe CNS-depression, falls with subsequent injuries and severe dyspnea. Causality for BDZ was formally assessed as 'possible' or 'probable' in 20 of those cases. Four cases with ME and associated severe ADE required administration of the BDZ antagonist flumazenil.BDZ use was remarkably high in the studied setting, frequently involved potential ME related to dosing, co-medication and comorbidities, and rarely cases with associated ADE. We propose the implementation of automated ME screening and validation for the prevention of BDZ-related ADE.

  8. Clinical errors and medical negligence. (United States)

    Oyebode, Femi


    This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3-16% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems. Copyright © 2013 S. Karger AG, Basel.

  9. Medication errors: prescribing faults and prescription errors. (United States)

    Velo, Giampaolo P; Minuz, Pietro


    1. Medication errors are common in general practice and in hospitals. Both errors in the act of writing (prescription errors) and prescribing faults due to erroneous medical decisions can result in harm to patients. 2. Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common. 3. Inadequate knowledge or competence and incomplete information about clinical characteristics and previous treatment of individual patients can result in prescribing faults, including the use of potentially inappropriate medications. 4. An unsafe working environment, complex or undefined procedures, and inadequate communication among health-care personnel, particularly between doctors and nurses, have been identified as important underlying factors that contribute to prescription errors and prescribing faults. 5. Active interventions aimed at reducing prescription errors and prescribing faults are strongly recommended. These should be focused on the education and training of prescribers and the use of on-line aids. The complexity of the prescribing procedure should be reduced by introducing automated systems or uniform prescribing charts, in order to avoid transcription and omission errors. Feedback control systems and immediate review of prescriptions, which can be performed with the assistance of a hospital pharmacist, are also helpful. Audits should be performed periodically.

  10. Prioritising interventions against medication errors

    DEFF Research Database (Denmark)

    Lisby, Marianne; Pape-Larsen, Louise; Sørensen, Ann Lykkegaard

    errors are therefore needed. Development of definition: A definition of medication errors including an index of error types for each stage in the medication process was developed from existing terminology and through a modified Delphi-process in 2008. The Delphi panel consisted of 25 interdisciplinary......Abstract Authors: Lisby M, Larsen LP, Soerensen AL, Nielsen LP, Mainz J Title: Prioritising interventions against medication errors – the importance of a definition Objective: To develop and test a restricted definition of medication errors across health care settings in Denmark Methods: Medication...... errors constitute a major quality and safety problem in modern healthcare. However, far from all are clinically important. The prevalence of medication errors ranges from 2-75% indicating a global problem in defining and measuring these [1]. New cut-of levels focusing the clinical impact of medication...

  11. Medication Error, What Is the Reason?

    Directory of Open Access Journals (Sweden)

    Ali Banaozar Mohammadi


    Full Text Available Background: Medication errors due to different reasons may alter the outcome of all patients, especially patients with drug poisoning. We introduce one of the most common type of medication error in the present article. Case:A 48 year old woman with suspected organophosphate poisoning was died due to lethal medication error. Unfortunately these types of errors are not rare and had some preventable reasons included lack of suitable and enough training and practicing of medical students and some failures in medical students’ educational curriculum. Conclusion:Hereby some important reasons are discussed because sometimes they are tre-mendous. We found that most of them are easily preventable. If someone be aware about the method of use, complications, dosage and contraindication of drugs, we can minimize most of these fatal errors.

  12. Barriers to medical error reporting

    Directory of Open Access Journals (Sweden)

    Jalal Poorolajal


    Full Text Available Background: This study was conducted to explore the prevalence of medical error underreporting and associated barriers. Methods: This cross-sectional study was performed from September to December 2012. Five hospitals, affiliated with Hamadan University of Medical Sciences, in Hamedan,Iran were investigated. A self-administered questionnaire was used for data collection. Participants consisted of physicians, nurses, midwives, residents, interns, and staffs of radiology and laboratory departments. Results: Overall, 50.26% of subjects had committed but not reported medical errors. The main reasons mentioned for underreporting were lack of effective medical error reporting system (60.0%, lack of proper reporting form (51.8%, lack of peer supporting a person who has committed an error (56.0%, and lack of personal attention to the importance of medical errors (62.9%. The rate of committing medical errors was higher in men (71.4%, age of 50-40 years (67.6%, less-experienced personnel (58.7%, educational level of MSc (87.5%, and staff of radiology department (88.9%. Conclusions: This study outlined the main barriers to reporting medical errors and associated factors that may be helpful for healthcare organizations in improving medical error reporting as an essential component for patient safety enhancement.

  13. [Second wave of the French drug harmonisation programme to prevent medication errors: overall appreciation of healthcare professionals]. (United States)

    Benhamou, D; Nacry, R; Journois, D; Auroy, Y; Durand, D; Arnoux, A; Olier, L; Castot, A


    Medication errors are a significant cause of severe healthcare-associated complications. In December 2006, the French Health Products Agency (Afssaps) has issued a protocol to harmonise labeling of injectable drugs vials. In 2007, a first change was launched for four drugs and was followed in 2008-2009 by a second wave concerning 42 active drugs. The present study describes how healthcare professionals have perceived this change and their overall appreciation of the drug harmonisation programme. A survey using an electronic questionnaire was distributed to medical and non-medical professionals in anaesthesia and intensive care and pharmacists in a representative sample of 200 French hospitals. The harmonisation procedure was felt as being overall satisfactory by 53% of professionals who had responded but it was recognised that the new procedure is associated with improved readability and understanding of drug dosage. The use of colour coding was also well accepted by the personnel of clinical units. Respondents expressed significant criticisms regarding both the communication plan and the way the plan was implemented locally in hospitals. Old and new labeling coexisted in 66% of responding hospitals and many respondents described being aware of errors or near-misses that were considered related to the transition. For many important topics, pharmacists had views that were significantly different from clinicians. This national survey describing the perception of healthcare professionals regarding the new harmonisation procedure for injectable drugs highlighted some progress but also a number of deficiencies, notably regarding communication and implementation of the change in clinical units. This survey will be used by the French Health Products Agency to improve future steps of the long-lasting campaign against medication errors. Copyright © 2011 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

  14. Learning from medication errors through a nationwide reporting programme

    NARCIS (Netherlands)

    Cheung, K.C.


    One of the strategies to enhance patient safety is the spontaneous reporting and analysis of medication errors. Sharing this information with other healthcare providers will help to prevent the reoccurrence of similar medication errors. In The Netherlands medication errors can be reported to a

  15. How Do Simulated Error Experiences Impact Attitudes Related to Error Prevention? (United States)

    Breitkreuz, Karen R; Dougal, Renae L; Wright, Melanie C


    The objective of this project was to determine whether simulated exposure to error situations changes attitudes in a way that may have a positive impact on error prevention behaviors. Using a stratified quasi-randomized experiment design, we compared risk perception attitudes of a control group of nursing students who received standard error education (reviewed medication error content and watched movies about error experiences) to an experimental group of students who reviewed medication error content and participated in simulated error experiences. Dependent measures included perceived memorability of the educational experience, perceived frequency of errors, and perceived caution with respect to preventing errors. Experienced nursing students perceived the simulated error experiences to be more memorable than movies. Less experienced students perceived both simulated error experiences and movies to be highly memorable. After the intervention, compared with movie participants, simulation participants believed errors occurred more frequently. Both types of education increased the participants' intentions to be more cautious and reported caution remained higher than baseline for medication errors 6 months after the intervention. This study provides limited evidence of an advantage of simulation over watching movies describing actual errors with respect to manipulating attitudes related to error prevention. Both interventions resulted in long-term impacts on perceived caution in medication administration. Simulated error experiences made participants more aware of how easily errors can occur, and the movie education made participants more aware of the devastating consequences of errors.

  16. Analysis of Medication Error Reports

    Energy Technology Data Exchange (ETDEWEB)

    Whitney, Paul D.; Young, Jonathan; Santell, John; Hicks, Rodney; Posse, Christian; Fecht, Barbara A.


    In medicine, as in many areas of research, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been, however, a corresponding lag in our abilities to analyze this overwhelming mass of data, and classic forms of statistical analysis may not allow researchers to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports has been carried out based on an approach of data comparison, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. Traditionally, USP has conducted an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.

  17. Medication errors in pediatric inpatients

    DEFF Research Database (Denmark)

    Rishoej, Rikke Mie; Almarsdóttir, Anna Birna; Christesen, Henrik Thybo


    The aim was to describe medication errors (MEs) in hospitalized children reported to the national mandatory reporting and learning system, the Danish Patient Safety Database (DPSD). MEs were extracted from DPSD from the 5-year period of 2010–2014. We included reports from public hospitals on pati...... safety in pediatric inpatients.(Table presented.)...

  18. Preventing medical device recalls

    CERN Document Server

    Raheja, Dev


    Introduction to Medical Device RequirementsIntroductionThe ChallengesSources of ErrorsUnderstanding the Science of Safety     Overview of FDA Quality System Regulation     Overview of Risk Management Standard ISO 14971     Overview of FDA Device Approval Process     Overview of Regulatory Requirements for Clinical TrialsSummaryReferencesPreventing Recalls during Specification WritingIntroductionConduct Requirements Analysis to Identify Missing RequirementsSpecifications for Safety, Durability, and

  19. Examining the link between burnout and medical error: A checklist approach

    Directory of Open Access Journals (Sweden)

    Evangelia Tsiga


    Conclusions: The Medical Error Checklists developed in this study advance the study of medical errors by proposing a comprehensive, valid and reliable self-assessment tool. The results highlight the importance of hospital organizational factors in preventing medical errors.

  20. Medication administration errors in Eastern Saudi Arabia

    International Nuclear Information System (INIS)

    Mir Sadat-Ali


    To assess the prevalence and characteristics of medication errors (ME) in patients admitted to King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia. Medication errors are documented by the nurses and physicians standard reporting forms (Hospital Based Incident Report). The study was carried out in King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia and all the incident reports were collected during the period from January 2008 to December 2009. The incident reports were analyzed for age, gender, nationality, nursing unit, and time where ME was reported. The data were analyzed and the statistical significance differences between groups were determined by Student's t-test, and p-values of <0.05 using confidence interval of 95% were considered significant. There were 38 ME reported for the study period. The youngest patient was 5 days and the oldest 70 years. There were 31 Saudis, and 7 non-Saudi patients involved. The most common error was missed medication, which was seen in 15 (39.5%) patients. Over 15 (39.5%) of errors occurred in 2 units (pediatric medicine, and obstetrics and gynecology). Nineteen (50%) of the errors occurred during the 3-11 pm shift. Our study shows that the prevalence of ME in our institution is low, in comparison with the world literature. This could be due to under reporting of the errors, and we believe that ME reporting should be made less punitive so that ME can be studied and preventive measures implemented (Author).

  1. Characteristics of medication errors with parenteral cytotoxic drugs


    Fyhr, A; Akselsson, R


    Errors involving cytotoxic drugs have the potential of being fatal and should therefore be prevented. The objective of this article is to identify the characteristics of medication errors involving parenteral cytotoxic drugs in Sweden. A total of 60 cases reported to the national error reporting systems from 1996 to 2008 were reviewed. Classification was made to identify cytotoxic drugs involved, type of error, where the error occurred, error detection mechanism, and consequences for the pati...

  2. Barriers to medication error reporting among hospital nurses. (United States)

    Rutledge, Dana N; Retrosi, Tina; Ostrowski, Gary


    errors, especially errors where patient harm is not apparent or where an error might be hidden. Such under-reporting impedes collection of accurate medication error data and prevents hospitals from changing harmful practices. © 2018 John Wiley & Sons Ltd.

  3. Investigating Medication Errors in Educational Health Centers of Kermanshah

    Directory of Open Access Journals (Sweden)

    Mohsen Mohammadi


    Full Text Available Background and objectives : Medication errors can be a threat to the safety of patients. Preventing medication errors requires reporting and investigating such errors. The present study was conducted with the purpose of investigating medication errors in educational health centers of Kermanshah. Material and Methods: The present research is an applied, descriptive-analytical study and is done as a survey. Error Report of Ministry of Health and Medical Education was used for data collection. The population of the study included all the personnel (nurses, doctors, paramedics of educational health centers of Kermanshah. Among them, those who reported the committed errors were selected as the sample of the study. The data analysis was done using descriptive statistics and Chi 2 Test using SPSS version 18. Results: The findings of the study showed that most errors were related to not using medication properly, the least number of errors were related to improper dose, and the majority of errors occurred in the morning. The most frequent reason for errors was staff negligence and the least frequent was the lack of knowledge. Conclusion: The health care system should create an environment for detecting and reporting errors by the personnel, recognizing related factors causing errors, training the personnel and create a good working environment and standard workload.

  4. Heuristic thinking: interdisciplinary perspectives on medical error

    Directory of Open Access Journals (Sweden)

    Annegret F. Hannawa


    Full Text Available Approximately 43 million adverse events occur across the globe each year at a cost of at least 23 million disability-adjusted life years and $132 billion in excess health care spending, ranking this safety burden among the top 10 medical causes of disability in the world.1 These findings are likely to be an understatement of the actual severity of the problem, given that the numbers merely reflect seven types of adverse events and completely neglect ambulatory care, and of course they only cover reported incidents. Furthermore, they do not include statistics on children and incidents from India and China, which host more than a third of the world’s population. Best estimates imply that about two thirds of these incidents are preventable. Thus, from a public health perspective, medical errors are a seri- ous global health burden, in fact ahead of high-profile health problems like AIDS and cancer. Interventions to date have not reduced medical errors to satisfactory rates. Even today, far too often, hand hygiene is not practiced properly (even in developed countries, surgical procedures take place in underequipped operating theaters, and checklists are missing or remain uncompleted. The healthcare system seems to be failing in managing its errors − it is costing too much, and the complexity of care causes severe safety hazards that too often harm rather than help patients. In response to this evolving discussion, the International Society for Quality in Healthcare recently nominated an Innovations Team that is now developing new strategies. One of the emerging themes is that the medical field cannot resolve this problem on its own. Instead, interdisciplinary collaborations are needed to advance effective, evidence-based interventions that will eventually result in competent changes. In March 2013, the Institute of Communication and Health at the University of Lugano organized a conference on Communicating Medical Error (COME 2013 in

  5. Medication errors in home care: a qualitative focus group study. (United States)

    Berland, Astrid; Bentsen, Signe Berit


    To explore registered nurses' experiences of medication errors and patient safety in home care. The focus of care for older patients has shifted from institutional care towards a model of home care. Medication errors are common in this situation and can result in patient morbidity and mortality. An exploratory qualitative design with focus group interviews was used. Four focus group interviews were conducted with 20 registered nurses in home care. The data were analysed using content analysis. Five categories were identified as follows: lack of information, lack of competence, reporting medication errors, trade name products vs. generic name products, and improving routines. Medication errors occur frequently in home care and can threaten the safety of patients. Insufficient exchange of information and poor communication between the specialist and home-care health services, and between general practitioners and healthcare workers can lead to medication errors. A lack of competence in healthcare workers can also lead to medication errors. To prevent these, it is important that there should be up-to-date information and communication between healthcare workers during the transfer of patients from specialist to home care. Ensuring competence among healthcare workers with regard to medication is also important. In addition, there should be openness and accurate reporting of medication errors, as well as in setting routines for the preparation, alteration and administration of medicines. To prevent medication errors in home care, up-to-date information and communication between healthcare workers is important when patients are transferred from specialist to home care. It is also important to ensure adequate competence with regard to medication, and that there should be openness when medication errors occur, as well as in setting routines for the preparation, alteration and administration of medications. © 2017 John Wiley & Sons Ltd.

  6. Learning mechanisms to limit medication administration errors. (United States)

    Drach-Zahavy, Anat; Pud, Dorit


    This paper is a report of a study conducted to identify and test the effectiveness of learning mechanisms applied by the nursing staff of hospital wards as a means of limiting medication administration errors. Since the influential report ;To Err Is Human', research has emphasized the role of team learning in reducing medication administration errors. Nevertheless, little is known about the mechanisms underlying team learning. Thirty-two hospital wards were randomly recruited. Data were collected during 2006 in Israel by a multi-method (observations, interviews and administrative data), multi-source (head nurses, bedside nurses) approach. Medication administration error was defined as any deviation from procedures, policies and/or best practices for medication administration, and was identified using semi-structured observations of nurses administering medication. Organizational learning was measured using semi-structured interviews with head nurses, and the previous year's reported medication administration errors were assessed using administrative data. The interview data revealed four learning mechanism patterns employed in an attempt to learn from medication administration errors: integrated, non-integrated, supervisory and patchy learning. Regression analysis results demonstrated that whereas the integrated pattern of learning mechanisms was associated with decreased errors, the non-integrated pattern was associated with increased errors. Supervisory and patchy learning mechanisms were not associated with errors. Superior learning mechanisms are those that represent the whole cycle of team learning, are enacted by nurses who administer medications to patients, and emphasize a system approach to data analysis instead of analysis of individual cases.

  7. Hospital medication errors in a pharmacovigilance system in Colombia

    Directory of Open Access Journals (Sweden)

    Jorge Enrique Machado-Alba


    Full Text Available Objective: this study analyzes the medication errors reported to a pharmacovigilance system by 26 hospitals for patients in the healthcare system of Colombia. Methods: this retrospective study analyzed the medication errors reported to a systematized database between 1 January 2008 and 12 September 2013. The medication is dispensed by the company Audifarma S.A. to hospitals and clinics around Colombia. Data were classified according to the taxonomy of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP. The data analysis was performed using SPSS 22.0 for Windows, considering p-values < 0.05 significant. Results: there were 9 062 medication errors in 45 hospital pharmacies. Real errors accounted for 51.9% (n = 4 707, of which 12.0% (n = 567 reached the patient (Categories C to I and caused harm (Categories E to I to 17 subjects (0.36%. The main process involved in errors that occurred (categories B to I was prescription (n = 1 758, 37.3%, followed by dispensation (n = 1 737, 36.9%, transcription (n = 970, 20.6% and administration (n = 242, 5.1%. The errors in the administration process were 45.2 times more likely to reach the patient (CI 95%: 20.2–100.9. Conclusions: medication error reporting systems and prevention strategies should be widespread in hospital settings, prioritizing efforts to address the administration process.


    Buletsa, S; Drozd, O; Yunin, O; Mohilevskyi, L


    The scientific article is focused on the research of the notion of medical error, medical and legal aspects of this notion have been considered. The necessity of the legislative consolidation of the notion of «medical error» and criteria of its legal estimation have been grounded. In the process of writing a scientific article, we used the empirical method, general scientific and comparative legal methods. A comparison of the concept of medical error in civil and legal aspects was made from the point of view of Ukrainian, European and American scientists. It has been marked that the problem of medical errors is known since ancient times and in the whole world, in fact without regard to the level of development of medicine, there is no country, where doctors never make errors. According to the statistics, medical errors in the world are included in the first five reasons of death rate. At the same time the grant of medical services practically concerns all people. As a man and his life, health in Ukraine are acknowledged by a higher social value, medical services must be of high-quality and effective. The grant of not quality medical services causes harm to the health, and sometimes the lives of people; it may result in injury or even death. The right to the health protection is one of the fundamental human rights assured by the Constitution of Ukraine; therefore the issue of medical errors and liability for them is extremely relevant. The authors make conclusions, that the definition of the notion of «medical error» must get the legal consolidation. Besides, the legal estimation of medical errors must be based on the single principles enshrined in the legislation and confirmed by judicial practice.

  9. FMEA: a model for reducing medical errors. (United States)

    Chiozza, Maria Laura; Ponzetti, Clemente


    Patient safety is a management issue, in view of the fact that clinical risk management has become an important part of hospital management. Failure Mode and Effect Analysis (FMEA) is a proactive technique for error detection and reduction, firstly introduced within the aerospace industry in the 1960s. Early applications in the health care industry dating back to the 1990s included critical systems in the development and manufacture of drugs and in the prevention of medication errors in hospitals. In 2008, the Technical Committee of the International Organization for Standardization (ISO), licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. Here we describe the main steps of the FMEA process and review data available on the application of this technique to laboratory medicine. A significant reduction of the risk priority number (RPN) was obtained when applying FMEA to blood cross-matching, to clinical chemistry analytes, as well as to point-of-care testing (POCT).

  10. Physician assistants and the disclosure of medical error. (United States)

    Brock, Douglas M; Quella, Alicia; Lipira, Lauren; Lu, Dave W; Gallagher, Thomas H


    Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.

  11. [Medication errors in Spanish intensive care units]. (United States)

    Merino, P; Martín, M C; Alonso, A; Gutiérrez, I; Alvarez, J; Becerril, F


    To estimate the incidence of medication errors in Spanish intensive care units. Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU. Spanish intensive care units. Patients admitted to the intensive care unit participating in the SYREC during the period of study. Risk, individual risk, and rate of medication errors. The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable". Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

  12. Medication errors in outpatient care in Colombia, 2005-2013. (United States)

    Machado-Alba, Jorge E; Moncada, Juan Carlos; Moreno-Gutiérrez, Paula Andrea


    Medication errors outside the hospital have been poorly studied despite representing an important threat to patient safety. To describe the characteristics of medication errors in outpatient dispensing pharmacists reported in a pharmaco-surveillance system between 2005 and 2013 in Colombia. We conducted a descriptive study by reviewing and categorizing medication error reports from outpatient pharmacy services to a national medication dispensing company between January, 2005 and September, 2013. Variables considered included: process involved (administration, dispensing, prescription and transcription), wrong drug, time delay for the report, error type, cause and severity. The analysis was conducted in the SPSS® software, version 22.0. A total of 14,873 medication errors were reviewed, of which 67.2% in fact occurred, 15.5% reached the patient and 0.7% caused harm. Administration (OR=93.61, CI 95%: 48.510-180.655, perrors (OR=5.64; CI 95%: 3.488-9.142, perror reaching the patient. It is necessary to develop surveillance systems for medication errors in ambulatory care, focusing on the prescription, transcription and dispensation processes. Special strategies are needed for the prevention of medication errors related to anti-infective drugs.

  13. Barriers to Medical Error Reporting for Physicians and Nurses. (United States)

    Soydemir, Dilek; Seren Intepeler, Seyda; Mert, Hatice


    The purpose of the study was to determine what barriers to error reporting exist for physicians and nurses. The study, of descriptive qualitative design, was conducted with physicians and nurses working at a training and research hospital. In-depth interviews were held with eight physicians and 15 nurses, a total of 23 participants. Physicians and nurses do not choose to report medical errors that they experience or witness. When barriers to error reporting were examined, it was seen that there were four main themes involved: fear, the attitude of administration, barriers related to the system, and the employees' perceptions of error. It is important in terms of preventing medical errors to identify the barriers that keep physicians and nurses from reporting errors.

  14. Addressing Medical Errors in Hand Surgery


    Johnson, Shepard P.; Adkinson, Joshua M.; Chung, Kevin C.


    Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is...

  15. Error begat error: design error analysis and prevention in social infrastructure projects. (United States)

    Love, Peter E D; Lopez, Robert; Edwards, David J; Goh, Yang M


    Design errors contribute significantly to cost and schedule growth in social infrastructure projects and to engineering failures, which can result in accidents and loss of life. Despite considerable research that has addressed their error causation in construction projects they still remain prevalent. This paper identifies the underlying conditions that contribute to design errors in social infrastructure projects (e.g. hospitals, education, law and order type buildings). A systemic model of error causation is propagated and subsequently used to develop a learning framework for design error prevention. The research suggests that a multitude of strategies should be adopted in congruence to prevent design errors from occurring and so ensure that safety and project performance are ameliorated. Copyright © 2011. Published by Elsevier Ltd.

  16. Recognition of medical errors' reporting system dimensions in educational hospitals. (United States)

    Yarmohammadian, Mohammad H; Mohammadinia, Leila; Tavakoli, Nahid; Ghalriz, Parvin; Haghshenas, Abbas


    characteristics, and the quality of error experiences' transmission in the health-care system. Although, appropriate achievements have been assured in Shahid Beheshti Hospital, but it seems necessary that in order to immune promotion not only in this hospital, but in the other organizations, necessary infrastructures have been provided for an error reporting system performance. An appropriate medical error reporting system could be educated and prevent the occurrence of repeated errors.

  17. 2010 drug packaging review: identifying problems to prevent errors. (United States)


    Prescrire's analyses showed that the quality of drug packaging in 2010 still left much to be desired. Potentially dangerous packaging remains a significant problem: unclear labelling is source of medication errors; dosing devices for some psychotropic drugs create a risk of overdose; child-proof caps are often lacking; and too many patient information leaflets are misleading or difficult to understand. Everything that is needed for safe drug packaging is available; it is now up to regulatory agencies and drug companies to act responsibly. In the meantime, health professionals can help their patients by learning to identify the pitfalls of drug packaging and providing safe information to help prevent medication errors.

  18. Analyzing temozolomide medication errors: potentially fatal. (United States)

    Letarte, Nathalie; Gabay, Michael P; Bressler, Linda R; Long, Katie E; Stachnik, Joan M; Villano, J Lee


    The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.

  19. Detection of Patients at High Risk of Medication Errors

    DEFF Research Database (Denmark)

    Sædder, Eva Aggerholm; Lisby, Marianne; Nielsen, Lars Peter


    Medication errors (MEs) are preventable and can result in patient harm and increased expenses in the healthcare system in terms of hospitalization, prolonged hospitalizations and even death. We aimed to develop a screening tool to detect acutely admitted patients at low or high risk of MEs...

  20. [Errors in Peruvian medical journals references]. (United States)

    Huamaní, Charles; Pacheco-Romero, José


    References are fundamental in our studies; an adequate selection is asimportant as an adequate description. To determine the number of errors in a sample of references found in Peruvian medical journals. We reviewed 515 scientific papers references selected by systematic randomized sampling and corroborated reference information with the original document or its citation in Pubmed, LILACS or SciELO-Peru. We found errors in 47,6% (245) of the references, identifying 372 types of errors; the most frequent were errors in presentation style (120), authorship (100) and title (100), mainly due to spelling mistakes (91). References error percentage was high, varied and multiple. We suggest systematic revision of references in the editorial process as well as to extend the discussion on this theme. references, periodicals, research, bibliometrics.

  1. The Causes of Medical Error from the Perspective of Nurses

    Directory of Open Access Journals (Sweden)

    Oguz Isik


    Full Text Available This study was conducted as a descriptive study in order to determine the medical errors in hospital services and preventive measures that could be taken to reduce these errors, from the perspective of nurses. The population of the study is composed of nurses working in 2 public hospitals in center of the province of Sakarya. We haven’t selected sample and it was aimed to reach as many nurses as possible in the study. A total of 441 questionnaires were send and 324 were returned. A questionnaire as a means of data collection was prepared and used by the authors. Structural Equation Modeling, confirmatory factor analysis, descriptive statistical methods, the significance control test between compared means and ANOVA test were used in statistical analysis. Physicians, nurses, work environment and lack of communication are stated as possible causes of medical error. According to nurses, the major causes of medical errors, in order of their frequency, were inadequate number of health personnel, excessive work stress, high number of patients per nurse, the weariness due to the behavior and attitudes of superiors and the pressure to care so many patients in a very short period of time, and long time of study. Compensation of medical error is very difficult in health care. A great amount of health care is provided in hospitals and medical errors in hospital services must be prevented. In order to prevent these errors which directly affect human life, it is thought that adequate number of staff should be employed in hospitals and the attitude of superiors towards the employees should be motivating. [TAF Prev Med Bull 2012; 11(4.000: 421-430

  2. Medication errors: the role of the patient. (United States)

    Britten, Nicky


    1. Patients and their carers will usually be the first to notice any observable problems resulting from medication errors. They will probably be unable to distinguish between medication errors, adverse drug reactions, or 'side effects'. 2. Little is known about how patients understand drug related problems or how they make attributions of adverse effects. Some research suggests that patients' cognitive models of adverse drug reactions bear a close relationship to models of illness perception. 3. Attributions of adverse drug reactions are related to people's previous experiences and to their level of education. The evidence suggests that on the whole patients' reports of adverse drug reactions are accurate. However, patients do not report all the problems they perceive and are more likely to report those that they do perceive as severe. Patients may not report problems attributed to their medications if they are fearful of doctors' reactions. Doctors may respond inappropriately to patients' concerns, for example by ignoring them. Some authors have proposed the use of a symptom checklist to elicit patients' reports of suspected adverse drug reactions. 4. Many patients want information about adverse drug effects, and the challenge for the professional is to judge how much information to provide and the best way of doing so. Professionals' inappropriate emphasis on adherence may be dangerous when a medication error has occurred. 5. Recent NICE guidelines recommend that professionals should ask patients if they have any concerns about their medicines, and this approach is likely to yield information conducive to the identification of medication errors.

  3. Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012). (United States)

    Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi; Wan-Mohaina, W M


    Reporting and analysing the data on medication errors (MEs) is important and contributes to a better understanding of the error-prone environment. This study aims to examine the characteristics of errors submitted to the National Medication Error Reporting System (MERS) in Malaysia. A retrospective review of reports received from 1 January 2009 to 31 December 2012 was undertaken. Descriptive statistics method was applied. A total of 17,357 MEs reported were reviewed. The majority of errors were from public-funded hospitals. Near misses were classified in 86.3 % of the errors. The majority of errors (98.1 %) had no harmful effects on the patients. Prescribing contributed to more than three-quarters of the overall errors (76.1 %). Pharmacists detected and reported the majority of errors (92.1 %). Cases of erroneous dosage or strength of medicine (30.75 %) were the leading type of error, whilst cardiovascular (25.4 %) was the most common category of drug found. MERS provides rich information on the characteristics of reported MEs. Low contribution to reporting from healthcare facilities other than government hospitals and non-pharmacists requires further investigation. Thus, a feasible approach to promote MERS among healthcare providers in both public and private sectors needs to be formulated and strengthened. Preventive measures to minimise MEs should be directed to improve prescribing competency among the fallible prescribers identified.

  4. Sources of medical error in refractive surgery. (United States)

    Moshirfar, Majid; Simpson, Rachel G; Dave, Sonal B; Christiansen, Steven M; Edmonds, Jason N; Culbertson, William W; Pascucci, Stephen E; Sher, Neal A; Cano, David B; Trattler, William B


    To evaluate the causes of laser programming errors in refractive surgery and outcomes in these cases. In this multicenter, retrospective chart review, 22 eyes of 18 patients who had incorrect data entered into the refractive laser computer system at the time of treatment were evaluated. Cases were analyzed to uncover the etiology of these errors, patient follow-up treatments, and final outcomes. The results were used to identify potential methods to avoid similar errors in the future. Every patient experienced compromised uncorrected visual acuity requiring additional intervention, and 7 of 22 eyes (32%) lost corrected distance visual acuity (CDVA) of at least one line. Sixteen patients were suitable candidates for additional surgical correction to address these residual visual symptoms and six were not. Thirteen of 22 eyes (59%) received surgical follow-up treatment; nine eyes were treated with contact lenses. After follow-up treatment, six patients (27%) still had a loss of one line or more of CDVA. Three significant sources of error were identified: errors of cylinder conversion, data entry, and patient identification error. Twenty-seven percent of eyes with laser programming errors ultimately lost one or more lines of CDVA. Patients who underwent surgical revision had better outcomes than those who did not. Many of the mistakes identified were likely avoidable had preventive measures been taken, such as strict adherence to patient verification protocol or rigorous rechecking of treatment parameters. Copyright 2013, SLACK Incorporated.

  5. Adverse Drug Events caused by Serious Medication Administration Errors (United States)

    Sawarkar, Abhivyakti; Keohane, Carol A.; Maviglia, Saverio; Gandhi, Tejal K; Poon, Eric G


    medication doses administered, in a hospital where 6 million doses are administered per year, about 4000 preventable ADEs would be attributable to medication administration errors annually. PMID:22791691

  6. Osseous Metastase of Occult Paraganglioma: A Diagnostic Medical Error

    Directory of Open Access Journals (Sweden)

    Ghasemi TA


    Full Text Available Introduction: Diagnostic errors have a natural complexity. Medical diagnoses make up a large proportion of all medical errors and cause much suffering and harm. Compared to other types of error, diagnostic errors receive little attention-a major factor in continuity of unacceptable rates of diagnostic error. Case: A 55-year-old woman presented to the emergency department (ED complaining of bone pain which has been started a month ago and increased gradually in the upper right thigh. Following the emergency evaluation she was sent home with pain medication. On the second visit, a femur neck fracture was seen in the x-ray. She underwent hemiarthroplasty and was discharged. Over several weeks she was reevaluated by many Physicians, because of her worsening pain .In the third visit after the surgery, her x-ray showed bone destruction and following bone biopsy, malignant paraganglioma was diagnosed. Discussion and solution: In all cases in which patient comes to us with skeletal pain, getting a comprehensive history and a full physical examination are prior to lab tests and x-rays. Bone metastasis which can develop severe pain and pathological fractures, is common in patients with malignant paraganglioma. Effective steps for diagnostic error prevention are: Considering the diagnostic error in the normal range of quality assurance surveillance and review, identifying the elements leading to diagnostic errors and getting feedback on the diagnoses Physicians make, in order to improve their skills. Conclusion: It is an every health system priority to identify, analyze, and prevent diagnostic errors in order to improve patient safety

  7. [Monitoring medication errors in an internal medicine service]. (United States)

    Smith, Ann-Loren M; Ruiz, Inés A; Jirón, Marcela A


    Patients admitted to internal medicine services receive multiple drugs and thus are at risk of medication errors. To determine the frequency of medication errors (ME) among patients admitted to an internal medicine service of a high complexity hospital. A prospective observational study conducted in 225 patients admitted to an internal medicine service. Each stage of drug utilization system (prescription, transcription, dispensing, preparation and administration) was directly observed by trained pharmacists not related to hospital staff during three months. ME were described and categorized according to the National Coordinating Council for Medication Error Reporting and Prevention. In each stage of medication use, the frequency of ME and their characteristics were determined. A total of 454 drugs were prescribed to the studied patients. In 138 (30,4%) indications, at least one ME occurred, involving 67 (29,8%) patients. Twenty four percent of detected ME occurred during administration, mainly due to wrong time schedules. Anticoagulants were the therapeutic group with the highest occurrence of ME. At least one ME occurred in approximately one third of patients studied, especially during the administration stage. These errors could affect the medication safety and avoid achieving therapeutic goals. Strategies to improve the quality and safe use of medications can be implemented using this information.

  8. The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong. (United States)

    Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y


    The primary goal of reducing medication errors is to eliminate those that reach the patient. We aimed to study the pattern of interceptions to tackle medication errors along the medication use processes. Tertiary care hospital in Hong Kong. The 'Swiss Cheese Model' was used to explain the interceptions targeting medication error reporting over 5 years (2006-2010). Proportions of prescribing, dispensing and drug administration errors intercepted by pharmacists and nurses; proportions of prescribing, dispensing and drug administration errors that reached the patient. Our analysis included 1,268 in-patient medication errors, of which 53.4% were related to prescribing, 29.0% to administration and 17.6% to dispensing. 34.1% of all medication errors (4.9% prescribing, 26.8% drug administration and 2.4% dispensing) were not intercepted. Pharmacy staff intercepted 85.4% of the prescribing errors. Nurses detected 83.0% of dispensing and 5.0% of prescribing errors. However, 92.4% of all drug administration errors reached the patient. Having a preventive measure at each stage of the medication use process helps to prevent most errors. Most drug administration errors reach the patient as there is no defense against these. Therefore, more interventions to prevent drug administration errors are warranted.

  9. Medication error in anaesthesia and critical care: A cause for concern

    Directory of Open Access Journals (Sweden)

    Dilip Kothari


    Full Text Available Medication error is a major cause of morbidity and mortality in medical profession, and anaesthesia and critical care are no exception to it. Man, medicine, machine and modus operandi are the main contributory factors to it. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.

  10. An Analysis of Medication Errors at the Military Medical Center: Implications for a Systems Approach for Error Reduction

    National Research Council Canada - National Science Library

    Scheirman, Katherine


    An analysis was accomplished of all inpatient medication errors at a military academic medical center during the year 2000, based on the causes of medication errors as described by current research in the field...

  11. Changes in medical errors after implementation of a handoff program. (United States)

    Starmer, Amy J; Spector, Nancy D; Srivastava, Rajendu; West, Daniel C; Rosenbluth, Glenn; Allen, April D; Noble, Elizabeth L; Tse, Lisa L; Dalal, Anuj K; Keohane, Carol A; Lipsitz, Stuart R; Rothschild, Jeffrey M; Wien, Matthew F; Yoon, Catherine S; Zigmont, Katherine R; Wilson, Karen M; O'Toole, Jennifer K; Solan, Lauren G; Aylor, Megan; Bismilla, Zia; Coffey, Maitreya; Mahant, Sanjay; Blankenburg, Rebecca L; Destino, Lauren A; Everhart, Jennifer L; Patel, Shilpa J; Bale, James F; Spackman, Jaime B; Stevenson, Adam T; Calaman, Sharon; Cole, F Sessions; Balmer, Dorene F; Hepps, Jennifer H; Lopreiato, Joseph O; Yu, Clifton E; Sectish, Theodore C; Landrigan, Christopher P


    Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events

  12. Preventing statistical errors in scientific journals.

    NARCIS (Netherlands)

    Nuijten, M.B.


    There is evidence for a high prevalence of statistical reporting errors in psychology and other scientific fields. These errors display a systematic preference for statistically significant results, distorting the scientific literature. There are several possible causes for this systematic error

  13. Nature and frequency of medication errors in a geriatric ward: an Indonesian experience

    Directory of Open Access Journals (Sweden)

    Ernawati DK


    Full Text Available Desak Ketut Ernawati,1,2 Ya Ping Lee,2 Jeffery David Hughes21Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia; 2School of Pharmacy and Curtin Health Innovation and Research Institute, Curtin University, Perth, WA, AustraliaPurpose: To determine the nature and frequency of medication errors during medication delivery processes in a public teaching hospital geriatric ward in Bali, Indonesia.Methods: A 20-week prospective study on medication errors occurring during the medication delivery process was conducted in a geriatric ward in a public teaching hospital in Bali, Indonesia. Participants selected were inpatients aged more than 60 years. Patients were excluded if they had a malignancy, were undergoing surgery, or receiving chemotherapy treatment. The occurrence of medication errors in prescribing, transcribing, dispensing, and administration were detected by the investigator providing in-hospital clinical pharmacy services.Results: Seven hundred and seventy drug orders and 7,662 drug doses were reviewed as part of the study. There were 1,563 medication errors detected among the 7,662 drug doses reviewed, representing an error rate of 20.4%. Administration errors were the most frequent medication errors identified (59%, followed by transcription errors (15%, dispensing errors (14%, and prescribing errors (7%. Errors in documentation were the most common form of administration errors. Of these errors, 2.4% were classified as potentially serious and 10.3% as potentially significant.Conclusion: Medication errors occurred in every stage of the medication delivery process, with administration errors being the most frequent. The majority of errors identified in the administration stage were related to documentation. Provision of in-hospital clinical pharmacy services could potentially play a significant role in detecting and preventing medication errors.Keywords: geriatric, medication errors, inpatients, medication delivery process

  14. Identifying medication errors in the neonatal intensive care unit and ...

    African Journals Online (AJOL)

    Background. Paediatric patients are particularly prone to medication errors as they are classified as the most fragile population in a hospital setting. Paediatric medication errors in the South African healthcare setting are comparatively understudied. Objectives. To determine the incidence of medication errors in neonatal ...

  15. Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative. (United States)

    Lobaugh, Lauren M Y; Martin, Lizabeth D; Schleelein, Laura E; Tyler, Donald C; Litman, Ronald S


    Wake Up Safe is a quality improvement initiative of the Society for Pediatric Anesthesia that contains a deidentified registry of serious adverse events occurring in pediatric anesthesia. The aim of this study was to describe and characterize reported medication errors to find common patterns amenable to preventative strategies. In September 2016, we analyzed approximately 6 years' worth of medication error events reported to Wake Up Safe. Medication errors were classified by: (1) medication category; (2) error type by phase of administration: prescribing, preparation, or administration; (3) bolus or infusion error; (4) provider type and level of training; (5) harm as defined by the National Coordinating Council for Medication Error Reporting and Prevention; and (6) perceived preventability. From 2010 to the time of our data analysis in September 2016, 32 institutions had joined and submitted data on 2087 adverse events during 2,316,635 anesthetics. These reports contained details of 276 medication errors, which comprised the third highest category of events behind cardiac and respiratory related events. Medication errors most commonly involved opioids and sedative/hypnotics. When categorized by phase of handling, 30 events occurred during preparation, 67 during prescribing, and 179 during administration. The most common error type was accidental administration of the wrong dose (N = 84), followed by syringe swap (accidental administration of the wrong syringe, N = 49). Fifty-seven (21%) reported medication errors involved medications prepared as infusions as opposed to 1 time bolus administrations. Medication errors were committed by all types of anesthesia providers, most commonly by attendings. Over 80% of reported medication errors reached the patient and more than half of these events caused patient harm. Fifteen events (5%) required a life sustaining intervention. Nearly all cases (97%) were judged to be either likely or certainly preventable. Our findings

  16. The effectiveness of risk management program on pediatric nurses' medication error. (United States)

    Dehghan-Nayeri, Nahid; Bayat, Fariba; Salehi, Tahmineh; Faghihzadeh, Soghrat


    Medication therapy is one of the most complex and high-risk clinical processes that nurses deal with. Medication error is the most common type of error that brings about damage and death to patients, especially pediatric ones. However, these errors are preventable. Identifying and preventing undesirable events leading to medication errors are the main risk management activities. The aim of this study was to investigate the effectiveness of a risk management program on the pediatric nurses' medication error rate. This study is a quasi-experimental one with a comparison group. In this study, 200 nurses were recruited from two main pediatric hospitals in Tehran. In the experimental hospital, we applied the risk management program for a period of 6 months. Nurses of the control hospital did the hospital routine schedule. A pre- and post-test was performed to measure the frequency of the medication error events. SPSS software, t-test, and regression analysis were used for data analysis. After the intervention, the medication error rate of nurses at the experimental hospital was significantly lower (P error-reporting rate was higher (P medical environment, applying the quality-control programs such as risk management can effectively prevent the occurrence of the hospital undesirable events. Nursing mangers can reduce the medication error rate by applying risk management programs. However, this program cannot succeed without nurses' cooperation.

  17. Impact of clinical pharmacy interventions on medication error nodes. (United States)

    Chamoun, Nibal R; Zeenny, Rony; Mansour, Hanine


    Background Pharmacists' involvement in patient care has improved the quality of care and reduced medication errors. However, this has required a lot of work that could not have been accomplished without documentation of interventions. Several means of documenting errors have been proposed in the literature but without a consistent comprehensive process. Recently, the American College of Clinical Pharmacy (ACCP) recognized that pharmacy practice lacks a consistent process for direct patient care and discussed several options for a pharmaceutical care plan, essentially encompassing medication therapy assessment, development and implementation of a pharmaceutical care plan and finally evaluation of the outcome. Therefore, as per the recommendations of ACCP, we sought to retrospectively analyze interventions by grouping them according to medication related problems (MRP) and their nodes such as prescribing; administering; monitoring; documenting and dispensing. Objective The aim of this study is to report interventions according to medication error (ME) nodes and show the impact of pharmacy interventions in reducing MRPs. Setting The study was conducted at the cardiology and infectious diseases services at a teaching hospital located in Beirut, Lebanon. Methods Intervention documentation was completed by pharmacy students on infectious diseases and cardiology rotations then reviewed by clinical pharmacists with respective specialties. Before data analysis, a new pharmacy reporting sheet was developed in order to link interventions according to MRP. Then, MRPs were grouped in the five ME nodes. During the documentation process, whether MRP had reached the patient or not may have not been reported which prevented the classification to the corresponding medication error nodes as ME. Main outcome Reduction in medication related problems across all ME nodes. Results A total of n = 1174 interventions were documented. N = 1091 interventions were classified as MRPs

  18. Speak Up: Help Prevent Errors in Your Care: Laboratory Services (United States)

    SpeakUP TM Help Prevent Errors in Your Care Laboratory Services To prevent health care errors, patients are urged to... SpeakUP TM ... are more likely to get better faster. To help prevent health care mistakes, patients are urged to “ ...

  19. The economics of health care quality and medical errors. (United States)

    Andel, Charles; Davidow, Stephen L; Hollander, Mark; Moreno, David A


    Hospitals have been looking for ways to improve quality and operational efficiency and cut costs for nearly three decades, using a variety of quality improvement strategies. However, based on recent reports, approximately 200,000 Americans die from preventable medical errors including facility-acquired conditions and millions may experience errors. In 2008, medical errors cost the United States $19.5 billion. About 87 percent or $17 billion were directly associated with additional medical cost, including: ancillary services, prescription drug services, and inpatient and outpatient care, according to a study sponsored by the Society for Actuaries and conducted by Milliman in 2010. Additional costs of $1.4 billion were attributed to increased mortality rates with $1.1 billion or 10 million days of lost productivity from missed work based on short-term disability claims. The authors estimate that the economic impact is much higher, perhaps nearly $1 trillion annually when quality-adjusted life years (QALYs) are applied to those that die. Using the Institute of Medicine's (IOM) estimate of 98,000 deaths due to preventable medical errors annually in its 1998 report, To Err Is Human, and an average of ten lost years of life at $75,000 to $100,000 per year, there is a loss of $73.5 billion to $98 billion in QALYs for those deaths--conservatively. These numbers are much greater than those we cite from studies that explore the direct costs of medical errors. And if the estimate of a recent Health Affairs article is correct-preventable death being ten times the IOM estimate-the cost is $735 billion to $980 billion. Quality care is less expensive care. It is better, more efficient, and by definition, less wasteful. It is the right care, at the right time, every time. It should mean that far fewer patients are harmed or injured. Obviously, quality care is not being delivered consistently throughout U.S. hospitals. Whatever the measure, poor quality is costing payers and

  20. Awareness of technology-induced errors and processes for identifying and preventing such errors. (United States)

    Bellwood, Paule; Borycki, Elizabeth M; Kushniruk, Andre W


    There is a need to determine if organizations working with health information technology are aware of technology-induced errors and how they are addressing and preventing them. The purpose of this study was to: a) determine the degree of technology-induced error awareness in various Canadian healthcare organizations, and b) identify those processes and procedures that are currently in place to help address, manage, and prevent technology-induced errors. We identified a lack of technology-induced error awareness among participants. Participants identified there was a lack of well-defined procedures in place for reporting technology-induced errors, addressing them when they arise, and preventing them.

  1. Pediatric Nurses' Perceptions of Medication Safety and Medication Error: A Mixed Methods Study. (United States)

    Alomari, Albara; Wilson, Val; Solman, Annette; Bajorek, Beata; Tinsley, Patricia


    This study aims to outline the current workplace culture of medication practice in a pediatric medical ward. The objective is to explore the perceptions of nurses in a pediatric clinical setting as to why medication administration errors occur. As nurses have a central role in the medication process, it is essential to explore nurses' perceptions of the factors influencing the medication process. Without this understanding, it is difficult to develop effective prevention strategies aimed at reducing medication administration errors. Previous studies were limited to exploring a single and specific aspect of medication safety. The methods used in these studies were limited to survey designs which may lead to incomplete or inadequate information being provided. This study is phase 1 on an action research project. Data collection included a direct observation of nurses during medication preparation and administration, audit based on the medication policy, and guidelines and focus groups with nursing staff. A thematic analysis was undertaken by each author independently to analyze the observation notes and focus group transcripts. Simple descriptive statistics were used to analyze the audit data. The study was conducted in a specialized pediatric medical ward. Four key themes were identified from the combined quantitative and qualitative data: (1) understanding medication errors, (2) the busy-ness of nurses, (3) the physical environment, and (4) compliance with medication policy and practice guidelines. Workload, frequent interruptions to process, poor physical environment design, lack of preparation space, and impractical medication policies are identified as barriers to safe medication practice. Overcoming these barriers requires organizations to review medication process policies and engage nurses more in medication safety research and in designing clinical guidelines for their own practice.

  2. Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia. (United States)

    Martin, Lizabeth D; Grigg, Eliot B; Verma, Shilpa; Latham, Gregory J; Rampersad, Sally E; Martin, Lynn D


    The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety. © 2017 John Wiley & Sons Ltd.

  3. Building a learning culture and prevention of error - to near miss or not. (United States)

    Arnold, Anthony


    This editorial provides an insight into learning and prevention of error through near miss event reporting. © 2017 The Author. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.

  4. An overview of intravenous-related medication administration errors as reported to MEDMARX, a national medication error-reporting program. (United States)

    Hicks, Rodney W; Becker, Shawn C


    Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes-product shortage, calculation errors, and tubing interconnectivity-emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.

  5. Systematic literature review of hospital medication administration errors in children

    Directory of Open Access Journals (Sweden)

    Ameer A


    Full Text Available Ahmed Ameer,1 Soraya Dhillon,1 Mark J Peters,2 Maisoon Ghaleb11Department of Pharmacy, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK; 2Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK Objective: Medication administration is the last step in the medication process. It can act as a safety net to prevent unintended harm to patients if detected. However, medication administration errors (MAEs during this process have been documented and thought to be preventable. In pediatric medicine, doses are usually administered based on the child's weight or body surface area. This in turn increases the risk of drug miscalculations and therefore MAEs. The aim of this review is to report MAEs occurring in pediatric inpatients. Methods: Twelve bibliographic databases were searched for studies published between January 2000 and February 2015 using “medication administration errors”, “hospital”, and “children” related terminologies. Handsearching of relevant publications was also carried out. A second reviewer screened articles for eligibility and quality in accordance with the inclusion/exclusion criteria. Key findings: A total of 44 studies were systematically reviewed. MAEs were generally defined as a deviation of dose given from that prescribed; this included omitted doses and administration at the wrong time. Hospital MAEs in children accounted for a mean of 50% of all reported medication error reports (n=12,588. It was also identified in a mean of 29% of doses observed (n=8,894. The most prevalent type of MAEs related to preparation, infusion rate, dose, and time. This review has identified five types of interventions to reduce hospital MAEs in children: barcode medicine administration, electronic prescribing, education, use of smart pumps, and standard concentration. Conclusion: This review has identified a wide variation in the prevalence of hospital MAEs in children. This is attributed to

  6. Assessing explicit error reporting in the narrative electronic medical record using keyword searching. (United States)

    Cao, Hui; Stetson, Peter; Hripcsak, George


    Many types of medical errors occur in and outside of hospitals, some of which have very serious consequences and increase cost. Identifying errors is a critical step for managing and preventing them. In this study, we assessed the explicit reporting of medical errors in the electronic record. We used five search terms "mistake," "error," "incorrect," "inadvertent," and "iatrogenic" to survey several sets of narrative reports including discharge summaries, sign-out notes, and outpatient notes from 1991 to 2000. We manually reviewed all the positive cases and identified them based on the reporting of physicians. We identified 222 explicitly reported medical errors. The positive predictive value varied with different keywords. In general, the positive predictive value for each keyword was low, ranging from 3.4 to 24.4%. Therapeutic-related errors were the most common reported errors and these reported therapeutic-related errors were mainly medication errors. Keyword searches combined with manual review indicated some medical errors that were reported in medical records. It had a low sensitivity and a moderate positive predictive value, which varied by search term. Physicians were most likely to record errors in the Hospital Course and History of Present Illness sections of discharge summaries. The reported errors in medical records covered a broad range and were related to several types of care providers as well as non-health care professionals.

  7. Iatrogenic medication errors in a paediatric intensive care unit in ...

    African Journals Online (AJOL)

    Errors most frequently encountered included failure to calculate rates of infusion and the conversion of mL to mEq or mL to mg for potassium, phenobarbitone and digoxin. Of the 117 children admitted, 111 (94.9%) were exposed to at least one medication error. Two or more medication errors occurred in 34.1% of cases.

  8. Analysis of Employee's Survey for Preventing Human-Errors

    International Nuclear Information System (INIS)

    Sung, Chanho; Kim, Younggab; Joung, Sanghoun


    Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses

  9. Characteristics of pediatric chemotherapy medication errors in a national error reporting database. (United States)

    Rinke, Michael L; Shore, Andrew D; Morlock, Laura; Hicks, Rodney W; Miller, Marlene R


    Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors. The authors queried the United States Pharmacopeia MEDMARX database, a national, voluntary, Internet-accessible error reporting system, for all error reports from 1999 through 2004 that involved chemotherapy medications and patients aged error reports, 85% reached the patient, and 15.6% required additional patient monitoring or therapeutic intervention. Forty-eight percent of errors originated in the administering phase of medication delivery, and 30% originated in the drug-dispensing phase. Of the 387 medications cited, 39.5% were antimetabolites, 14.0% were alkylating agents, 9.3% were anthracyclines, and 9.3% were topoisomerase inhibitors. The most commonly involved chemotherapeutic agents were methotrexate (15.3%), cytarabine (12.1%), and etoposide (8.3%). The most common error types were improper dose/quantity (22.9% of 327 cited error types), wrong time (22.6%), omission error (14.1%), and wrong administration technique/wrong route (12.2%). The most common error causes were performance deficit (41.3% of 547 cited error causes), equipment and medication delivery devices (12.4%), communication (8.8%), knowledge deficit (6.8%), and written order errors (5.5%). Four of the 5 most serious errors occurred at community hospitals. Pediatric chemotherapy errors often reached the patient, potentially were harmful, and differed in quality between outpatient and inpatient areas. This study indicated which chemotherapeutic agents most often were involved in errors and that administering errors were common. Investigation is needed regarding targeted medication administration safeguards for these high-risk medications. Copyright (c) 2007 American Cancer Society.

  10. Proportion of medication error reporting and associated factors among nurses: a cross sectional study. (United States)

    Jember, Abebaw; Hailu, Mignote; Messele, Anteneh; Demeke, Tesfaye; Hassen, Mohammed


    A medication error (ME) is any preventable event that may cause or lead to inappropriate medication use or patient harm. Voluntary reporting has a principal role in appreciating the extent and impact of medication errors. Thus, exploration of the proportion of medication error reporting and associated factors among nurses is important to inform service providers and program implementers so as to improve the quality of the healthcare services. Institution based quantitative cross-sectional study was conducted among 397 nurses from March 6 to May 10, 2015. Stratified sampling followed by simple random sampling technique was used to select the study participants. The data were collected using structured self-administered questionnaire which was adopted from studies conducted in Australia and Jordan. A pilot study was carried out to validate the questionnaire before data collection for this study. Bivariate and multivariate logistic regression models were fitted to identify factors associated with the proportion of medication error reporting among nurses. An adjusted odds ratio with 95% confidence interval was computed to determine the level of significance. The proportion of medication error reporting among nurses was found to be 57.4%. Regression analysis showed that sex, marital status, having made a medication error and medication error experience were significantly associated with medication error reporting. The proportion of medication error reporting among nurses in this study was found to be higher than other studies.

  11. Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals

    NARCIS (Netherlands)

    van der Veen, Willem; van den Bemt, Patricia M L A; Wouters, Hans; Bates, David W; Twisk, Jos W R; de Gier, Johan J; Taxis, Katja

    Objective: To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors. Materials and Methods: A prospective observational study in

  12. Medical Services: Preventive Medicine (United States)


    those at risk. Isoniazid (INH)administered orally is normally used for preventive therapy (300 mg daily for adults and 10 to 14 mg/kg body weight not to...netting, and insecticide aerosols; by taking approved chemoprophylaxis; and by wearing the uniform properly. d. Enteric disease by using iodine tablets ...National stock number: 6850–00–985–7166 Description: Water purification tablet , iodine, 50’s Unit/Issue: BT Allowance: 400 Authority: CTA 8–100 Notes: 1

  13. Medication errors detected in non-traditional databases

    DEFF Research Database (Denmark)

    Perregaard, Helene; Aronson, Jeffrey K; Dalhoff, Kim


    AIMS: We have looked for medication errors involving the use of low-dose methotrexate, by extracting information from Danish sources other than traditional pharmacovigilance databases. We used the data to establish the relative frequencies of different types of errors. METHODS: We searched four...... errors, whereas knowledge-based errors more often resulted in near misses. CONCLUSIONS: The medication errors in this survey were most often action-based (50%) and knowledge-based (34%), suggesting that greater attention should be paid to education and surveillance of medical personnel who prescribe...

  14. Detecting medication errors in the New Zealand pharmacovigilance database: a retrospective analysis. (United States)

    Kunac, Desireé L; Tatley, Michael V


    Despite the traditional focus being adverse drug reactions (ADRs), pharmacovigilance centres have recently been identified as a potentially rich and important source of medication error data. To identify medication errors in the New Zealand Pharmacovigilance database (Centre for Adverse Reactions Monitoring [CARM]), and to describe the frequency and characteristics of these events. A retrospective analysis of the CARM pharmacovigilance database operated by the New Zealand Pharmacovigilance Centre was undertaken for the year 1 January-31 December 2007. All reports, excluding those relating to vaccines, clinical trials and pharmaceutical company reports, underwent a preventability assessment using predetermined criteria. Those events deemed preventable were subsequently classified to identify the degree of patient harm, type of error, stage of medication use process where the error occurred and origin of the error. A total of 1412 reports met the inclusion criteria and were reviewed, of which 4.3% (61/1412) were deemed preventable. Not all errors resulted in patient harm: 29.5% (18/61) were 'no harm' errors but 65.5% (40/61) of errors were deemed to have been associated with some degree of patient harm (preventable adverse drug events [ADEs]). For 5.0% (3/61) of events, the degree of patient harm was unable to be determined as the patient outcome was unknown. The majority of preventable ADEs (62.5% [25/40]) occurred in adults aged 65 years and older. The medication classes most involved in preventable ADEs were antibacterials for systemic use and anti-inflammatory agents, with gastrointestinal and respiratory system disorders the most common adverse events reported. For both preventable ADEs and 'no harm' events, most errors were incorrect dose and drug therapy monitoring problems consisting of failures in detection of significant drug interactions, past allergies or lack of necessary clinical monitoring. Preventable events were mostly related to the prescribing and

  15. Putting a face on medical errors: a patient perspective. (United States)

    Kooienga, Sarah; Stewart, Valerie T


    Knowledge of the patient's perspective on medical error is limited. Research efforts have centered on how best to disclose error and how patients desire to have medical error disclosed. On the basis of a qualitative descriptive component of a mixed method study, a purposive sample of 30 community members told their stories of medical error. Their experiences focused on lack of communication, missed communication, or provider's poor interpersonal style of communication, greatly contrasting with the formal definition of error as failure to follow a set standard of care. For these participants, being a patient was more important than error or how an error is disclosed. The patient's understanding of error must be a key aspect of any quality improvement strategy. © 2010 National Association for Healthcare Quality.

  16. Medication prescribing errors in a public teaching hospital in India: A prospective study.

    Directory of Open Access Journals (Sweden)

    Pote S


    Full Text Available Background: To prevent medication errors in prescribing, one needs to know their types and relative occurrence. Such errors are a great cause of concern as they have the potential to cause patient harm. The aim of this study was to determine the nature and types of medication prescribing errors in an Indian setting.Methods: The medication errors were analyzed in a prospective observational study conducted in 3 medical wards of a public teaching hospital in India. The medication errors were analyzed by means of Micromedex Drug-Reax database.Results: Out of 312 patients, only 304 were included in the study. Of the 304 cases, 103 (34% cases had at least one error. The total number of errors found was 157. The drug-drug interactions were the most frequently (68.2% occurring type of error, which was followed by incorrect dosing interval (12% and dosing errors (9.5%. The medication classes involved most were antimicrobial agents (29.4%, cardiovascular agents (15.4%, GI agents (8.6% and CNS agents (8.2%. The moderate errors contributed maximum (61.8% to the total errors when compared to the major (25.5% and minor (12.7% errors. The results showed that the number of errors increases with age and number of medicines prescribed.Conclusion: The results point to the establishment of medication error reporting at each hospital and to share the data with other hospitals. The role of clinical pharmacist in this situation appears to be a strong intervention; and the clinical pharmacist, initially, could confine to identification of the medication errors.

  17. Heuristics and Cognitive Error in Medical Imaging. (United States)

    Itri, Jason N; Patel, Sohil H


    The field of cognitive science has provided important insights into mental processes underlying the interpretation of imaging examinations. Despite these insights, diagnostic error remains a major obstacle in the goal to improve quality in radiology. In this article, we describe several types of cognitive bias that lead to diagnostic errors in imaging and discuss approaches to mitigate cognitive biases and diagnostic error. Radiologists rely on heuristic principles to reduce complex tasks of assessing probabilities and predicting values into simpler judgmental operations. These mental shortcuts allow rapid problem solving based on assumptions and past experiences. Heuristics used in the interpretation of imaging studies are generally helpful but can sometimes result in cognitive biases that lead to significant errors. An understanding of the causes of cognitive biases can lead to the development of educational content and systematic improvements that mitigate errors and improve the quality of care provided by radiologists.

  18. Error budget calculations in laboratory medicine: linking the concepts of biological variation and allowable medical errors

    NARCIS (Netherlands)

    Stroobants, A. K.; Goldschmidt, H. M. J.; Plebani, M.


    Background: Random, systematic and sporadic errors, which unfortunately are not uncommon in laboratory medicine, can have a considerable impact on the well being of patients. Although somewhat difficult to attain, our main goal should be to prevent all possible errors. A good insight on error-prone

  19. Technology and medication errors: impact in nursing homes. (United States)

    Baril, Chantal; Gascon, Viviane; St-Pierre, Liette; Lagacé, Denis


    The purpose of this paper is to study a medication distribution technology's (MDT) impact on medication errors reported in public nursing homes in Québec Province. The work was carried out in six nursing homes (800 patients). Medication error data were collected from nursing staff through a voluntary reporting process before and after MDT was implemented. The errors were analysed using: totals errors; medication error type; severity and patient consequences. A statistical analysis verified whether there was a significant difference between the variables before and after introducing MDT. The results show that the MDT detected medication errors. The authors' analysis also indicates that errors are detected more rapidly resulting in less severe consequences for patients. MDT is a step towards safer and more efficient medication processes. Our findings should convince healthcare administrators to implement technology such as electronic prescriber or bar code medication administration systems to improve medication processes and to provide better healthcare to patients. Few studies have been carried out in long-term healthcare facilities such as nursing homes. The authors' study extends what is known about MDT's impact on medication errors in nursing homes.

  20. Audit of medication errors by anesthetists in North Western Nigeria ...

    African Journals Online (AJOL)

    ... errors do occur in the everyday practice of anesthetists in Nigeria as in other countries and can lead to morbidity and mortality in our patients. Routine audit and reporting of critical incidents including errors in drug administration should be encouraged. Reduction of medication errors is an important aspect of patient safety, ...

  1. Automated drug dispensing system reduces medication errors in an intensive care setting. (United States)

    Chapuis, Claire; Roustit, Matthieu; Bal, Gaëlle; Schwebel, Carole; Pansu, Pascal; David-Tchouda, Sandra; Foroni, Luc; Calop, Jean; Timsit, Jean-François; Allenet, Benoît; Bosson, Jean-Luc; Bedouch, Pierrick


    We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction. Preintervention and postintervention study involving a control and an intervention medical intensive care unit. Two medical intensive care units in the same department of a 2,000-bed university hospital. Adult medical intensive care patients. After a 2-month observation period, we implemented an automated dispensing system in one of the units (study unit) chosen randomly, with the other unit being the control. The overall error rate was expressed as a percentage of total opportunities for error. The severity of errors was classified according to National Coordinating Council for Medication Error Reporting and Prevention categories by an expert committee. User satisfaction was assessed through self-administered questionnaires completed by nurses. A total of 1,476 medications for 115 patients were observed. After automated dispensing system implementation, we observed a reduced percentage of total opportunities for error in the study compared to the control unit (13.5% and 18.6%, respectively; perror (20.4% and 13.5%; perror showed a significant impact of the automated dispensing system in reducing preparation errors (perrors caused no harm (National Coordinating Council for Medication Error Reporting and Prevention category C). The automated dispensing system did not reduce errors causing harm. Finally, the mean for working conditions improved from 1.0±0.8 to 2.5±0.8 on the four-point Likert scale. The implementation of an automated dispensing system reduced overall medication errors related to picking, preparation, and administration of drugs in the intensive care unit. Furthermore, most nurses favored the new drug dispensation organization.

  2. Medical Error Types and Causes Made by Nurses in Turkey

    Directory of Open Access Journals (Sweden)

    Dilek Kucuk Alemdar


    Full Text Available AIM: This study was carried out as a descriptive study in order to determine types, causes and prevalence of medical errors made by nurses in Turkey. METHOD: Seventy eight (78 nurses who have worked in a randomly selected hospital from five hospitals in Giresun city centre were enrolled in the study. The data was collected by the researchers using the ‘Information Form for Nurses’ and ‘Medical Error Form’. The Medical Error Form consists of 2 parts and 40 items including types and causes of medical errors. Nurses’ socio-demographic variables, medical error types and causes were evaluated using the percentage distribution and mean. RESULTS: The mean age of the nurses was 25.5 years, with a standard deviation 6.03 years. 50% of the nurses graduated health professional high school in the study. 53.8% of the nurses are single, 63.1% worked between 1-5 years, 71.8% day and night shifts and 42.3% in medical clinics. The common types of medical errors were hospital infection rate of 15.4%, diagnostic errors 12.8%, needle or cutting tool injuries and problems related to drug usage which has side effects 10.3%. In the study 38.5% of the nurses reported that they thought the cause of medical error highly was tiredness, 36.4% increased workload and 34.6% long working hours. CONCLUSION: As a result of the present study, nurses mentioned hospital infection, diagnostic errors, needle or cutting tool injuries as the most common medical errors and fatigue, over work load and long working hours as the most common medical error reasons. [TAF Prev Med Bull 2013; 12(3.000: 307-314

  3. Medication Administration Errors Involving Paediatric In-Patients in a ...

    African Journals Online (AJOL)


    In-Patients in a Hospital in Ethiopia. Yemisirach Feleke ... Purpose: To assess the type and frequency of medication administration errors (MAEs) in the paediatric ward of .... prescribers, does not go beyond obeying ... specialists, 43 general practitioners, 2 health officers ..... Medication Errors, International Council of Nurses.

  4. Nurses' attitude and intention of medication administration error reporting. (United States)

    Hung, Chang-Chiao; Chu, Tsui-Ping; Lee, Bih-O; Hsiao, Chia-Chi


    The Aims of this study were to explore the effects of nurses' attitudes and intentions regarding medication administration error reporting on actual reporting behaviours. Underreporting of medication errors is still a common occurrence. Whether attitude and intention towards medication administration error reporting connect to actual reporting behaviours remain unclear. This study used a cross-sectional design with self-administered questionnaires, and the theory of planned behaviour was used as the framework for this study. A total of 596 staff nurses who worked in general wards and intensive care units in a hospital were invited to participate in this study. The researchers used the instruments measuring nurses' attitude, nurse managers' and co-workers' attitude, report control, and nurses' intention to predict nurses' actual reporting behaviours. Data were collected from September-November 2013. Path analyses were used to examine the hypothesized model. Of the 596 nurses invited to participate, 548 (92%) completed and returned a valid questionnaire. The findings indicated that nurse managers' and co-workers' attitudes are predictors for nurses' attitudes towards medication administration error reporting. Nurses' attitudes also influenced their intention to report medication administration errors; however, no connection was found between intention and actual reporting behaviour. The findings reflected links among colleague perspectives, nurses' attitudes, and intention to report medication administration errors. The researchers suggest that hospitals should increase nurses' awareness and recognition of error occurrence. Regardless of nurse managers' and co-workers' attitudes towards medication administration error reporting, nurses are likely to report medication administration errors if they detect them. Management of medication administration errors should focus on increasing nurses' awareness and recognition of error occurrence. © 2015 John Wiley & Sons Ltd.

  5. Medication administration errors in an intensive care unit in Ethiopia

    Directory of Open Access Journals (Sweden)

    Agalu Asrat


    Full Text Available Abstract Background Medication administration errors in patient care have been shown to be frequent and serious. Such errors are particularly prevalent in highly technical specialties such as the intensive care unit (ICU. In Ethiopia, the prevalence of medication administration errors in the ICU is not studied. Objective To assess medication administration errors in the intensive care unit of Jimma University Specialized Hospital (JUSH, Southwest Ethiopia. Methods Prospective observation based cross-sectional study was conducted in the ICU of JUSH from February 7 to March 24, 2011. All medication interventions administered by the nurses to all patients admitted to the ICU during the study period were included in the study. Data were collected by directly observing drug administration by the nurses supplemented with review of medication charts. Data was edited, coded and entered in to SPSS for windows version 16.0. Descriptive statistics was used to measure the magnitude and type of the problem under study. Results Prevalence of medication administration errors in the ICU of JUSH was 621 (51.8%. Common administration errors were attributed to wrong timing (30.3%, omission due to unavailability (29.0% and missed doses (18.3% among others. Errors associated with antibiotics took the lion's share in medication administration errors (36.7%. Conclusion Medication errors at the administration phase were highly prevalent in the ICU of Jimma University Specialized Hospital. Supervision to the nurses administering medications by more experienced ICU nurses or other relevant professionals in regular intervals is helpful in ensuring that medication errors don’t occur as frequently as observed in this study.

  6. Medication error detection in two major teaching hospitals: What are the types of errors?

    Directory of Open Access Journals (Sweden)

    Fatemeh Saghafi


    Full Text Available Background: Increasing number of reports on medication errors and relevant subsequent damages, especially in medical centers has become a growing concern for patient safety in recent decades. Patient safety and in particular, medication safety is a major concern and challenge for health care professionals around the world. Our prospective study was designed to detect prescribing, transcribing, dispensing, and administering medication errors in two major university hospitals. Materials and Methods: After choosing 20 similar hospital wards in two large teaching hospitals in the city of Isfahan, Iran, the sequence was randomly selected. Diagrams for drug distribution were drawn by the help of pharmacy directors. Direct observation technique was chosen as the method for detecting the errors. A total of 50 doses were studied in each ward to detect prescribing, transcribing and administering errors in each ward. The dispensing error was studied on 1000 doses dispensed in each hospital pharmacy. Results: A total of 8162 number of doses of medications were studied during the four stages, of which 8000 were complete data to be analyzed. 73% of prescribing orders were incomplete and did not have all six parameters (name, dosage form, dose and measuring unit, administration route, and intervals of administration. We found 15% transcribing errors. One-third of administration of medications on average was erroneous in both hospitals. Dispensing errors ranged between 1.4% and 2.2%. Conclusion: Although prescribing and administrating compromise most of the medication errors, improvements are needed in all four stages with regard to medication errors. Clear guidelines must be written and executed in both hospitals to reduce the incidence of medication errors.

  7. Analysis of Medication Errors in Simulated Pediatric Resuscitation by Residents

    Directory of Open Access Journals (Sweden)

    Evelyn Porter


    Full Text Available Introduction: The objective of our study was to estimate the incidence of prescribing medication errors specifically made by a trainee and identify factors associated with these errors during the simulated resuscitation of a critically ill child. Methods: The results of the simulated resuscitation are described. We analyzed data from the simulated resuscitation for the occurrence of a prescribing medication error. We compared univariate analysis of each variable to medication error rate and performed a separate multiple logistic regression analysis on the significant univariate variables to assess the association between the selected variables. Results: We reviewed 49 simulated resuscitations . The final medication error rate for the simulation was 26.5% (95% CI 13.7% - 39.3%. On univariate analysis, statistically significant findings for decreased prescribing medication error rates included senior residents in charge, presence of a pharmacist, sleeping greater than 8 hours prior to the simulation, and a visual analog scale score showing more confidence in caring for critically ill children. Multiple logistic regression analysis using the above significant variables showed only the presence of a pharmacist to remain significantly associated with decreased medication error, odds ratio of 0.09 (95% CI 0.01 - 0.64. Conclusion: Our results indicate that the presence of a clinical pharmacist during the resuscitation of a critically ill child reduces the medication errors made by resident physician trainees.

  8. Unit of measurement used and parent medication dosing errors. (United States)

    Yin, H Shonna; Dreyer, Benard P; Ugboaja, Donna C; Sanchez, Dayana C; Paul, Ian M; Moreira, Hannah A; Rodriguez, Luis; Mendelsohn, Alan L


    Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship. Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site. Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2-4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03-3.5) dose; associations greater for parents with low health literacy and non-English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon-associated measurement errors. Findings support a milliliter-only standard to reduce medication errors. Copyright © 2014 by the American Academy of Pediatrics.

  9. A preliminary taxonomy of medical errors in family practice. (United States)

    Dovey, S M; Meyers, D S; Phillips, R L; Green, L A; Fryer, G E; Galliher, J M; Kappus, J; Grob, P


    To develop a preliminary taxonomy of primary care medical errors. Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. The National Network for Family Practice and Primary Care Research. Family physicians. Medical error category, context, and consequence. Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

  10. Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana. (United States)

    Acheampong, Franklin; Tetteh, Ashalley Raymond; Anto, Berko Panyin


    This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana. This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes. Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems. This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.

  11. Medication prescribing errors in the medical intensive care unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. (United States)

    Sada, Oumer; Melkie, Addisu; Shibeshi, Workineh


    Medication errors (MEs) are important problems in all hospitalized populations, especially in intensive care unit (ICU). Little is known about the prevalence of medication prescribing errors in the ICU of hospitals in Ethiopia. The aim of this study was to assess medication prescribing errors in the ICU of Tikur Anbessa Specialized Hospital using retrospective cross-sectional analysis of patient cards and medication charts. About 220 patient charts were reviewed with a total of 1311 patient-days, and 882 prescription episodes. 359 MEs were detected; with prevalence of 40 per 100 orders. Common prescribing errors were omission errors 154 (42.89%), 101 (28.13%) wrong combination, 48 (13.37%) wrong abbreviation, 30 (8.36%) wrong dose, wrong frequency 18 (5.01%) and wrong indications 8 (2.23%). The present study shows that medication errors are common in medical ICU of Tikur Anbessa Specialized Hospital. These results suggest future targets of prevention strategies to reduce the rate of medication error.

  12. Medical Errors in Cyprus: The 2005 Eurobarometer Survey

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    Andreas Pavlakis


    Full Text Available Background: Medical errors have been highlighted in recent years by different agencies, scientific bodies and research teams alike. We sought to explore the issue of medical errors in Cyprus using data from the Eurobarometer survey.Methods: Data from the special Eurobarometer survey conducted in 2005 across all European Union countries (EU-25 and the acceding countries were obtained from the corresponding EU office. Statisticalanalyses including logistic regression models were performed using SPSS.Results: A total of 502 individuals participated in the Cyprus survey. About 90% reported that they had often or sometimes heard about medical errors, while 22% reported that a family member or they had suffered a serious medical error in a local hospital. In addition, 9.4% reported a serious problem from a prescribed medicine. We also found statistically significant differences across different ages and gender and in rural versus urban residents. Finally, using multivariable-adjusted logistic regression models, wefound that residents in rural areas were more likely to have suffered a serious medical error in a local hospital or from a prescribed medicine.Conclusion: Our study shows that the vast majority of residents in Cyprus in parallel with the other Europeans worry about medical errors and a significant percentage report having suffered a serious medical error at a local hospital or from a prescribed medicine. The results of our study could help the medical community in Cyprus and the society at large to enhance its vigilance with respect to medical errors in order to improve medical care.

  13. Errors in the administration of intravenous medication in Brazilian hospitals. (United States)

    Anselmi, Maria Luiza; Peduzzi, Marina; Dos Santos, Claudia Benedita


    To verify the frequency of errors in the preparation and administration of intravenous medication in three Brazilian hospitals in the State of Bahia. The administration of intravenous medications constitutes a central activity in Brazilian nursing. Errors in performing this activity may result in irreparable damage to patients and may compromise the quality of care. Cross-sectional study, conducted in three hospitals in the State of Bahia, Brazil. Direct observation of the nursing staff (nurse technicians, auxiliary nurses and nurse attendants), preparing and administering intravenous medication. When preparing medication, wrong patient error did not occur in any of the three hospitals, whereas omission dose was the most frequent error in all study sites. When administering medication, the most frequent errors in the three hospitals were wrong dose and omission dose. The rates of error found are considered low compared with similar studies. The most frequent types of errors were wrong dose and omission dose. The hospitals studied showed different results with the smallest rates of errors occurring in hospital 1 that presented the best working conditions. Relevance to clinical practice. Studies such as this one have the potential to improve the quality of care.

  14. PS-022 Complex automated medication systems reduce medication administration error rates in an acute medical ward

    DEFF Research Database (Denmark)

    Risør, Bettina Wulff; Lisby, Marianne; Sørensen, Jan


    Background Medication errors have received extensive attention in recent decades and are of significant concern to healthcare organisations globally. Medication errors occur frequently, and adverse events associated with medications are one of the largest causes of harm to hospitalised patients...... cabinet, automated dispensing and barcode medication administration; (2) non-patient specific automated dispensing and barcode medication administration. The occurrence of administration errors was observed in three 3 week periods. The error rates were calculated by dividing the number of doses with one...

  15. Error detection and prevention in Embedded Systems Software

    DEFF Research Database (Denmark)

    Kamel, Hani Fouad


    Despite many efforts to structure the development and design processes of embedded systems, errors are discovered at the final stages of production and sometimes after the delivery of the products. The cost of such errors can be prohibitive.Different design techniques to detect such errors...... systems, a formal model for such systems is introduced. The main characteristics of embedded systems design and the interaction of these properties are described. A taxonomy for the structure of the software developed for such systems based on the amount of processes and processors involved is presented.......The second part includes methods and techniques to detect software design errors.The third part deals with error prevention. It starts with a presentation of different models of the development processes used in industry and taught at universities. This leads us to deduce the major causes of errors...

  16. Organizational safety culture and medical error reporting by Israeli nurses. (United States)

    Kagan, Ilya; Barnoy, Sivia


    To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%). The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data. Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance. This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level. A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety. © 2013 Sigma Theta Tau International.

  17. Medication errors in chemotherapy preparation and administration: a survey conducted among oncology nurses in Turkey. (United States)

    Ulas, Arife; Silay, Kamile; Akinci, Sema; Dede, Didem Sener; Akinci, Muhammed Bulent; Sendur, Mehmet Ali Nahit; Cubukcu, Erdem; Coskun, Hasan Senol; Degirmenci, Mustafa; Utkan, Gungor; Ozdemir, Nuriye; Isikdogan, Abdurrahman; Buyukcelik, Abdullah; Inanc, Mevlude; Bilici, Ahmet; Odabasi, Hatice; Cihan, Sener; Avci, Nilufer; Yalcin, Bulent


    Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures

  18. Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients. (United States)

    Commers, Tessa; Swindells, Susan; Sayles, Harlan; Gross, Alan E; Devetten, Marcel; Sandkovsky, Uriel


    Errors in prescribing antiretroviral therapy (ART) often occur with the hospitalization of HIV-infected patients. The rapid identification and prevention of errors may reduce patient harm and healthcare-associated costs. A retrospective review of hospitalized HIV-infected patients was carried out between 1 January 2009 and 31 December 2011. Errors were documented as omission, underdose, overdose, duplicate therapy, incorrect scheduling and/or incorrect therapy. The time to error correction was recorded. Relative risks (RRs) were computed to evaluate patient characteristics and error rates. A total of 289 medication errors were identified in 146/416 admissions (35%). The most common was drug omission (69%). At an error rate of 31%, nucleoside reverse transcriptase inhibitors were associated with an increased risk of error when compared with protease inhibitors (RR 1.32; 95% CI 1.04-1.69) and co-formulated drugs (RR 1.59; 95% CI 1.19-2.09). Of the errors, 31% were corrected within the first 24 h, but over half (55%) were never remedied. Admissions with an omission error were 7.4 times more likely to have all errors corrected within 24 h than were admissions without an omission. Drug interactions with ART were detected on 51 occasions. For the study population (n = 177), an increased risk of admission error was observed for black (43%) compared with white (28%) individuals (RR 1.53; 95% CI 1.16-2.03) but no significant differences were observed between white patients and other minorities or between men and women. Errors in inpatient ART were common, and the majority were never detected. The most common errors involved omission of medication, and nucleoside reverse transcriptase inhibitors had the highest rate of prescribing error. Interventions to prevent and correct errors are urgently needed.

  19. Economic impact of medication error: a systematic review. (United States)

    Walsh, Elaine K; Hansen, Christina Raae; Sahm, Laura J; Kearney, Patricia M; Doherty, Edel; Bradley, Colin P


    Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

  20. Identifying medication errors in the neonatal intensive care unit and ...

    African Journals Online (AJOL)

    of the health care professional, patient, or consumer. ... Department of Pharmacy, Faculty of Health Sciences, School of Health Care Sciences, ..... patient safety. ... Clifton-Koeppel R. What nurses can do right now to reduce medication errors.

  1. Audit of medication errors by anesthetists in North Western Nigeria

    African Journals Online (AJOL)


    Aug 3, 2013 ... Materials and Methods. This multi‑center cross‑sectional survey was conducted ... vigilance (9), appropriate and double checking of drug labels (18), and color coding of syringes (7) as ways to minimize medication errors.

  2. Interventions for reducing medication errors in children in hospital

    NARCIS (Netherlands)

    Maaskant, Jolanda M; Vermeulen, Hester; Apampa, Bugewa; Fernando, Bernard; Ghaleb, Maisoon A; Neubert, Antje; Thayyil, Sudhin; Soe, Aung


    BACKGROUND: Many hospitalised patients are affected by medication errors (MEs) that may cause discomfort, harm and even death. Children are at especially high risk of harm as the result of MEs because such errors are potentially more hazardous to them than to adults. Until now, interventions to

  3. Interventions for reducing medication errors in children in hospital

    NARCIS (Netherlands)

    Maaskant, Jolanda M.; Vermeulen, Hester; Apampa, Bugewa; Fernando, Bernard; Ghaleb, Maisoon A.; Neubert, Antje; Thayyil, Sudhin; Soe, Aung


    Background Many hospitalised patients are affected by medication errors (MEs) that may cause discomfort, harm and even death. Children are at especially high risk of harm as the result of MEs because such errors are potentially more hazardous to them than to adults. Until now, interventions to

  4. Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center. (United States)

    McKaig, Donald; Collins, Christine; Elsaid, Khaled A


    A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site. During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors. Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.

  5. Identification of Medication Errors with Similar Pronunciation, Spelling and Packaging in Tabriz Shahid Madani Hospital -1392

    Directory of Open Access Journals (Sweden)

    Gisoo Alizadeh


    Full Text Available Background and objectives: Evidence suggests that medication errors are among the most common types of medical errors, and over fifty percent of them are preventable. Since a significant proportion of these errors are related to the similarity between drug names, this study was designed to evaluate drugs with similar spelling, spelling and packaging. Material and Methods: This is a qualitative study with phenomenological approach. Participants were selected by purposive sampling. Data were collected through semi-structured interviews and with the help of previously designed guide. Data were analyzed using content analysis. Results: The central themes of the findings of this study include: the accuracy of drug use, the way of recording and monitoring used medication, the storage, reporting, and notification of similar medications, verbal or telephone orders, medication lists with similar spelling, pronunciation and packaging and recommendations of the participants. The most errors in the Heparin-Atropine pair was the packaging of the drugs, spelling was the highest error in Dopamine- Dobutamine pair drug and spelling was the highest error in Atropine and Atorvastatin pair drug. Conclusion: The study findings indicate that there is no certain system for recording, monitoring and storage of similar drugs. Therefore, identifying the medication list with similar pronunciation, spelling and packaging is an opportunity to reduce these types of errors with appropriate interventions. ​

  6. (How) do we learn from errors? A prospective study of the link between the ward's learning practices and medication administration errors. (United States)

    Drach-Zahavy, A; Somech, A; Admi, H; Peterfreund, I; Peker, H; Priente, O


    Attention in the ward should shift from preventing medication administration errors to managing them. Nevertheless, little is known in regard with the practices nursing wards apply to learn from medication administration errors as a means of limiting them. To test the effectiveness of four types of learning practices, namely, non-integrated, integrated, supervisory and patchy learning practices in limiting medication administration errors. Data were collected from a convenient sample of 4 hospitals in Israel by multiple methods (observations and self-report questionnaires) at two time points. The sample included 76 wards (360 nurses). Medication administration error was defined as any deviation from prescribed medication processes and measured by a validated structured observation sheet. Wards' use of medication administration technologies, location of the medication station, and workload were observed; learning practices and demographics were measured by validated questionnaires. Results of the mixed linear model analysis indicated that the use of technology and quiet location of the medication cabinet were significantly associated with reduced medication administration errors (estimate=.03, perrors (estimate=.04, plearning practices, supervisory learning was the only practice significantly linked to reduced medication administration errors (estimate=-.04, plearning were significantly linked to higher levels of medication administration errors (estimate=-.03, plearning was not associated with it (p>.05). How wards manage errors might have implications for medication administration errors beyond the effects of typical individual, organizational and technology risk factors. Head nurse can facilitate learning from errors by "management by walking around" and monitoring nurses' medication administration behaviors. Copyright © 2013 Elsevier Ltd. All rights reserved.

  7. Medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in Sweden. (United States)

    Björkstén, Karin Sparring; Bergqvist, Monica; Andersén-Karlsson, Eva; Benson, Lina; Ulfvarson, Johanna


    Many studies address the prevalence of medication errors but few address medication errors serious enough to be regarded as malpractice. Other studies have analyzed the individual and system contributory factor leading to a medication error. Nurses have a key role in medication administration, and there are contradictory reports on the nurses' work experience in relation to the risk and type for medication errors. All medication errors where a nurse was held responsible for malpractice (n = 585) during 11 years in Sweden were included. A qualitative content analysis and classification according to the type and the individual and system contributory factors was made. In order to test for possible differences between nurses' work experience and associations within and between the errors and contributory factors, Fisher's exact test was used, and Cohen's kappa (k) was performed to estimate the magnitude and direction of the associations. There were a total of 613 medication errors in the 585 cases, the most common being "Wrong dose" (41 %), "Wrong patient" (13 %) and "Omission of drug" (12 %). In 95 % of the cases, an average of 1.4 individual contributory factors was found; the most common being "Negligence, forgetfulness or lack of attentiveness" (68 %), "Proper protocol not followed" (25 %), "Lack of knowledge" (13 %) and "Practice beyond scope" (12 %). In 78 % of the cases, an average of 1.7 system contributory factors was found; the most common being "Role overload" (36 %), "Unclear communication or orders" (30 %) and "Lack of adequate access to guidelines or unclear organisational routines" (30 %). The errors "Wrong patient due to mix-up of patients" and "Wrong route" and the contributory factors "Lack of knowledge" and "Negligence, forgetfulness or lack of attentiveness" were more common in less experienced nurses. The experienced nurses were more prone to "Practice beyond scope of practice" and to make errors in spite of "Lack of adequate

  8. Iatrogenic medication errors in a paediatric intensive care unit in ...

    African Journals Online (AJOL)

    This unit has guided the development of various types of adverse event reporting, ... iatrogenic medi cation errors in children at healthcare facilities in industrialised .... A pharmacist dispenses electronically submitted medication orders but ..... Hand-held devices such as smartphones with medication dosage applications.

  9. Medication errors of nurses and factors in refusal to report medication errors among nurses in a teaching medical center of iran in 2012. (United States)

    Mostafaei, Davoud; Barati Marnani, Ahmad; Mosavi Esfahani, Haleh; Estebsari, Fatemeh; Shahzaidi, Shiva; Jamshidi, Ensiyeh; Aghamiri, Seyed Samad


    About one third of unwanted reported medication consequences are due to medication errors, resulting in one-fifth of hospital injuries. The aim of this study was determined formal and informal medication errors of nurses and the level of importance of factors in refusal to report medication errors among nurses. The cross-sectional study was done on the nursing staff of Shohada Tajrish Hospital, Tehran, Iran in 2012. The data was gathered through a questionnaire, made by the researchers. The questionnaires' face and content validity was confirmed by experts and for measuring its reliability test-retest was used. The data was analyzed by descriptive statistics. We used SPSS for related statistical analyses. The most important factors in refusal to report medication errors respectively were: lack of medication error recording and reporting system in the hospital (3.3%), non-significant error reporting to hospital authorities and lack of appropriate feedback (3.1%), and lack of a clear definition for a medication error (3%). There were both formal and informal reporting of medication errors in this study. Factors pertaining to management in hospitals as well as the fear of the consequences of reporting are two broad fields among the factors that make nurses not report their medication errors. In this regard, providing enough education to nurses, boosting the job security for nurses, management support and revising related processes and definitions are some factors that can help decreasing medication errors and increasing their report in case of occurrence.

  10. Content Validity of a Tool Measuring Medication Errors. (United States)

    Tabassum, Nishat; Allana, Saleema; Saeed, Tanveer; Dias, Jacqueline Maria


    The objective of this study was to determine content and face validity of a tool measuring medication errors among nursing students in baccalaureate nursing education. Data was collected from the Aga Khan University School of Nursing and Midwifery (AKUSoNaM), Karachi, from March to August 2014. The tool was developed utilizing literature and the expertise of the team members, expert in different areas. The developed tool was then sent to five experts from all over Karachi for ensuring the content validity of the tool, which was measured on relevance and clarity of the questions. The Scale Content Validity Index (S-CVI) for clarity and relevance of the questions was found to be 0.94 and 0.98, respectively. The tool measuring medication errors has an excellent content validity. This tool should be used for future studies on medication errors, with different study populations such as medical students, doctors, and nurses.

  11. Disclosing harmful medical errors to patients: tackling three tough cases. (United States)

    Gallagher, Thomas H; Bell, Sigall K; Smith, Kelly M; Mello, Michelle M; McDonald, Timothy B


    A gap exists between recommendations to disclose errors to patients and current practice. This gap may reflect important, yet unanswered questions about implementing disclosure principles. We explore some of these unanswered questions by presenting three real cases that pose challenging disclosure dilemmas. The first case involves a pancreas transplant that failed due to the pancreas graft being discarded, an error that was not disclosed partly because the family did not ask clarifying questions. Relying on patient or family questions to determine the content of disclosure is problematic. We propose a standard of materiality that can help clinicians to decide what information to disclose. The second case involves a fatal diagnostic error that the patient's widower was unaware had happened. The error was not disclosed out of concern that disclosure would cause the widower more harm than good. This case highlights how institutions can overlook patients' and families' needs following errors and emphasizes that benevolent deception has little role in disclosure. Institutions should consider whether involving neutral third parties could make disclosures more patient centered. The third case presents an intraoperative cardiac arrest due to a large air embolism where uncertainty around the clinical event was high and complicated the disclosure. Uncertainty is common to many medical errors but should not deter open conversations with patients and families about what is and is not known about the event. Continued discussion within the medical profession about applying disclosure principles to real-world cases can help to better meet patients' and families' needs following medical errors.

  12. Speak Up: Help Prevent Errors in Your Care: Ambulatory Care (United States)

    ... Your Care Ambulatory Care To prevent health care errors, patients are urged to... SpeakUP TM Everyone has a ... he or she has confused you with another patient. P ay attention to the ... for their identification (ID) badges. • Notice whether your caregivers have washed ...

  13. Speak Up: Help Prevent Errors in Your Care: Home Care (United States)

    ... Your Care Home Care To prevent health care errors, patients are urged to... SpeakUP TM Everyone has a ... you think they have confused you with another patient. P ay attention to the care you ... for their identification (ID) badges. • Make sure you or family members ...

  14. Errors in the administration of intravenous medications in patients undergoing anesthesia in the operating room

    Directory of Open Access Journals (Sweden)

    Juan David Miranda


    Full Text Available Errors in medication administration have affected the anesthetic practice over the time and have become a major cause of perioperative morbidity and mortality. Among different medical specialties, anesthesiology is perhaps the most likely to make mistakes in this procedure. This is because in many places around the world, a single professional "anesthesiologist" orders, prepares and administers a drug at one time and setting. For thirty years, Cooper disclosed the first reports of critical incidents and perioperative safety scheme, and in the 90s', Chopra performed a retrospective analysis, found that medication errors are the fourth most common that results in disability in 17% and death in 8%, these being preventable errors in 51% of cases. It’s essential for the safe practice of anesthesia to establish interventions for improving prevention programs, education, research and development, enabling break traditional paradigms, with the aim of making recommendations and standardize the safe administration of drugs in this field.

  15. Carers' Medication Administration Errors in the Domiciliary Setting: A Systematic Review.

    Directory of Open Access Journals (Sweden)

    Anam Parand

    Full Text Available Medications are mostly taken in patients' own homes, increasingly administered by carers, yet studies of medication safety have been largely conducted in the hospital setting. We aimed to review studies of how carers cause and/or prevent medication administration errors (MAEs within the patient's home; to identify types, prevalence and causes of these MAEs and any interventions to prevent them.A narrative systematic review of literature published between 1 Jan 1946 and 23 Sep 2013 was carried out across the databases EMBASE, MEDLINE, PSYCHINFO, COCHRANE and CINAHL. Empirical studies were included where carers were responsible for preventing/causing MAEs in the home and standardised tools used for data extraction and quality assessment.Thirty-six papers met the criteria for narrative review, 33 of which included parents caring for children, two predominantly comprised adult children and spouses caring for older parents/partners, and one focused on paid carers mostly looking after older adults. The carer administration error rate ranged from 1.9 to 33% of medications administered and from 12 to 92.7% of carers administering medication. These included dosage errors, omitted administration, wrong medication and wrong time or route of administration. Contributory factors included individual carer factors (e.g. carer age, environmental factors (e.g. storage, medication factors (e.g. number of medicines, prescription communication factors (e.g. comprehensibility of instructions, psychosocial factors (e.g. carer-to-carer communication, and care-recipient factors (e.g. recipient age. The few interventions effective in preventing MAEs involved carer training and tailored equipment.This review shows that home medication administration errors made by carers are a potentially serious patient safety issue. Carers made similar errors to those made by professionals in other contexts and a wide variety of contributory factors were identified. The home care

  16. Comprehensive analysis of a medication dosing error related to CPOE. (United States)

    Horsky, Jan; Kuperman, Gilad J; Patel, Vimla L


    This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.

  17. Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review. (United States)

    Mekonnen, Alemayehu B; Alhawassi, Tariq M; McLachlan, Andrew J; Brien, Jo-Anne E


    Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5-20.1%), while adverse drug events causing admission were reported in 2.8% (0.7-6.4%) of patients but it was reported that a median of 43.5% (20.0-47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0-0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8-72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5-50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge

  18. Contribution of renal impairment to potentially preventable medication-related hospital admissions

    NARCIS (Netherlands)

    A.J. Leendertse (Anne); E.A. van Dijk (Elisabeth); P.A. de Smet (Peter); T.C.G. Egberts (Toine); P.M.L.A. van den Bemt (Patricia)


    textabstractBackground: Medication errors and renal impairment contribute to severe adverse drug events, which may lead to hospital admission. Objective: To determine whether medication errors and renal impairment contribute to hospital admission and examine these errors for strategies to prevent

  19. Implementation of pharmacists’ interventions and assessment of medication errors in an intensive care unit of a Chinese tertiary hospital

    Directory of Open Access Journals (Sweden)

    Jiang SP


    Full Text Available Sai-Ping Jiang,1,* Jian Chen,2,* Xing-Guo Zhang,1 Xiao-Yang Lu,1 Qing-Wei Zhao1 1Department of Pharmacy, 2Intensive Care Unit, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China *These authors contributed equally to this work Background: Pharmacist interventions and medication errors potentially differ between the People’s Republic of China and other countries. This study aimed to report interventions administered by clinical pharmacists and analyze medication errors in an intensive care unit (ICU in a tertiary hospital in People’s Republic of China.Method: A prospective, noncomparative, 6-month observational study was conducted in a general ICU of a tertiary hospital in the People’s Republic of China. Clinical pharmacists performed interventions to prevent or resolve medication errors during daily rounds and documented all of these interventions and medication errors. Such interventions and medication errors were categorized and then analyzed.Results: During the 6-month observation period, a total of 489 pharmacist interventions were reported. Approximately 407 (83.2% pharmacist interventions were accepted by ICU physicians. The incidence rate of medication errors was 124.7 per 1,000 patient-days. Improper drug frequency or dosing (n=152, 37.3%, drug omission (n=83, 20.4%, and potential or actual occurrence of adverse drug reaction (n=54, 13.3% were the three most commonly committed medication errors. Approximately 339 (83.4% medication errors did not pose any risks to the patients. Antimicrobials (n=171, 35.0% were the most frequent type of medication associated with errors.Conclusion: Medication errors during prescription frequently occurred in an ICU of a tertiary hospital in the People’s Republic of China. Pharmacist interventions were also efficient in preventing medication errors. Keywords: pharmacist, medication error, preva­lence rate, type, severity, intensive care

  20. Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system. (United States)

    Bledsoe, Sarah; Van Buskirk, Alex; Falconer, R James; Hollon, Andrew; Hoebing, Wendy; Jokic, Sladan


    The effectiveness of barcode-assisted medication preparation (BCMP) technology on detecting oral liquid dose preparation errors. From June 1, 2013, through May 31, 2014, a total of 178,344 oral doses were processed at Children's Mercy, a 301-bed pediatric hospital, through an automated workflow management system. Doses containing errors detected by the system's barcode scanning system or classified as rejected by the pharmacist were further reviewed. Errors intercepted by the barcode-scanning system were classified as (1) expired product, (2) incorrect drug, (3) incorrect concentration, and (4) technological error. Pharmacist-rejected doses were categorized into 6 categories based on the root cause of the preparation error: (1) expired product, (2) incorrect concentration, (3) incorrect drug, (4) incorrect volume, (5) preparation error, and (6) other. Of the 178,344 doses examined, 3,812 (2.1%) errors were detected by either the barcode-assisted scanning system (1.8%, n = 3,291) or a pharmacist (0.3%, n = 521). The 3,291 errors prevented by the barcode-assisted system were classified most commonly as technological error and incorrect drug, followed by incorrect concentration and expired product. Errors detected by pharmacists were also analyzed. These 521 errors were most often classified as incorrect volume, preparation error, expired product, other, incorrect drug, and incorrect concentration. BCMP technology detected errors in 1.8% of pediatric oral liquid medication doses prepared in an automated workflow management system, with errors being most commonly attributed to technological problems or incorrect drugs. Pharmacists rejected an additional 0.3% of studied doses. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  1. Association of medication errors with drug classifications, clinical units, and consequence of errors: Are they related? (United States)

    Muroi, Maki; Shen, Jay J; Angosta, Alona


    Registered nurses (RNs) play an important role in safe medication administration and patient safety. This study examined a total of 1276 medication error (ME) incident reports made by RNs in hospital inpatient settings in the southwestern region of the United States. The most common drug class associated with MEs was cardiovascular drugs (24.7%). Among this class, anticoagulants had the most errors (11.3%). The antimicrobials was the second most common drug class associated with errors (19.1%) and vancomycin was the most common antimicrobial that caused errors in this category (6.1%). MEs occurred more frequently in the medical-surgical and intensive care units than any other hospital units. Ten percent of MEs reached the patients with harm and 11% reached the patients with increased monitoring. Understanding the contributing factors related to MEs, addressing and eliminating risk of errors across hospital units, and providing education and resources for nurses may help reduce MEs. Copyright © 2016 Elsevier Inc. All rights reserved.

  2. Medication Errors in a Swiss Cardiovascular Surgery Department: A Cross-Sectional Study Based on a Novel Medication Error Report Method

    Directory of Open Access Journals (Sweden)

    Kaspar Küng


    Full Text Available The purpose of this study was (1 to determine frequency and type of medication errors (MEs, (2 to assess the number of MEs prevented by registered nurses, (3 to assess the consequences of ME for patients, and (4 to compare the number of MEs reported by a newly developed medication error self-reporting tool to the number reported by the traditional incident reporting system. We conducted a cross-sectional study on ME in the Cardiovascular Surgery Department of Bern University Hospital in Switzerland. Eligible registered nurses ( involving in the medication process were included. Data on ME were collected using an investigator-developed medication error self reporting tool (MESRT that asked about the occurrence and characteristics of ME. Registered nurses were instructed to complete a MESRT at the end of each shift even if there was no ME. All MESRTs were completed anonymously. During the one-month study period, a total of 987 MESRTs were returned. Of the 987 completed MESRTs, 288 (29% indicated that there had been an ME. Registered nurses reported preventing 49 (5% MEs. Overall, eight (2.8% MEs had patient consequences. The high response rate suggests that this new method may be a very effective approach to detect, report, and describe ME in hospitals.

  3. The Impact of Bar Code Medication Administration Technology on Reported Medication Errors (United States)

    Holecek, Andrea


    The use of bar-code medication administration technology is on the rise in acute care facilities in the United States. The technology is purported to decrease medication errors that occur at the point of administration. How significantly this technology affects actual rate and severity of error is unknown. This descriptive, longitudinal research…

  4. Medication Errors in the Southeast Asian Countries: A Systematic Review.

    Directory of Open Access Journals (Sweden)

    Shahrzad Salmasi

    Full Text Available Medication error (ME is a worldwide issue, but most studies on ME have been undertaken in developed countries and very little is known about ME in Southeast Asian countries. This study aimed systematically to identify and review research done on ME in Southeast Asian countries in order to identify common types of ME and estimate its prevalence in this region.The literature relating to MEs in Southeast Asian countries was systematically reviewed in December 2014 by using; Embase, Medline, Pubmed, ProQuest Central and the CINAHL. Inclusion criteria were studies (in any languages that investigated the incidence and the contributing factors of ME in patients of all ages.The 17 included studies reported data from six of the eleven Southeast Asian countries: five studies in Singapore, four in Malaysia, three in Thailand, three in Vietnam, one in the Philippines and one in Indonesia. There was no data on MEs in Brunei, Laos, Cambodia, Myanmar and Timor. Of the seventeen included studies, eleven measured administration errors, four focused on prescribing errors, three were done on preparation errors, three on dispensing errors and two on transcribing errors. There was only one study of reconciliation error. Three studies were interventional.The most frequently reported types of administration error were incorrect time, omission error and incorrect dose. Staff shortages, and hence heavy workload for nurses, doctor/nurse distraction, and misinterpretation of the prescription/medication chart, were identified as contributing factors of ME. There is a serious lack of studies on this topic in this region which needs to be addressed if the issue of ME is to be fully understood and addressed.

  5. Medical error, malpractice and complications: a moral geography. (United States)

    Zientek, David M


    This essay reviews and defines avoidable medical error, malpractice and complication. The relevant ethical principles pertaining to unanticipated medical outcomes are identified. In light of these principles I critically review the moral culpability of the agents in each circumstance and the resulting obligations to patients, their families, and the health care system in general. While I touch on some legal implications, a full discussion of legal obligations and liability issues is beyond the scope of this paper.

  6. The alarming reality of medication error: a patient case and review of Pennsylvania and National data. (United States)

    da Silva, Brianna A; Krishnamurthy, Mahesh


    A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs) account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Medication reconciliation including an 'indication review' for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider-patient relationship.

  7. The alarming reality of medication error: a patient case and review of Pennsylvania and National data

    Directory of Open Access Journals (Sweden)

    Brianna A. da Silva


    Full Text Available Case description: A 71-year-old female accidentally received thiothixene (Navane, an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Discussion: Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Conclusion: Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider–patient relationship.

  8. Successful remediation of patient safety incidents: a tale of two medication errors. (United States)

    Helmchen, Lorens A; Richards, Michael R; McDonald, Timothy B


    As patient safety acquires strategic importance for all stakeholders in the health care delivery chain, one promising mechanism centers on the proactive disclosure of medical errors to patients. Yet, disclosure and apology alone will not be effective in fully addressing patients' concerns after an adverse event unless they are paired with a remediation component. The purpose of this study was to identify key features of successful remediation efforts that accompany the proactive disclosure of medical errors to patients. We describe and contrast two recent and very similar cases of preventable medical error involving inappropriate medication at a large tertiary-care academic medical center in the Midwestern United States. Despite their similarity, the two medical errors led to very different health outcomes and remediation trajectories for the injured patients. Although one error causing no permanent harm was mismanaged to the lasting dissatisfaction of the patient, the other resulted in the death of the patient but was remediated to the point of allowing the family to come to terms with the loss and even restored a modicum of trust in the providers' sincerity. To maximize the opportunities for successful remediation, as soon as possible after the incident, providers should pledge to injured patients and their relatives that they will assist and accompany them in their recovery as long as necessary and then follow through on their pledge. As the two case studies show, it takes training and vigilance to ensure adherence to these principles and reach an optimal outcome for patients and their relatives.

  9. The importance of intra-hospital pharmacovigilance in the detection of medication errors (United States)

    Villegas, Francisco; Figueroa-Montero, David; Barbero-Becerra, Varenka; Juárez-Hernández, Eva; Uribe, Misael; Chávez-Tapia, Norberto; González-Chon, Octavio


    Hospitalized patients are susceptible to medication errors, which represent between the fourth and the sixth cause of death. The department of intra-hospital pharmacovigilance intervenes in the entire process of medication with the purpose to prevent, repair and assess damages. To analyze medication errors reported by Mexican Fundación Clínica Médica Sur pharmacovigilance system and their impact on patients. Prospective study carried out from 2012 to 2015, where medication prescriptions given to patients were recorded. Owing to heterogeneity, data were described as absolute numbers in a logarithmic scale. 292 932 prescriptions of 56 368 patients were analyzed, and 8.9% of medication errors were identified. The treating physician was responsible of 83.32% of medication errors, residents of 6.71% and interns of 0.09%. No error caused permanent damage or death. This is the pharmacovigilance study with the largest sample size reported. Copyright: © 2018 SecretarÍa de Salud.

  10. Preventing marine accidents caused by technology-induced human error


    Bielić, Toni; Hasanspahić, Nermin; Čulin, Jelena


    The objective of embedding technology on board ships, to improve safety, is not fully accomplished. The paper studies marine accidents caused by human error resulting from improper human-technology interaction. The aim of the paper is to propose measures to prevent reoccurrence of such accidents. This study analyses the marine accident reports issued by Marine Accidents Investigation Branch covering the period from 2012 to 2014. The factors that caused these accidents are examined and categor...

  11. Prescription Errors in Psychiatry | Nair | Internet Journal of Medical ...

    African Journals Online (AJOL)

    Adverse events involving psychotropic drugs are common and some may be due to errors in clinical decision making of a type not detected by the studies reviewed. These are potentially preventable. On the basis of this, it is recommended that medicine management in mental health settings should be a priority for future ...

  12. Potential for medical error: Incorrectly completed request forms for ...

    African Journals Online (AJOL)

    Thyroid-stimulating hormone (TSH) is a first-line thyroid function test and, if abnormal, reflex thyroxine (T4) or tri-iodothyronine (T3) testing is requested, depending on clinical and medication data provided. Interpretative comments are added to all TFT results. Objectives. In view of the paucity of articles describing such errors ...

  13. Reduced error signalling in medication-naive children with ADHD

    DEFF Research Database (Denmark)

    Plessen, Kerstin J; Allen, Elena A; Eichele, Heike


    BACKGROUND: We examined the blood-oxygen level-dependent (BOLD) activation in brain regions that signal errors and their association with intraindividual behavioural variability and adaptation to errors in children with attention-deficit/hyperactivity disorder (ADHD). METHODS: We acquired...... functional MRI data during a Flanker task in medication-naive children with ADHD and healthy controls aged 8-12 years and analyzed the data using independent component analysis. For components corresponding to performance monitoring networks, we compared activations across groups and conditions...... and correlated them with reaction times (RT). Additionally, we analyzed post-error adaptations in behaviour and motor component activations. RESULTS: We included 25 children with ADHD and 29 controls in our analysis. Children with ADHD displayed reduced activation to errors in cingulo-opercular regions...

  14. How to manage a claim for medical and technical error

    International Nuclear Information System (INIS)

    Nguyen, T.D.


    Purpose. - The fast modifications in French medical legislation, the increasing number of litigations and the professional consequences for the practitioner warrant the necessity to recall the 'how to manage' a claim for medical error. Patients and methods. - Four cases of legal action against oncologists are presented. Results and discussion. - The importance of quality and traceability of the given information, the essential pieces of the medical file, the description of the different process steps and of the contradictory meeting are presented and discussed. Conclusion. - Beyond the control of medical and technical risks, the practitioners in general and the radiation oncologist in particular should learn on the daily management of the risk related to medical claim. (authors)

  15. Pharyngitis – fatal infectious disease or medical error?

    Directory of Open Access Journals (Sweden)

    Marta Rorat


    Full Text Available Reporting on adverse events is essential to create a culture of safety, which focuses on protecting doctors and patients from medical errors. We present a fatal case of Streptococcus C pharyngitis in a 56-year-old man. The clinical course and the results of additional diagnostics and autopsy showed that sepsis followed by multiple organ failure was the ultimate cause of death. The clinical course appeared fatal due to a chain of adverse events, including errors made by the physicians caring for the patient for 10 days.

  16. Medical Error Avoidance in Intraoperative Neurophysiological Monitoring: The Communication Imperative. (United States)

    Skinner, Stan; Holdefer, Robert; McAuliffe, John J; Sala, Francesco


    Error avoidance in medicine follows similar rules that apply within the design and operation of other complex systems. The error-reduction concepts that best fit the conduct of testing during intraoperative neuromonitoring are forgiving design (reversibility of signal loss to avoid/prevent injury) and system redundancy (reduction of false reports by the multiplication of the error rate of tests independently assessing the same structure). However, error reduction in intraoperative neuromonitoring is complicated by the dichotomous roles (and biases) of the neurophysiologist (test recording and interpretation) and surgeon (intervention). This "interventional cascade" can be given as follows: test → interpretation → communication → intervention → outcome. Observational and controlled trials within operating rooms demonstrate that optimized communication, collaboration, and situational awareness result in fewer errors. Well-functioning operating room collaboration depends on familiarity and trust among colleagues. Checklists represent one method to initially enhance communication and avoid obvious errors. All intraoperative neuromonitoring supervisors should strive to use sufficient means to secure situational awareness and trusted communication/collaboration. Face-to-face audiovisual teleconnections may help repair deficiencies when a particular practice model disallows personal operating room availability. All supervising intraoperative neurophysiologists need to reject an insular or deferential or distant mindset.

  17. Checklist Usage as a Guidance on Read-Back Reducing the Potential Risk of Medication Error

    Directory of Open Access Journals (Sweden)

    Ida Bagus N. Maharjana


    Full Text Available Hospital as a last line of health services shall provide quality service and oriented on patient safety, one responsibility in preventing medication errors. Effective collaboration and communication between the profession needed to achieve patient safety. Read-back is one way of doing effective communication. Before-after study with PDCA TQM approach. The samples were on the medication chart patient medical rd rd records in the 3 week of May (before and the 3 week in July (after 2013. Treatment using the check list, asked for time 2 minutes to read-back by the doctors and nurses after the visit together. Obtained 57 samples (before and 64 samples (after. Before charging 45.54% incomplete medication chart on patient medical records that have the potential risk of medication error to 10.17% after treatment with a read back check list for 10 weeks, with 77.78% based on the achievement of the PDCA TQM approach. Checklist usage as a guidance on Read-back as an effective communication can reduce charging incompleteness drug records on medical records that have the potential risk of medication errors, 45.54% to 10.17%.

  18. A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: A prospective observational study. (United States)

    Gilmartin-Thomas, Julia Fiona-Maree; Smith, Felicity; Wolfe, Rory; Jani, Yogini


    systems (RR=4.3, 95%CI 2.7 to 6.8, ppackaging and multi-compartment compliance aids supports the use of the latter in care homes, as well as local investigation of tablet and capsule impact on medication administration errors and staff training to prevent errors occurring. As a significant difference in error rate was not observed between use of a single or combination medication administration system, common practice of using both multi-compartment compliance aids (for most medications) and original packaging (for medications with stability issues) is supported. Copyright © 2017 Elsevier Ltd. All rights reserved.

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

    Kawamura, H


    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.

  20. Medication Errors in Vietnamese Hospitals : Prevalence, Potential Outcome and Associated Factors

    NARCIS (Netherlands)

    Huong-Thao Nguyen, [Unknown; Tuan-Dung Nguyen, [No Value; van den Heuvel, Edwin R.; Haaijer-Ruskamp, Flora M.; Taxis, Katja


    Background Evidence from developed countries showed that medication errors are common and harmful. Little is known about medication errors in resource-restricted settings, including Vietnam. Objectives To determine the prevalence and potential clinical outcome of medication preparation and

  1. [Prospective assessment of medication errors in critically ill patients in a university hospital]. (United States)

    Salazar L, Nicole; Jirón A, Marcela; Escobar O, Leslie; Tobar, Eduardo; Romero, Carlos


    Critically ill patients are especially vulnerable to medication errors (ME) due to their severe clinical situation and the complexities of their management. To determine the frequency and characteristics of ME and identify shortcomings in the processes of medication management in an Intensive Care Unit. During a 3 months period, an observational prospective and randomized study was carried out in the ICU of a university hospital. Every step of patient's medication management (prescription, transcription, dispensation, preparation and administration) was evaluated by an external trained professional. Steps with higher frequency of ME and their therapeutic groups involved were identified. Medications errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention. In 52 of 124 patients evaluated, 66 ME were found in 194 drugs prescribed. In 34% of prescribed drugs, there was at least 1 ME during its use. Half of ME occurred during medication administration, mainly due to problems in infusion rates and schedule times. Antibacterial drugs had the highest rate of ME. We found a 34% rate of ME per drug prescribed, which is in concordance with international reports. The identification of those steps more prone to ME in the ICU, will allow the implementation of an intervention program to improve the quality and security of medication management.

  2. Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

    Directory of Open Access Journals (Sweden)

    Gabriella Rejane dos Santos Dalmolin


    Full Text Available Medication errors can be frequent in hospitals; these errors are multidisciplinary and occur at various stages of the drug therapy. The present study evaluated the seriousness, the type and the drugs involved in medication errors reported at the Hospital de Clínicas de Porto Alegre. We analyzed written error reports for 2010-2011. The sample consisted of 165 reports. The errors identified were classified according to seriousness, type and pharmacological class. 114 reports were categorized as actual errors (medication errors and 51 reports were categorized as potential errors. There were more medication error reports in 2011 compared to 2010, but there was no significant change in the seriousness of the reports. The most common type of error was prescribing error (48.25%. Errors that occurred during the process of drug therapy sometimes generated additional medication errors. In 114 reports of medication errors identified, 122 drugs were cited. The reflection on medication errors, the possibility of harm resulting from these errors, and the methods for error identification and evaluation should include a broad perspective of the aspects involved in the occurrence of errors. Patient safety depends on the process of communication involving errors, on the proper recording of information, and on the monitoring itself.

  3. Using Authentic Medication Errors to Promote Pharmacy Student Critical Thinking and Active Learning

    Directory of Open Access Journals (Sweden)

    Reza Karimi


    Full Text Available Objective: To promote first year (P1 pharmacy students’ awareness of medication error prevention and to support student learning in biomedical and pharmaceutical sciences. Innovation: A novel curricular activity was created and referred to as “Medication Errors and Sciences Applications (MESA”. The MESA activity encouraged discussions of patient safety among students and faculty to link medication errors to biomedical and pharmaceutical sciences, which ultimately reinforced student learning in P1 curricular topics.   Critical Analysis: Three P1 cohorts implemented the MESA activity and approximately 75% of students from each cohort completed a reliable assessment instrument. Each P1 cohort had at least 14 student teams who generated professional reports analyzing authentic medication errors. The quantitative assessment results indicated that 70-85% of students believed that the MESA activity improved student learning in biomedical and pharmaceutical sciences. More than 95% of students agreed that the MESA activity introduced them to medication errors. Approximately 90% of students agreed that the MESA activity integrated the knowledge and skills they developed through the P1 curriculum, promoted active learning and critical thinking, and encouraged students to be self-directed learners. Furthermore, our data indicated that approximately 90% of students stated that the achievement of Bloom’s taxonomy's six learning objectives was promoted by completing the MESA activity. Next Steps: Pharmacy students’ awareness of medication errors is a critical component of pharmacy education, which pharmacy educators can integrate with biomedical and pharmaceutical sciences to enhance student learning in the P1 year. Treatment of Human Subjects: IRB exemption granted   Type: Note License: CC BY

  4. Barriers to the medication error reporting process within the Irish National Ambulance Service, a focus group study. (United States)

    Byrne, Eamonn; Bury, Gerard


    Incident reporting is vital to identifying pre-hospital medication safety issues because literature suggests that the majority of errors pre-hospital are self-identified. In 2016, the National Ambulance Service (NAS) reported 11 medication errors to the national body with responsibility for risk management and insurance cover. The Health Information and Quality Authority in 2014 stated that reporting of clinical incidents, of which medication errors are a subset, was not felt to be representative of the actual events occurring. Even though reporting systems are in place, the levels appear to be well below what might be expected. Little data is available to explain this apparent discrepancy. To identify, investigate and document the barriers to medication error reporting within the NAS. An independent moderator led four focus groups in March of 2016. A convenience sample of 18 frontline Paramedics and Advanced Paramedics from Cork City and County discussed medication errors and the medication error reporting process. The sessions were recorded and anonymised, and the data was analysed using a process of thematic analysis. Practitioners understood the value of reporting errors. Barriers to reporting included fear of consequences and ridicule, procedural ambiguity, lack of feedback and a perceived lack of both consistency and confidentiality. The perceived consequences for making an error included professional, financial, litigious and psychological. Staff appeared willing to admit errors in a psychologically safe environment. Barriers to reporting are in line with international evidence. Time constraints prevented achievement of thematic saturation. Further study is warranted.

  5. Benefits and risks of using smart pumps to reduce medication error rates: a systematic review. (United States)

    Ohashi, Kumiko; Dalleur, Olivia; Dykes, Patricia C; Bates, David W


    Smart infusion pumps have been introduced to prevent medication errors and have been widely adopted nationally in the USA, though they are not always used in Europe or other regions. Despite widespread usage of smart pumps, intravenous medication errors have not been fully eliminated. Through a systematic review of recent studies and reports regarding smart pump implementation and use, we aimed to identify the impact of smart pumps on error reduction and on the complex process of medication administration, and strategies to maximize the benefits of smart pumps. The medical literature related to the effects of smart pumps for improving patient safety was searched in PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (2000-2014) and relevant papers were selected by two researchers. After the literature search, 231 papers were identified and the full texts of 138 articles were assessed for eligibility. Of these, 22 were included after removal of papers that did not meet the inclusion criteria. We assessed both the benefits and negative effects of smart pumps from these studies. One of the benefits of using smart pumps was intercepting errors such as the wrong rate, wrong dose, and pump setting errors. Other benefits include reduction of adverse drug event rates, practice improvements, and cost effectiveness. Meanwhile, the current issues or negative effects related to using smart pumps were lower compliance rates of using smart pumps, the overriding of soft alerts, non-intercepted errors, or the possibility of using the wrong drug library. The literature suggests that smart pumps reduce but do not eliminate programming errors. Although the hard limits of a drug library play a main role in intercepting medication errors, soft limits were still not as effective as hard limits because of high override rates. Compliance in using smart pumps is key towards effectively preventing errors. Opportunities for improvement include upgrading drug

  6. Identifying medication error chains from critical incident reports: a new analytic approach. (United States)

    Huckels-Baumgart, Saskia; Manser, Tanja


    Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process-oriented approach to medication incident analysis focusing on medication error chains. Our study was conducted across a 900-bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009-2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). "Non-consideration of documentation/prescribing" during the drug preparation was the most frequent contributor for "wrong dose" during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety. © 2014, The American College of Clinical Pharmacology.

  7. Medication Errors in an Internal Intensive Care Unit of a Large Teaching Hospital: A Direct Observation Study

    Directory of Open Access Journals (Sweden)

    Saadat Delfani


    Full Text Available Medication errors account for about 78% of serious medical errors in intensive care unit (ICU. So far no study has been performed in Iran to evaluate all type of possible medication errors in ICU. Therefore the objective of this study was to reveal the frequency, type and consequences of all type of errors in an ICU of a large teaching hospital. The prospective observational study was conducted in an 11 bed internal ICU of a university hospital in Shiraz. In each shift all processes that were performed on one selected patient was observed and recorded by a trained pharmacist. Observer would intervene only if medication error would cause substantial harm. The data was evaluated and then were entered in a form that was designed for this purpose. The study continued for 38 shifts. During this period, a total of 442 errors per 5785 opportunities for errors (7.6% occurred. Of those, there were 9.8% administration errors, 6.8% prescribing errors, 3.3% transcription errors and, 2.3% dispensing errors. Totally 45 interventions were made, 40% of interventions result in the correction of errors. The most common causes of errors were observed to be: rule violations, slip and memory lapses and lack of drug knowledge. According to our results, the rate of errors is alarming and requires implementation of a serious solution. Since our system lacks a well-organize detection and reporting mechanism, there is no means for preventing errors in the first place. Hence, as the first step we must implement a system where errors are routinely detected and reported.

  8. The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland. (United States)

    Cassidy, Nicola; Duggan, Edel; Williams, David J P; Tracey, Joseph A


    Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication

  9. The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland.

    LENUS (Irish Health Repository)

    Cassidy, Nicola


    INTRODUCTION: Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. AIM: The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. METHODS: A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. RESULTS: Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (>\\/= 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for

  10. Medication errors: an analysis comparing PHICO's closed claims data and PHICO's Event Reporting Trending System (PERTS). (United States)

    Benjamin, David M; Pendrak, Robert F


    Clinical pharmacologists are all dedicated to improving the use of medications and decreasing medication errors and adverse drug reactions. However, quality improvement requires that some significant parameters of quality be categorized, measured, and tracked to provide benchmarks to which future data (performance) can be compared. One of the best ways to accumulate data on medication errors and adverse drug reactions is to look at medical malpractice data compiled by the insurance industry. Using data from PHICO insurance company, PHICO's Closed Claims Data, and PHICO's Event Reporting Trending System (PERTS), this article examines the significance and trends of the claims and events reported between 1996 and 1998. Those who misread history are doomed to repeat the mistakes of the past. From a quality improvement perspective, the categorization of the claims and events is useful for reengineering integrated medication delivery, particularly in a hospital setting, and for redesigning drug administration protocols on low therapeutic index medications and "high-risk" drugs. Demonstrable evidence of quality improvement is being required by state laws and by accreditation agencies. The state of Florida requires that quality improvement data be posted quarterly on the Web sites of the health care facilities. Other states have followed suit. The insurance industry is concerned with costs, and medication errors cost money. Even excluding costs of litigation, an adverse drug reaction may cost up to $2500 in hospital resources, and a preventable medication error may cost almost $4700. To monitor costs and assess risk, insurance companies want to know what errors are made and where the system has broken down, permitting the error to occur. Recording and evaluating reliable data on adverse drug events is the first step in improving the quality of pharmacotherapy and increasing patient safety. Cost savings and quality improvement evolve on parallel paths. The PHICO data

  11. Eponyms in medical sciences: historical errors that lead to injustice

    Directory of Open Access Journals (Sweden)

    Jorge Eduardo Duque-Parra


    Full Text Available Introduction: Throughout history, eponyms have been used in medical sciences to designate anatomical structures although they do not provide any descriptive or functional information, which is equivalent to a mistake in the light of current thinking. Double and triple eponyms have been used to name the same structure, thus creating confusion that leads to believe that a discovery or description was made by several persons at the same time. Although eponyms have been abolished from anatomical terminology for over eight decades and still generate problems in communication and in the teachinglearning process, medical sciences professionals continue to use them. Objective: To analyze some examples of arbitrary assignment of eponyms in morphology that have led to historical errors and perpetuated them. Conclusion: Granting an eponym to an anatomical structure may not reflect the truth about the person who discovered it and may obey to arbitrary factors that induce possible historical errors and injustice. In addition, using them hinders communication between health professionals, as well as the teaching-learning process.

  12. A logic programming approach to medical errors in imaging. (United States)

    Rodrigues, Susana; Brandão, Paulo; Nelas, Luís; Neves, José; Alves, Victor


    In 2000, the Institute of Medicine reported disturbing numbers on the scope it covers and the impact of medical error in the process of health delivery. Nevertheless, a solution to this problem may lie on the adoption of adverse event reporting and learning systems that can help to identify hazards and risks. It is crucial to apply models to identify the adverse events root causes, enhance the sharing of knowledge and experience. The efficiency of the efforts to improve patient safety has been frustratingly slow. Some of this insufficiency of progress may be assigned to the lack of systems that take into account the characteristic of the information about the real world. In our daily lives, we formulate most of our decisions normally based on incomplete, uncertain and even forbidden or contradictory information. One's knowledge is less based on exact facts and more on hypothesis, perceptions or indications. From the data collected on our adverse event treatment and learning system on medical imaging, and through the use of Extended Logic Programming to knowledge representation and reasoning, and the exploitation of new methodologies for problem solving, namely those based on the perception of what is an agent and/or multi-agent systems, we intend to generate reports that identify the most relevant causes of error and define improvement strategies, concluding about the impact, place of occurrence, form or type of event recorded in the healthcare institutions. The Eindhoven Classification Model was extended and adapted to the medical imaging field and used to classify adverse events root causes. Extended Logic Programming was used for knowledge representation with defective information, allowing for the modelling of the universe of discourse in terms of data and knowledge default. A systematization of the evolution of the body of knowledge about Quality of Information embedded in the Root Cause Analysis was accomplished. An adverse event reporting and learning system

  13. [Medication reconciliation: an innovative experience in an internal medicine unit to decrease errors due to inacurrate medication histories]. (United States)

    Pérennes, Maud; Carde, Axel; Nicolas, Xavier; Dolz, Manuel; Bihannic, René; Grimont, Pauline; Chapot, Thierry; Granier, Hervé


    An inaccurate medication history may prevent the discovery of a pre-admission iatrogenic event or lead to interrupted drug therapy during hospitalization. Medication reconciliation is a process that ensures the transfer of medication information at admission to the hospital. The aims of this prospective study were to evaluate the interest in clinical practice of this concept and the resources needed for its implementation. We chose to include patients aged 65 years or over admitted in the internal medicine unit between June and October 2010. We obtained an accurate list of each patient's home medications. This list was then compared with medication orders. All medication variances were classified as intended or unintended. An internist and a pharmacist classified the clinical importance of each unintended variance. Sixty-one patients (mean age: 78 ± 7.4 years) were included in our study. We identified 38 unintended discrepancies. The average number of unintended discrepancies was 0.62 per patient. Twenty-five patients (41%) had one or more unintended discrepancies at admission. The contact with the community pharmacist permitted us to identify 21 (55%) unintended discrepancies. The most common errors were the omission of a regularly used medication (76%) and an incorrect dosage (16%). Our intervention resulted in order changes by the physician for 30 (79%) unintended discrepancies. Fifty percent of the unintended variances were judged by the internist and 76% by the pharmacist to be clinically significant. The admission to the hospital is a critical transition point for the continuity of care in medication management. Medication reconciliation can identify and resolve errors due to inaccurate medication histories. Copyright © 2011 Elsevier Masson SAS. All rights reserved.

  14. Preventing errors in clinical practice: a call for self-awareness. (United States)

    Borrell-Carrió, Francesc; Epstein, Ronald M


    While ascribing medical errors primarily to systems factors can free clinicians from individual blame, there are elements of medical errors that can and should be attributed to individual factors. These factors are related less commonly to lack of knowledge and skill than to the inability to apply the clinician's abilities to situations under certain circumstances. In concert with efforts to improve health care systems, refining physicians' emotional and cognitive capacities might also prevent many errors. In general, physicians have the sensation of making a mistake because of the interference of emotional elements. We propose a so-called rational-emotive model that emphasizes 2 factors in error causation: (1) difficulty in reframing the first hypothesis that goes to the physician's mind in an automatic way, and (2) premature closure of the clinical act to avoid confronting inconsistencies, low-level decision rules, and emotions. We propose a teaching strategy based on developing the physician's insight and self-awareness to detect the inappropriate use of low-level decision rules, as well as detecting the factors that limit a physician's capacity to tolerate the tension of uncertainty and ambiguity. Emotional self-awareness and self-regulation of attention can be consciously cultivated as habits to help physicians function better in clinical situations.

  15. How are medication errors defined? A systematic literature review of definitions and characteristics

    DEFF Research Database (Denmark)

    Lisby, Marianne; Nielsen, L P; Brock, Birgitte


    Multiplicity in terminology has been suggested as a possible explanation for the variation in the prevalence of medication errors. So far, few empirical studies have challenged this assertion. The objective of this review was, therefore, to describe the extent and characteristics of medication er...... error definitions in hospitals and to consider the consequences for measuring the prevalence of medication errors....

  16. Human errors, countermeasures for their prevention and evaluation

    International Nuclear Information System (INIS)

    Kohda, Takehisa; Inoue, Koichi


    The accidents originated in human errors have occurred as ever in recent large accidents such as the TMI accident and the Chernobyl accident. The proportion of the accidents originated in human errors is unexpectedly high, therefore, the reliability and safety of hardware are improved hereafter, but the improvement of human reliability cannot be expected. Human errors arise by the difference between the function required for men and the function actually accomplished by men, and the results exert some adverse effect to systems. Human errors are classified into design error, manufacture error, operation error, maintenance error, checkup error and general handling error. In terms of behavior, human errors are classified into forget to do, fail to do, do that must not be done, mistake in order and do at improper time. The factors in human error occurrence are circumstantial factor, personal factor and stress factor. As the method of analyzing and evaluating human errors, system engineering method such as probabilistic risk assessment is used. The technique for human error rate prediction, the method for human cognitive reliability, confusion matrix and SLIM-MAUD are also used. (K.I.)

  17. Effects of learning climate and registered nurse staffing on medication errors. (United States)

    Chang, YunKyung; Mark, Barbara


    Despite increasing recognition of the significance of learning from errors, little is known about how learning climate contributes to error reduction. The purpose of this study was to investigate whether learning climate moderates the relationship between error-producing conditions and medication errors. A cross-sectional descriptive study was done using data from 279 nursing units in 146 randomly selected hospitals in the United States. Error-producing conditions included work environment factors (work dynamics and nurse mix), team factors (communication with physicians and nurses' expertise), personal factors (nurses' education and experience), patient factors (age, health status, and previous hospitalization), and medication-related support services. Poisson models with random effects were used with the nursing unit as the unit of analysis. A significant negative relationship was found between learning climate and medication errors. It also moderated the relationship between nurse mix and medication errors: When learning climate was negative, having more registered nurses was associated with fewer medication errors. However, no relationship was found between nurse mix and medication errors at either positive or average levels of learning climate. Learning climate did not moderate the relationship between work dynamics and medication errors. The way nurse mix affects medication errors depends on the level of learning climate. Nursing units with fewer registered nurses and frequent medication errors should examine their learning climate. Future research should be focused on the role of learning climate as related to the relationships between nurse mix and medication errors.

  18. Medication Administration Errors Involving Paediatric In-Patients in a ...

    African Journals Online (AJOL)

    The drug mostly associated with error was gentamicin with 29 errors (1.2 %). Conclusion: During the study, a high frequency of error was observed. There is a need to modify the way information is handled and shared by professionals as wrong time error was the most implicated error. Attention should also be given to IV ...

  19. Medication Review and Transitions of Care: A Case Report of a Decade-Old Medication Error. (United States)

    Comer, Rachel; Lizer, Mitsi


    A 69-year-old Caucasian male with a 25-year history of paranoid schizophrenia was brought to the emergency department because of violence toward the staff in his nursing facility. He was diagnosed with a urinary tract infection and was admitted to the behavioral health unit for medication stabilization. History included a five-year state psychiatric hospital admission and nursing facility placement. Because of poor cognitive function, the patient was unable to corroborate medication history, so the pharmacy student on rotation performed an in-depth chart review. The review revealed a transcription error in 2003 deleting amantadine 100 mg twice daily and adding amiodarone 100 mg twice daily. Subsequent hospitalization resulted in another transcription error increasing the amiodarone to 200 mg twice daily. All electrocardiograms conducted were negative for atrial fibrillation. Once detected, the consulted cardiologist discontinued the amiodarone, and the primary care provider was notified via letter and discharge papers. An admission four months later revealed that the nursing facility restarted the amiodarone. Amiodarone was discontinued and the facility was again notified. This case reviews how a 10-year-old medication error went undetected in the electronic medical records through numerous medication reconciliations, but was uncovered when a single comprehensive medication review was conducted.

  20. Medical error disclosure and patient safety: legal aspects

    Directory of Open Access Journals (Sweden)

    Olivier Guillod


    Full Text Available Reducing the number of preventable adverse events has become a public health issue. The paper discusses in which ways the law can contribute to that goal, especially by encouraging a culture of safety among healthcare professionals. It assesses the need or the usefulness to pass so-called disclosure laws and apology laws, to adopt mandatory but strictly confidential Critical Incidents Reporting Systems in hospitals, to change the fault-based system of medical liability or to amend the rules on criminal liability. The paper eventually calls for adding the law to the present agenda of patient safety.

  1. Estratégias para prevenção de erros na medicação no setor de emergência Estrategias para prevenir errores en la medicación en el sector de urgencia Strategies for prevention of medication errors in emergengy services

    Directory of Open Access Journals (Sweden)

    Regina Célia de Oliveira


    Full Text Available O estudo identificou as situações indicativas de erro ou quase erro na medicação através da análise das prescrições de medicamentos e evoluções de enfermagem. A partir dos dados obtidos foram implementados um ciclo de palestras e um curso sobre a segurança na administração de medicamentos para profissionais do setor de emergência de um hospital do nordeste. Os resultados revelaram que das 1.585 prescrições analisadas, 83,9% não explicitava a apresentação do medicamento e 84,6% a dose do medicamento. Dos medicamentos prescritos 34,2% apresentaram horários em que não havia registro da administração de medicamentos e 22,5% tinham o horário circulado. Dentre os medicamentos não-administrados 26% eram antibióticos e anticoagulantes; 15% analgésicos. As estratégias implementadas tiveram participação dos profissionais com bons índices de freqüência.El estudio identificó las situaciones indicadoras de errores o probables errores en la medicación, a de las prescripciones de medicamentos y fichas de evolución de enfermería. Además se llevó a cabo un ciclo de conferencias y un curso sobre seguridad en la administración de medicamentos, para los profesionales del Sector de Emergencia. Los resultados revelaron que de las 1.585 prescripciones analizadas, un 83,9% no expresaban con claridad la presentación del medicamento y un 84,6% la dosis del medicamento. De los medicamentos prescritos, un 34,2% no presentaban registro de la administración de los fármacos y un 22,5% tenían el horario circulado. Dentro de los medicamentos no administrados, un 26% eran antibióticos y anticoagulantes y un 15% analgésicos. Las estrategias implementadas tuvieron la participación de los profesionales, con buenos índices de frecuencia.This study identified situations indicating medication errors or near misses by analyzing medication orders and the nursing staff's performance. It also implemented a cycle of lectures and a course on

  2. Prevalence and cost of hospital medical errors in the general and elderly United States populations. (United States)

    Mallow, Peter J; Pandya, Bhavik; Horblyuk, Ruslan; Kaplan, Harold S


    The primary objective of this study was to quantify the differences in the prevalence rate and costs of hospital medical errors between the general population and an elderly population aged ≥65 years. Methods from an actuarial study of medical errors were modified to identify medical errors in the Premier Hospital Database using data from 2009. Visits with more than four medical errors were removed from the population to avoid over-estimation of cost. Prevalence rates were calculated based on the total number of inpatient visits. There were 3,466,596 total inpatient visits in 2009. Of these, 1,230,836 (36%) occurred in people aged ≥ 65. The prevalence rate was 49 medical errors per 1000 inpatient visits in the general cohort and 79 medical errors per 1000 inpatient visits for the elderly cohort. The top 10 medical errors accounted for more than 80% of the total in the general cohort and the 65+ cohort. The most costly medical error for the general population was postoperative infection ($569,287,000). Pressure ulcers were most costly ($347,166,257) in the elderly population. This study was conducted with a hospital administrative database, and assumptions were necessary to identify medical errors in the database. Further, there was no method to identify errors of omission or misdiagnoses within the database. This study indicates that prevalence of hospital medical errors for the elderly is greater than the general population and the associated cost of medical errors in the elderly population is quite substantial. Hospitals which further focus their attention on medical errors in the elderly population may see a significant reduction in costs due to medical errors as a disproportionate percentage of medical errors occur in this age group.

  3. Comparison of medication reconciliation and medication review: errors and clinical importance

    DEFF Research Database (Denmark)

    Bjeldbak-Olesen, Mette; Danielsen, Anja Gadsbølle; Tomsen, Dorthe Vilstrup


    in the patient record and the EMS. 15% of the discrepancies were potentially serious or fatal, 62% were potentially significant and 23% were potentially non-significant. A total of 129 DRPs were identified by medication review, 1.7 per patient. The most frequent DRPs were sub therapeutic dosage, inappropriate......Introduction: The objective of this study was to compare medication reconciliation and medication review based on number, type and severity of discrepancies and drug-re­lated problems (DRPs), denoted errors. Material and methods: This was a retrospective study conducted at the Department...... of Cardiology, Hillerød Hos­pital. Medication reconciliation compared the prescriptions in patient records, an electronic medication system (EMS) and in discharge summaries (DS). The medication review was based on the EMS. The two methods were performed on the same data material. To assess the clinical...

  4. Preventing treatment errors in radiotherapy by identifying and evaluating near misses and actual incidents

    International Nuclear Information System (INIS)

    Holmberg, Ola; McClean, Brendan


    The aim of this work is to study the effectiveness of a multilayered error prevention system by analysing both the near misses found at calculation-check stations and the actual treatment errors originating in the treatment preparation chain

  5. Preventing treatment errors in radiotherapy by identifying and evaluating near misses and actual incidents

    LENUS (Irish Health Repository)

    Holmberg, Ola


    When preparing radiation treatment, the prescribed dose and irradiation geometry must be translated into physical machine parameters. An error in the calculations or machine settings can negatively affect the intended treatment outcome. Analysing incidents originating in the treatment preparation chain makes it possible to find weak links and prevent treatment errors. The aim of this work is to study the effectiveness of a multilayered error prevention system by analysing both near misses and actual treatment errors.

  6. A systematic review of patient medication error on self-administering medication at home. (United States)

    Mira, José Joaquín; Lorenzo, Susana; Guilabert, Mercedes; Navarro, Isabel; Pérez-Jover, Virtudes


    Medication errors have been analyzed as a health professionals' responsibility (due to mistakes in prescription, preparation or dispensing). However, sometimes, patients themselves (or their caregivers) make mistakes in the administration of the medication. The epidemiology of patient medication errors (PEs) has been scarcely reviewed in spite of its impact on people, on therapeutic effectiveness and on incremental cost for the health systems. This study reviews and describes the methodological approaches and results of published studies on the frequency, causes and consequences of medication errors committed by patients at home. A review of research articles published between 1990 and 2014 was carried out using MEDLINE, Web-of-Knowledge, Scopus, Tripdatabase and Index Medicus. The frequency of PE was situated between 19 and 59%. The elderly and the preschooler population constituted a higher number of mistakes than others. The most common were: incorrect dosage, forgetting, mixing up medications, failing to recall indications and taking out-of-date or inappropriately stored drugs. The majority of these mistakes have no negative consequences. Health literacy, information and communication and complexity of use of dispensing devices were identified as causes of PEs. Apps and other new technologies offer several opportunities for improving drug safety.

  7. Near field communications technology and the potential to reduce medication errors through multidisciplinary application

    LENUS (Irish Health Repository)

    O’Connell, Emer


    Patient safety requires optimal management of medications. Electronic systems are encouraged to reduce medication errors. Near field communications (NFC) is an emerging technology that may be used to develop novel medication management systems.

  8. Medication errors in the Middle East countries: a systematic review of the literature. (United States)

    Alsulami, Zayed; Conroy, Sharon; Choonara, Imti


    Medication errors are a significant global concern and can cause serious medical consequences for patients. Little is known about medication errors in Middle Eastern countries. The objectives of this systematic review were to review studies of the incidence and types of medication errors in Middle Eastern countries and to identify the main contributory factors involved. A systematic review of the literature related to medication errors in Middle Eastern countries was conducted in October 2011 using the following databases: Embase, Medline, Pubmed, the British Nursing Index and the Cumulative Index to Nursing & Allied Health Literature. The search strategy included all ages and languages. Inclusion criteria were that the studies assessed or discussed the incidence of medication errors and contributory factors to medication errors during the medication treatment process in adults or in children. Forty-five studies from 10 of the 15 Middle Eastern countries met the inclusion criteria. Nine (20 %) studies focused on medication errors in paediatric patients. Twenty-one focused on prescribing errors, 11 measured administration errors, 12 were interventional studies and one assessed transcribing errors. Dispensing and documentation errors were inadequately evaluated. Error rates varied from 7.1 % to 90.5 % for prescribing and from 9.4 % to 80 % for administration. The most common types of prescribing errors reported were incorrect dose (with an incidence rate from 0.15 % to 34.8 % of prescriptions), wrong frequency and wrong strength. Computerised physician rder entry and clinical pharmacist input were the main interventions evaluated. Poor knowledge of medicines was identified as a contributory factor for errors by both doctors (prescribers) and nurses (when administering drugs). Most studies did not assess the clinical severity of the medication errors. Studies related to medication errors in the Middle Eastern countries were relatively few in number and of poor quality

  9. Characteristics and evidence of nursing scientific production for medication errors at the hospital environment

    Directory of Open Access Journals (Sweden)

    Lolita Dopico da Silva


    Full Text Available This study aimed to identify the characteristics of nurses’ publications about medication errors. It was used an Integrative methodology review covering January 2005 to October 2010 with "medication errors" and "nursing" descriptors and it was also collected data from electronic databases via “Capes Portal”. Results show four categories, the conduct of health professionals in medication errors, types and rates of errors, medication system weaknesses, and barriers to error. Discussion of the prevalent practice was not to notify the error. The prevalent error type was administration and error rates which ranged from 14.8 to 56.7%. Ilegible handwriting, communication failures among professionals, and lack of technical knowledge were weaknesses. Among the barriers, the civility from patient, nurses and technology were evident. Advances in researches for testing barriers were found and some gaps were apparent concerning lack of study that address pharmacodynamics or pharmacokinetic aspects of drugs involved in errors.

  10. Nurses' Perceived Skills and Attitudes About Updated Safety Concepts: Impact on Medication Administration Errors and Practices. (United States)

    Armstrong, Gail E; Dietrich, Mary; Norman, Linda; Barnsteiner, Jane; Mion, Lorraine

    Approximately a quarter of medication errors in the hospital occur at the administration phase, which is solely under the purview of the bedside nurse. The purpose of this study was to assess bedside nurses' perceived skills and attitudes about updated safety concepts and examine their impact on medication administration errors and adherence to safe medication administration practices. Findings support the premise that medication administration errors result from an interplay among system-, unit-, and nurse-level factors.

  11. Adherence with Preventive Medication in Childhood Asthma

    Directory of Open Access Journals (Sweden)

    Scott Burgess


    Full Text Available Suboptimal adherence with preventive medication is common and often unrecognised as a cause of poor asthma control. A number of risk factors for nonadherence have emerged from well-conducted studies. Unfortunately, patient report a physician's estimation of adherence and knowledge of these risk factors may not assist in determining whether non-adherence is a significant factor. Electronic monitoring devices are likely to be more frequently used to remind patients to take medication, as a strategy to motivate patients to maintain adherence, and a tool to evaluate adherence in subjects with poor disease control. The aim of this paper is to review non-adherence with preventive medication in childhood asthma, its impact on asthma control, methods of evaluating non-adherence, risk factors for suboptimal adherence, and strategies to enhance adherence.

  12. Medication errors in anaesthetic practice: a report of two cases and ...

    African Journals Online (AJOL)



    Sep 3, 2013 ... Key words: Medication errors, anaesthetic practice, vigilance, safety .... reports in the Australian Incident Monitoring Study. (AIMS). ... contribute to systems failure and prescription errors were most ... being due to equipment error.17 Previous studies have ... errors reported occurred during day shifts and they.

  13. Perspective of midwives working at hospitals affiliated to the Isfahan University of Medical Sciences regarding medical errors

    Directory of Open Access Journals (Sweden)

    Mahboubeh Valiani


    Conclusions: Based on the results of this study on the perspectives of participants, among the three factors of medical errors (human factors, structural factors, and management factors, human factors are the biggest threat in committing medical errors. Modification in the pattern of teaching by the midwifery professors and their presence in the hospitals, creating a no-blame culture, and sharing of alerts in medical errors are among appropriate actions in the dimensions of human, structural, and managerial factors.

  14. Analysis of Employee's Survey for Preventing Human-Errors

    Energy Technology Data Exchange (ETDEWEB)

    Sung, Chanho; Kim, Younggab; Joung, Sanghoun [KHNP Central Research Institute, Daejeon (Korea, Republic of)


    Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses.

  15. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. (United States)

    Patanwala, Asad E; Sanders, Arthur B; Thomas, Michael C; Acquisto, Nicole M; Weant, Kyle A; Baker, Stephanie N; Merritt, Erica M; Erstad, Brian L


    The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED). This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables. A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%). Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities. Copyright © 2011. Published by Mosby, Inc.

  16. Near field communications technology and the potential to reduce medication errors through multidisciplinary application. (United States)

    O'Connell, Emer; Pegler, Joe; Lehane, Elaine; Livingstone, Vicki; McCarthy, Nora; Sahm, Laura J; Tabirca, Sabin; O'Driscoll, Aoife; Corrigan, Mark


    Patient safety requires optimal management of medications. Electronic systems are encouraged to reduce medication errors. Near field communications (NFC) is an emerging technology that may be used to develop novel medication management systems. An NFC-based system was designed to facilitate prescribing, administration and review of medications commonly used on surgical wards. Final year medical, nursing, and pharmacy students were recruited to test the electronic system in a cross-over observational setting on a simulated ward. Medication errors were compared against errors recorded using a paper-based system. A significant difference in the commission of medication errors was seen when NFC and paper-based medication systems were compared. Paper use resulted in a mean of 4.09 errors per prescribing round while NFC prescribing resulted in a mean of 0.22 errors per simulated prescribing round (P=0.000). Likewise, medication administration errors were reduced from a mean of 2.30 per drug round with a Paper system to a mean of 0.80 errors per round using NFC (PNFC based medication system may be used to effectively reduce medication errors in a simulated ward environment.

  17. Diagnostic Error in Medical Education: Where Wrongs Can Make Rights (United States)

    Eva, Kevin W.


    This paper examines diagnostic error from an educational perspective. Rather than addressing the question of how educators in the health professions can help learners avoid error, however, the literature reviewed leads to the conclusion that educators should be working to induce error in learners, leading them to short term pain for long term…

  18. Frequency of medical errors in hospitalized children in khorramabad Madani hospital during six months in 2008

    Directory of Open Access Journals (Sweden)

    azam Mohsenzadeh


    Full Text Available Many hospitalized children are suffered from medical errors that may cause serious injuries. The aim of this study was to evaluate medical errors in hospitalized children in khorramabad Madani hospital in the first half of 2008. Materials and Methods: This study was a cross sectional that was performed for all medical errors in hospitalized children in khorramabad Madani hospital from 21/3/2008 to 21/9/2008. The sampling method was census. Studied variables included: age, sex, weight, kinds of errers, education of parents, job of parents. Data was collected by questionnaire and analyzed by SPSS software. Results: In this study out of 2250 records, 151 (6/3% had medical errors. 53%were girls and 47% were boys that there was a significant relation between sex and medical errors. 46/4%were related to age group lower than 2 years old. Most of the errors were occurred in weight group of 6kg. Types of medical errors included drug ordering 46/3% (involved incorrect dosage of drug (37%, frequency 28%, rout 19% and others 16%, transcribing10%, administering32/4%, dispensing11/3%. Most errors related to liquid therapy 76/2% and intravenous rout 85/4%. Most errors were occurred during night 47% and during weekend 56/6%. Conclusion: Medical errors are common in hospitalized patients, and in our study the rate of medical errors was 6/3%. So further efforts are needed to reduce them.

  19. Learning from mistakes. Factors that influence how students and residents learn from medical errors. (United States)

    Fischer, Melissa A; Mazor, Kathleen M; Baril, Joann; Alper, Eric; DeMarco, Deborah; Pugnaire, Michele


    Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. To identify major factors and areas of tension in trainees' learning from medical errors. Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.

  20. Searching for the Final Answer: Factors Contributing to Medication Administration Errors. (United States)

    Pape, Tess M.


    Causal factors contributing to errors in medication administration should be thoroughly investigated, focusing on systems rather than individual nurses. Unless systemic causes are addressed, many errors will go unreported for fear of reprisal. (Contains 42 references.) (SK)

  1. Epidemic of medical errors and hospital-acquired infections: systemic and social causes

    National Research Council Canada - National Science Library

    Charney, William


    ...) and pharmaceutical errors combined are the second or third leading killer of Americans annually: approximately 300,000 die from a combination of medical errors, hospital acquired infections (HAIs...

  2. A description of medication errors reported by pharmacists in a neonatal intensive care unit. (United States)

    Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila


    Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.

  3. Clinical relevance of and risk factors associated with medication administration time errors

    NARCIS (Netherlands)

    Teunissen, R.; Bos, J.; Pot, H.; Pluim, M.; Kramers, C.


    PURPOSE: The clinical relevance of and risk factors associated with errors related to medication administration time were studied. METHODS: In this explorative study, 66 medication administration rounds were studied on two wards (surgery and neurology) of a hospital. Data on medication errors were

  4. Medical negligence--prevention and management. (United States)

    Chao, T C


    The rising spate of malpractice cases against doctors appearing in the press and annual reports of medical insurance companies causes concern. Are our doctors more careless or is the public more conscious of litigation? A well publicized malpractice case can ruin the doctor's career and practice. It is well worth a doctor's while to know the pitfalls and learn how to prevent them, and if a mistake happens, how to manage it. Not all mistakes amount to negligence. How will the court view these cases? Some local cases are cited to illustrate the difference between misadventure and negligence. They will serve as guidelines for good medical practice.

  5. Nursing Associated Medication Errors: Are Internationally Educated Nurses Different from U.S. Educated Nurses?

    Directory of Open Access Journals (Sweden)

    Jay J. Shen


    Full Text Available Medication errors can be detrimental to patient safety and contribute to additional costs in healthcare. The United States has seen a steady increase in internationally-educated nurses (IENs entering the nursing workforce. The current study builds upon the existing research examining the relationship between IENs and medication errors by controlling for confounding factors and testing whether IENs were more likely to make multiple medication errors compared to USENs. This study was a quasi-case control study. The 2006 and 2010 medication error incident data from hospital risk management departments were used. The final sample was 1,773, representing 788 registered nurse in the case group and 985 registered nurses in the control group. Multivariable analyses were conducted to examine single medication error, multiple errors, and consequence of medication errors, in comparing the IENs to USENs. IENs tended to have multiple errors more often than USENs in 2006 (31.7% for IENs and 20.5% for USENs, p = 0.03, but these differences became marginally significant after combining both years of data and completing the multivariable models adjusting for covariates (Odds ratio = 1.38, p = 0.06. No significant differences in making a single error and medication error consequences were observed between IENs and USENs. Although no significant differences between IENs and USENs in having medication error incidents were observed, IENs might be more likely to have multiple medication error incidents in a year compared to USENs. Policies that encourage targeted orientation addressing implicit belief systems about the nursing role and explains patient safety expectations as well as procedures for medication administration may be beneficial for IENs. Supportive leadership that is culturally competent, ensures ongoing continuing education in pharmacology, and provides culturally appropriate incentives for self-reporting medication errors are important.

  6. Policies on documentation and disciplinary action in hospital pharmacies after a medication error. (United States)

    Bauman, A N; Pedersen, C A; Schommer, J C; Griffith, N L


    Hospital pharmacies were surveyed about policies on medication error documentation and actions taken against pharmacists involved in an error. The survey was mailed to 500 randomly selected hospital pharmacy directors in the United States. Data were collected on the existence of medication error reporting policies, what types of errors were documented and how, and hospital demographics. The response rate was 28%. Virtually all of the hospitals had policies and procedures for medication error reporting. Most commonly, documentation of oral and written reprimand was placed in the personnel file of a pharmacist involved in an error. One sixth of respondents had no policy on documentation or disciplinary action in the event of an error. Approximately one fourth of respondents reported that suspension or termination had been used as a form of disciplinary action; legal action was rarely used. Many respondents said errors that caused harm (42%) or death (40%) to the patient were documented in the personnel file, but 34% of hospitals did not document errors in the personnel file regardless of error type. Nearly three fourths of respondents differentiated between errors caught and not caught before a medication leaves the pharmacy and between errors caught and not caught before administration to the patient. More emphasis is needed on documentation of medication errors in hospital pharmacies.



    Ningsih, Yunita; Maidin, Alimin; Kapalawi, Irwandy


    Kejadian medication error merupakan indikator penting keselamatan pasien. Medication error yang terjadi di Rumah Sakit Universitas Hasanuddin tahun 2013 terdapat 4 kasus dan tahun 2014 terdapat 1 kasus. Penelitian ini bertujuan mengetahui gambaran risiko kejadian medication error.Jenis penelitian yang digunakan penelitian deskriptif. Teknik pengambilan sampel yang digunakan yaitu teknik total sampling sebanyak 115 responden. Analisis data yang dilakukan adalah analisis univariat. Hasil peneli...

  8. The Impact of a Patient Safety Program on Medical Error Reporting (United States)


    307 The Impact of a Patient Safety Program on Medical Error Reporting Donald R. Woolever Abstract Background: In response to the occurrence of...a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF) Regional Hospital developed and implemented a patient safety...communication, teamwork, and reporting. Objective: To determine the impact of a patient safety program on patterns of medical error reporting. Methods: This

  9. Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents. (United States)

    Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y


    Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  10. Sleep Loss in Resident Physicians: The Cause of Medical Errors?

    Directory of Open Access Journals (Sweden)

    Milton eKramer


    Full Text Available This review begins with the history of the events starting with the death of Libby Zion that lead to the Bell Commission, that the studied her death and made recommendations for improvement that were codified into law in New York state as the 405 law that the ACGME essentially adopted in putting a cap on work hours and establishing the level of staff supervision that must be available to residents in clinical situations particularly the emergency room and acute care units. A summary is then provided of the findings of the laboratory effects of total sleep deprivation including acute total sleep loss and the consequent widespread physiologic alterations, and of the effects of selective and chronic sleep loss. Generally the sequence of responses to increasing sleep loss goes from mood changes to cognitive effects to performance deficits. In the laboratory situation, deficits resulting from sleep deprivation are clearly and definitively demonstrable. Sleep loss in the clinical situation is usually sleep deprivation superimposed on chronic sleep loss. An examination of questionnaire studies, the literature on reports of sleep loss, studies of the reduction of work hours on performance as well as observational and a few interventional studies have yielded contradictory and often equivocal results. The residents generally find they feel better working fewer hours but improvements in patient care are often not reported or do not occur. A change in the attitude of the resident toward his role and his patient has not been salutary. Decreasing sleep loss should have had a positive effect on patient care in reducing medical error, but this remains to be unequivocally demonstrated.

  11. Error analysis and prevention of cosmic ion-induced soft errors in static CMOS RAMS

    International Nuclear Information System (INIS)

    Diehl, S.E.; Ochoa, A. Jr.; Dressendorfer, P.V.; Koga, R.; Kolasinski, W.A.


    Cosmic ray interactions with memory cells are known to cause temporary, random, bit errors in some designs. The sensitivity of polysilicon gate CMOS static RAM designs to logic upset by impinging ions has been studied using computer simulations and experimental heavy ion bombardment. Results of the simulations are confirmed by experimental upset cross-section data. Analytical models have been extended to determine and evaluate design modifications which reduce memory cell sensitivity to cosmic ions. A simple design modification, the addition of decoupling resistance in the feedback path, is shown to produce static RAMs immune to cosmic ray-induced bit errors

  12. Medical errors in hospitalized pediatric trauma patients with chronic health conditions

    Directory of Open Access Journals (Sweden)

    Xiaotong Liu


    Full Text Available Objective: This study compares medical errors in pediatric trauma patients with and without chronic conditions. Methods: The 2009 Kids’ Inpatient Database, which included 123,303 trauma discharges, was analyzed. Medical errors were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The medical error rates per 100 discharges and per 1000 hospital days were calculated and compared between inpatients with and without chronic conditions. Results: Pediatric trauma patients with chronic conditions experienced a higher medical error rate compared with patients without chronic conditions: 4.04 (95% confidence interval: 3.75–4.33 versus 1.07 (95% confidence interval: 0.98–1.16 per 100 discharges. The rate of medical error differed by type of chronic condition. After controlling for confounding factors, the presence of a chronic condition increased the adjusted odds ratio of medical error by 37% if one chronic condition existed (adjusted odds ratio: 1.37, 95% confidence interval: 1.21–1.5, and 69% if more than one chronic condition existed (adjusted odds ratio: 1.69, 95% confidence interval: 1.48–1.53. In the adjusted model, length of stay had the strongest association with medical error, but the adjusted odds ratio for chronic conditions and medical error remained significantly elevated even when accounting for the length of stay, suggesting that medical complexity has a role in medical error. Higher adjusted odds ratios were seen in other subgroups. Conclusion: Chronic conditions are associated with significantly higher rate of medical errors in pediatric trauma patients. Future research should evaluate interventions or guidelines for reducing the risk of medical errors in pediatric trauma patients with chronic conditions.

  13. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. (United States)

    Farag, Amany; Blegen, Mary; Gedney-Lose, Amalia; Lose, Daniel; Perkhounkova, Yelena


    Medication errors are one of the most frequently occurring errors in health care settings. The complexity of the ED work environment places patients at risk for medication errors. Most hospitals rely on nurses' voluntary medication error reporting, but these errors are under-reported. The purpose of this study was to examine the relationship among work environment (nurse manager leadership style and safety climate), social capital (warmth and belonging relationships and organizational trust), and nurses' willingness to report medication errors. A cross-sectional descriptive design using a questionnaire with a convenience sample of emergency nurses was used. Data were analyzed using descriptive, correlation, Mann-Whitney U, and Kruskal-Wallis statistics. A total of 71 emergency nurses were included in the study. Emergency nurses' willingness to report errors decreased as the nurses' years of experience increased (r = -0.25, P = .03). Their willingness to report errors increased when they received more feedback about errors (r = 0.25, P = .03) and when their managers used a transactional leadership style (r = 0.28, P = .01). ED nurse managers can modify their leadership style to encourage error reporting. Timely feedback after an error report is particularly important. Engaging experienced nurses to understand error root causes could increase voluntary error reporting. Published by Elsevier Inc.

  14. Error prevention at a radon measurement service laboratory

    International Nuclear Information System (INIS)

    Cohen, B.L.; Cohen, F.


    This article describes the steps taken at a high volume counting laboratory to avoid human, instrument, and computer errors. The laboratory analyzes diffusion barrier charcoal adsorption canisters which have been used to test homes and commercial buildings. A series of computer and human cross-checks are utilized to assure that accurate results are reported to the correct client

  15. Safety climate and attitude toward medication error reporting after hospital accreditation in South Korea. (United States)

    Lee, Eunjoo


    This study compared registered nurses' perceptions of safety climate and attitude toward medication error reporting before and after completing a hospital accreditation program. Medication errors are the most prevalent adverse events threatening patient safety; reducing underreporting of medication errors significantly improves patient safety. Safety climate in hospitals may affect medication error reporting. This study employed a longitudinal, descriptive design. Data were collected using questionnaires. A tertiary acute hospital in South Korea undergoing a hospital accreditation program. Nurses, pre- and post-accreditation (217 and 373); response rate: 58% and 87%, respectively. Hospital accreditation program. Perceived safety climate and attitude toward medication error reporting. The level of safety climate and attitude toward medication error reporting increased significantly following accreditation; however, measures of institutional leadership and management did not improve significantly. Participants' perception of safety climate was positively correlated with their attitude toward medication error reporting; this correlation strengthened following completion of the program. Improving hospitals' safety climate increased nurses' medication error reporting; interventions that help hospital administration and managers to provide more supportive leadership may facilitate safety climate improvement. Hospitals and their units should develop more friendly and intimate working environments that remove nurses' fear of penalties. Administration and managers should support nurses who report their own errors. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail:

  16. Standardizing Medication Error Event Reporting in the U.S. Department of Defense

    National Research Council Canada - National Science Library

    Nosek, Ronald A., Jr; McMeekin, Judy; Rake, Geoffrey W


    ...) began an aggressive examination of medical errors and the strategies for minimizing them. A primary goal was the creation of a standardized medication event reporting system, including a central registry for the compilation of reported data...

  17. Unintentional Pharmaceutical-Related Medication Errors Caused by Laypersons Reported to the Toxicological Information Centre in the Czech Republic. (United States)

    Urban, Michal; Leššo, Roman; Pelclová, Daniela


    The purpose of the article was to study unintentional pharmaceutical-related poisonings committed by laypersons that were reported to the Toxicological Information Centre in the Czech Republic. Identifying frequency, sources, reasons and consequences of the medication errors in laypersons could help to reduce the overall rate of medication errors. Records of medication error enquiries from 2013 to 2014 were extracted from the electronic database, and the following variables were reviewed: drug class, dosage form, dose, age of the subject, cause of the error, time interval from ingestion to the call, symptoms, prognosis at the time of the call and first aid recommended. Of the calls, 1354 met the inclusion criteria. Among them, central nervous system-affecting drugs (23.6%), respiratory drugs (18.5%) and alimentary drugs (16.2%) were the most common drug classes involved in the medication errors. The highest proportion of the patients was in the youngest age subgroup 0-5 year-old (46%). The reasons for the medication errors involved the leaflet misinterpretation and mistaken dose (53.6%), mixing up medications (19.2%), attempting to reduce pain with repeated doses (6.4%), erroneous routes of administration (2.2%), psychiatric/elderly patients (2.7%), others (9.0%) or unknown (6.9%). A high proportion of children among the patients may be due to the fact that children's dosages for many drugs vary by their weight, and more medications come in a variety of concentrations. Most overdoses could be prevented by safer labelling, proper cap closure systems for liquid products and medication reconciliation by both physicians and pharmacists. © 2016 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).

  18. A continuous quality improvement project to reduce medication error in the emergency department. (United States)

    Lee, Sara Bc; Lee, Larry Ly; Yeung, Richard Sd; Chan, Jimmy Ts


    Medication errors are a common source of adverse healthcare incidents particularly in the emergency department (ED) that has a number of factors that make it prone to medication errors. This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED. In 2009, a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems. Responsible officers were assigned to look after seven error-prone areas. Strategies were proposed, discussed, endorsed and promulgated to eliminate the problems identified. A reduction of medication incidents (MI) from 16 to 6 was achieved before and after the improvement work. This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.

  19. Using snowball sampling method with nurses to understand medication administration errors. (United States)

    Sheu, Shuh-Jen; Wei, Ien-Lan; Chen, Ching-Huey; Yu, Shu; Tang, Fu-In


    We aimed to encourage nurses to release information about drug administration errors to increase understanding of error-related circumstances and to identify high-alert situations. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Snowball sampling was conducted to recruit participants. A semi-structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Eighty-five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one-third of total errors. Among 259 actual errors, 83.8% resulted in no adverse effects; among remaining 16.2%, 6.6% had mild consequences and 9.6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double-check procedures by colleagues and nurses responsible for errors; reporting rates were 62.5% (162/259) vs. 50.7% (35/69) and only 3.5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High-alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR). Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high-alert situations. Strategies for reducing drug administration errors by nurses are suggested. Survey results suggest that nurses should double check medication administration in known high-alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non

  20. Medical error reduction and tort reform through private, contractually-based quality medicine societies. (United States)

    MacCourt, Duncan; Bernstein, Joseph


    physicians cede their implicit "right to remain silent", even if some injured patients will receive less than they do today. Likewise, physicians will be happier with a system that avoids blame-even if this system placed strict requirements for high quality care and disclosure of error. We therefore conceive of de facto trade between patients and physicians, a Pareto improvement, taking form via the establishment of "Societies of Quality Medicine." Physicians working within these societies would consent to onerous processes for disclosing, rectifying and preventing medical error. Patients would in turn contractually agree to assert their claims in arbitration and with limits on recovery. The role of plaintiffs' lawyers would be unchanged, but due to increased disclosure, discovery costs would diminish and the likelihood of prevailing will more than triple. This article examines the legal and policy issues surrounding the establishment of Societies of Quality Medicine, particularly the issues of contracting over liability, and outlines a means of overcoming the theoretical and practical difficulties with enterprise liability, alternative dispute resolution and the imposition of limits on recovery for non-pecuniary damages. We aim to build a welfare enhancing system that rebuffs the culture of silence and promotes error reduction, a system that is at the same time legally sound, fiscally prudent and politically possible.

  1. [Patient safety and errors in medicine: development, prevention and analyses of incidents]. (United States)

    Rall, M; Manser, T; Guggenberger, H; Gaba, D M; Unertl, K


    "Patient safety" and "errors in medicine" are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a "systems" approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology--within which realistic simulators were developed--is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of "culture" throughout the entire health care system. The "culture of blame" focused on individuals should be replaced by a "safety culture", that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a "preventive and proactive safety culture" should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient

  2. Reduced error signalling in medication-naive children with ADHD

    DEFF Research Database (Denmark)

    Plessen, Kerstin J; Allen, Elena A; Eichele, Heike


    reduced in children with ADHD. This adaptation was inversely related to activation of the right-lateralized ventral attention network (VAN) on error trials and to task-driven connectivity between the cingulo-opercular system and the VAN. LIMITATIONS: Our study was limited by the modest sample size......BACKGROUND: We examined the blood-oxygen level-dependent (BOLD) activation in brain regions that signal errors and their association with intraindividual behavioural variability and adaptation to errors in children with attention-deficit/hyperactivity disorder (ADHD). METHODS: We acquired...

  3. [Medication errors in a neonatal unit: One of the main adverse events]. (United States)

    Esqué Ruiz, M T; Moretones Suñol, M G; Rodríguez Miguélez, J M; Sánchez Ortiz, E; Izco Urroz, M; de Lamo Camino, M; Figueras Aloy, J


    Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. An analysis was performed on the ME declared in a neonatal unit. A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.

  4. Review of errors in the issue of medical certificates of cause of death ...

    African Journals Online (AJOL)

    ... significant errors in MCCD records, with the errors more likely in certificates issued by non-specialist medical officers. All the certificates audited had at least one minor error. Training of doctors on proper completion of MCCDs is strongly advocated. Funding: None of the authors received any financial support for this study.

  5. Erro médico em pacientes hospitalizados Medical errors in hospitalized patients

    Directory of Open Access Journals (Sweden)

    Manoel de Carvalho


    sistema, e encarados como oportunidade de revisão do processo e aprimoramento da assistência prestada ao paciente.Objective: to review the current literature and to discuss medical errors in hospitalized patients emphasizing its incidence, predisposing factors and prevention mechanism. Special attention is given to medication errors and adverse drug events in newborn infants and pediatric patients. Sources: bibliographic review of the current literature through electronic search in Medline data-base, with selection of the most relevant articles. Summary of the findings: even though most medical errors are not reported, it is important to notice that its incidence is greater than previously assumed. In the USA, approximately one million of patients/year are victims of medical errors and adverse drug events. Today, deaths resulting from these episodes are the fourth cause of mortality in the USA. In neonatal and pediatric intensive care units, where the complexity and frequency of technical procedures are high, medical errors are frequent. Fifteen percent of all admissions to a neonatal intensive care unit is followed by medical errors. Most of these errors occur during night shifts and include incorrect administration of drugs (35% and errors regarding the interpretation of medical prescription (26%. Environmental factors (noise, heat, psychological factors (anxiety, stress and physiologic factors (fatigue, absence of sleep contribute to the occurrence of errors. Recent study shows that after working 24 hours without sleeping, the performance of a health professional is similar to a legally drunk person (serum alcohol level > 0.08%. Conclusions: errors are part of human behavior. The prevention of errors should include a careful review of the organizational system. Medical errors should be seen as an opportunity to change or re-structure the system and to improve the quality of health care delivered and patient safety.

  6. Medication administration errors in assisted living: scope, characteristics, and the importance of staff training. (United States)

    Zimmerman, Sheryl; Love, Karen; Sloane, Philip D; Cohen, Lauren W; Reed, David; Carder, Paula C


    To compare rates of medication errors committed by assisted living staff with different training and to examine characteristics of errors. Observation of medication preparation and passes, chart review, interviews, and questionnaires. Stratified random sample of 11 assisted living communities in South Carolina (which permits nonnurses to administer medications) and Tennessee (which does not). All staff who prepared or passed medications: nurses (one registered nurse and six licensed practical nurses (LPNs)); medication aides (n=10); and others (n=19), including those with more and less training. Rates of errors related to medication, dose and form, preparation, route, and timing. Medication preparation and administration were observed for 4,957 administrations during 83 passes for 301 residents. The error rate was 42% (20% when omitting timing errors). Of all administrations, 7% were errors with moderate or high potential for harm. The odds of such an error by a medication aide were no more likely than by a LPN, but the odds of one by staff with less training was more than two times as great (odds ratio=2.10, 95% confidence interval=1.27-3.49). A review of state regulations found that 20 states restrict nonnurses to assisting with self-administration of medications. Medication aides do not commit more errors than LPNs, but other nonnurses who administered a significant number of medications and assisted with self-administration committed more errors. Consequently, all staff who handle medications should be trained to the level of a medication aide. © 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.

  7. The impact of work-related stress on medication errors in Eastern Region Saudi Arabia. (United States)

    Salam, Abdul; Segal, David M; Abu-Helalah, Munir Ahmad; Gutierrez, Mary Lou; Joosub, Imran; Ahmed, Wasim; Bibi, Rubina; Clarke, Elizabeth; Qarni, Ali Ahmed Al


    To examine the relationship between overall level and source-specific work-related stressors on medication errors rate. A cross-sectional study examined the relationship between overall levels of stress, 25 source-specific work-related stressors and medication error rate based on documented incident reports in Saudi Arabia (SA) hospital, using secondary databases. King Abdulaziz Hospital in Al-Ahsa, Eastern Region, SA. Two hundred and sixty-nine healthcare professionals (HCPs). The odds ratio (OR) and corresponding 95% confidence interval (CI) for HCPs documented incident report medication errors and self-reported sources of Job Stress Survey. Multiple logistic regression analysis identified source-specific work-related stress as significantly associated with HCPs who made at least one medication error per month (P stress were two times more likely to make at least one medication error per month than non-stressed HCPs (OR: 1.95, P = 0.081). This is the first study to use documented incident reports for medication errors rather than self-report to evaluate the level of stress-related medication errors in SA HCPs. Job demands, such as social stressors (home life disruption, difficulties with colleagues), time pressures, structural determinants (compulsory night/weekend call duties) and higher income, were significantly associated with medication errors whereas overall stress revealed a 2-fold higher trend.

  8. Families, nurses and organisations contributing factors to medication administration error in paediatrics: a literature review

    Directory of Open Access Journals (Sweden)

    Albara Alomari


    Full Text Available Background: Medication error is the most common adverse event for hospitalised children and can lead to significant harm. Despite decades of research and implementation of a number of initiatives, the error rates continue to rise, particularly those associated with administration. Objectives: The objective of this literature review is to explore the factors involving nurses, families and healthcare systems that impact on medication administration errors in paediatric patients. Design: A review was undertaken of studies that reported on factors that contribute to a rise or fall in medication administration errors, from family, nurse and organisational perspectives. The following databases were searched: Medline, Embase, CINAHL and the Cochrane library. The title, abstract and full article were reviewed for relevance. Articles were excluded if they were not research studies, they related to medications and not medication administration errors or they referred to medical errors rather than medication errors. Results: A total of 15 studies met the inclusion criteria. The factors contributing to medication administration errors are communication failure between the parents and healthcare professionals, nurse workload, failure to adhere to policy and guidelines, interruptions, inexperience and insufficient nurse education from organisations. Strategies that were reported to reduce errors were doublechecking by two nurses, implementing educational sessions, use of computerised prescribing and barcoding administration systems. Yet despite such interventions, errors persist. The review highlighted families that have a central role in caring for the child and therefore are key to the administration process, but have largely been ignored in research studies relating to medication administration. Conclusions: While there is a consensus about the factors that contribute to errors, sustainable and effective solutions remain elusive. To date, families have not

  9. Frecuencia de errores de los pacientes con su medicación Frequency of medication errors by patients

    Directory of Open Access Journals (Sweden)

    José Joaquín Mira


    Full Text Available OBJETIVO: Analizar la frecuencia de errores de medicación que son cometidos e informados por los pacientes. MÉTODOS: Estudio descriptivo basado en encuestas telefónicas a una muestra aleatoria de pacientes adultos del nivel primario de salud del sistema público español. Respondieron un total de 1 247 pacientes (tasa de respuesta, 75%. El 63% eran mujeres y 29% eran mayores de 70 años. RESULTADOS: Mientras 37 pacientes (3%, IC 95%: 2-4 sufrieron complicaciones asociadas a la medicación en el curso del tratamiento, 241 (19,4%, IC 95%: 17-21 informaron haber cometido algún error con la medicación. Un menor tiempo de consulta (P OBJECTIVE: Analyze the frequency of medication errors committed and reported by patients. METHODS: Descriptive study based on a telephone survey of a random sample of adult patients from the primary care level of the Spanish public health care system. A total of 1 247 patients responded (75% response rate; 63% were women and 29% were older than 70 years. RESULTS: While 37 patients (3%, 95% CI: 2-4 experienced complications associated with medication in the course of treatment, 241 (19.4%, 95% CI: 17-21 reported having made some mistake with their medication. A shorter consultation time (P < 0.01 and a worse assessment of the information provided by the physician (P < 0.01 were associated with the fact that during pharmacy dispensing the patient was told that the prescribed treatment was not appropriate. CONCLUSIONS: In addition to the known risks of an adverse event due to a health intervention resulting from a system or practitioner error, there are risks associated with patient errors in the self-administration of medication. Patients who were unsatisfied with the information provided by the physician reported a greater number of errors.

  10. The incidence and severity of errors in pharmacist-written discharge medication orders


    Onatade, Raliat; Sawieres, Sara; Veck, Alexandra; Smith, Lindsay; Gore, Shivani; Al-Azeib, Sumiah


    Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists’ medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routin...

  11. Medication reconciliation errors in a tertiary care hospital in Saudi Arabia: admission discrepancies and risk factors

    Directory of Open Access Journals (Sweden)

    Mazhar F


    Full Text Available Background: Medication reconciliation is a major component of safe patient care. One of the main problems in the implementation of a medication reconciliation process is the lack of human resources. With limited resources, it is better to target medication reconciliation resources to patients who will derive the most benefit from it. Objective: The primary objective of this study was to determine the frequency and types of medication reconciliation errors identified by pharmacists performing medication reconciliation at admission. Each medication error was rated for its potential to cause patient harm during hospitalization. A secondary objective was to determine risk factors associated with medication reconciliation errors. Methods: This was a prospective, single-center pilot study conducted in the internal medicine and surgical wards of a tertiary care teaching hospital in the Eastern province of Saudi Arabia. A clinical pharmacist took the best possible medication history of patients admitted to medical and surgical services and compared with the medication orders at hospital admission; any identified discrepancies were noted and analyzed for reconciliation errors. Multivariate logistic regression was performed to determine the risk factors related to reconciliation errors. Results: A total of 328 patients (138 in surgical and 198 in medical were included in the study. For the 1419 medications recorded, 1091 discrepancies were discovered out of which 491 (41.6% were reconciliation errors. The errors affected 177 patients (54%. The incidence of reconciliation errors in the medical patient group was 25.1% and 32.0% in the surgical group (p<0.001. In both groups, the most frequent reconciliation error was the omission (43.5% and 51.2%. Lipid-lowering (12.4% and antihypertensive agents were most commonly involved. If undetected, 43.6% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 17

  12. A Cycle of Redemption in a Medical Error Disclosure and Apology Program. (United States)

    Carmack, Heather J


    Physicians accept that they have an ethical responsibility to disclose and apologize for medical errors; however, when physicians make a medical error, they are often not given the opportunity to disclose and apologize for the mistake. In this article, I explore how one hospital negotiated the aftermath of medical mistakes through a disclosure and apology program. Specifically, I used Burke's cycle of redemption to position the hospital's disclosure and apology program as a redemption process and explore how the hospital physicians and administrators worked through the experiences of disclosing and apologizing for medical errors. © The Author(s) 2014.

  13. Professional, structural and organisational interventions in primary care for reducing medication errors. (United States)

    Khalil, Hanan; Bell, Brian; Chambers, Helen; Sheikh, Aziz; Avery, Anthony J


    Medication-related adverse events in primary care represent an important cause of hospital admissions and mortality. Adverse events could result from people experiencing adverse drug reactions (not usually preventable) or could be due to medication errors (usually preventable). To determine the effectiveness of professional, organisational and structural interventions compared to standard care to reduce preventable medication errors by primary healthcare professionals that lead to hospital admissions, emergency department visits, and mortality in adults. We searched CENTRAL, MEDLINE, Embase, three other databases, and two trial registries on 4 October 2016, together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several sources of grey literature. We included randomised trials in which healthcare professionals provided community-based medical services. We also included interventions in outpatient clinics attached to a hospital where people are seen by healthcare professionals but are not admitted to hospital. We only included interventions that aimed to reduce medication errors leading to hospital admissions, emergency department visits, or mortality. We included all participants, irrespective of age, who were prescribed medication by a primary healthcare professional. Three review authors independently extracted data. Each of the outcomes (hospital admissions, emergency department visits, and mortality), are reported in natural units (i.e. number of participants with an event per total number of participants at follow-up). We presented all outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We used the GRADE tool to assess the certainty of evidence. We included 30 studies (169,969 participants) in the review addressing various interventions to prevent medication errors; four studies addressed professional interventions (8266 participants) and 26 studies described

  14. Types and Severity of Medication Errors in Iran; a Review of the Current Literature

    Directory of Open Access Journals (Sweden)

    Ava Mansouri


    Full Text Available Medication error (ME is the most common single preventable cause of adverse drug events which negatively affects patient safety. ME prevalence is a valuable safety indicator in healthcare system. Inadequate studies on ME, shortage of high-quality studies and wide variations in estimations from developing countries including Iran, decreases the reliability of ME evaluations. In order to clarify the status of MEs, we aimed to review current available literature on this subject from Iran. We searched Scopus, Web of Science, PubMed, CINAHL, EBSCOHOST and also Persian databases (IranMedex, and SID up to October 2012 to find studies on adults and children about prescription, transcription, dispensing, and administration errors. Two authors independently selected and one of them reviewed and extracted data for types, definitions and severity of MEs. The results were classified based on different stages of drug delivery process. Eighteen articles (11 Persian and 7 English were included in our review. All study designs were cross-sectional and conducted in hospital settings. Nursing staff and students were the most frequent populations under observation (12 studies; 66.7%. Most of studies did not report the overall frequency of MEs aside from ME types. Most of studies (15; 83.3% reported prevalence of administration errors between 14.3%-70.0%. Prescribing error prevalence ranged from 29.8%-47.8%. The prevalence of dispensing and transcribing errors were from 11.3%-33.6% and 10.0%-51.8% respectively. We did not find any follow up or repeated studies. Only three studies reported findings on severity of MEs. The most reported types of and the highest percentages for any type of ME in Iran were administration errors. Studying ME in Iran is a new area considering the duration and number of publications. Wide ranges of estimations for MEs in different stages may be because of the poor quality of studies with diversity in definitions, methods, and populations

  15. Learning from prescribing errors


    Dean, B



 The importance of learning from medical error has recently received increasing emphasis. This paper focuses on prescribing errors and argues that, while learning from prescribing errors is a laudable goal, there are currently barriers that can prevent this occurring. Learning from errors can take place on an individual level, at a team level, and across an organisation. Barriers to learning from prescribing errors include the non-discovery of many prescribing errors, lack of feedback to th...

  16. The approach of Bayesian model indicates media awareness of medical errors (United States)

    Ravichandran, K.; Arulchelvan, S.


    This research study brings out the factors behind the increase in medical malpractices in the Indian subcontinent in the present day environment and impacts of television media awareness towards it. Increased media reporting of medical malpractices and errors lead to hospitals taking corrective action and improve the quality of medical services that they provide. The model of Cultivation Theory can be used to measure the influence of media in creating awareness of medical errors. The patient's perceptions of various errors rendered by the medical industry from different parts of India were taken up for this study. Bayesian method was used for data analysis and it gives absolute values to indicate satisfaction of the recommended values. To find out the impact of maintaining medical records of a family online by the family doctor in reducing medical malpractices which creates the importance of service quality in medical industry through the ICT.

  17. Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol. (United States)

    Hutchinson, Alison M; Sales, Anne E; Brotto, Vanessa; Bucknall, Tracey K


    Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals' medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change

  18. Effects of a direct refill program for automated dispensing cabinets on medication-refill errors. (United States)

    Helmons, Pieter J; Dalton, Ashley J; Daniels, Charles E


    The effects of a direct refill program for automated dispensing cabinets (ADCs) on medication-refill errors were studied. This study was conducted in designated acute care areas of a 386-bed academic medical center. A wholesaler-to-ADC direct refill program, consisting of prepackaged delivery of medications and bar-code-assisted ADC refilling, was implemented in the inpatient pharmacy of the medical center in September 2009. Medication-refill errors in 26 ADCs from the general medicine units, the infant special care unit, the surgical and burn intensive care units, and intermediate units were assessed before and after the implementation of this program. Medication-refill errors were defined as an ADC pocket containing the wrong drug, wrong strength, or wrong dosage form. ADC refill errors decreased by 77%, from 62 errors per 6829 refilled pockets (0.91%) to 8 errors per 3855 refilled pockets (0.21%) (p error type detected before the intervention was the incorrect medication (wrong drug, wrong strength, or wrong dosage form) in the ADC pocket. Of the 54 incorrect medications found before the intervention, 38 (70%) were loaded in a multiple-drug drawer. After the implementation of the new refill process, 3 of the 5 incorrect medications were loaded in a multiple-drug drawer. There were 3 instances of expired medications before and only 1 expired medication after implementation of the program. A redesign of the ADC refill process using a wholesaler-to-ADC direct refill program that included delivery of prepackaged medication and bar-code-assisted refill significantly decreased the occurrence of ADC refill errors.

  19. Wrong decisions in radiology. Analysis of causes and strategies for error prevention

    International Nuclear Information System (INIS)

    Lackner, Klaus-Juergen; Krug, Kathrin Barbara


    The book covers observations on errors concerning radiological decisions within a ten-year period. The compiled information is supposed to prevent similar errors in the future. The case studies cover the following issues: cranium, thorax, mamma, abdomen (liver, pancreas, colon), (gastrointestinal tract, urogenital tract), spinal cord, skeleton and blood vessels.

  20. A comparative study of voluntarily reported medication errors among ...

    African Journals Online (AJOL)

    errors among adult patients in intensive care (IC) and non-. IC settings in Riyadh, ... safety “To err is human: Building a safer health care system” .... regression analysis was used to identify factors affecting the .... that work in non-ICU areas are less likely to report such ..., which permit unrestricted use, distribution ...

  1. Patients' knowledge and perceived reactions to medical errors in a ...

    African Journals Online (AJOL)

    Severity of error (88.5%) and the perception of negligence mediated intention to litigate. Voluntary disclosure significantly reduced patients' intention to litigate caregivers (chi2=3.584; df=1; P=0.053). Frustration/anger was not more likely to influence patient to litigate than feelings of resignation/forgiveness (chi2=2.156; df=1; ...

  2. Frequency of medication errors in an emergency department of a large teaching hospital in southern Iran

    Directory of Open Access Journals (Sweden)

    Vazin A


    Full Text Available Afsaneh Vazin,1 Zahra Zamani,1 Nahid Hatam2 1Department of Clinical Pharmacy, Faculty of Pharmacy, 2School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran Abstract: This study was conducted with the purpose of determining the frequency of medication errors (MEs occurring in tertiary care emergency department (ED of a large academic hospital in Iran. The incidence of MEs was determined through the disguised direct observation method conducted by a trained observer. A total of 1,031 medication doses administered to 202 patients admitted to the tertiary care ED were observed over a course of 54 6-hour shifts. Following collection of the data and analysis of the errors with the assistance of a clinical pharmacist, frequency of errors in the different stages was reported and analyzed in SPSS-21 software. For the 202 patients and the 1,031 medication doses evaluated in the present study, 707 (68.5% MEs were recorded in total. In other words, 3.5 errors per patient and almost 0.69 errors per medication are reported to have occurred, with the highest frequency of errors pertaining to cardiovascular (27.2% and antimicrobial (23.6% medications. The highest rate of errors occurred during the administration phase of the medication use process with a share of 37.6%, followed by errors of prescription and transcription with a share of 21.1% and 10% of errors, respectively. Omission (7.6% and wrong time error (4.4% were the most frequent administration errors. The less-experienced nurses (P=0.04, higher patient-to-nurse ratio (P=0.017, and the morning shifts (P=0.035 were positively related to administration errors. Administration errors marked the highest share of MEs occurring in the different medication use processes. Increasing the number of nurses and employing the more experienced of them in EDs can help reduce nursing errors. Addressing the shortcomings with further research should result in reduction

  3. Electronic error-reporting systems: a case study into the impact on nurse reporting of medical errors. (United States)

    Lederman, Reeva; Dreyfus, Suelette; Matchan, Jessica; Knott, Jonathan C; Milton, Simon K


    Underreporting of errors in hospitals persists despite the claims of technology companies that electronic systems will facilitate reporting. This study builds on previous analyses to examine error reporting by nurses in hospitals using electronic media. This research asks whether the electronic media creates additional barriers to error reporting, and, if so, what practical steps can all hospitals take to reduce these barriers. This is a mixed-method case study nurses' use of an error reporting system, RiskMan, in two hospitals. The case study involved one large private hospital and one large public hospital in Victoria, Australia, both of which use the RiskMan medical error reporting system. Information technology-based error reporting systems have unique access problems and time demands and can encourage nurses to develop alternative reporting mechanisms. This research focuses on nurses and raises important findings for hospitals using such systems or considering installation. This article suggests organizational and technical responses that could reduce some of the identified barriers. Crown Copyright © 2013. Published by Mosby, Inc. All rights reserved.

  4. [Responsibility due to medication errors in France: a study based on SHAM insurance data]. (United States)

    Theissen, A; Orban, J-C; Fuz, F; Guerin, J-P; Flavin, P; Albertini, S; Maricic, S; Saquet, D; Niccolai, P


    The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications. The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010). Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy. The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

  5. Analyzing the knowledge and attitude of nurses regarding medication error and its prophylactic ways in educational and therapeutic hospitals of Khorramabad

    Directory of Open Access Journals (Sweden)

    fatemeh Ghasemi


    .5%, and adequate information about medications (69.8% were reported as the most important ways to prevent medication errors. Also 62.8% of the cases had moderate knowledge regarding medication error and its prophylactic ways. Conclusion: The data analysis showed that from the nurses viewpoints, some interventions including increasing adequate nurse to patient ratio, improving environmental conditions of work, reducing environmental distractions such as interruptions and stressors, increasing staffs’ information about medications, increasing the role of clinical pharmacologists, creating medication error reporting systems, supportive attitude of nursing officials, focusing on causes of errors, and improving controlling and supervising systems can have remarkable effects on reducing medication errors. Moreover, both individuals and systems have to be taken into consideration when rules and regulations concerning medication error reporting and prevention are made.

  6. Medication errors in residential aged care facilities: a distributed cognition analysis of the information exchange process. (United States)

    Tariq, Amina; Georgiou, Andrew; Westbrook, Johanna


    Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding

  7. Assessment of medication errors and adherence to WHO prescription writing guidelines in a tertiary care hospital

    Directory of Open Access Journals (Sweden)

    Dilnasheen Sheikh


    Full Text Available The objective of the study is to assess the medication errors and adherence to WHO prescription writing guidelines in a tertiary care hospital. A prospective observational study was carried out for a period of 8 months from June 2015 to February 2016 at tertiary care hospital. At inpatient department regular chart review of patient case records was carried out to assess the medication errors. The observed medication errors were assessed for level of harm by using NCCMERP index. The outpatient prescriptions were screened for adherence to WHO prescription writing guidelines. Out of 200 patients, 40 patients developed medication errors. Most of the medication errors were observed in the age group above 61 years (40%. Majority of the medication errors were observed with drug class of antibiotics 9 (22.5% and bronchodilators 9 (22.5%. Most of the errors were under the NCCMERP index category C. Out of 545 outpatient prescriptions, 51 (9.37% prescriptions did not have prescriber’s name and all of the prescriptions lack prescriber’s personal contact number. Eighteen prescriptions did not have patient’s name and 426 (78.2% prescriptions did not have patient’s age. The prevalence of medication errors in this study was relatively low (20% without any fatal outcome. Omission error was the most frequently observed medication errors 31 (77.5%. In the present study, the patient’s age was missing in 78.2% of the prescriptions and none of the prescriptions had patient’s address and the drug names were not mentioned by their generic names.

  8. Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center: A 3-Year, Multiphase Study. (United States)

    Zucker, Jason; Mittal, Jaimie; Jen, Shin-Pung; Cheng, Lucy; Cennimo, David


    There is a high prevalence of HIV infection in Newark, New Jersey, with University Hospital admitting approximately 600 HIV-infected patients per year. Medication errors involving antiretroviral therapy (ART) could significantly affect treatment outcomes. The goal of this study was to evaluate the effectiveness of various stewardship interventions in reducing the prevalence of prescribing errors involving ART. This was a retrospective review of all inpatients receiving ART for HIV treatment during three distinct 6-month intervals over a 3-year period. During the first year, the baseline prevalence of medication errors was determined. During the second year, physician and pharmacist education was provided, and a computerized order entry system with drug information resources and prescribing recommendations was implemented. Prospective audit of ART orders with feedback was conducted in the third year. Analyses and comparisons were made across the three phases of this study. Of the 334 patients with HIV admitted in the first year, 45% had at least one antiretroviral medication error and 38% had uncorrected errors at the time of discharge. After education and computerized order entry, significant reductions in medication error rates were observed compared to baseline rates; 36% of 315 admissions had at least one error and 31% had uncorrected errors at discharge. While the prevalence of antiretroviral errors in year 3 was similar to that of year 2 (37% of 276 admissions), there was a significant decrease in the prevalence of uncorrected errors at discharge (12%) with the use of prospective review and intervention. Interventions, such as education and guideline development, can aid in reducing ART medication errors, but a committed stewardship program is necessary to elicit the greatest impact. © 2016 Pharmacotherapy Publications, Inc.

  9. Medication Errors: Cut Your Risk with These Tips (United States)

    ... medication, make sure you know the answers to these questions: What is the brand or generic name ... have happened to some people. Don't make these same mistakes: Confusing eardrops and eyedrops. Always double- ...

  10. Iatrogenic medication errors in a paediatric intensive care unit in ...

    African Journals Online (AJOL)

    trigger tool method rather than a real-time reporting tool in both ... Therapeutic skills of healthcare professionals working in the PICU need to be improved to decrease ..... devices such as smartphones with medication dosage applications.

  11. Error prevention in radiotherapy treatments using a record and verify system

    International Nuclear Information System (INIS)

    Navarrete Campos, S.; Hernandez Vitoria, A.; Canellas Anoz, M.; Millan Cebrian, E.; Garcia Romero, A.


    Computerized record-and-verify systems (RVS) are being used increasingly to improve the precision of radiotherapy treatments. With the introduction of new treatment devices, such as multileaf or asymmetric collimators and virtual wedges, the responsibility to ensure correct treatment has increased. The purpose of this paper is to present the method that we are following to prevent some potential radiotherapy errors and to point out some errors that can be easily detected using a RVS, through a check of the daily recorded treatment information. We conclude that a RVS prevents the occurrence of many errors, when the settings of the treatment machine do not match the intended parameters within some maximal authorized deviation, and allows to detect easily other potential errors related with a incorrect selection of the treatment patient data. A quality assurance program, including a check of all beam data and a weekly control of the manual and electronic chart, has helped reduce errors. (author)


    Directory of Open Access Journals (Sweden)

    Volodymyr Kharchenko


    Full Text Available Purpose: the aim of this study is to research applied models of air traffic controllers’ errors prevention in terminal control areas (TMA under uncertainty conditions. In this work the theoretical framework descripting safety events and errors of air traffic controllers connected with the operations in TMA is proposed. Methods: optimisation of terminal control area formal description based on the Threat and Error management model and the TMA network model of air traffic flows. Results: the human factors variables associated with safety events in work of air traffic controllers under uncertainty conditions were obtained. The Threat and Error management model application principles to air traffic controller operations and the TMA network model of air traffic flows were proposed. Discussion: Information processing context for preventing air traffic controller errors, examples of threats in work of air traffic controllers, which are relevant for TMA operations under uncertainty conditions.

  13. Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode. (United States)

    Hwang, Yeonsoo; Yoon, Dukyong; Ahn, Eun Kyoung; Hwang, Hee; Park, Rae Woong


    To determine the risk factors and rate of medication administration error (MAE) alerts by analyzing large-scale medication administration data and related error logs automatically recorded in a closed-loop medication administration system using radio-frequency identification and barcodes. The subject hospital adopted a closed-loop medication administration system. All medication administrations in the general wards were automatically recorded in real-time using radio-frequency identification, barcodes, and hand-held point-of-care devices. MAE alert logs recorded during a full 1 year of 2012. We evaluated risk factors for MAE alerts including administration time, order type, medication route, the number of medication doses administered, and factors associated with nurse practices by logistic regression analysis. A total of 2 874 539 medication dose records from 30 232 patients (882.6 patient-years) were included in 2012. We identified 35 082 MAE alerts (1.22% of total medication doses). The MAE alerts were significantly related to administration at non-standard time [odds ratio (OR) 1.559, 95% confidence interval (CI) 1.515-1.604], emergency order (OR 1.527, 95%CI 1.464-1.594), and the number of medication doses administered (OR 0.993, 95%CI 0.992-0.993). Medication route, nurse's employment duration, and working schedule were also significantly related. The MAE alert rate was 1.22% over the 1-year observation period in the hospital examined in this study. The MAE alerts were significantly related to administration time, order type, medication route, the number of medication doses administered, nurse's employment duration, and working schedule. The real-time closed-loop medication administration system contributed to improving patient safety by preventing potential MAEs. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  14. Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation. (United States)

    Wolf, Dwayne A; Drake, Stacy A; Snow, Francine K


    In the course of fulfilling their statutory role, physicians performing medicolegal investigations may recognize clinical colleagues' medical errors. If the error is found to have led directly to the patient's death (missed diagnosis or incorrect diagnosis, for example), then the forensic pathologist has a professional responsibility to include the information in the autopsy report and make sure that the family is appropriately informed. When the error is significant but did not lead directly to the patient's demise, ethical questions may arise regarding the obligations of the medical examiner to disclose the error to the clinicians or to the family. This case depicts the discovery of medical error likely unrelated to the cause of death and describes one possible ethical approach to disclosure derived from an ethical reasoning model addressing ethical principles of respect for persons/autonomy, beneficence, nonmaleficence, and justice.

  15. Learning from errors: analysis of medication order voiding in CPOE systems. (United States)

    Kannampallil, Thomas G; Abraham, Joanna; Solotskaya, Anna; Philip, Sneha G; Lambert, Bruce L; Schiff, Gordon D; Wright, Adam; Galanter, William L


    Medication order voiding allows clinicians to indicate that an existing order was placed in error. We explored whether the order voiding function could be used to record and study medication ordering errors. We examined medication orders from an academic medical center for a 6-year period (2006-2011; n  = 5 804 150). We categorized orders based on status (void, not void) and clinician-provided reasons for voiding. We used multivariable logistic regression to investigate the association between order voiding and clinician, patient, and order characteristics. We conducted chart reviews on a random sample of voided orders ( n  = 198) to investigate the rate of medication ordering errors among voided orders, and the accuracy of clinician-provided reasons for voiding. We found that 0.49% of all orders were voided. Order voiding was associated with clinician type (physician, pharmacist, nurse, student, other) and order type (inpatient, prescription, home medications by history). An estimated 70 ± 10% of voided orders were due to medication ordering errors. Clinician-provided reasons for voiding were reasonably predictive of the actual cause of error for duplicate orders (72%), but not for other reasons. Medication safety initiatives require availability of error data to create repositories for learning and training. The voiding function is available in several electronic health record systems, so order voiding could provide a low-effort mechanism for self-reporting of medication ordering errors. Additional clinician training could help increase the quality of such reporting. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email:

  16. Analysis of errors during medical and computerized diagnostics of spherical lung neoplasms

    International Nuclear Information System (INIS)

    Pozmogov, A.I.; Petruk, D.A.


    Reasons for errors in medical and computerized diagnostics of spherical lung neoplasms are studied based on material of 212 case records and clinicoroentgenological data; it should promote improvement of their diagnostics

  17. Impacts of nurses’ circadian rhythm sleep disorders, fatigue, and depression on medication administration errors

    Directory of Open Access Journals (Sweden)

    Abdelbaset M. Saleh


    Conclusions: Medication administration errors, fatigue and depression were all significantly affected by circadian sleep disorders. An administration’s control of work flow to provide convenient sleep hours will help in improving sleep circadian rhythms and consequently minimize these problems.

  18. Medication errors in the adult emergency unit of a tertiary care teaching hospital in Addis Ababa

    Directory of Open Access Journals (Sweden)

    Gediwon Negash


    Conclusion: Incidence and types of medication errors committed in Tikur Anbesa Specialized Hospital Adult Emergency Unit were substantiated; moreover, necessary information on factors within the healthcare delivery system that predispose healthcare professionals to commit errors have been pointed, which should be addressed by healthcare professionals through multidisciplinary efforts and involvement of decision makers at national level.

  19. Medication Errors in Patients with Enteral Feeding Tubes in the Intensive Care Unit. (United States)

    Sohrevardi, Seyed Mojtaba; Jarahzadeh, Mohammad Hossein; Mirzaei, Ehsan; Mirjalili, Mahtabalsadat; Tafti, Arefeh Dehghani; Heydari, Behrooz


    Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients' pharmacotherapy, and more attention should be paid to this issue.

  20. Eponyms in medical sciences: historical errors that lead to injustice


    Jorge Eduardo Duque-Parra; John Barco-Ríos; Natalia Dávila-Alzate


    Introduction: Throughout history, eponyms have been used in medical sciences to designate anatomical structures although they do not provide any descriptive or functional information, which is equivalent to a mistake in the light of current thinking. Double and triple eponyms have been used to name the same structure, thus creating confusion that leads to believe that a discovery or description was made by several persons at the same time. Although eponyms have been abolished from anatomical ...

  1. Association Between Workarounds and Medication Administration Errors in Bar Code-Assisted Medication Administration : Protocol of a Multicenter Study

    NARCIS (Netherlands)

    van der Veen, Willem; van den Bemt, Patricia Mla; Bijlsma, Maarten; de Gier, Han J; Taxis, Katja


    BACKGROUND: Information technology-based methods such as bar code-assisted medication administration (BCMA) systems have the potential to reduce medication administration errors (MAEs) in hospitalized patients. In practice, however, systems are often not used as intended, leading to workarounds.

  2. SIMulation of Medication Error induced by Clinical Trial drug labeling: the SIMME-CT study. (United States)

    Dollinger, Cecile; Schwiertz, Vérane; Sarfati, Laura; Gourc-Berthod, Chloé; Guédat, Marie-Gabrielle; Alloux, Céline; Vantard, Nicolas; Gauthier, Noémie; He, Sophie; Kiouris, Elena; Caffin, Anne-Gaelle; Bernard, Delphine; Ranchon, Florence; Rioufol, Catherine


    To assess the impact of investigational drug labels on the risk of medication error in drug dispensing. A simulation-based learning program focusing on investigational drug dispensing was conducted. The study was undertaken in an Investigational Drugs Dispensing Unit of a University Hospital of Lyon, France. Sixty-three pharmacy workers (pharmacists, residents, technicians or students) were enrolled. Ten risk factors were selected concerning label information or the risk of confusion with another clinical trial. Each risk factor was scored independently out of 5: the higher the score, the greater the risk of error. From 400 labels analyzed, two groups were selected for the dispensing simulation: 27 labels with high risk (score ≥3) and 27 with low risk (score ≤2). Each question in the learning program was displayed as a simulated clinical trial prescription. Medication error was defined as at least one erroneous answer (i.e. error in drug dispensing). For each question, response times were collected. High-risk investigational drug labels correlated with medication error and slower response time. Error rates were significantly 5.5-fold higher for high-risk series. Error frequency was not significantly affected by occupational category or experience in clinical trials. SIMME-CT is the first simulation-based learning tool to focus on investigational drug labels as a risk factor for medication error. SIMME-CT was also used as a training tool for staff involved in clinical research, to develop medication error risk awareness and to validate competence in continuing medical education. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

  3. Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ? (United States)

    Hobgood, Cherri; Weiner, Bryan; Tamayo-Sarver, Joshua H


    To determine if the three types of emergency medicine providers--physicians, nurses, and out-of-hospital providers (emergency medical technicians [EMTs])--differ in their identification, disclosure, and reporting of medical error. A convenience sample of providers in an academic emergency department evaluated ten case vignettes that represented two error types (medication and cognitive) and three severity levels. For each vignette, providers were asked the following: 1) Is this an error? 2) Would you tell the patient? 3) Would you report this to a hospital committee? To assess differences in identification, disclosure, and reporting by provider type, error type, and error severity, the authors constructed three-way tables with the nonparametric Somers' D clustered on participant. To assess the contribution of disclosure instruction and environmental variables, fixed-effects regression stratified by provider type was used. Of the 116 providers who were eligible, 103 (40 physicians, 26 nurses, and 35 EMTs) had complete data. Physicians were more likely to classify an event as an error (78%) than nurses (71%; p = 0.04) or EMTs (68%; p error to the patient (59%) than physicians (71%; p = 0.04). Physicians were the least likely to report the error (54%) compared with nurses (68%; p = 0.02) or EMTs (78%; p error types, identification, disclosure, and reporting increased with increasing severity. Improving patient safety hinges on the ability of health care providers to accurately identify, disclose, and report medical errors. Interventions must account for differences in error identification, disclosure, and reporting by provider type.

  4. Evaluation of medication errors with implementation of electronic health record technology in the medical intensive care unit

    Directory of Open Access Journals (Sweden)

    Liao TV


    Full Text Available T Vivian Liao,1 Marina Rabinovich,2 Prasad Abraham,2 Sebastian Perez,3 Christiana DiPlotti,4 Jenny E Han,5 Greg S Martin,5 Eric Honig5 1Department of Pharmacy Practice, College of Pharmacy, Mercer Health Sciences Center, 2Department of Pharmacy and Clinical Nutrition, Grady Health System, 3Department of Surgery, Emory University, 4Pharmacy, Ingles Markets, 5Department of Medicine, Emory University, Atlanta, GA, USA Purpose: Patients in the intensive care unit (ICU are at an increased risk for medication errors (MEs and adverse drug events from multifactorial causes. ME rate ranges from 1.2 to 947 per 1,000 patient days in the medical ICU (MICU. Studies with the implementation of electronic health records (EHR have concluded that it significantly reduced overall prescribing errors and the number of errors that caused patient harm decreased. However, other types of errors, such as wrong dose and omission of required medications increased after EHR implementation. We sought to compare the number of MEs before and after EHR implementation in the MICU, with additional evaluation of error severity.Patients and methods: Prospective, observational, quality improvement study of all patients admitted to a single MICU service at an academic medical center. Patients were evaluated during four periods over 2 years: August–September 2010 (preimplementation; period I, January–February 2011 (2 months postimplementation; period II, August–September 2012 (21 months postimplementation; period III, and January–February 2013 (25 months postimplementation; period IV. All medication orders and administration records were reviewed by an ICU clinical pharmacist and ME was defined as a deviation from established standards for prescribing, dispensing, administering, or documenting medication. The frequency and classification of MEs were compared between groups by chi square; p<0.05 was considered significant.Results: There was a statistically significant increase

  5. Active Mycobacterium Infection Due to Intramuscular BCG Administration Following Multi-Steps Medication Errors

    Directory of Open Access Journals (Sweden)

    MohammadReza Rafati


    Full Text Available Bacillus Calmette-Guérin (BCG is indicated for treatment of primary or relapsing flat urothelial cell carcinoma in situ (CIS of the urinary bladder. Disseminated infectious complications occasionally occur due to BCG as a vaccine and intravesical therapy.  Intramuscular (IM or Intravenous (IV administrations of BCG are rare medication errors which are more probable to produce systemic infections. This report presents 13 years old case that several steps medication errors occurred consequently from physician handwriting, pharmacy dispensing, nursing administration and patient family. The physician wrote βHCG instead of HCG in the prescription. βHCG was read as BCG by the pharmacy staff and 6 vials of intravesical BCG were administered IM twice a week for 3 consecutive weeks. The patient experienced fever and chills after each injection, but he was admitted 2 months after first IM administration of BCG with fever and pancytopenia. Unfortunately four month after using drug, during second admission duo to cellulitis at the sites of BCG injection the physicians diagnosed the medication error. Using handwritten prescription and inappropriate abbreviations, spending inadequate time for taking a brief medical history in pharmacy, lack of verifying name, dose and wrote before medication administration and lack of considering medication error as an important differential diagnosis had roles to occur this multi-steps medication error.

  6. Medication administration error: magnitude and associated factors among nurses in Ethiopia. (United States)

    Feleke, Senafikish Amsalu; Mulatu, Muluadam Abebe; Yesmaw, Yeshaneh Seyoum


    The significant impact of medication administration errors affect patients in terms of morbidity, mortality, adverse drug events, and increased length of hospital stay. It also increases costs for clinicians and healthcare systems. Due to this, assessing the magnitude and associated factors of medication administration error has a significant contribution for improving the quality of patient care. The aim of this study was to assess the magnitude and associated factors of medication administration errors among nurses at the Felege Hiwot Referral Hospital inpatient department. A prospective, observation-based, cross-sectional study was conducted from March 24-April 7, 2014 at the Felege Hiwot Referral Hospital inpatient department. A total of 82 nurses were interviewed using a pre-tested structured questionnaire, and observed while administering 360 medications by using a checklist supplemented with a review of medication charts. Data were analyzed by using SPSS version 20 software package and logistic regression was done to identify possible factors associated with medication administration error. The incidence of medication administration error was 199 (56.4 %). The majority (87.5 %) of the medications have documentation error, followed by technique error 263 (73.1 %) and time error 193 (53.6 %). Variables which were significantly associated with medication administration error include nurses between the ages of 18-25 years [Adjusted Odds Ratio (AOR) = 2.9, 95 % CI (1.65,6.38)], 26-30 years [AOR = 2.3, 95 % CI (1.55, 7.26)] and 31-40 years [AOR = 2.1, 95 % CI (1.07, 4.12)], work experience of less than or equal to 10 years [AOR = 1.7, 95 % CI (1.33, 4.99)], nurse to patient ratio of 7-10 [AOR = 1.6, 95 % CI (1.44, 3.19)] and greater than 10 [AOR = 1.5, 95 % CI (1.38, 3.89)], interruption of the respondent at the time of medication administration [AOR = 1.5, 95 % CI (1.14, 3.21)], night shift of medication administration

  7. Disclosing medical errors: the view from the USA. (United States)

    Kachalia, Allen; Bates, David W


    Disclosure is increasingly seen as a key component of efforts to improve safety, but does not yet reliably occur in all organizations in the U.S. We describe the experience to date with disclosure in the U.S. and illustrate the issues with specific clinical examples. Both reputational and legal concerns represent substantial barriers. The evidence to date-mostly from single sites - shows that not only is disclosure the right thing to do, it also appears to decrease malpractice risk. We also discuss the related issue of compensation-practices around this vary greatly. Underlying the push for greater disclosure is also the belief that better disclosure results in an improved culture of safety, which in turn may improve the quality and safety of care. Providers have an ethical imperative to disclosure error to patients, and the limited available evidence shows that doing so actually decreases malpractice risk. While disclosure is not yet routine practice in the U.S., the approach is clearly gaining momentum. Telling patients what happened is not enough. They also deserve an apology, and if harmed, to be made whole emotionally and financially. Greater disclosure may not only help individual patients, but may also help with improving safety overall. Copyright © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

  8. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. (United States)

    Sirriyeh, Reema; Lawton, Rebecca; Gardner, Peter; Armitage, Gerry


    Previous research has established health professionals as secondary victims of medical error, with the identification of a range of emotional and psychological repercussions that may occur as a result of involvement in error.2 3 Due to the vast range of emotional and psychological outcomes, research to date has been inconsistent in the variables measured and tools used. Therefore, differing conclusions have been drawn as to the nature of the impact of error on professionals and the subsequent repercussions for their team, patients and healthcare institution. A systematic review was conducted. Data sources were identified using database searches, with additional reference and hand searching. Eligibility criteria were applied to all studies identified, resulting in a total of 24 included studies. Quality assessment was conducted with the included studies using a tool that was developed as part of this research, but due to the limited number and diverse nature of studies, no exclusions were made on this basis. Review findings suggest that there is consistent evidence for the widespread impact of medical error on health professionals. Psychological repercussions may include negative states such as shame, self-doubt, anxiety and guilt. Despite much attention devoted to the assessment of negative outcomes, the potential for positive outcomes resulting from error also became apparent, with increased assertiveness, confidence and improved colleague relationships reported. It is evident that involvement in a medical error can elicit a significant psychological response from the health professional involved. However, a lack of literature around coping and support, coupled with inconsistencies and weaknesses in methodology, may need be addressed in future work.

  9. Warfarin and Rivaroxaban Duplication: A Case Report and Medication Error Analysis. (United States)

    Fusco, Julie A; Paulus, Eric J; Shubat, Alexandra R; Miah, Sharminara


    A 62-year-old African American man received unintentional duplicate anticoagulation therapy with warfarin 5 mg and rivaroxaban 20 mg daily for the treatment of recurrent pulmonary embolism. The patient presented to the anticoagulation clinic 6 days after hospital discharge with an International Normalized Ratio (INR) of 2.3 and he was instructed to continue warfarin 5 mg daily. Seven days later, he returned to the clinic with an INR >8.0 using a point-of-care device. He denied any signs or symptoms of bleeding. During the interview, he reported starting a new medication for neuropathy 5 days earlier. The clinical pharmacist contacted the dispensing pharmacy and determined rivaroxaban 20 mg was the new medication. The patient denied receiving new prescription counseling at the dispensing pharmacy. Because rivaroxaban can falsely elevate INR results, the actual INR value was unknown. To minimize the risk for recurrent venous thromboembolism, vitamin K was not administered and no warfarin doses were held. Rather, the patient was instructed to stop rivaroxaban and reduce the warfarin dose. Five days later, the patient returned with an INR of 4.3. He still had not experienced any signs or symptoms of bleeding. The patient was quickly stabilized on a warfarin maintenance dose of 22.5 mg weekly. The anticoagulation clinic pharmacist notified management at the clinic and at the dispensing pharmacy in an effort to identify process errors and prevent additional incidents.

  10. Frequency of Burnout, Sleepiness and Depression in Emergency Medicine Residents with Medical Errors in the Emergency Department

    Directory of Open Access Journals (Sweden)

    Alireza Aala


    Full Text Available Aims: Medical error is a great concern of the patients and physicians. It usually occurs due to physicians’ exhaustion, distress and fatigue. In this study, we aimed to evaluate frequency of distress and fatigue among emergency medicine residents reporting a medical error. Materials and Methods: The study population consisted of emergency medicine residents who completed an emailed questionnaire including self-assessment of medical errors, the Epworth Sleepiness Scale (ESS score, the Maslach Burnout Inventory, and PRIME-MD validated depression screening tool.   Results: In this survey, 100 medical errors were reported including diagnostic errors in 53, therapeutic errors in 24 and following errors in 23 subjects. Most errors were reported by males and third year residents. Residents had no signs of depression, but all had some degrees of sleepiness and burnout. There were significant differences between errors subtypes and age, residency year, depression, sleepiness and burnout scores (p<0.0001.   Conclusion: In conclusion, residents committing a medical error usually experience burnout and have some grades of sleepiness that makes them less motivated increasing the probability of medical errors. However, as none of the residents had depression, it could be concluded that depression has no significant role in medical error occurrence and perhaps it is a possible consequence of medical error.    Keywords: Residents; Medical error; Burnout; Sleepiness; Depression

  11. Quality of IT service delivery — Analysis and framework for human error prevention

    KAUST Repository

    Shwartz, L.


    In this paper, we address the problem of reducing the occurrence of Human Errors that cause service interruptions in IT Service Support and Delivery operations. Analysis of a large volume of service interruption records revealed that more than 21% of interruptions were caused by human error. We focus on Change Management, the process with the largest risk of human error, and identify the main instances of human errors as the 4 Wrongs: request, time, configuration item, and command. Analysis of change records revealed that the humanerror prevention by partial automation is highly relevant. We propose the HEP Framework, a framework for execution of IT Service Delivery operations that reduces human error by addressing the 4 Wrongs using content integration, contextualization of operation patterns, partial automation of command execution, and controlled access to resources.

  12. Sleep, mental health status, and medical errors among hospital nurses in Japan. (United States)

    Arimura, Mayumi; Imai, Makoto; Okawa, Masako; Fujimura, Toshimasa; Yamada, Naoto


    Medical error involving nurses is a critical issue since nurses' actions will have a direct and often significant effect on the prognosis of their patients. To investigate the significance of nurse health in Japan and its potential impact on patient services, a questionnaire-based survey amongst nurses working in hospitals was conducted, with the specific purpose of examining the relationship between shift work, mental health and self-reported medical errors. Multivariate analysis revealed significant associations between the shift work system, General Health Questionnaire (GHQ) scores and nurse errors: the odds ratios for shift system and GHQ were 2.1 and 1.1, respectively. It was confirmed that both sleep and mental health status among hospital nurses were relatively poor, and that shift work and poor mental health were significant factors contributing to medical errors.

  13. Maths anxiety and medication dosage calculation errors: A scoping review. (United States)

    Williams, Brett; Davis, Samantha


    A student's accuracy on drug calculation tests may be influenced by maths anxiety, which can impede one's ability to understand and complete mathematic problems. It is important for healthcare students to overcome this barrier when calculating drug dosages in order to avoid administering the incorrect dose to a patient when in the clinical setting. The aim of this study was to examine the effects of maths anxiety on healthcare students' ability to accurately calculate drug dosages by performing a scoping review of the existing literature. This review utilised a six-stage methodology using the following databases; CINAHL, Embase, Medline, Scopus, PsycINFO, Google Scholar, Trip database ( and Grey Literature report ( After an initial title/abstract review of relevant papers, and then full text review of the remaining papers, six articles were selected for inclusion in this study. Of the six articles included, there were three experimental studies, two quantitative studies and one mixed method study. All studies addressed nursing students and the presence of maths anxiety. No relevant studies from other disciplines were identified in the existing literature. Three studies took place in the U.S, the remainder in Canada, Australia and United Kingdom. Upon analysis of these studies, four factors including maths anxiety were identified as having an influence on a student's drug dosage calculation abilities. Ultimately, the results from this review suggest more research is required in nursing and other relevant healthcare disciplines regarding the effects of maths anxiety on drug dosage calculations. This additional knowledge will be important to further inform development of strategies to decrease the potentially serious effects of errors in drug dosage calculation to patient safety. Copyright © 2016 Elsevier Ltd. All rights reserved.

  14. Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. (United States)

    Scobie, Andrea


    To identify risk factors associated with self-reported medical, medication and laboratory error in eight countries. The Commonwealth Fund's 2008 International Health Policy Survey of chronically ill patients in eight countries. None. A multi-country telephone survey was conducted between 3 March and 30 May 2008 with patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK and the USA who self-reported being chronically ill. A bivariate analysis was performed to determine significant explanatory variables of medical, medication and laboratory error (P error: age 65 and under, education level of some college or less, presence of two or more chronic conditions, high prescription drug use (four+ drugs), four or more doctors seen within 2 years, a care coordination problem, poor doctor-patient communication and use of an emergency department. Risk factors with the greatest ability to predict experiencing an error encompassed issues with coordination of care and provider knowledge of a patient's medical history. The identification of these risk factors could help policymakers and organizations to proactively reduce the likelihood of error through greater examination of system- and organization-level practices.

  15. Medication errors in anaesthetic practice: A report of two cases and ...

    African Journals Online (AJOL)

    Background: Mistakes in the identification and administration of drugs may be fatal. This is especially so in the practice of anaesthesia. This is a report of 2 cases of near fatality due to mistakes in drug administration from look-alike medications. Objective: To highlight the significance of medication errors in our practice and ...

  16. Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system. (United States)

    Mikuls, Ted R; Curtis, Jeffrey R; Allison, Jeroan J; Hicks, Rodney W; Saag, Kenneth G


    To more closely assess medication errors in gout care, we examined data from a national, Internet-accessible error reporting program over a 5-year reporting period. We examined data from the MEDMARX database, covering the period from January 1, 1999 through December 31, 2003. For allopurinol and colchicine, we examined error severity, source, type, contributing factors, and healthcare personnel involved in errors, and we detailed errors resulting in patient harm. Causes of error and the frequency of other error characteristics were compared for gout medications versus other musculoskeletal treatments using the chi-square statistic. Gout medication errors occurred in 39% (n = 273) of facilities participating in the MEDMARX program. Reported errors were predominantly from the inpatient hospital setting and related to the use of allopurinol (n = 524), followed by colchicine (n = 315), probenecid (n = 50), and sulfinpyrazone (n = 2). Compared to errors involving other musculoskeletal treatments, allopurinol and colchicine errors were more often ascribed to problems with physician prescribing (7% for other therapies versus 23-39% for allopurinol and colchicine, p < 0.0001) and less often due to problems with drug administration or nursing error (50% vs 23-27%, p < 0.0001). Our results suggest that inappropriate prescribing practices are characteristic of errors occurring with the use of allopurinol and colchicine. Physician prescribing practices are a potential target for quality improvement interventions in gout care.

  17. Identification of factors which affect the tendency towards and attitudes of emergency unit nurses to make medical errors. (United States)

    Kiymaz, Dilek; Koç, Zeliha


    To determine individual and professional factors affecting the tendency of emergency unit nurses to make medical errors and their attitudes towards these errors in Turkey. Compared with other units, the emergency unit is an environment where there is an increased tendency for making medical errors due to its intensive and rapid pace, noise and complex and dynamic structure. A descriptive cross-sectional study. The study was carried out from 25 July 2014-16 September 2015 with the participation of 284 nurses who volunteered to take part in the study. Data were gathered using the data collection survey for nurses, the Medical Error Tendency Scale and the Medical Error Attitude Scale. It was determined that 40.1% of the nurses previously witnessed medical errors, 19.4% made a medical error in the last year, 17.6% of medical errors were caused by medication errors where the wrong medication was administered in the wrong dose, and none of the nurses filled out a case report form about the medical errors they made. Regarding the factors that caused medical errors in the emergency unit, 91.2% of the nurses stated excessive workload as a cause; 85.1% stated an insufficient number of nurses; and 75.4% stated fatigue, exhaustion and burnout. The study showed that nurses who loved their job were satisfied with their unit and who always worked during day shifts had a lower medical error tendency. It is suggested to consider the following actions: increase awareness about medical errors, organise training to reduce errors in medication administration, develop procedures and protocols specific to the emergency unit health care and create an environment which is not punitive wherein nurses can safely report medical errors. © 2017 John Wiley & Sons Ltd.

  18. Decrease in medical command errors with use of a "standing orders" protocol system. (United States)

    Holliman, C J; Wuerz, R C; Meador, S A


    The purpose of this study was to determine the physician medical command error rates and paramedic error rates after implementation of a "standing orders" protocol system for medical command. These patient-care error rates were compared with the previously reported rates for a "required call-in" medical command system (Ann Emerg Med 1992; 21(4):347-350). A secondary aim of the study was to determine if the on-scene time interval was increased by the standing orders system. Prospectively conducted audit of prehospital advanced life support (ALS) trip sheets was made at an urban ALS paramedic service with on-line physician medical command from three local hospitals. All ALS run sheets from the start time of the standing orders system (April 1, 1991) for a 1-year period ending on March 30, 1992 were reviewed as part of an ongoing quality assurance program. Cases were identified as nonjustifiably deviating from regional emergency medical services (EMS) protocols as judged by agreement of three physician reviewers (the same methodology as a previously reported command error study in the same ALS system). Medical command and paramedic errors were identified from the prehospital ALS run sheets and categorized. Two thousand one ALS runs were reviewed; 24 physician errors (1.2% of the 1,928 "command" runs) and eight paramedic errors (0.4% of runs) were identified. The physician error rate was decreased from the 2.6% rate in the previous study (P < .0001 by chi 2 analysis). The on-scene time interval did not increase with the "standing orders" system.(ABSTRACT TRUNCATED AT 250 WORDS)

  19. How common are errors in the medication process in a psychiatric hospital?

    DEFF Research Database (Denmark)

    Sørensen, Ann Lykkegaard; Mainz, Jan; Lisby, Marianne

    frequency, type and potential clinical consequences of errors in all stages of the medication process in an inpatient psychiatric setting. Methods and materials: A cross-sectional study in two general psychiatric wards and one acute psychiatric ward. Participants were eligible psychiatric in......-hospital patients (n=67), physicians prescribing drugs and ward staff (nurses and nurses assistants) dispensing and administering drugs. The study was carried out using 3 methods of investigation – an observational study, an unannounced control visit and an audit of medical records. Medication errors were evaluated...

  20. The incidence and types of medication errors in patients receiving antiretroviral therapy in resource-constrained settings.

    Directory of Open Access Journals (Sweden)

    Kenneth Anene Agu

    Full Text Available This study assessed the incidence and types of medication errors, interventions and outcomes in patients on antiretroviral therapy (ART in selected HIV treatment centres in Nigeria.Of 69 health facilities that had program for active screening of medication errors, 14 were randomly selected for prospective cohort assessment. All patients who filled/refilled their antiretroviral medications between February 2009 and March 2011 were screened for medication errors using study-specific pharmaceutical care daily worksheet (PCDW. All potential or actual medication errors identified, interventions provided and the outcomes were documented in the PCDW. Interventions included pharmaceutical care in HIV training for pharmacists amongst others. Chi-square was used for inferential statistics and P0.05. The major medications errors identified were 26.4% incorrect ART regimens prescribed; 19.8% potential drug-drug interaction or contraindication present; and 16.6% duration and/or frequency of medication inappropriate. Interventions provided included 67.1% cases of prescriber contacted to clarify/resolve errors and 14.7% cases of patient counselling and education; 97.4% of potential/actual medication error(s were resolved.The incidence rate of medication errors was somewhat high; and majority of identified errors were related to prescription of incorrect ART regimens and potential drug-drug interactions; the prescriber was contacted and the errors were resolved in majority of cases. Active screening for medication errors is feasible in resource-limited settings following a capacity building intervention.

  1. Air Force Medical Service > Resources > Suicide Prevention (United States)

    Health Suicide Prevention ACE Questions Risk Factors Warning Signs Protective Factors Helping Resources Force Social Media Guide (PDF) USAF Social Media Sites Suicide Prevention Banner prevnext General . What do you need to know to effectively raise awareness about suicide prevention? Daily connections can

  2. Medical Errors Management Before and After Implementation of Accreditation in Hospital

    Directory of Open Access Journals (Sweden)

    Ghassem Abedi


    Full Text Available Background and purpose: This study aimed to manage medical errors before and after the implementation of accreditation in public, private, and social security hospitals of Mazandaran, Iran. Materials and Methods: This descriptive study has been done in 38 hospitals. Data were collected through documents reviewed relating to 2013 and 2014. The paired t-test and Friedman test were used by statistical software SPSS. Results: Results showed that the most and the least percent of reported errors, before accreditation, in sequence, were related to public clinical unit (55.9% and operating rooms (0.6%, and after accreditation in public clinical unit (46.6% and operating rooms (2.3% in teaching centers. The most errors (before accreditation occurred in the morning (62% and the least, in the evening (8.3% in teaching centers. Furthermore, after accreditation, the most errors occurred in the morning (64.8% and the least, in the night (17.3% in therapeutic hospitals. Paired t-test showed that there is no significant difference between medical errors before and after accreditation. Friedman test showed that structural/systemic errors reported were the most important medical errors in teaching centers after accreditation and therapeutic hospitals before accreditation (P < 0.05. Conclusion: There is no significant difference between the rate of reported errors before and after the implementation of accreditation. This illustrates that the role of management in controlling of medical errors has been poor, and stronger management should be applied in providing health care services.

  3. Suffering in Silence: Medical Error and its Impact on Health Care Providers. (United States)

    Robertson, Jennifer J; Long, Brit


    All humans are fallible. Because physicians are human, unintentional errors unfortunately occur. While unintentional medical errors have an impact on patients and their families, they may also contribute to adverse mental and emotional effects on the involved provider(s). These may include burnout, lack of concentration, poor work performance, posttraumatic stress disorder, depression, and even suicidality. The objectives of this article are to 1) discuss the impact medical error has on involved provider(s), 2) provide potential reasons why medical error can have a negative impact on provider mental health, and 3) suggest solutions for providers and health care organizations to recognize and mitigate the adverse effects medical error has on providers. Physicians and other providers may feel a variety of adverse emotions after medical error, including guilt, shame, anxiety, fear, and depression. It is thought that the pervasive culture of perfectionism and individual blame in medicine plays a considerable role toward these negative effects. In addition, studies have found that despite physicians' desire for support after medical error, many physicians feel a lack of personal and administrative support. This may further contribute to poor emotional well-being. Potential solutions in the literature are proposed, including provider counseling, learning from mistakes without fear of punishment, discussing mistakes with others, focusing on the system versus the individual, and emphasizing provider wellness. Much of the reviewed literature is limited in terms of an emergency medicine focus or even regarding physicians in general. In addition, most studies are survey- or interview-based, which limits objectivity. While additional, more objective research is needed in terms of mitigating the effects of error on physicians, this review may help provide insight and support for those who feel alone in their attempt to heal after being involved in an adverse medical event

  4. Factors contributing to registered nurse medication administration error: a narrative review. (United States)

    Parry, Angela M; Barriball, K Louise; While, Alison E


    To explore the factors contributing to Registered Nurse medication administration error behaviour. A narrative review. Electronic databases (Cochrane, CINAHL, MEDLINE, BNI, EmBase, and PsycINFO) were searched from 1 January 1999 to 31 December 2012 in the English language. 1127 papers were identified and 26 papers were included in the review. Data were extracted by one reviewer and checked by a second reviewer. A thematic analysis and narrative synthesis of the factors contributing to Registered Nurses' medication administration behaviour. Bandura's (1986) theory of reciprocal determinism was used as an organising framework. This theory proposes that there is a reciprocal interplay between the environment, the person and their behaviour. Medication administration error is an outcome of RN behaviour. The 26 papers reported studies conducted in 4 continents across 11 countries predominantly in North America and Europe, with one multi-national study incorporating 27 countries. Within both the environment and person domain of the reciprocal determinism framework, a number of factors emerged as influencing Registered Nurse medication administration error behaviour. Within the environment domain, two key themes of clinical workload and work setting emerged, and within the person domain the Registered Nurses' characteristics and their lived experience of work emerged as themes. Overall, greater attention has been given to the contribution of the environment domain rather than the person domain as contributing to error, with the literature viewing an error as an event rather than the outcome of behaviour. The interplay between factors that influence behaviour were poorly accounted for within the selected studies. It is proposed that a shift away from error as an event to a focus on the relationships between the person, the environment and Registered Nurse medication administration behaviour is needed to better understand medication administration error. Copyright © 2014

  5. Medication errors with electronic prescribing (eP): Two views of the same picture (United States)


    Background Quantitative prospective methods are widely used to evaluate the impact of new technologies such as electronic prescribing (eP) on medication errors. However, they are labour-intensive and it is not always feasible to obtain pre-intervention data. Our objective was to compare the eP medication error picture obtained with retrospective quantitative and qualitative methods. Methods The study was carried out at one English district general hospital approximately two years after implementation of an integrated electronic prescribing, administration and records system. Quantitative: A structured retrospective analysis was carried out of clinical records and medication orders for 75 randomly selected patients admitted to three wards (medicine, surgery and paediatrics) six months after eP implementation. Qualitative: Eight doctors, 6 nurses, 8 pharmacy staff and 4 other staff at senior, middle and junior grades, and 19 adult patients on acute surgical and medical wards were interviewed. Staff interviews explored experiences of developing and working with the system; patient interviews focused on experiences of medicine prescribing and administration on the ward. Interview transcripts were searched systematically for accounts of medication incidents. A classification scheme was developed and applied to the errors identified in the records review. Results The two approaches produced similar pictures of the drug use process. Interviews identified types of error identified in the retrospective notes review plus two eP-specific errors which were not detected by record review. Interview data took less time to collect than record review, and provided rich data on the prescribing process, and reasons for delays or non-administration of medicines, including "once only" orders and "as required" medicines. Conclusions The qualitative approach provided more understanding of processes, and some insights into why medication errors can happen. The method is cost-effective and

  6. Transparency When Things Go Wrong: Physician Attitudes About Reporting Medical Errors to Patients, Peers, and Institutions. (United States)

    Bell, Sigall K; White, Andrew A; Yi, Jean C; Yi-Frazier, Joyce P; Gallagher, Thomas H


    Transparent communication after medical error includes disclosing the mistake to the patient, discussing the event with colleagues, and reporting to the institution. Little is known about whether attitudes about these transparency practices are related. Understanding these relationships could inform educational and organizational strategies to promote transparency. We analyzed responses of 3038 US and Canadian physicians to a medical error communication survey. We used bivariate correlations, principal components analysis, and linear regression to determine whether and how physician attitudes about transparent communication with patients, peers, and the institution after error were related. Physician attitudes about disclosing errors to patients, peers, and institutions were correlated (all P's transparent communication with patients and peers/institution included female sex, US (vs Canadian) doctors, academic (vs private) practice, the belief that disclosure decreased likelihood of litigation, and the belief that system changes occur after error reporting. In addition, younger physicians, surgeons, and those with previous experience disclosing a serious error were more likely to agree with disclosure to patients. In comparison, doctors who believed that disclosure would decrease patient trust were less likely to agree with error disclosure to patients. Previous disclosure education was associated with attitudes supporting greater transparency with peers/institution. Physician attitudes about discussing errors with patients, colleagues, and institutions are related. Several predictors of transparency affect all 3 practices and are potentially modifiable by educational and institutional strategies.

  7. Female residents experiencing medical errors in general internal medicine: a qualitative study. (United States)

    Mankaka, Cindy Ottiger; Waeber, Gérard; Gachoud, David


    Doctors, especially doctors-in-training such as residents, make errors. They have to face the consequences even though today's approach to errors emphasizes systemic factors. Doctors' individual characteristics play a role in how medical errors are experienced and dealt with. The role of gender has previously been examined in a few quantitative studies that have yielded conflicting results. In the present study, we sought to qualitatively explore the experience of female residents with respect to medical errors. In particular, we explored the coping mechanisms displayed after an error. This study took place in the internal medicine department of a Swiss university hospital. Within a phenomenological framework, semi-structured interviews were conducted with eight female residents in general internal medicine. All interviews were audiotaped, fully transcribed, and thereafter analyzed. Seven main themes emerged from the interviews: (1) A perception that there is an insufficient culture of safety and error; (2) The perceived main causes of errors, which included fatigue, work overload, inadequate level of competences in relation to assigned tasks, and dysfunctional communication; (3) Negative feelings in response to errors, which included different forms of psychological distress; (4) Variable attitudes of the hierarchy toward residents involved in an error; (5) Talking about the error, as the core coping mechanism; (6) Defensive and constructive attitudes toward one's own errors; and (7) Gender-specific experiences in relation to errors. Such experiences consisted in (a) perceptions that male residents were more confident and therefore less affected by errors than their female counterparts and (b) perceptions that sexist attitudes among male supervisors can occur and worsen an already painful experience. This study offers an in-depth account of how female residents specifically experience and cope with medical errors. Our interviews with female residents convey the

  8. Variability in Threshold for Medication Error Reporting Between Physicians, Nurses, Pharmacists, and Families. (United States)

    Keefer, Patricia; Kidwell, Kelley; Lengyel, Candice; Warrier, Kavita; Wagner, Deborah


    Voluntary medication error reporting is an imperfect resource used to improve the quality of medication administration. It requires judgment by front-line staff to determine how to report enough to identify opportunities to improve patients' safety but not jeopardize that safety by creating a culture of "report fatigue." This study aims to provide information on interpretability of medication error and the variability between the subgroups of caregivers in the hospital setting. Survey participants included nursing, physician (trainee and graduated), patient/families, pharmacist across a large academic health system, including an attached free-standing pediatric hospital. Demographics and survey questions were collected and analyzed using Fischer's exact testing with SAS v9.3. Statistically significant variability existed between the four groups for a majority of the questions. This included all cases designated as administration errors and many, but not all, cases of prescribing events. Commentary provided in the free-text portion of the survey was sub-analyzed and found to be associated with medication allergy reporting and lack of education surrounding report characteristics. There is significant variability in the threshold to report specific medication errors in the hospital setting. More work needs to be done to further improve the education surrounding error reporting in hospitals for all noted subgroups. Copyright© Bentham Science Publishers; For any queries, please email at

  9. System care improves trauma outcome: patient care errors dominate reduced preventable death rate. (United States)

    Thoburn, E; Norris, P; Flores, R; Goode, S; Rodriguez, E; Adams, V; Campbell, S; Albrink, M; Rosemurgy, A


    A review of 452 trauma deaths in Hillsborough County, Florida, in 1984 documented that 23% of non-CNS trauma deaths were preventable and occurred because of inadequate resuscitation or delay in proper surgical care. In late 1988 Hillsborough County organized a County Trauma Agency (HCTA) to coordinate trauma care among prehospital providers and state-designated trauma centers. The purpose of this study was to review county trauma deaths after the inception of the HCTA to determine the frequency of preventable deaths. 504 trauma deaths occurring between October 1989 and April 1991 were reviewed. Through committee review, 10 deaths were deemed preventable; 2 occurred outside the trauma system. Of the 10 deaths, 5 preventable deaths occurred late in severely injured patients. The preventable death rate has decreased to 7.0% with system care. The causes of preventable deaths have changed from delayed or inadequate intervention to postoperative care errors.

  10. The application of human error prevention tool in Tianwan nuclear power station

    International Nuclear Information System (INIS)

    Qiao Zhiguo


    This paper mainly discusses the application and popularization of human error prevention tool in Tianwan nuclear power station, including the study on project implementation background, main contents and innovation, performance management, innovation practice and development, and performance of innovation application. (authors)

  11. Cause analysis and preventives for human error events in Daya Bay NPP

    International Nuclear Information System (INIS)

    Huang Weigang; Zhang Li


    Daya Bay Nuclear Power Plant is put into commercial operation in 1994 Until 1996, there are 368 human error events in operating and maintenance area, occupying 39% of total events. These events occurred mainly in the processes of maintenance, test equipment isolation and system on-line, in particular in refuelling and maintenance. The author analyses root causes for human errorievents, which are mainly operator omission or error procedure deficiency; procedure not followed; lack of training; communication failures; work management inadequacy. The protective measures and treatment principle for human error events are also discussed, and several examples applying them are given. Finally, it is put forward that key to prevent human error event lies in the coordination and management, person in charge of work, and good work habits of staffs

  12. [Medication errors in a hospital emergency department: study of the current situation and critical points for improving patient safety]. (United States)

    Pérez-Díez, Cristina; Real-Campaña, José Manuel; Noya-Castro, María Carmen; Andrés-Paricio, Felicidad; Reyes Abad-Sazatornil, María; Bienvenido Povar-Marco, Javier


    To determine the frequency of medication errors and incident types in a tertiary-care hospital emergency department. To quantify and classify medication errors and identify critical points where measures should be implemented to improve patient safety. Prospective direct-observation study to detect errors made in June and July 2016. The overall error rate was 23.7%. The most common errors were made while medications were administered (10.9%). We detected 1532 incidents: 53.6% on workdays (P=.001), 43.1% during the afternoon/evening shift (P=.004), and 43.1% in observation areas (P=.004). The medication error rate was significant. Most errors and incidents occurred during the afternoon/evening shift and in the observation area. Most errors were related to administration of medications.

  13. Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis. (United States)

    Freundlich, Robert E; Grondin, Louise; Tremper, Kevin K; Saran, Kelly A; Kheterpal, Sachin


    In this case report, the authors present an adverse event possibly caused by miscommunication among three separate medical teams at their hospital. The authors then discuss the hospital's root cause analysis and its proposed solutions, focusing on the subsequent hospital-wide implementation of an automated electronic reminder for abnormal laboratory values that may have helped to prevent similar medical errors.

  14. [Monitoring medication errors in personalised dispensing using the Sentinel Surveillance System method]. (United States)

    Pérez-Cebrián, M; Font-Noguera, I; Doménech-Moral, L; Bosó-Ribelles, V; Romero-Boyero, P; Poveda-Andrés, J L


    To assess the efficacy of a new quality control strategy based on daily randomised sampling and monitoring a Sentinel Surveillance System (SSS) medication cart, in order to identify medication errors and their origin at different levels of the process. Prospective quality control study with one year follow-up. A SSS medication cart was randomly selected once a week and double-checked before dispensing medication. Medication errors were recorded before it was taken to the relevant hospital ward. Information concerning complaints after receiving medication and 24-hour monitoring were also noted. Type and origin error data were assessed by a Unit Dose Quality Control Group, which proposed relevant improvement measures. Thirty-four SSS carts were assessed, including 5130 medication lines and 9952 dispensed doses, corresponding to 753 patients. Ninety erroneous lines (1.8%) and 142 mistaken doses (1.4%) were identified at the Pharmacy Department. The most frequent error was dose duplication (38%) and its main cause inappropriate management and forgetfulness (69%). Fifty medication complaints (6.6% of patients) were mainly due to new treatment at admission (52%), and 41 (0.8% of all medication lines), did not completely match the prescription (0.6% lines) as recorded by the Pharmacy Department. Thirty-seven (4.9% of patients) medication complaints due to changes at admission and 32 matching errors (0.6% medication lines) were recorded. The main cause also was inappropriate management and forgetfulness (24%). The simultaneous recording of incidences due to complaints and new medication coincided in 33.3%. In addition, 433 (4.3%) of dispensed doses were returned to the Pharmacy Department. After the Unit Dose Quality Control Group conducted their feedback analysis, 64 improvement measures for Pharmacy Department nurses, 37 for pharmacists, and 24 for the hospital ward were introduced. The SSS programme has proven to be useful as a quality control strategy to identify Unit

  15. Pediatric Anesthesiology Fellows' Perception of Quality of Attending Supervision and Medical Errors. (United States)

    Benzon, Hubert A; Hajduk, John; De Oliveira, Gildasio; Suresh, Santhanam; Nizamuddin, Sarah L; McCarthy, Robert; Jagannathan, Narasimhan


    Appropriate supervision has been shown to reduce medical errors in anesthesiology residents and other trainees across various specialties. Nonetheless, supervision of pediatric anesthesiology fellows has yet to be evaluated. The main objective of this survey investigation was to evaluate supervision of pediatric anesthesiology fellows in the United States. We hypothesized that there was an indirect association between perceived quality of faculty supervision of pediatric anesthesiology fellow trainees and the frequency of medical errors reported. A survey of pediatric fellows from 53 pediatric anesthesiology fellowship programs in the United States was performed. The primary outcome was the frequency of self-reported errors by fellows, and the primary independent variable was supervision scores. Questions also assessed barriers for effective faculty supervision. One hundred seventy-six pediatric anesthesiology fellows were invited to participate, and 104 (59%) responded to the survey. Nine of 103 (9%, 95% confidence interval [CI], 4%-16%) respondents reported performing procedures, on >1 occasion, for which they were not properly trained for. Thirteen of 101 (13%, 95% CI, 7%-21%) reported making >1 mistake with negative consequence to patients, and 23 of 104 (22%, 95% CI, 15%-31%) reported >1 medication error in the last year. There were no differences in median (interquartile range) supervision scores between fellows who reported >1 medication error compared to those reporting ≤1 errors (3.4 [3.0-3.7] vs 3.4 [3.1-3.7]; median difference, 0; 99% CI, -0.3 to 0.3; P = .96). Similarly, there were no differences in those who reported >1 mistake with negative patient consequences, 3.3 (3.0-3.7), compared with those who did not report mistakes with negative patient consequences (3.4 [3.3-3.7]; median difference, 0.1; 99% CI, -0.2 to 0.6; P = .35). We detected a high rate of self-reported medication errors in pediatric anesthesiology fellows in the United States

  16. Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital. (United States)

    Michaelson, M; Walsh, E; Bradley, C P; McCague, P; Owens, R; Sahm, L J


    Prescribing error may result in adverse clinical outcomes leading to increased patient morbidity, mortality and increased economic burden. Many errors occur during transitional care as patients move between different stages and settings of care. To conduct a review of medication information and identify prescribing error among an adult population in an urban hospital. Retrospective review of medication information was conducted. Part 1: an audit of discharge prescriptions which assessed: legibility, compliance with legal requirements, therapeutic errors (strength, dose and frequency) and drug interactions. Part 2: A review of all sources of medication information (namely pre-admission medication list, drug Kardex, discharge prescription, discharge letter) for 15 inpatients to identify unintentional prescription discrepancies, defined as: "undocumented and/or unjustified medication alteration" throughout the hospital stay. Part 1: of the 5910 prescribed items; 53 (0.9%) were deemed illegible. Of the controlled drug prescriptions 11.1% (n = 167) met all the legal requirements. Therapeutic errors occurred in 41% of prescriptions (n = 479) More than 1 in 5 patients (21.9%) received a prescription containing a drug interaction. Part 2: 175 discrepancies were identified across all sources of medication information; of which 78 were deemed unintentional. Of these: 10.2% (n = 8) occurred at the point of admission, whereby 76.9% (n = 60) occurred at the point of discharge. The study identified the time of discharge as a point at which prescribing errors are likely to occur. This has implications for patient safety and provider work load in both primary and secondary care.

  17. Identification and Evaluation of Human Errors in the Medication Process Using the Extended CREAM Technique

    Directory of Open Access Journals (Sweden)

    Iraj Mohammadfam


    Full Text Available Background Medication process is a powerful instrument for curing patients. Obeying the commands of this process has an important role in the treatment and provision of care to patients. Medication error, as a complicated process, can occur in any stage of this process, and to avoid it, appropriate decision-making, cognition, and performance of the hospital staff are needed. Objectives The present study aimed at identifying and evaluating the nature and reasons of human errors in the medication process in a hospital using the extended CREAM method. Methods This was a qualitative and cross-sectional study conducted in a hospital in Hamadan. In this study, first, the medication process was selected as a critical issue based on the opinions of experts, specialists, and experienced individuals in the nursing and medical departments. Then, the process was analyzed into relative steps and substeps using the method of HTA and was evaluated using extended CREAM technique considering the probability of human errors. Results Based on the findings achieved through the basic CREAM method, the highest CFPt was in the step of medicine administration to patients (0.056. Moreover, the results revealed that the highest CFPt was in the substeps of calculating the dose of medicine and determining the method of prescription and identifying the patient (0.0796 and 0.0785, respectively. Also, the least CFPt was related to transcribing the prescribed medicine from file to worksheet of medicine (0.0106. Conclusions Considering the critical consequences of human errors in the medication process, holding pharmacological retraining classes, using the principles of executing pharmaceutical orders, increasing medical personnel, reducing working overtime, organizing work shifts, and using error reporting systems are of paramount importance.

  18. Medication knowledge, certainty, and risk of errors in health care: a cross-sectional study

    Directory of Open Access Journals (Sweden)

    Johansson Inger


    Full Text Available Abstract Background Medication errors are often involved in reported adverse events. Drug therapy, prescribed by physicians, is mostly carried out by nurses, who are expected to master all aspects of medication. Research has revealed the need for improved knowledge in drug dose calculation, and medication knowledge as a whole is poorly investigated. The purpose of this survey was to study registered nurses' medication knowledge, certainty and estimated risk of errors, and to explore factors associated with good results. Methods Nurses from hospitals and primary health care establishments were invited to carry out a multiple-choice test in pharmacology, drug management and drug dose calculations (score range 0-14. Self-estimated certainty in each answer was recorded, graded from 0 = very uncertain to 3 = very certain. Background characteristics and sense of coping were recorded. Risk of error was estimated by combining knowledge and certainty scores. The results are presented as mean (±SD. Results Two-hundred and three registered nurses participated (including 16 males, aged 42.0 (9.3 years with a working experience of 12.4 (9.2 years. Knowledge scores in pharmacology, drug management and drug dose calculations were 10.3 (1.6, 7.5 (1.6, and 11.2 (2.0, respectively, and certainty scores were 1.8 (0.4, 1.9 (0.5, and 2.0 (0.6, respectively. Fifteen percent of the total answers showed a high risk of error, with 25% in drug management. Independent factors associated with high medication knowledge were working in hospitals (p Conclusions Medication knowledge was found to be unsatisfactory among practicing nurses, with a significant risk for medication errors. The study revealed a need to improve the nurses' basic knowledge, especially when referring to drug management.

  19. Medical error

    African Journals Online (AJOL)


    Department of Psychiatry, University of Melbourne, Australia systems of ... traditional M&M (morbidity and mortality) meetings play a significant role in education .... inaccurate and inflammatory media reports their community accepted the ex-.


    Directory of Open Access Journals (Sweden)

    V. V. Franchuk


    Full Text Available Background. The professional occupation of a doctor quite often meets different imperfections, which have negative outcome for patients. Objective. The study was aimed to investigate the expert characteristics of improper performance of the professional duties by medical staff on the example of a particular region of Ukraine. Methods. In the study the archival materials (commission on forensic medical examinations held in Ternopil Regional Bureau of Forensic Medical Examination in 2007-2014 years were analysed. The research results are summarized and processed with the use of general statistical methods. Results. It is defined that during this period 112 examinations concerning medical malpractice were implemented (9.05% of all commission examinations. Conclusions. Medical errors were combined, especially during the diagnostics, treatment and in medical records. The majority of cases (82.1% of medical malpractice were caused by the objective reasons.

  1. [Statistical Process Control (SPC) can help prevent treatment errors without increasing costs in radiotherapy]. (United States)

    Govindarajan, R; Llueguera, E; Melero, A; Molero, J; Soler, N; Rueda, C; Paradinas, C


    Statistical Process Control (SPC) was applied to monitor patient set-up in radiotherapy and, when the measured set-up error values indicated a loss of process stability, its root cause was identified and eliminated to prevent set-up errors. Set up errors were measured for medial-lateral (ml), cranial-caudal (cc) and anterior-posterior (ap) dimensions and then the upper control limits were calculated. Once the control limits were known and the range variability was acceptable, treatment set-up errors were monitored using sub-groups of 3 patients, three times each shift. These values were plotted on a control chart in real time. Control limit values showed that the existing variation was acceptable. Set-up errors, measured and plotted on a X chart, helped monitor the set-up process stability and, if and when the stability was lost, treatment was interrupted, the particular cause responsible for the non-random pattern was identified and corrective action was taken before proceeding with the treatment. SPC protocol focuses on controlling the variability due to assignable cause instead of focusing on patient-to-patient variability which normally does not exist. Compared to weekly sampling of set-up error in each and every patient, which may only ensure that just those sampled sessions were set-up correctly, the SPC method enables set-up error prevention in all treatment sessions for all patients and, at the same time, reduces the control costs. Copyright © 2009 SECA. Published by Elsevier Espana. All rights reserved.

  2. The PoET (Prevention of Error-Based Transfers) Project. (United States)

    Oliver, Jill; Chidwick, Paula


    The PoET (Prevention of Error-based Transfers) Project is one of the Ethics Quality Improvement Projects (EQIPs) taking place at William Osler Health System. This specific project is designed to reduce transfers from long-term care to hospital that are caused by legal and ethical errors related to consent, capacity and substitute decision-making. The project is currently operating in eight long-term care homes in the Central West Local Health Integration Network and has seen a 56% reduction in multiple transfers before death in hospital.

  3. A vignette study to examine health care professionals' attitudes towards patient involvement in error prevention. (United States)

    Schwappach, David L B; Frank, Olga; Davis, Rachel E


    Various authorities recommend the participation of patients in promoting patient safety, but little is known about health care professionals' (HCPs') attitudes towards patients' involvement in safety-related behaviours. To investigate how HCPs evaluate patients' behaviours and HCP responses to patient involvement in the behaviour, relative to different aspects of the patient, the involved HCP and the potential error. Cross-sectional fractional factorial survey with seven factors embedded in two error scenarios (missed hand hygiene, medication error). Each survey included two randomized vignettes that described the potential error, a patient's reaction to that error and the HCP response to the patient. Twelve hospitals in Switzerland. A total of 1141 HCPs (response rate 45%). Approval of patients' behaviour, HCP response to the patient, anticipated effects on the patient-HCP relationship, HCPs' support for being asked the question, affective response to the vignettes. Outcomes were measured on 7-point scales. Approval of patients' safety-related interventions was generally high and largely affected by patients' behaviour and correct identification of error. Anticipated effects on the patient-HCP relationship were much less positive, little correlated with approval of patients' behaviour and were mainly determined by the HCP response to intervening patients. HCPs expressed more favourable attitudes towards patients intervening about a medication error than about hand sanitation. This study provides the first insights into predictors of HCPs' attitudes towards patient engagement in safety. Future research is however required to assess the generalizability of the findings into practice before training can be designed to address critical issues. © 2012 John Wiley & Sons Ltd.

  4. An Experimental Study of Medical Error Explanations: Do Apology, Empathy, Corrective Action, and Compensation Alter Intentions and Attitudes? (United States)

    Nazione, Samantha; Pace, Kristin


    Medical malpractice lawsuits are a growing problem in the United States, and there is much controversy regarding how to best address this problem. The medical error disclosure framework suggests that apologizing, expressing empathy, engaging in corrective action, and offering compensation after a medical error may improve the provider-patient relationship and ultimately help reduce the number of medical malpractice lawsuits patients bring to medical providers. This study provides an experimental examination of the medical error disclosure framework and its effect on amount of money requested in a lawsuit, negative intentions, attitudes, and anger toward the provider after a medical error. Results suggest empathy may play a large role in providing positive outcomes after a medical error.

  5. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience


    Westbrook, Johanna I; Rob, Marilyn I; Woods, Amanda; Parry, Dave


    Background Intravenous medication administrations have a high incidence of error but there is limited evidence of associated factors or error severity. Objective To measure the frequency, type and severity of intravenous administration errors in hospitals and the associations between errors, procedural failures and nurse experience. Methods Prospective observational study of 107 nurses preparing and administering 568 intravenous medications on six wards across two teaching hospitals. Procedur...

  6. [Current status of medical accident prevention in our pathology section]. (United States)

    Uehara, Takeshi; Kobayashi, Yukihiro; Honda, Takayuki


    Preventive measures against medical accident should be addressed in the pathology section. Medical accidents occur while preparing tissue specimens and making pathological diagnoses. For the preparation of tissue specimens, we have developed a work manual in consultation with past incident reports and update this manual regularly. We can reduce medical accidents by including a check system for each task. For pathological diagnosis, we perform some of the same checks as for tissue specimen preparation and can make more correct diagnoses by conferring with other departments. It is also important to check each other's work to prevent medical accidents.

  7. Proposal of procedures to prevent errors in radiotherapy based in learned lessons of accidental expositions

    International Nuclear Information System (INIS)

    Bueno, Giselle Oliveira Vieira


    In order to consider some procedures to prevent errors in radiotherapy based in learned lessons of accidental expositions and in accordance with information contained in international reports elaborated by International Atomic Energy Agency (IAEA) and of the data base availability by the European group Radiation Oncology Safety Information System (ROSIS) on the events, a research of the occurred errors was performed. For the evaluation of the incidents a data base based in the ROSIS and added plus a parameter was created 'type of error'. All the stored data make possible the evaluation of the 839 incidents in terms of frequency of the type of error, the process of detention, the number of reached patients and the degree of severity. Of the 50 types of found errors, the type of error more frequently was 'incorrect treatment coordinate', confirmed with the data of literature and representing 28,96 por cent of the total of the incidents. The results showed 44,44 por cent are discovered at the moment of the treatment and that the process of verification of the fiche or clinical revision of the patient is a verification more occurred insurance and in 43,33 por cent of the searched events. The results indicated that more than 50 por cent of the incidents the severity degree are void and approximately 62 por cent a patient are affected during the accomplishment of the radiotherapy. This work showed that to analyze the data base according to methodology proposal for Klein et al.; for Reason, and Dunscombe et al. is interesting to insert more characteristic detailed in the data base such as: the number of fractions for affected patient, number of fields of treatment for fraction that was affected, shunting line of the prescribed dose and shunting line of the volume prescribed in all the registered in cadastral map events. Some causes exist that can lead the errors when patient they are submitted to the radiotherapy. Some measures can be taken so that these errors do not

  8. 75 FR 18514 - Developing Guidance on Naming, Labeling, and Packaging Practices to Reduce Medication Errors... (United States)


    ... packaging designs. Among these measures, FDA agreed that by the end of FY 2010, after public consultation... product names and designing product labels and packaging to reduce medication errors. Four panel... of product packaging design, and costs associated with designing product packaging. Panel 3 will...

  9. Translating Research Into Practice: Voluntary Reporting of Medication Errors in Critical Access Hospitals (United States)

    Jones, Katherine J.; Cochran, Gary; Hicks, Rodney W.; Mueller, Keith J.


    Context:Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals. This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health…

  10. Effects of Crew Resource Management Training on Medical Errors in a Simulated Prehospital Setting (United States)

    Carhart, Elliot D.


    This applied dissertation investigated the effect of crew resource management (CRM) training on medical errors in a simulated prehospital setting. Specific areas addressed by this program included situational awareness, decision making, task management, teamwork, and communication. This study is believed to be the first investigation of CRM…

  11. Errors prevention in manufacturing process through integration of Poka Yoke and TRIZ (United States)

    Helmi, Syed Ahmad; Nordin, Nur Nashwa; Hisjam, Muhammad


    Integration of Poka Yoke and TRIZ is a method of solving problems by using a different approach. Poka Yoke is a trial and error method while TRIZ is using a systematic approach. The main purpose of this technique is to get rid of product defects by preventing or correcting errors as soon as possible. Blame the workers for their mistakes is not the best way, but the work process should be reviewed so that every workers behavior or movement may not cause errors. This study is to demonstrate the importance of using both of these methods in which everyone in the industry needs to improve quality, increase productivity and at the same time reducing production cost.

  12. Medication errors with the use of allopurinol and colchicine : A retrospective study of a national, anonymous Internet-accessible error reporting system

    NARCIS (Netherlands)

    Mikuls, TR; Curtis, [No Value; Allison, JJ; Hicks, RW; Saag, KG

    Objectives. To more closely assess medication errors in gout care, we examined data from a national, Internet-accessible error reporting program over a 5-year reporting period. Methods. We examined data from the MEDMARX (TM) database, covering the period from January 1, 1999 through December 31,

  13. [Plagiarism in medical schools, and its prevention]. (United States)

    Annane, Djillali; Annane, Frédérique


    The plagiarism has become very common in universities and medical school. Undoubtedly, the easy access to a huge amount of electronic documents is one explanation for the increasing prevalence of plagiarism among students. While most of universities and medical school have clear statements and rules about plagiarism, available tools for the detection of plagiarism remain inefficient and dedicate training program for students and teachers too scarce. As lack of time is one reason for students to choose plagiarism, it should be one main target for educational programs. Copyright © 2012. Published by Elsevier Masson SAS.

  14. A trend analysis of human error events for proactive prevention of accidents. Methodology development and effective utilization

    International Nuclear Information System (INIS)

    Hirotsu, Yuko; Ebisu, Mitsuhiro; Aikawa, Takeshi; Matsubara, Katsuyuki


    This paper described methods for analyzing human error events that has been accumulated in the individual plant and for utilizing the result to prevent accidents proactively. Firstly, a categorization framework of trigger action and causal factors of human error events were reexamined, and the procedure to analyze human error events was reviewed based on the framework. Secondly, a method for identifying the common characteristics of trigger action data and of causal factor data accumulated by analyzing human error events was clarified. In addition, to utilize the results of trend analysis effectively, methods to develop teaching material for safety education, to develop the checkpoints for the error prevention and to introduce an error management process for strategic error prevention were proposed. (author)

  15. Comprehensive framework for preventive maintenance priority of medical equipment. (United States)

    Saleh, Neven; Balestra, Gabriella


    Throughout the medical equipment life cycle, preventive maintenance is considered one of the most important stages that should be managed properly. However, the need for better management and control by giving a reasonable prioritization for preventive maintenance becomes essential. The purpose of this study is to develop a comprehensive framework for preventive maintenance priority of medical equipment using Quality Function Deployment (QFD) and Fuzzy Logic (FL). The quality function deployment is proposed in order to identify the most important criteria that could impact preventive maintenance priority decision; meanwhile the role of the fuzzy logic is to generate a priority index of the list of equipment considering those criteria. The model validation was carried out on 140 pieces of medical equipment belonging to two hospitals. In application, we propose to classify the priority index into five classes. The results indicate that the strong correlation existence between risk-based criteria and preventive maintenance priority decision.

  16. Learning from incident reports in the Australian medical imaging setting: handover and communication errors. (United States)

    Hannaford, N; Mandel, C; Crock, C; Buckley, K; Magrabi, F; Ong, M; Allen, S; Schultz, T


    To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings. Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.

  17. Erros medicamentosos em unidade de terapia intensiva neonatal Medication errors in a neonatal intensive care unit

    Directory of Open Access Journals (Sweden)

    Renata Bandeira de Melo Escovedo Lerner


    Full Text Available OBJETIVO: Determinar a incidência e o tipo de erros médicos em uma unidade de terapia intensiva neonatal e a relação entre o erro e o estado clínico do paciente. MÉTODOS: Revisamos os prontuários médicos, durante os primeiros 7 dias de hospitalização, de todos os recém-nascidos de alto risco admitidos por um período de 3 meses. RESULTADOS: Setenta e três pacientes foram admitidos durante o período de estudo. A média de peso de nascimento foi de 2.140 g (640-5.020 g, e a idade gestacional média foi de 34 semanas (25-40 semanas. Dos 73 prontuários analisados, 40 (55% apresentaram um ou mais erros. Um total de 365 dias de hospitalização foi analisado, e 95 erros médicos foram detectados (um erro por 3,9 dias de hospitalização. O erro mais freqüente esteve associado com uso de medicamentos (84,2%. Uso de procedimentos terapêuticos (medicamentos, fototerapia, etc. sem prescrição adequada no prontuário do paciente (erro de comissão representou 7,4% dos erros, e a incidência de erros de omissão foi de 8,4%. A incidência de erros médicos foi significativamente maior em recém-nascidos com idade gestacional menor. CONCLUSÕES: A incidência de erros no cuidado de recém-nascidos de alto risco é elevada. Deve-se incentivar estratégias para melhorar a educação de profissionais da saúde envolvidos no cuidado e o desenvolvimento da cultura local, divulgando algoritmos claros e acessíveis para orientar o comportamento quando há ocorrência de erros.OBJECTIVE: To determine the incidence and type of medical errors in a newborn intensive care unit and the relationship between the error and the patient's clinical status. METHODS: We reviewed the medical charts, during the first 7 days of hospitalization, of all high-risk newborn infants admitted for a period of 3 months. RESULTS: Seventy-three patients were admitted during the study period. Their mean birth weight was 2,140 g (640-5,020 g and mean gestational age was 34

  18. Preventive effectiveness of pre-employment medical assessments

    NARCIS (Netherlands)

    de Kort, W.; van Dijk, F.


    Health gain, prevention of health loss, and avoidance of financial risk all seem to be driving forces for the use of pre-employment medical assessment. An attempt is made to measure the effect of implementing the pre-employment medical assessment on these end points. The anticipated maximum

  19. Specialist Physicians' Attitudes and Practice Patterns Regarding Disclosure of Pre-referral Medical Errors. (United States)

    Dossett, Lesly A; Kauffmann, Rondi M; Lee, Jay S; Singh, Harkamal; Lee, M Catherine; Morris, Arden M; Jagsi, Reshma; Quinn, Gwendolyn P; Dimick, Justin B


    Our objective was to determine specialist physicians' attitudes and practices regarding disclosure of pre-referral errors. Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral. We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure. Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the profession's reputation, and to patient-physician relationships. Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development.

  20. Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia. (United States)

    Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi


    To explore and understand participants' perceptions and attitudes towards the reporting of medication errors (MEs). A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach. Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter's burden and benefit of reporting also were identified. Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use.

  1. How to minimize perceptual error and maximize expertise in medical imaging (United States)

    Kundel, Harold L.


    Visual perception is such an intimate part of human experience that we assume that it is entirely accurate. Yet, perception accounts for about half of the errors made by radiologists using adequate imaging technology. The true incidence of errors that directly affect patient well being is not known but it is probably at the lower end of the reported values of 3 to 25%. Errors in screening for lung and breast cancer are somewhat better characterized than errors in routine diagnosis. About 25% of cancers actually recorded on the images are missed and cancer is falsely reported in about 5% of normal people. Radiologists must strive to decrease error not only because of the potential impact on patient care but also because substantial variation among observers undermines confidence in the reliability of imaging diagnosis. Observer variation also has a major impact on technology evaluation because the variation between observers is frequently greater than the difference in the technologies being evaluated. This has become particularly important in the evaluation of computer aided diagnosis (CAD). Understanding the basic principles that govern the perception of medical images can provide a rational basis for making recommendations for minimizing perceptual error. It is convenient to organize thinking about perceptual error into five steps. 1) The initial acquisition of the image by the eye-brain (contrast and detail perception). 2) The organization of the retinal image into logical components to produce a literal perception (bottom-up, global, holistic). 3) Conversion of the literal perception into a preferred perception by resolving ambiguities in the literal perception (top-down, simulation, synthesis). 4) Selective visual scanning to acquire details that update the preferred perception. 5) Apply decision criteria to the preferred perception. The five steps are illustrated with examples from radiology with suggestions for minimizing error. The role of perceptual

  2. Medication administration error reporting and associated factors among nurses working at the University of Gondar referral hospital, Northwest Ethiopia, 2015. (United States)

    Bifftu, Berhanu Boru; Dachew, Berihun Assefa; Tiruneh, Bewket Tadesse; Beshah, Debrework Tesgera


    Medication administration is the final step/phase of medication process in which its error directly affects the patient health. Due to the central role of nurses in medication administration, whether they are the source of an error, a contributor, or an observer they have the professional, legal and ethical responsibility to recognize and report. The aim of this study was to assess the prevalence of medication administration error reporting and associated factors among nurses working at The University of Gondar Referral Hospital, Northwest Ethiopia. Institution based quantitative cross - sectional study was conducted among 282 Nurses. Data were collected using semi-structured, self-administered questionnaire of the Medication Administration Errors Reporting (MAERs). Binary logistic regression with 95 % confidence interval was used to identify factors associated with medication administration errors reporting. The estimated medication administration error reporting was found to be 29.1 %. The perceived rates of medication administration errors reporting for non-intravenous related medications were ranged from 16.8 to 28.6 % and for intravenous-related from 20.6 to 33.4 %. Education status (AOR =1.38, 95 % CI: 4.009, 11.128), disagreement over time - error definition (AOR = 0.44, 95 % CI: 0.468, 0.990), administrative reason (AOR = 0.35, 95 % CI: 0.168, 0.710) and fear (AOR = 0.39, 95 % CI: 0.257, 0.838) were factors statistically significant for the refusal of reporting medication administration errors at p-value definition, administrative reason and fear were factors statistically significant for the refusal of errors reporting at p-value definition of reportable errors and strengthen the educational status of nurses by the health care organization.

  3. The use of error and uncertainty methods in the medical laboratory. (United States)

    Oosterhuis, Wytze P; Bayat, Hassan; Armbruster, David; Coskun, Abdurrahman; Freeman, Kathleen P; Kallner, Anders; Koch, David; Mackenzie, Finlay; Migliarino, Gabriel; Orth, Matthias; Sandberg, Sverre; Sylte, Marit S; Westgard, Sten; Theodorsson, Elvar


    Error methods - compared with uncertainty methods - offer simpler, more intuitive and practical procedures for calculating measurement uncertainty and conducting quality assurance in laboratory medicine. However, uncertainty methods are preferred in other fields of science as reflected by the guide to the expression of uncertainty in measurement. When laboratory results are used for supporting medical diagnoses, the total uncertainty consists only partially of analytical variation. Biological variation, pre- and postanalytical variation all need to be included. Furthermore, all components of the measuring procedure need to be taken into account. Performance specifications for diagnostic tests should include the diagnostic uncertainty of the entire testing process. Uncertainty methods may be particularly useful for this purpose but have yet to show their strength in laboratory medicine. The purpose of this paper is to elucidate the pros and cons of error and uncertainty methods as groundwork for future consensus on their use in practical performance specifications. Error and uncertainty methods are complementary when evaluating measurement data.

  4. Current pulse: can a production system reduce medical errors in health care? (United States)

    Printezis, Antonios; Gopalakrishnan, Mohan


    One of the reasons for rising health care costs is medical errors, a majority of which result from faulty systems and processes. Health care in the past has used process-based initiatives such as Total Quality Management, Continuous Quality Improvement, and Six Sigma to reduce errors. These initiatives to redesign health care, reduce errors, and improve overall efficiency and customer satisfaction have had moderate success. Current trend is to apply the successful Toyota Production System (TPS) to health care since its organizing principles have led to tremendous improvement in productivity and quality for Toyota and other businesses that have adapted them. This article presents insights on the effectiveness of TPS principles in health care and the challenges that lie ahead in successfully integrating this approach with other quality initiatives.

  5. Apology in cases of medical error disclosure: Thoughts based on a preliminary study. (United States)

    Dahan, Sonia; Ducard, Dominique; Caeymaex, Laurence


    Disclosing medical errors is considered necessary by patients, ethicists, and health care professionals. Literature insists on the framing of this disclosure and describes the apology as appropriate and necessary. However, this policy seems difficult to put into practice. Few works have explored the function and meaning of the apology. The aim of this study was to explore the role ascribed to apology in communication between healthcare professionals and patients when disclosing a medical error, and to discuss these findings using a linguistic and philosophical perspective. Qualitative exploratory study, based on face-to-face semi-structured interviews, with seven physicians in a neonatal unit in France. Discourse analysis. Four themes emerged. Difference between apology in everyday life and in the medical encounter; place of the apology in the process of disclosure together with explanations, regrets, empathy and ways to avoid repeating the error; effects of the apology were to allow the patient-physician relationship undermined by the error, to be maintained, responsibility to be accepted, the first steps towards forgiveness to be taken, and a less hierarchical doctor-patient relationship to be created; ways of expressing apology ("I am sorry") reflected regrets and empathy more than an explicit apology. This study highlights how the act of apology can be seen as a "language act" as described by philosophers Austin and Searle, and how it functions as a technique for making amends following a wrongdoing and as an action undertaken in order that neither party should lose face, thus echoing the sociologist Goffmann's interaction theory. This interpretation also accords with the views of Lazare, for whom the function of apology is a restoration of dignity after the humiliation of the error. This approach to the apology illustrates how meaning and impact of real-life language acts can be clarified by philosophical and sociological ideas.

  6. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. (United States)

    Keers, Richard N; Williams, Steven D; Cooke, Jonathan; Ashcroft, Darren M


    Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence. This study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings. Nine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013. Inclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail. A total of 54 unique studies were included. Causes of MAEs were categorised according to Reason's model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used. Slips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality

  7. Methods to reduce medication errors in a clinical trial of an investigational parenteral medication

    Directory of Open Access Journals (Sweden)

    Gillian L. Fell


    Full Text Available There are few evidence-based guidelines to inform optimal design of complex clinical trials, such as those assessing the safety and efficacy of intravenous drugs administered daily with infusion times over many hours per day and treatment durations that may span years. This study is a retrospective review of inpatient administration deviation reports for an investigational drug that is administered daily with infusion times of 8–24 h, and variable treatment durations for each patient. We report study design modifications made in 2007–2008 aimed at minimizing deviations from an investigational drug infusion protocol approved by an institutional review board and the United States Food and Drug Administration. Modifications were specifically aimed at minimizing errors of infusion rate, incorrect dose, incorrect patient, or wrong drug administered. We found that the rate of these types of administration errors of the study drug was significantly decreased following adoption of the specific study design changes. This report provides guidance in the design of clinical trials testing the safety and efficacy of study drugs administered via intravenous infusion in an inpatient setting so as to minimize drug administration protocol deviations and optimize patient safety.

  8. Analysis of medication-related malpractice claims: causes, preventability, and costs. (United States)

    Rothschild, Jeffrey M; Federico, Frank A; Gandhi, Tejal K; Kaushal, Rainu; Williams, Deborah H; Bates, David W


    Adverse drug events (ADEs) may lead to serious injury and may result in malpractice claims. While ADEs resulting in claims are not representative of all ADEs, such data provide a useful resource for studying ADEs. Therefore, we conducted a review of medication-related malpractice claims to study their frequency, nature, and costs and to assess the human factor failures associated with preventable ADEs. We also assessed the potential benefits of proved effective ADE prevention strategies on ADE claims prevention. We conducted a retrospective analysis of a New England malpractice insurance company claims records from January 1, 1990, to December 31, 1999. Cases were electronically screened for possible ADEs and followed up by independent review of abstracts by 2 physician reviewers (T.K.G. and R.K.). Additional in-depth claims file reviews identified potential human factor failures associated with ADEs. Adverse drug events represented 6.3% (129/2040) of claims. Adverse drug events were judged preventable in 73% (n = 94) of the cases and were nearly evenly divided between outpatient and inpatient settings. The most frequently involved medication classes were antibiotics, antidepressants or antipsychotics, cardiovascular drugs, and anticoagulants. Among these ADEs, 46% were life threatening or fatal. System deficiencies and performance errors were the most frequent cause of preventable ADEs. The mean costs of defending malpractice claims due to ADEs were comparable for nonpreventable inpatient and outpatient ADEs and preventable outpatient ADEs (mean, $64,700-74,200), but costs were considerably greater for preventable inpatient ADEs (mean, $376,500). Adverse drug events associated with malpractice claims were often severe, costly, and preventable, and about half occurred in outpatients. Many interventions could potentially have prevented ADEs, with error proofing and process standardization covering the greatest proportion of events.

  9. Factors affecting nursing students' intention to report medication errors: An application of the theory of planned behavior. (United States)

    Ben Natan, Merav; Sharon, Ira; Mahajna, Marlen; Mahajna, Sara


    Medication errors are common among nursing students. Nonetheless, these errors are often underreported. To examine factors related to nursing students' intention to report medication errors, using the Theory of Planned Behavior, and to examine whether the theory is useful in predicting students' intention to report errors. This study has a descriptive cross-sectional design. Study population was recruited in a university and a large nursing school in central and northern Israel. A convenience sample of 250 nursing students took part in the study. The students completed a self-report questionnaire, based on the Theory of Planned Behavior. The findings indicate that students' intention to report medication errors was high. The Theory of Planned Behavior constructs explained 38% of variance in students' intention to report medication errors. The constructs of behavioral beliefs, subjective norms, and perceived behavioral control were found as affecting this intention, while the most significant factor was behavioral beliefs. The findings also reveal that students' fear of the reaction to disclosure of the error from superiors and colleagues may impede them from reporting the error. Understanding factors related to reporting medication errors is crucial to designing interventions that foster error reporting. Copyright © 2017 Elsevier Ltd. All rights reserved.

  10. Trend analysis of human error events and assessment of their proactive prevention measure at Rokkasho reprocessing plant

    International Nuclear Information System (INIS)

    Yamazaki, Satoru; Tanaka, Izumi; Wakabayashi, Toshio


    A trend analysis of human error events is important for preventing the recurrence of human error events. We propose a new method for identifying the common characteristics from results of trend analysis, such as the latent weakness of organization, and a management process for strategic error prevention. In this paper, we describe a trend analysis method for human error events that have been accumulated in the organization and the utilization of the results of trend analysis to prevent accidents proactively. Although the systematic analysis of human error events, the monitoring of their overall trend, and the utilization of the analyzed results have been examined for the plant operation, such information has never been utilized completely. Sharing information on human error events and analyzing their causes lead to the clarification of problems in the management and human factors. This new method was applied to the human error events that occurred in the Rokkasho reprocessing plant from 2010 October. Results revealed that the output of this method is effective in judging the error prevention plan and that the number of human error events is reduced to about 50% those observed in 2009 and 2010. (author)

  11. Need for Injury Prevention Education In Medical School Curriculum

    Directory of Open Access Journals (Sweden)

    Vaca, Federico E


    Full Text Available Injury is the leading cause of death and disability among the U.S. population aged 1 to 44 years. In 2006 more than 179,000 fatalities were attributed to injury. Despite increasing awareness of the global epidemic of injury and violence, a considerable gap remains between advances in injury-prevention research and prevention knowledge that is taught to medical students. This article discusses the growing need for U.S medical schools to train future physicians in the fundamentals of injury prevention and control. Teaching medical students to implement injury prevention in their future practice should help reduce injury morbidity and mortality. Deliberate efforts should be made to integrate injury-prevention education into existing curriculum. Key resources are available to do this. Emergency physicians can be essential advocates in establishing injury prevention training because of their clinical expertise in treating injury. Increasing the number of physicians with injury- and violence- prevention knowledge and skills is ultimately an important strategy to reduce the national and global burden of injury. [West J Emerg Med. 2010; 11(1:40-43].

  12. Modern Palliative Radiation Treatment: Do Complexity and Workload Contribute to Medical Errors?

    Energy Technology Data Exchange (ETDEWEB)

    D' Souza, Neil, E-mail: [Department of Radiation Oncology, University of Toronto, Toronto, Ontario (Canada); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Canada); Holden, Lori [Department of Radiation Oncology, University of Toronto, Toronto, Ontario (Canada); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Canada); Robson, Sheila [Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Canada); Mah, Kathy; Di Prospero, Lisa; Wong, C. Shun; Chow, Edward; Spayne, Jacqueline [Department of Radiation Oncology, University of Toronto, Toronto, Ontario (Canada); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Canada)


    Purpose: To examine whether treatment workload and complexity associated with palliative radiation therapy contribute to medical errors. Methods and Materials: In the setting of a large academic health sciences center, patient scheduling and record and verification systems were used to identify patients starting radiation therapy. All records of radiation treatment courses delivered during a 3-month period were retrieved and divided into radical and palliative intent. 'Same day consultation, planning and treatment' was used as a proxy for workload and 'previous treatment' and 'multiple sites' as surrogates for complexity. In addition, all planning and treatment discrepancies (errors and 'near-misses') recorded during the same time frame were reviewed and analyzed. Results: There were 365 new patients treated with 485 courses of palliative radiation therapy. Of those patients, 128 (35%) were same-day consultation, simulation, and treatment patients; 166 (45%) patients had previous treatment; and 94 (26%) patients had treatment to multiple sites. Four near-misses and 4 errors occurred during the audit period, giving an error per course rate of 0.82%. In comparison, there were 10 near-misses and 5 errors associated with 1100 courses of radical treatment during the audit period. This translated into an error rate of 0.45% per course. An association was found between workload and complexity and increased palliative therapy error rates. Conclusions: Increased complexity and workload may have an impact on palliative radiation treatment discrepancies. This information may help guide the necessary recommendations for process improvement for patients who require palliative radiation therapy.

  13. Effect of Professional Ethics on Reducing Medical Errors from the Viewpoint of Faculty Members in Medical School of Tabriz University of Medical Sciences

    Directory of Open Access Journals (Sweden)

    Fatemeh Donboli Miandoab


    Full Text Available Background: Professionalism and adherence to ethics and professional standards are among the most important topics in medical ethics that can play a role in reducing medical errors. This paper examines and evaluates the effect of professional ethics on reducing medical errors from the viewpoint of faculty members in the medical school of the Tabriz University of Medical Sciences. Methods: in this cross-sectional descriptive study, faculty members of the Tabriz University of Medical Sciences were the statistical population from whom 105 participants were randomly selected through simple random sampling. A questionnaire was used, to examine and compare the self-assessed opinions of faculty members in the internal, surgical, pediatric, gynecological, and psychiatric departments. The questionnaires were completed by a self-assessment method and the collected data was analyzed using SPSS 21. Results: Based on physicians’ opinions, professional ethical considerations and its three domains and aspects have a significant role in reducing medical errors and crimes. The mean scores (standard deviations of the managerial, knowledge and communication skills and environmental variables were respectively 46.7 (5.64, 64.6 (8.14 and 16.2 (2.97 from the physicians’ viewpoints. The significant factors with highest scores on the reduction of medical errors and crimes in all three domains were as follows: in the managerial skills variable, trust, physician’s sense of responsibility against the patient and his/her respect for patients’ rights; in the knowledge and communication skills domain, general competence and eligibility as a physician and examination and diagnosis skills; and, last, in the environmental domain, the sufficiency of trainings in ethical issues during education and their satisfaction with basic needs. Conclusion: Based on the findings of this research, attention to the improvement of communication, management and environment skills should

  14. A Robust Ultra-Low Voltage CPU Utilizing Timing-Error Prevention


    Hiienkari, Markus; Teittinen, Jukka; Koskinen, Lauri; Turnquist, Matthew; Mäkipää, Jani; Rantala, Arto; Sopanen, Matti; Kaltiokallio, Mikko


    To minimize energy consumption of a digital circuit, logic can be operated at sub- or near-threshold voltage. Operation at this region is challenging due to device and environment variations, and resulting performance may not be adequate to all applications. This article presents two variants of a 32-bit RISC CPU targeted for near-threshold voltage. Both CPUs are placed on the same die and manufactured in 28 nm CMOS process. They employ timing-error prevention with clock stretching to enable ...

  15. Multidisciplinary strategy to reduce errors with the use of medical gases. (United States)

    Amor-García, Miguel Ángel; Ibáñez-García, Sara; Díaz-Redondo, Alicia; Herranz Alonso, Ana; Sanjurjo Sáez, María


    Lack of awareness of the risks associated with the use of medical  gases amongst health professionals and health organizations is concerning. The  objective of this study is to redefine the use process of medical gases in a  hospital setting. A sentinel event took place in a clinical unit, the incorrect administration of a medical gas to an inpatient. A multidisciplinary  causeroot analysis of the sentinel event was carried out. Different improvement points were identified for each error detected and so we defined a  good strategy to ensure the safe use of these drugs. 9 errors were identified and the following improvement actions were  defined: storage (gases of clinical use were separated from those of industrial  use and proper identification signs were placed), prescription (6 protocols were  included in the hospital´s Computerized Physician Order Entry software),  validation (pharmacist validation of the prescription to ensure appropriate use of  these), dispensation (a new protocol for medical gases dispensation and  transportation was designed and implemented) and administration (information  on the pressure gauges used for each type of gas was collected and reviewed).  72 Signs with recommendations for medical gases identification and  administration were placed in all the clinical units. Specific training on the safe  use of medical gases and general safety training was imparted. The implementation of a process that integrates all phases of use  of medical gases and applies to all professionals involved is presented here as a  strategy to increase safety in the use of these medicines. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

  16. Analysis of liquid medication dose errors made by patients and caregivers using alternative measuring devices. (United States)

    Ryu, Gyeong Suk; Lee, Yu Jeung


    Patients use several types of devices to measure liquid medication. Using a criterion ranging from a 10% to 40% variation from a target 5 mL for a teaspoon dose, previous studies have found that a considerable proportion of patients or caregivers make errors when dosing liquid medication with measuring devices. To determine the rate and magnitude of liquid medication dose errors that occur with patient/caregiver use of various measuring devices in a community pharmacy. Liquid medication measurements by patients or caregivers were observed in a convenience sample of community pharmacy patrons in Korea during a 2-week period in March 2011. Participants included all patients or caregivers (N = 300) who came to the pharmacy to buy over-the-counter liquid medication or to have a liquid medication prescription filled during the study period. The participants were instructed by an investigator who was also a pharmacist to select their preferred measuring devices from 6 alternatives (etched-calibration dosing cup, printed-calibration dosing cup, dosing spoon, syringe, dispensing bottle, or spoon with a bottle adapter) and measure a 5 mL dose of Coben (chlorpheniramine maleate/phenylephrine HCl, Daewoo Pharm. Co., Ltd) syrup using the device of their choice. The investigator used an ISOLAB graduated cylinder (Germany, blue grad, 10 mL) to measure the amount of syrup dispensed by the study participants. Participant characteristics were recorded including gender, age, education level, and relationship to the person for whom the medication was intended. Of the 300 participants, 257 (85.7%) were female; 286 (95.3%) had at least a high school education; and 282 (94.0%) were caregivers (parent or grandparent) for the patient. The mean (SD) measured dose was 4.949 (0.378) mL for the 300 participants. In analysis of variance of the 6 measuring devices, the greatest difference from the 5 mL target was a mean 5.552 mL for 17 subjects who used the regular (etched) dosing cup and 4

  17. Barriers to reporting medication errors and near misses among nurses: A systematic review. (United States)

    Vrbnjak, Dominika; Denieffe, Suzanne; O'Gorman, Claire; Pajnkihar, Majda


    To explore barriers to nurses' reporting of medication errors and near misses in hospital settings. Systematic review. Medline, CINAHL, PubMed and Cochrane Library in addition to Google and Google Scholar and reference lists of relevant studies published in English between January 1981 and April 2015 were searched for relevant qualitative, quantitative or mixed methods empirical studies or unpublished PhD theses. Papers with a primary focus on barriers to reporting medication errors and near misses in nursing were included. The titles and abstracts of the search results were assessed for eligibility and relevance by one of the authors. After retrieval of the full texts, two of the authors independently made decisions concerning the final inclusion and these were validated by the third reviewer. Three authors independently assessed methodological quality of studies. Relevant data were extracted and findings were synthesised using thematic synthesis. From 4038 identified records, 38 studies were included in the synthesis. Findings suggest that organizational barriers such as culture, the reporting system and management behaviour in addition to personal and professional barriers such as fear, accountability and characteristics of nurses are barriers to reporting medication errors. To overcome reported barriers it is necessary to develop a non-blaming, non-punitive and non-fearful learning culture at unit and organizational level. Anonymous, effective, uncomplicated and efficient reporting systems and supportive management behaviour that provides open feedback to nurses is needed. Nurses are accountable for patients' safety, so they need to be educated and skilled in error management. Lack of research into barriers to reporting of near misses' and low awareness of reporting suggests the need for further research and development of educational and management approaches to overcome these barriers. Copyright © 2016 Elsevier Ltd. All rights reserved.

  18. Preventing errors in administration of parenteral drugs: the results of a four-year national patient safety program.

    NARCIS (Netherlands)

    Blok, C. de; Schilp, J.; Wagner, C.


    Objectives: To evaluate the implementation of a four-year national patient safety program concerning the parenteral drug administration process in the Netherlands. Methods: Structuring the preparation and administration process of parenteral drugs reduces the number of medication errors. A

  19. Preparing Emergency Medicine Residents to Disclose Medical Error Using Standardized Patients

    Directory of Open Access Journals (Sweden)

    Carmen N. Spalding


    Full Text Available Introduction Emergency Medicine (EM is a unique clinical learning environment. The American College of Graduate Medical Education Clinical Learning Environment Review Pathways to Excellence calls for “hands-on training” of disclosure of medical error (DME during residency. Training and practicing key elements of DME using standardized patients (SP may enhance preparedness among EM residents in performing this crucial skill in a clinical setting. Methods This training was developed to improve resident preparedness in DME in the clinical setting. Objectives included the following: the residents will be able to define a medical error; discuss ethical and professional standards of DME; recognize common barriers to DME; describe key elements in effective DME to patients and families; and apply key elements during a SP encounter. The four-hour course included didactic and experiential learning methods, and was created collaboratively by core EM faculty and subject matter experts in conflict resolution and healthcare simulation. Educational media included lecture, video exemplars of DME communication with discussion, small group case-study discussion, and SP encounters. We administered a survey assessing for preparedness in DME pre-and post-training. A critical action checklist was administered to assess individual performance of key elements of DME during the evaluated SP case. A total of 15 postgraduate-year 1 and 2 EM residents completed the training. Results After the course, residents reported increased comfort with and preparedness in performing several key elements in DME. They were able to demonstrate these elements in a simulated setting using SP. Residents valued the training, rating the didactic, SP sessions, and overall educational experience very high. Conclusion Experiential learning using SP is effective in improving resident knowledge of and preparedness in performing medical error disclosure. This educational module can be adapted

  20. [Medical negligence]. (United States)

    Zipper, St G


    Medical negligence is a matter of growing public interest. This review outlines various aspects of medical negligence: epidemiology, taxonomy, and the risks, causes, psychology, management and prevention of errors.

  1. Negligence, genuine error, and litigation


    Sohn DH


    David H SohnDepartment of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USAAbstract: Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort syst...

  2. Preventability of early vs. late readmissions in an academic medical center.

    Directory of Open Access Journals (Sweden)

    Kelly L Graham

    Full Text Available It is unclear if the 30-day unplanned hospital readmission rate is a plausible accountability metric.Compare preventability of hospital readmissions, between an early period [0-7 days post-discharge] and a late period [8-30 days post-discharge]. Compare causes of readmission, and frequency of markers of clinical instability 24h prior to discharge between early and late readmissions.120 patient readmissions in an academic medical center between 1/1/2009-12/31/2010.Sum-score based on a standard algorithm that assesses preventability of each readmission based on blinded hospitalist review; average causation score for seven types of adverse events; rates of markers of clinical instability within 24h prior to discharge.Readmissions were significantly more preventable in the early compared to the late period [median preventability sum score 8.5 vs. 8.0, p = 0.03]. There were significantly more management errors as causative events for the readmission in the early compared to the late period [mean causation score [scale 1-6, 6 most causal] 2.0 vs. 1.5, p = 0.04], and these errors were significantly more preventable in the early compared to the late period [mean preventability score 1.9 vs 1.5, p = 0.03]. Patients readmitted in the early period were significantly more likely to have mental status changes documented 24h prior to hospital discharge than patients readmitted in the late period [12% vs. 0%, p = 0.01].Readmissions occurring in the early period were significantly more preventable. Early readmissions were associated with more management errors, and mental status changes 24h prior to discharge. Seven-day readmissions may be a better accountability measure.

  3. Residents' Ratings of Their Clinical Supervision and Their Self-Reported Medical Errors: Analysis of Data From 2009. (United States)

    Baldwin, DeWitt C; Daugherty, Steven R; Ryan, Patrick M; Yaghmour, Nicholas A; Philibert, Ingrid


    Medical errors and patient safety are major concerns for the medical and medical education communities. Improving clinical supervision for residents is important in avoiding errors, yet little is known about how residents perceive the adequacy of their supervision and how this relates to medical errors and other education outcomes, such as learning and satisfaction. We analyzed data from a 2009 survey of residents in 4 large specialties regarding the adequacy and quality of supervision they receive as well as associations with self-reported data on medical errors and residents' perceptions of their learning environment. Residents' reports of working without adequate supervision were lower than data from a 1999 survey for all 4 specialties, and residents were least likely to rate "lack of supervision" as a problem. While few residents reported that they received inadequate supervision, problems with supervision were negatively correlated with sufficient time for clinical activities, overall ratings of the residency experience, and attending physicians as a source of learning. Problems with supervision were positively correlated with resident reports that they had made a significant medical error, had been belittled or humiliated, or had observed others falsifying medical records. Although working without supervision was not a pervasive problem in 2009, when it happened, it appeared to have negative consequences. The association between inadequate supervision and medical errors is of particular concern.

  4. Infection prevention and control in deployed military medical treatment facilities. (United States)

    Hospenthal, Duane R; Green, Andrew D; Crouch, Helen K; English, Judith F; Pool, Jane; Yun, Heather C; Murray, Clinton K


    Infections have complicated the care of combat casualties throughout history and were at one time considered part of the natural history of combat trauma. Personnel who survived to reach medical care were expected to develop and possibly succumb to infections during their care in military hospitals. Initial care of war wounds continues to focus on rapid surgical care with debridement and irrigation, aimed at preventing local infection and sepsis with bacteria from the environment (e.g., clostridial gangrene) or the casualty's own flora. Over the past 150 years, with the revelation that pathogens can be spread from patient to patient and from healthcare providers to patients (including via unwashed hands of healthcare workers, the hospital environment and fomites), a focus on infection prevention and control aimed at decreasing transmission of pathogens and prevention of these infections has developed. Infections associated with combat-related injuries in the recent operations in Iraq and Afghanistan have predominantly been secondary to multidrug-resistant pathogens, likely acquired within the military healthcare system. These healthcare-associated infections seem to originate throughout the system, from deployed medical treatment facilities through the chain of care outside of the combat zone. Emphasis on infection prevention and control, including hand hygiene, isolation, cohorting, and antibiotic control measures, in deployed medical treatment facilities is essential to reducing these healthcare-associated infections. This review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

  5. Medical error disclosure: from the therapeutic alliance to risk management: the vision of the new Italian code of medical ethics. (United States)

    Turillazzi, Emanuela; Neri, Margherita


    The Italian code of medical deontology recently approved stipulates that physicians have the duty to inform the patient of each unwanted event and its causes, and to identify, report and evaluate adverse events and errors. Thus the obligation to supply information continues to widen, in some way extending beyond the doctor-patient relationship to become an essential tool for improving the quality of professional services. The new deontological precepts intersect two areas in which the figure of the physician is paramount. On the one hand is the need for maximum integrity towards the patient, in the name of the doctor's own, and the other's (the patient's) dignity and liberty; on the other is the physician's developing role in the strategies of the health system to achieve efficacy, quality, reliability and efficiency, to reduce errors and adverse events and to manage clinical risk. In Italy, due to guidelines issued by the Ministry of Health and to the new code of medical deontology, the role of physicians becomes a part of a complex strategy of risk management based on a system focused approach in which increasing transparency regarding adverse outcomes and full disclosure of health- related negative events represent a key factor.

  6. Medical error disclosure: from the therapeutic alliance to risk management: the vision of the new Italian code of medical ethics (United States)


    Background The Italian code of medical deontology recently approved stipulates that physicians have the duty to inform the patient of each unwanted event and its causes, and to identify, report and evaluate adverse events and errors. Thus the obligation to supply information continues to widen, in some way extending beyond the doctor-patient relationship to become an essential tool for improving the quality of professional services. Discussion The new deontological precepts intersect two areas in which the figure of the physician is paramount. On the one hand is the need for maximum integrity towards the patient, in the name of the doctor’s own, and the other’s (the patient’s) dignity and liberty; on the other is the physician’s developing role in the strategies of the health system to achieve efficacy, quality, reliability and efficiency, to reduce errors and adverse events and to manage clinical risk. Summary In Italy, due to guidelines issued by the Ministry of Health and to the new code of medical deontology, the role of physicians becomes a part of a complex strategy of risk management based on a system focused approach in which increasing transparency regarding adverse outcomes and full disclosure of health- related negative events represent a key factor. PMID:25023339

  7. Is a shift from research on individual medical error to research on health information technology underway? A 40-year analysis of publication trends in medical journals. (United States)

    Erlewein, Daniel; Bruni, Tommaso; Gadebusch Bondio, Mariacarla


    In 1983, McIntyre and Popper underscored the need for more openness in dealing with errors in medicine. Since then, much has been written on individual medical errors. Furthermore, at the beginning of the 21st century, researchers and medical practitioners increasingly approached individual medical errors through health information technology. Hence, the question arises whether the attention of biomedical researchers shifted from individual medical errors to health information technology. We ran a study to determine publication trends concerning individual medical errors and health information technology in medical journals over the last 40 years. We used the Medical Subject Headings (MeSH) taxonomy in the database MEDLINE. Each year, we analyzed the percentage of relevant publications to the total number of publications in MEDLINE. The trends identified were tested for statistical significance. Our analysis showed that the percentage of publications dealing with individual medical errors increased from 1976 until the beginning of the 21st century but began to drop in 2003. Both the upward and the downward trends were statistically significant (P information technology doubled between 2003 and 2015. The upward trend was statistically significant (P information technology in the USA and the UK. © 2018 Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd.

  8. The role of radiology in diagnostic error: a medical malpractice claims review. (United States)

    Siegal, Dana; Stratchko, Lindsay M; DeRoo, Courtney


    Just as radiologic studies allow us to see past the surface to the vulnerable and broken parts of the human body, medical malpractice claims help us see past the surface of medical errors to the deeper vulnerabilities and potentially broken aspects of our healthcare delivery system. And just as the insights we gain through radiologic studies provide focus for a treatment plan for healing, so too can the analysis of malpractice claims provide insights to improve the delivery of safe patient care. We review 1325 coded claims where Radiology was the primary service provider to better understand the problems leading to patient harm, and the opportunities most likely to improve diagnostic care in the future.

  9. Preventable deaths following emergency medical dispatch - an audit study

    DEFF Research Database (Denmark)

    Andersen, Mikkel S; Johnsen, Søren; Hansen, Andreas


    an ambulance with lights and sirens by the Emergency Medical Communication Centre (EMCC).MethodsAn audit was performed by an external panel of experienced prehospital consultant anaesthesiologists. The panel focused exclusively on the role of the EMCC, assessing whether same-day deaths among 112 callers could...... have been prevented if the EMCC had assessed the situations as highly urgent. The panels¿ assessments were based on review of patient charts and voice-log recordings of 112 calls. All patient related material was reviewed by the audit panel and all cases where then scored as preventable, potentially......¿100 years) and 45.4% were female. The audit panel found no definitively preventable deaths; however, 18 (11.8%) of the analysed same-day deaths (0.02% of all non-high-acuity callers) were found to be potentially preventable. In 13 of these 18 cases, the dispatch protocol was either not used or not used...

  10. Organizational change and human expertise in nuclear power plants: some implications for training and error prevention

    International Nuclear Information System (INIS)

    Masson, M.; Malaise, N.; Housiaux, A.; Keyser, V. de


    Reliability and safety are two very important goals, which depend on technical and organizational factors, but also on human expertise. How to ensure a safe functioning of a nuclear power plant in a changing context, and what might be the role and aspects of training and transfer of knowledge? These are the questions we shall deal with in this paper, on the basis of two field studies. The two field studies stress the needs for setting up case based training, which best ensure the acquisition of know-how. Furthermore, as shown by the second one, gaining expertise involves developing large repertoires of highly skilled, semi-routinized activities. Supporting expert operators not only should tackle problem solving activities but should thus also include the prevention of routine errors, which go along with skill acquisition. (orig.)

  11. A Robust Ultra-Low Voltage CPU Utilizing Timing-Error Prevention

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    Markus Hiienkari


    Full Text Available To minimize energy consumption of a digital circuit, logic can be operated at sub- or near-threshold voltage. Operation at this region is challenging due to device and environment variations, and resulting performance may not be adequate to all applications. This article presents two variants of a 32-bit RISC CPU targeted for near-threshold voltage. Both CPUs are placed on the same die and manufactured in 28 nm CMOS process. They employ timing-error prevention with clock stretching to enable operation with minimal safety margins while maximizing performance and energy efficiency at a given operating point. Measurements show minimum energy of 3.15 pJ/cyc at 400 mV, which corresponds to 39% energy saving compared to operation based on static signoff timing.

  12. Establishment and application of medication error classification standards in nursing care based on the International Classification of Patient Safety

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    Xiao-Ping Zhu


    Conclusion: Application of this classification system will help nursing administrators to accurately detect system- and process-related defects leading to medication errors, and enable the factors to be targeted to improve the level of patient safety management.

  13. The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care

    NARCIS (Netherlands)

    Chedoe, Indra; Molendijk, Harry; Hospes, Wobbe; Van den Heuvel, Edwin B.; Taxis, Katja

    Objective To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU). Design Prospective study with a preintervention and postintervention measurement using direct observation. Setting

  14. Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm

    NARCIS (Netherlands)

    van de Plas, Afke; Slikkerveer, Mariëlle; Hoen, Saskia; Schrijnemakers, Rick; Driessen, Johanna; de Vries, Frank; van den Bemt, Patricia


    In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined. During baseline measurement, on control versus intervention ward, at least one administration error

  15. The effect of a clinical pharmacist-led training programme on intravenous medication errors : a controlled before and after study

    NARCIS (Netherlands)

    Nguyen, Huong; Pham, Hong-Tham; Vo, Dang-Khoa; Nguyen, Tuan-Dung; van den Heuvel, Edwin R.; Haaijer-Ruskamp, Flora M.; Taxis, Katja

    Background Little is known about interventions to reduce intravenous medication administration errors in hospitals, especially in low-and middle-income countries. Objective To assess the effect of a clinical pharmacist-led training programme on clinically relevant errors during intravenous

  16. Analysis of Factors and Medical Errors Involved in Patient Complaints in a European Emergency Department

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    Pauline Haroutunian


    Full Text Available Introduction: Patients’ complaints from Emergency Departments (ED are frequent and can be used as a quality assurance indicator. Objective: Factors contributing to patients’ complaints (PCs in the emergency department were analyzed.  Methods: It was a retrospective cohort study, the qualitative variables of patients’ complaints visiting ED of a university hospital were compared with Chi-Square and t test tests. Results: Eighty-five PC were analyzed. The factors contributing to PC were: communication (n=26, length of stay (LOS (n=24, diagnostic errors (n=21, comfort and privacy issues (n=7, pain management (n=6, inappropriate treatment (n=6, delay of care and billing issues (n=3. PCs were more frequent when patients were managed by residents, during night shifts, weekends, Saturdays, Mondays, January and June. Moreover, the factors contributing to diagnostic errors were due to poor communication, non-adherence to guidelines and lack of systematic proofreading of X-rays. In 98% of cases, disputes were resolved by apology and explanation and three cases resulted in financial compensation. Conclusion: Poor communication, LOS and medical errors are factors contributing to PCs. Improving communication, resolving issues leading to slow health care provision, adequate staffing and supervision of trainees may reduce PCs.

  17. The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care. (United States)

    Chedoe, Indra; Molendijk, Harry; Hospes, Wobbe; Van den Heuvel, Edwin R; Taxis, Katja


    To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU). Prospective study with a preintervention and postintervention measurement using direct observation. NICU in a tertiary hospital in the Netherlands. A multifaceted educational intervention including teaching and self-study. The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts. The incidence of errors decreased from 49% (43-54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25-36%). Preintervention, 0.3% (0-2%) medications contained severe errors, 26% (21-31%) moderate and 23% (18-28%) minor errors; postintervention, none 0% (0-2%) was severe, 23% (18-28%) moderate and 8% (5-12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29-0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)). The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.

  18. Study on the methodology for predicting and preventing errors to improve reliability of maintenance task in nuclear power plant

    International Nuclear Information System (INIS)

    Hanafusa, Hidemitsu; Iwaki, Toshio; Embrey, D.


    The objective of this study was to develop and effective methodology for predicting and preventing errors in nuclear power plant maintenance tasks. A method was established by which chief maintenance personnel can predict and reduce errors when reviewing the maintenance procedures and while referring to maintenance supporting systems and methods in other industries including aviation and chemical plant industries. The method involves the following seven steps: 1. Identification of maintenance tasks. 2. Specification of important tasks affecting safety. 3. Assessment of human errors occurring during important tasks. 4. Identification of Performance Degrading Factors. 5. Dividing important tasks into sub-tasks. 6. Extraction of errors using Predictive Human Error Analysis (PHEA). 7. Development of strategies for reducing errors and for recovering from errors. By way of a trial, this method was applied to the pump maintenance procedure in nuclear power plants. This method is believed to be capable of identifying the expected errors in important tasks and supporting the development of error reduction measures. By applying this method, the number of accidents resulting form human errors during maintenance can be reduced. Moreover, the maintenance support base using computers was developed. (author)

  19. Attitudes of Mashhad Public Hospital's Nurses and Midwives toward the Causes and Rates of Medical Errors Reporting. (United States)

    Mobarakabadi, Sedigheh Sedigh; Ebrahimipour, Hosein; Najar, Ali Vafaie; Janghorban, Roksana; Azarkish, Fatemeh


    Patient's safety is one of the main objective in healthcare services; however medical errors are a prevalent potential occurrence for the patients in treatment systems. Medical errors lead to an increase in mortality rate of the patients and challenges such as prolonging of the inpatient period in the hospitals and increased cost. Controlling the medical errors is very important, because these errors besides being costly, threaten the patient's safety. To evaluate the attitudes of nurses and midwives toward the causes and rates of medical errors reporting. It was a cross-sectional observational study. The study population was 140 midwives and nurses employed in Mashhad Public Hospitals. The data collection was done through Goldstone 2001 revised questionnaire. SPSS 11.5 software was used for data analysis. To analyze data, descriptive and inferential analytic statistics were used. Standard deviation and relative frequency distribution, descriptive statistics were used for calculation of the mean and the results were adjusted as tables and charts. Chi-square test was used for the inferential analysis of the data. Most of midwives and nurses (39.4%) were in age range of 25 to 34 years and the lowest percentage (2.2%) were in age range of 55-59 years. The highest average of medical errors was related to employees with three-four years of work experience, while the lowest average was related to those with one-two years of work experience. The highest average of medical errors was during the evening shift, while the lowest were during the night shift. Three main causes of medical errors were considered: illegibile physician prescription orders, similarity of names in different drugs and nurse fatigueness. The most important causes for medical errors from the viewpoints of nurses and midwives are illegible physician's order, drug name similarity with other drugs, nurse's fatigueness and damaged label or packaging of the drug, respectively. Head nurse feedback, peer

  20. Patient safety incident reports related to traditional Japanese Kampo medicines: medication errors and adverse drug events in a university hospital for a ten-year period. (United States)

    Shimada, Yutaka; Fujimoto, Makoto; Nogami, Tatsuya; Watari, Hidetoshi; Kitahara, Hideyuki; Misawa, Hiroki; Kimbara, Yoshiyuki


    transiently harmed and required substantial treatment). There are many patient safety issues related to Kampo medicines. Patient safety awareness should be raised to prevent medication errors, especially administration errors, and adverse drug events in Kampo medicine.

  1. Errores en la medicación: función del farmacéutico Medication errors: the pharmacist’s role

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    Amarilys Torres Domínguez


    Full Text Available El uso racional de los medicamentos contribuye significativamente al bienestar del individuo y por ende, al de la sociedad. Sin embargo, esta no es una situación fácil de lograr y mantener. La experiencia ha demostrado que en el camino entre la prescripción, la dispensación y la utilización final del medicamento por parte del paciente, a veces surgen problemas que llevan a una incorrecta utilización del fármaco o a la aparición de efectos indeseados. Esto genera inconvenientes para el paciente que no encuentra respuesta a su problema de salud y también para el sistema de salud que ven aumentados sus gastos. En este trabajo se propone describir los errores que pueden ocurrir con la medicación, su prevalencia en el mundo y las causas de este problema. Se destaca cual debe ser la función que le toca desempeñar a los farmacéuticos en la detección, prevención y resolución de estos, así como la necesidad de su vinculación con el equipo de salud, especialmente con los médicos, para garantizarle a los pacientes seguridad farmacoterapéutica.The rational use of drugs significantly contributes to the well-beign of the individual and, therefore, of society. However, it is not easy to attain and maintain this situation. Experience has proved that on the way among prescription, categorization and the final use of the drug by the patient, there appear problems leading to the incorrect administration of the drug or to the presence of undesired effects. This generates inconveniences for the patient that does not find an answer to his health problem and also to the health system, whose expenses increase. This paper is aimed at describing the errors found in medication, their prevalence in the world and the causes of this problem The role the pharmacist should play in the detection, prevention and resolution of them, is stressed, as well as the need of their connection with the health team, specially with doctors, to guarantee a .safe drug

  2. Medication Errors in Hospitals: A Study of Factors Affecting Nursing Reporting in a Selected Center Affiliated with Shahid Beheshti University of Medical Sciences

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    HamidReza Mirzaee


    Full Text Available Background: Medication errors are mentioned as the most common important challenges threatening healthcare system in all countries worldwide. This study is conducted to investigate the most significant factors in refusal to report medication errors among nursing staff.Methods: The cross-sectional study was conducted on all nursing staff of a selected Education& Treatment Center in 2013. Data was collected through a teacher made questionnaire. The questionnaires’ face and content validity was confirmed by experts and for measuring its reliability test-retest was used. Data was analyzed by descriptive and analytic statistics. 16th  version of SPSS was also used for related statistics.Results: The most important factors in refusal to report medication errors respectively are: lack of reporting system in the hospital(3.3%, non-significance of reporting medication errors to hospital authorities and lack of appropriate feedback(3.1%, and lack of a clear definition for a medication error (3%. there was a significant relationship between the most important factors of refusal to report medication errors and work shift (p:0.002, age(p:0.003, gender(p:0.005, work experience(p<0.001 and employment type of nurses(p:0.002.Conclusion: Factors pertaining to management in hospitals as well as the fear of the consequences of reporting are two broad fields among the factors that make nurses not report their medication errors. In this regard, providing enough education to nurses, boosting the job security for nurses, management support and revising related processes and definitions are some factors that can help decreasing medication errors and increasing their report in case of occurrence.

  3. Caffeine for the prevention of injuries and errors in shift workers. (United States)

    Ker, Katharine; Edwards, Philip James; Felix, Lambert M; Blackhall, Karen; Roberts, Ian


    Sleepiness leads to a deterioration in performance and attention, and is associated with an increased risk of injury. Jet lag and shift work disorder are circadian rhythm sleep disorders which result in sleepiness and can elevate injury risk. They create a need for individuals to operate at times which are different to those dictated by their circadian rhythms. Consequently there is also a need for interventions to help ensure that these persons can do so safely. Caffeine has a potential role in promoting alertness during times of desired wakefulness in persons with jet lag or shift work disorder, however its effects on injury and error are unclear. To assess the effects of caffeine for preventing injuries caused by impaired alertness in persons with jet lag or shift work disorder. We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, CINAHL, TRANSPORT (to July 2008); and PubMed databases (to April 2010). We also searched the Internet and checked reference lists of relevant papers. Randomised controlled trials investigating the effects of caffeine on injury, error or cognitive performance in people with jet lag or shift work disorder. Two authors independently screened search results and assessed full texts for inclusion. Data were extracted and risk of bias was assessed. Estimates of treatment effect (odds ratio and standardised mean difference (SMD)) and 95% confidence intervals (CI) were calculated and pooled using the fixed-effect model. Thirteen trials were included. None measured an injury outcome. Two trials measured error, and the remaining trials used neuropsychological tests to assess cognitive performance. The trials assessing the impact on errors found that caffeine significantly reduced the number of errors compared to placebo. The pooled effect estimates on performance by cognitive domain suggest that, when compared to placebo, caffeine improved concept formation and reasoning (SMD -0

  4. Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes. (United States)

    Verghese, Abraham; Charlton, Blake; Kassirer, Jerome P; Ramsey, Meghan; Ioannidis, John P A


    Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences. A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting. Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to perform the physical examination in 63%; 14% reported that the correct physical examination sign was elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought. Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the finding was 2, but many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66 took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen, groin, and genitourinary area could reduce the reported oversights by half. Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform the relevant examination. Copyright © 2015 Elsevier Inc. All rights reserved.

  5. Putting tobacco cessation and prevention into undergraduate medical education

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    Sanghamitra Pati


    Full Text Available Background: Training medical students in tobacco prevention and cessation skills is critical to have competent physicians who are prepared to address the grave levels of morbidity and mortality associated with tobacco use. However, in India, enough attention has not been given to elicit the active participation of physicians in tobacco control. Keeping this in view, a program was undertaken to develop the skills and competence of medical students with the objective of improving medical student inquiry into smoking and the delivery of advice accordingly for patients in their clinical year′s routine consultations. Methods: The targeted learners were 149 1 st -year medical and dental students of SCB Medical College, Cuttack, Orissa, India, who had appeared the second semester examination; 84 of the participants were male. Students were allowed to appear a test before the training session on knowledge of tobacco cessation and post test was done after 1.5 months of training. The knowledge score was evaluated to evaluate the learning outcome. Results: We observed that a curriculum on tobacco intervention could improve relevant knowledge, attitudes and self-confidence and be applied in students early clinical experiences. Conclusions: There is need of joint action by practicing clinicians, the medical faculty and the curriculum planners of the country to incorporate tobacco cessation into the curriculum.

  6. Evaluation of real-time data obtained from gravimetric preparation of antineoplastic agents shows medication errors with possible critical therapeutic impact: Results of a large-scale, multicentre, multinational, retrospective study. (United States)

    Terkola, R; Czejka, M; Bérubé, J


    Medication errors are a significant cause of morbidity and mortality especially with antineoplastic drugs, owing to their narrow therapeutic index. Gravimetric workflow software systems have the potential to reduce volumetric errors during intravenous antineoplastic drug preparation which may occur when verification is reliant on visual inspection. Our aim was to detect medication errors with possible critical therapeutic impact as determined by the rate of prevented medication errors in chemotherapy compounding after implementation of gravimetric measurement. A large-scale, retrospective analysis of data was carried out, related to medication errors identified during preparation of antineoplastic drugs in 10 pharmacy services ("centres") in five European countries following the introduction of an intravenous workflow software gravimetric system. Errors were defined as errors in dose volumes outside tolerance levels, identified during weighing stages of preparation of chemotherapy solutions which would not otherwise have been detected by conventional visual inspection. The gravimetric system detected that 7.89% of the 759 060 doses of antineoplastic drugs prepared at participating centres between July 2011 and October 2015 had error levels outside the accepted tolerance range set by individual centres, and prevented these doses from reaching patients. The proportion of antineoplastic preparations with deviations >10% ranged from 0.49% to 5.04% across sites, with a mean of 2.25%. The proportion of preparations with deviations >20% ranged from 0.21% to 1.27% across sites, with a mean of 0.71%. There was considerable variation in error levels for different antineoplastic agents. Introduction of a gravimetric preparation system for antineoplastic agents detected and prevented dosing errors which would not have been recognized with traditional methods and could have resulted in toxicity or suboptimal therapeutic outcomes for patients undergoing anticancer treatment.

  7. Physician Acceptance of Pharmacist Recommendations about Medication Prescribing Errors in Iraqi Hospitals

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    Full Text Available The objectives of this study were to measure the incidence and types of medication prescribing errors (MPEs in Iraqi hospitals, to calculate for the first time the percentage of physician agreement with pharmacist medication regimen review (MRR recommendations regarding MPEs, and to identify the factors influencing the physician agreement rate with these recommendations. Methods: Fourteen pharmacists (10 females and 4 males reviewed each hand-written physician order for 1506 patients who were admitted to two public hospitals in Al-Najaf, Iraq during August 2015. The pharmacists identified medication prescribing errors using the Medscape WebMD, LCC phone application as a reference. The pharmacists contacted the physicians (2 females and 34 males in-person to address MPEs that were identified. Results: The pharmacists identified 78 physician orders containing 99 MPEs with an incidence of 6.57 percent of all the physician orders reviewed. The patients with MPEs were taking 4.8 medications on average. The MPEs included drug-drug interactions (65.7%, incorrect doses (16.2%, unnecessary medications (8.1%, contra-indications (7.1%, incorrect drug duration (2%, and untreated conditions (1%. The physicians implemented 37 (37.4% pharmacist recommendations. Three factors were significantly related to physician acceptance of pharmacist recommendations. These were physician specialty, pharmacist gender, and patient gender. Pediatricians were less likely (OR= 0.1 to accept pharmacist recommendations compared to internal medicine physicians. Male pharmacists received more positive responses from physicians (OR=7.11 than female pharmacists. Lastly, the recommendations were significantly more likely to be accepted (OR= 3.72 when the patients were females. Conclusions: The incidence of MPEs is higher in Iraqi hospitalized patients than in the U.S. and U.K, but lower than in Brazil, Ethiopia, India, and Croatia. Drug-drug interactions were the most common type of

  8. Simulated disclosure of a medical error by residents: development of a course in specific communication skills. (United States)

    Raper, Steven E; Resnick, Andrew S; Morris, Jon B


    Surgery residents are expected to demonstrate the ability to communicate with patients, families, and the public in a wide array of settings on a wide variety of issues. One important setting in which residents may be required to communicate with patients is in the disclosure of medical error. This article details one approach to developing a course in the disclosure of medical errors by residents. Before the development of this course, residents had no education in the skills necessary to disclose medical errors to patients. Residents viewed a Web-based video didactic session and associated slide deck and then were filmed disclosing a wrong-site surgery to a standardized patient (SP). The filmed encounter was reviewed by faculty, who then along with the SP scored each encounter (5-point Likert scale) over 10 domains of physician-patient communication. The residents received individualized written critique, the numerical analysis of their individual scenario, and an opportunity to provide feedback over a number of domains. A mean score of 4.00 or greater was considered satisfactory. Faculty and SP assessments were compared with Student t test. Residents were filmed in a one-on-one scenario in which they had to disclose a wrong-site surgery to a SP in a Simulation Center. A total of 12 residents, shortly to enter the clinical postgraduate year 4, were invited to participate, as they will assume service leadership roles. All were finishing their laboratory experiences, and all accepted the invitation. Residents demonstrated satisfactory competence in 4 of the 10 domains assessed by the course faculty. There were significant differences in the perceptions of the faculty and SP in 5 domains. The residents found this didactic, simulated experience of value (Likert score ≥4 in 5 of 7 domains assessed in a feedback tool). Qualitative feedback from the residents confirmed the realistic feel of the encounter and other impressions. We were able to quantitatively

  9. Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting. (United States)

    Patterson, Mark E; Pace, Heather A; Fincham, Jack E


    Although error-reporting systems enable hospitals to accurately track safety climate through the identification of adverse events, these systems may be underused within a work climate of poor communication. The objective of this analysis is to identify the extent to which perceived communication climate among hospital pharmacists impacts medical error reporting rates. This cross-sectional study used survey responses from more than 5000 pharmacists responding to the 2010 Hospital Survey on Patient Safety Culture (HSOPSC). Two composite scores were constructed for "communication openness" and "feedback and about error," respectively. Error reporting frequency was defined from the survey question, "In the past 12 months, how many event reports have you filled out and submitted?" Multivariable logistic regressions were used to estimate the likelihood of medical error reporting conditional upon communication openness or feedback levels, controlling for pharmacist years of experience, hospital geographic region, and ownership status. Pharmacists with higher communication openness scores compared with lower scores were 40% more likely to have filed or submitted a medical error report in the past 12 months (OR, 1.4; 95% CI, 1.1-1.7; P = 0.004). In contrast, pharmacists with higher communication feedback scores were not any more likely than those with lower scores to have filed or submitted a medical report in the past 12 months (OR, 1.0; 95% CI, 0.8-1.3; P = 0.97). Hospital work climates that encourage pharmacists to freely communicate about problems related to patient safety is conducive to medical error reporting. The presence of feedback infrastructures about error may not be sufficient to induce error-reporting behavior.

  10. Comparison of community and hospital pharmacists' attitudes and behaviors on medication error disclosure to the patient: A pilot study. (United States)

    Kim, ChungYun; Mazan, Jennifer L; Quiñones-Boex, Ana C

    To determine pharmacists' attitudes and behaviors on medication errors and their disclosure and to compare community and hospital pharmacists on such views. An online questionnaire was developed from previous studies on physicians' disclosure of errors. Questionnaire items included demographics, environment, personal experiences, and attitudes on medication errors and the disclosure process. An invitation to participate along with the link to the questionnaire was electronically distributed to members of two Illinois pharmacy associations. A follow-up reminder was sent 4 weeks after the original message. Data were collected for 3 months, and statistical analyses were performed with the use of IBM SPSS version 22.0. The overall response rate was 23.3% (n = 422). The average employed respondent was a 51-year-old white woman with a BS Pharmacy degree working in a hospital pharmacy as a clinical staff member. Regardless of practice settings, pharmacist respondents agreed that medication errors were inevitable and that a disclosure process is necessary. Respondents from community and hospital settings were further analyzed to assess any differences. Community pharmacist respondents were more likely to agree that medication errors were inevitable and that pharmacists should address the patient's emotions when disclosing an error. Community pharmacist respondents were also more likely to agree that the health care professional most closely involved with the error should disclose the error to the patient and thought that it was the pharmacists' responsibility to disclose the error. Hospital pharmacist respondents were more likely to agree that it was important to include all details in a disclosure process and more likely to disagree on putting a "positive spin" on the event. Regardless of practice setting, responding pharmacists generally agreed that errors should be disclosed to patients. There were, however, significant differences in their attitudes and behaviors

  11. Adherence to the Australian National Inpatient Medication Chart: the efficacy of a uniform national drug chart on improving prescription error. (United States)

    Atik, Alp


    In 2006, the National Inpatient Medication Chart (NIMC) was introduced as a uniform medication chart in Australian public hospitals with the aim of reducing prescription error. The rate of regular medication prescription error in the NIMC was assessed. Data was collected using the NIMC Audit Tool and analyzed with respect to causes of error per medication prescription and per medication chart. The following prescription requirements were assessed: date, generic drug name, route of administration, dose, frequency, administration time, indication, signature, name and contact details. A total of 1877 medication prescriptions were reviewed. 1653 prescriptions (88.07%) had no contact number, 1630 (86.84%) did not have an indication, 1230 and 675 (35.96%) used a drug's trade name. Within 261 medication charts, all had at least one entry, which did not include an indication, 258 (98.85%) had at least one entry, which did not have a contact number and 200 (76.63%) had at least one entry, which used a trade name. The introduction of a uniform national medication chart is a positive step, but more needs to be done to address the root causes of prescription error. © 2012 John Wiley & Sons Ltd.

  12. Role of the pharmacist in preventing distribution of counterfeit medications. (United States)

    Chambliss, Walter G; Carroll, Wesley A; Kennedy, Daniel; Levine, Donald; Moné, Michael A; Ried, L Douglas; Shepherd, Marv; Yelvigi, Mukund


    To provide an overview of the counterfeit medication problem and recommendations of a joint American Pharmacists Association (APhA) Academy of Pharmaceutical Research and Science and APhA Academy of Pharmacy Practice and Management taskforce. SciFinder and PubMed were searched from 1980 to March 2011 using the following keywords: counterfeit drug product, counterfeit medications, drug product authentication, drug product verification, and track-and-trace. Publications, presentations, and websites of organizations that research the counterfeit medication problem in the United States and other countries were reviewed. A representative from the security division of a pharmaceutical manufacturer and a representative from a supplier of anticounterfeiting technologies gave presentations to the taskforce. The taskforce recommends that pharmacists (1) purchase medications from known, reliable sources; (2) warn patients of the dangers of purchasing medications over the Internet; (3) confirm with distributors that products were purchased from manufacturers or other reliable sources; (4) monitor counterfeit product alerts; (5) examine products for suspicious appearance; (6) work with the pharmaceutical industry, distributors, and the Food and Drug Administration (FDA) to close gaps in the supply chain, especially for drugs in short supply; (7) use scanning technology in the pharmacy as part of a prescription verification process; (8) educate themselves, coworkers, and patients about the risks of counterfeit medications; and (9) report suspicious medications to FDA, the distributor, and the manufacturer. The consequence of a patient receiving a counterfeit medication in the United States could be catastrophic, and pharmacists must play an active role in preventing such an event from occurring.

  13. Medication effectiveness may not be the major reason for accepting cardiovascular preventive medication

    DEFF Research Database (Denmark)

    Harmsen, Charlotte Gry; Støvring, Henrik; Jarbøl, Dorte Ejg


    Shared decision-making and patients' choice of interventions are areas of increasing importance, not least seen in the light of the fact that chronic conditions are increasing, interventions considered important for public health, and still non-acceptance of especially risk-reducing treatments...... of cardiovascular diseases (CVD) is prevalent. A better understanding of patients' medication-taking behavior is needed and may be reached by studying the reasons why people accept or decline medication recommendations. The aim of this paper was to identify factors that may influence people's decisions...... and reasoning for accepting or declining a cardiovascular preventive medication offer....

  14. Medical identity theft: prevention and reconciliation initiatives at Massachusetts General Hospital. (United States)

    Judson, Timothy; Haas, Mark; Lagu, Tara


    Medical identity theft refers to the misuse of another individual's identifying medical information to receive medical care. Beyond the financial burden on patients, hospitals, health insurance companies, and government insurance programs, undetected cases pose major patient safety challenges. Inaccuracies in the medical record may persist even after the theft has been identified because of restrictions imposed by patient privacy laws. Massachusetts General Hospital (MGH; Boston) has conducted initiatives to prevent medical identity theft and to better identify and respond to cases when they occur. Since 2007, MGH has used a notification tree to standardize reporting of red flag incidents (warning signs of identity theft, such as suspicious personal identifiers or account activity). A Data Integrity Dashboard allows for tracking and reviewing of all potential incidents of medical identity theft to detect trends and targets for mitigation. An identity-checking policy, VERI-(Verify Everyone's Identity) Safe Patient Care, requires photo identification at every visit and follow-up if it is not provided. Data from MGH suggest that an estimated 120 duplicate medical records are created each month, 25 patient encounters are likely tied to identity theft or fraud each quarter, and 14 patients are treated under the wrong medical record number each year. As of December 2013, 80%-85% of patients were showing photo identification at appointments. Although an organization's policy changes and educational campaigns can improve detection and reconciliation of medical identity theft cases, national policies should be implemented to streamline the process of correcting errors in medical records, reduce the financial disincentive for hospitals to detect and report cases, and create a single point of entry to reduce the burden on individuals and providers to reconcile cases.

  15. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. (United States)

    Garrouste-Orgeas, Maité; Perrin, Marion; Soufir, Lilia; Vesin, Aurélien; Blot, François; Maxime, Virginie; Beuret, Pascal; Troché, Gilles; Klouche, Kada; Argaud, Laurent; Azoulay, Elie; Timsit, Jean-François


    Staff behaviours to optimise patient safety may be influenced by burnout, depression and strength of the safety culture. We evaluated whether burnout, symptoms of depression and safety culture affected the frequency of medical errors and adverse events (selected using Delphi techniques) in ICUs. Prospective, observational, multicentre (31 ICUs) study from August 2009 to December 2011. Burnout, depression symptoms and safety culture were evaluated using the Maslach Burnout Inventory (MBI), CES-Depression scale and Safety Attitudes Questionnaire, respectively. Of 1,988 staff members, 1,534 (77.2 %) participated. Frequencies of medical errors and adverse events were 804.5/1,000 and 167.4/1,000 patient-days, respectively. Burnout prevalence was 3 or 40 % depending on the definition (severe emotional exhaustion, depersonalisation and low personal accomplishment; or MBI score greater than -9). Depression symptoms were identified in 62/330 (18.8 %) physicians and 188/1,204 (15.6 %) nurses/nursing assistants. Median safety culture score was 60.7/100 [56.8-64.7] in physicians and 57.5/100 [52.4-61.9] in nurses/nursing assistants. Depression symptoms were an independent risk factor for medical errors. Burnout was not associated with medical errors. The safety culture score had a limited influence on medical errors. Other independent risk factors for medical errors or adverse events were related to ICU organisation (40 % of ICU staff off work on the previous day), staff (specific safety training) and patients (workload). One-on-one training of junior physicians during duties and existence of a hospital risk-management unit were associated with lower risks. The frequency of selected medical errors in ICUs was high and was increased when staff members had symptoms of depression.

  16. Culture, ritual, and errors of repudiation: some implications for the assessment of alternative medical traditions. (United States)

    Trotter, G


    In this article, sources of error that are likely involved when alternative medical traditions are assessed from the standpoint of orthodox biomedicine are discussed. These sources include (1) biomedicine's implicit reductive materialism (manifested in its negative orientation toward placebo effects), (2) a related bias against ritual, and (3) cultural barriers to the construction of externally valid protocols. To overcome these biases, investigators must attend to ritualistic elements in alternative treatments and should recruit patients from appropriate cultural groups. Collaborative research may be the key. Benefits of collaborative research include (1) increased mutual respect and integration between culturally distinct groups and practices, (2) increased understanding and use of sophisticated techniques of empirical analysis among practitioners from the alternative traditions, (3) increased appropriation of the therapeutic benefits of ritual, and (4) enhanced overall benefit for patients of all cultural backgrounds.

  17. The impact of participative management perceptions on customer service, medical errors, burnout, and turnover intentions. (United States)

    Angermeier, Ingo; Dunford, Benjamin B; Boss, Alan D; Boss, R Wayne


    Numerous challenges confront managers in the healthcare industry, making it increasingly difficult for healthcare organizations to gain and sustain a competitive advantage. Contemporary management challenges in the industry have many different origins (e.g., economic, financial, clinical, and legal), but there is growing recognition that some of management's greatest problems have organizational roots. Thus, healthcare organizations must examine their personnel management strategies to ensure that they are optimized for fostering a highly committed and productive workforce. Drawing on a sample of 2,522 employees spread across 312 departments within a large U.S. healthcare organization, this article examines the impact of a participative management climate on four employee-level outcomes that represent some of the greatest challenges in the healthcare industry: customer service, medical errors, burnout, and turnover intentions. This study provides clear evidence that employee perceptions of the extent to which their work climate is participative rather than authoritarian have important implications for critical work attitudes and behavior. Specifically, employees in highly participative work climates provided 14 percent better customer service, committed 26 percent fewer clinical errors, demonstrated 79 percent lower burnout, and felt 61 percent lower likelihood of leaving the organization than employees in more authoritarian work climates. These findings suggest that participative management initiatives have a significant impact on the commitment and productivity of individual employees, likely improving the patient care and effectiveness of healthcare organizations as a whole.

  18. Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding. (United States)

    MacKay, Mark; Anderson, Collin; Boehme, Sabrina; Cash, Jared; Zobell, Jeffery


    The Institute for Safe Medication Practices has stated that parenteral nutrition (PN) is considered a high-risk medication and has the potential of causing harm. Three organizations--American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society of Health-System Pharmacists, and National Advisory Group--have published guidelines for ordering, transcribing, compounding and administering PN. These national organizations have published data on compliance to the guidelines and the risk of errors. The purpose of this article is to compare total compliance with ordering, transcription, compounding, administration, and error rate with a large pediatric institution. A computerized prescriber order entry (CPOE) program was developed that incorporates dosing with soft and hard stop recommendations and simultaneously eliminating the need for paper transcription. A CPOE team prioritized and identified issues, then developed solutions and integrated innovative CPOE and automated compounding device (ACD) technologies and practice changes to minimize opportunities for medication errors in PN prescription, transcription, preparation, and administration. Thirty developmental processes were identified and integrated in the CPOE program, resulting in practices that were compliant with A.S.P.E.N. safety consensus recommendations. Data from 7 years of development and implementation were analyzed and compared with published literature comparing error, harm rates, and cost reductions to determine if our process showed lower error rates compared with national outcomes. The CPOE program developed was in total compliance with the A.S.P.E.N. guidelines for PN. The frequency of PN medication errors at our hospital over the 7 years was 230 errors/84,503 PN prescriptions, or 0.27% compared with national data that determined that 74 of 4730 (1.6%) of prescriptions over 1.5 years were associated with a medication error. Errors were categorized by steps in the PN process

  19. Social network approaches to recruitment, HIV prevention, medical care, and medication adherence. (United States)

    Latkin, Carl A; Davey-Rothwell, Melissa A; Knowlton, Amy R; Alexander, Kamila A; Williams, Chyvette T; Boodram, Basmattee


    This article reviews the current issues and advancements in social network approaches to HIV prevention and care. Social network analysis can provide a method to understand health disparities in HIV rates, treatment access, and outcomes. Social network analysis is a valuable tool to link social structural factors to individual behaviors. Social networks provide an avenue for low-cost and sustainable HIV prevention interventions that can be adapted and translated into diverse populations. Social networks can be utilized as a viable approach to recruitment for HIV testing and counseling, HIV prevention interventions, optimizing HIV medical care, and medication adherence. Social network interventions may be face-to-face or through social media. Key issues in designing social network interventions are contamination due to social diffusion, network stability, density, and the choice and training of network members. There are also ethical issues involved in the development and implementation of social network interventions. Social network analyses can also be used to understand HIV transmission dynamics.

  20. Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry. (United States)

    Oliven, A; Zalman, D; Shilankov, Y; Yeshurun, D; Odeh, M


    Computerized prescription of drugs is expected to reduce the number of many preventable drug ordering errors. In the present study we evaluated the usefullness of a computerized drug order entry (CDOE) system in reducing prescription errors. A department of internal medicine using a comprehensive CDOE, which included also patient-related drug-laboratory, drug-disease and drug-allergy on-line surveillance was compared to a similar department in which drug orders were handwritten. CDOE reduced prescription errors to 25-35%. The causes of errors remained similar, and most errors, on both departments, were associated with abnormal renal function and electrolyte balance. Residual errors remaining on the CDOE-using department were due to handwriting on the typed order, failure to feed patients' diseases, and system failures. The use of CDOE was associated with a significant reduction in mean hospital stay and in the number of changes performed in the prescription. The findings of this study both quantity the impact of comprehensive CDOE on prescription errors and delineate the causes for remaining errors.

  1. ِDesigning a Model to Medical Errors Prediction for Outpatients Visits According to Rganizational Commitment and Job Involvement

    Directory of Open Access Journals (Sweden)

    SM Mirhosseini


    Full Text Available Abstract Introduction: A wide ranges of variables effect on the medical errors such as job involvement and organizational commitment. Coincidental relationship between two variables on medical errors during outpatients’ visits has been investigated to design a model. Methods: A field study with 114 physicians during outpatients’ visits revealed the mean of medical errors. Azimi and Allen-meyer questionnaires were used to measure Job involvement and organizational commitment. Physicians divided into four groups according to the Job involvement and organizational commitment in two dimensions (Zone1: high job involvement and high organizational commitment, Zone2: high job involvement and low organizational commitment, Zone3: low job involvement and high organizational commitment, Zone 4: low job involvement and low organizational commitment. ANOVA and Scheffe test were conducted to analyse the medical errors in four Zones by SPSS22. A guideline was presented according to the relationship between errors and two other variables. Results: The mean of organizational commitment was 79.50±12.30 and job involvement 12.72±3.66, medical errors in first group (0.32, second group (0.51, third group (0.41 and last one (0.50. ANOVA (F test=22.20, sig=0.00 and Scheffé were significant except for the second and forth group. The validity of the model was 73.60%. Conclusion: Applying some strategies to boost the organizational commitment and job involvement can help for diminishing the medical errors during outpatients’ visits. Thus, the investigation to comprehend the factors contributing organizational commitment and job involvement can be helpful.

  2. Is it possible to eliminate patient identification errors in medical imaging? (United States)

    Danaher, Luke A; Howells, Joan; Holmes, Penny; Scally, Peter


    The aim of this article is to review a system that validates and documents the process of ensuring the correct patient, correct site and side, and correct procedure (commonly referred to as the 3 C's) within medical imaging. A 4-step patient identification and procedure matching process was developed using health care and aviation models. The process was established in medical imaging departments after a successful interventional radiology pilot program. The success of the project was evaluated using compliance audit data, incident reporting data before and after the implementation of the process, and a staff satisfaction survey. There was 95% to 100% verification of site and side and 100% verification of correct patient, procedure, and consent. Correct patient data and side markers were present in 82% to 95% of cases. The number of incidents before and after the implementation of the 3 C's was difficult to assess because of a change in reporting systems and incident underreporting. More incidents are being reported, particularly "near misses." All near misses were related to incorrect patient identification stickers being placed on request forms. The majority of staff members surveyed found the process easy (55.8%), quick (47.7%), relevant (51.7%), and useful (60.9%). Although identification error is difficult to eliminate, practical initiatives can engender significant systems improvement in complex health care environments. Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.

  3. Applying Intelligent Algorithms to Automate the Identification of Error Factors. (United States)

    Jin, Haizhe; Qu, Qingxing; Munechika, Masahiko; Sano, Masataka; Kajihara, Chisato; Duffy, Vincent G; Chen, Han


    Medical errors are the manifestation of the defects occurring in medical processes. Extracting and identifying defects as medical error factors from these processes are an effective approach to prevent medical errors. However, it is a difficult and time-consuming task and requires an analyst with a professional medical background. The issues of identifying a method to extract medical error factors and reduce the extraction difficulty need to be resolved. In this research, a systematic methodology to extract and identify error factors in the medical administration process was proposed. The design of the error report, extraction of the error factors, and identification of the error factors were analyzed. Based on 624 medical error cases across four medical institutes in both Japan and China, 19 error-related items and their levels were extracted. After which, they were closely related to 12 error factors. The relational model between the error-related items and error factors was established based on a genetic algorithm (GA)-back-propagation neural network (BPNN) model. Additionally, compared to GA-BPNN, BPNN, partial least squares regression and support vector regression, GA-BPNN exhibited a higher overall prediction accuracy, being able to promptly identify the error factors from the error-related items. The combination of "error-related items, their different levels, and the GA-BPNN model" was proposed as an error-factor identification technology, which could automatically identify medical error factors.

  4. Optical correction of refractive error for preventing and treating eye symptoms in computer users. (United States)

    Heus, Pauline; Verbeek, Jos H; Tikka, Christina


    Computer users frequently complain about problems with seeing and functioning of the eyes. Asthenopia is a term generally used to describe symptoms related to (prolonged) use of the eyes like ocular fatigue, headache, pain or aching around the eyes, and burning and itchiness of the eyelids. The prevalence of asthenopia during or after work on a computer ranges from 46.3% to 68.5%. Uncorrected or under-corrected refractive error can contribute to the development of asthenopia. A refractive error is an error in the focusing of light by the eye and can lead to reduced visual acuity. There are various possibilities for optical correction of refractive errors including eyeglasses, contact lenses and refractive surgery. To examine the evidence on the effectiveness, safety and applicability of optical correction of refractive error for reducing and preventing eye symptoms in computer users. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; Embase; Web of Science; and OSH update, all to 20 December 2017. Additionally, we searched trial registries and checked references of included studies. We included randomised controlled trials (RCTs) and quasi-randomised trials of interventions evaluating optical correction for computer workers with refractive error for preventing or treating asthenopia and their effect on health related quality of life. Two authors independently assessed study eligibility and risk of bias, and extracted data. Where appropriate, we combined studies in a meta-analysis. We included eight studies with 381 participants. Three were parallel group RCTs, three were cross-over RCTs and two were quasi-randomised cross-over trials. All studies evaluated eyeglasses, there were no studies that evaluated contact lenses or surgery. Seven studies evaluated computer glasses with at least one focal area for the distance of the computer screen with or without additional focal areas in presbyopic persons. Six studies compared computer

  5. Epidemiology of Adverse Events and Medical Errors in the Care of Cardiology Patients. (United States)

    Ohta, Yoshinori; Miki, Izumi; Kimura, Takeshi; Abe, Mitsuru; Sakuma, Mio; Koike, Kaoru; Morimoto, Takeshi


    There have been epidemiological studies of adverse events (AEs) among general patients but those of patients cared by cardiologist are not well scrutinized. We investigated the occurrence of AEs and medical errors (MEs) among adult patients with cardiology in Japan. We conducted a cross-sectional study of adult outpatients at a Japanese teaching hospital from February through November 2006. We measured AE and ME incidents from patient report, which were verified by medical records, laboratory data, incident reports, and prescription queries. Two independent physicians reviewed the incidents to determine whether they were AEs or MEs and to assess severity and symptoms. We identified 144 AEs and 30 MEs (16.3 and 3.9 per 100 patients, respectively). Of the 144 AEs, 99 were solely adverse drug events (ADEs), 20 were solely non-ADEs, and the remaining 25 were both causes. The most frequent symptoms of ADEs were skin and allergic reactions due to medication. The most frequent symptoms of non-ADEs were bleeding due to therapeutic interventions. Among AEs, 12% was life threatening. Life-threatening AEs were 25% of non-ADEs and 5% of ADEs (P = 0.0003). Among the 30 MEs, 21MEs (70%) were associated with drugs. Adverse events were common among cardiology patients. Adverse drug events were the most frequent AEs, and non-ADEs were more critical than ADEs. Such data should be recognized among practicing physicians to improve the patients' outcomes.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

  6. [Accuracy in the medication history and reconciliation errors in the emergency department]. (United States)

    de Andrés-Lázaro, Ana M; Sevilla-Sánchez, Daniel; Ortega-Romero, M del Mar; Codina-Jané, Carles; Calderón-Hernanz, Beatriz; Sánchez-Sánchez, Miquel


    To assess the accuracy of pharmaceutical anamnesis obtained at the Emergency Department (ED) of a tertiary referral hospital and to determine the prevalence of medication reconciliation errors (RE). This was a single-center, prospective, interventional study. The home medication list obtained by a pharmacist was compared with the one recorded by a doctor to identify inaccuracies. Subsequently, the home medication list was compared with the active prescription at the ED. All unexplained discrepancies were checked with the doctor in charge to evaluate if a RE has occurred. An univariate analysis was performed to identify factors associated with RE. The pharmacist identified a higher number of drugs than doctors (6.89 versus 5.70; P<0.05). Only 39% of the drugs obtained by doctors were properly written down in the patient's record. The main cause of discrepancy was omission of information regarding the name of the drug (39%) or its dosage (33%). One hundred and fifty-seven RE were identified and they affected 85 patients (43%), mainly related to information omission (62%). Age and polymedication were identified as main risk factors of RE. The presence of a caregiver or relative in the ED was judged to be a protective factor. No relationship was found between inaccuracies in the registries and RE. The process of obtaining a proper pharmaceutical anamnesis still needs improvement. The pharmacist may play a role in the process of obtaining a good quality anamnesis and increase patient safety by detecting RE. Better information systems are needed to avoid this type of incidents. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

  7. Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era. (United States)

    Wang, Hua-Fen; Jin, Jing-Fen; Feng, Xiu-Qin; Huang, Xin; Zhu, Ling-Ling; Zhao, Xiao-Ying; Zhou, Quan


    Medication errors may occur during prescribing, transcribing, prescription auditing, preparing, dispensing, administration, and monitoring. Medication administration errors (MAEs) are those that actually reach patients and remain a threat to patient safety. The Joint Commission International (JCI) advocates medication error prevention, but experience in reducing MAEs during the period of before and after JCI accreditation has not been reported. An intervention study, aimed at reducing MAEs in hospitalized patients, was performed in the Second Affiliated Hospital of Zhejiang University, Hangzhou, People's Republic of China, during the journey to JCI accreditation and in the post-JCI accreditation era (first half-year of 2011 to first half-year of 2014). Comprehensive interventions included organizational, information technology, educational, and process optimization-based measures. Data mining was performed on MAEs derived from a compulsory electronic reporting system. The number of MAEs continuously decreased from 143 (first half-year of 2012) to 64 (first half-year of 2014), with a decrease in occurrence rate by 60.9% (0.338% versus 0.132%, P<0.05). The number of MAEs related to high-alert medications decreased from 32 (the second half-year of 2011) to 16 (the first half-year of 2014), with a decrease in occurrence rate by 57.9% (0.0787% versus 0.0331%, P<0.05). Omission was the top type of MAE during the first half-year of 2011 to the first half-year of 2014, with a decrease by 50% (40 cases versus 20 cases). Intravenous administration error was the top type of error regarding administration route, but it continuously decreased from 64 (first half-year of 2012) to 27 (first half-year of 2014). More experienced registered nurses made fewer medication errors. The number of MAEs in surgical wards was twice that in medicinal wards. Compared with non-intensive care units, the intensive care units exhibited higher occurrence rates of MAEs (1.81% versus 0.24%, P<0

  8. A Research on the Responsibility of Accounting Professionals to Determine and Prevent Accounting Errors and Frauds: Edirne Sample

    Directory of Open Access Journals (Sweden)

    Semanur Adalı


    Full Text Available In this study, the ethical dimensions of accounting professionals related to accounting errors and frauds were examined. Firstly, general and technical information about accounting were provided. Then, some terminology on error, fraud and ethics in accounting were discussed. Study also included recent statistics about accounting errors and fraud as well as presenting a literature review. As the methodology of research, a questionnaire was distributed to 36 accounting professionals residing in Edirne city of Turkey. The collected data were then entered to the SPSS package program for analysis. The study revealed very important results. Accounting professionals think that, accounting chambers do not organize enough seminars/conferences on errors and fraud. They also believe that supervision and disciplinary boards of professional accounting chambers fulfill their responsibilities partially. Attitude of professional accounting chambers in terms of errors, fraud and ethics is considered neither strict nor lenient. But, most accounting professionals are aware of colleagues who had disciplinary penalties. Most important and effective tool to prevent errors and fraud is indicated as external audit, but internal audit and internal control are valued as well. According to accounting professionals, most errors occur due to incorrect data received from clients and as a result of recording. Fraud is generally made in order to get credit from banks and for providing benefits to the organization by not showing the real situation of the firm. Finally, accounting professionals state that being honest, trustworthy and impartial is the basis of accounting profession and accountants must adhere to ethical rules.

  9. An Enhancement of Campaign Posters for Human Error Prevention in NPPs

    International Nuclear Information System (INIS)

    Lee, Yong Hee; Lee, Yong Hee; Kwon, Soon Il


    Accidents in high reliability systems such as nuclear power plants (NPPs) give rise to not only a loss of property and life, but also social problems. One of the most frequently used techniques to grasp the current situation for hazard factors in the NPPs is an event investigation analysis based on the INPO's Human Performance Enhancement System (HPES), and the Korean Human Performance Enhancement System (K-HPES) in Korea, respectively. There are many methods and approaches for an HE assessment that is valuable for investigating the causes of undesirable events and counter-plans to prevent their recurrence in the NPPs. They differ from each other according to the objectives of the analysis; the explanation of the event, the investigation of the causes, the allocation of the responsibility, and the establishment of the counter-plan. Event databases include their own events and information from various sources such as the IAEA, regulatory bodies, and also from the INPO and WANO. As many as 111 reactor trips have occurred in the past 5 years ('01∼'05), and 26 cases of them have occurred due to HE. The trend of human error rate didn't decrease in 2004, so the KHNP started to make efforts to decrease HEs. The KHNP created as many as 40 posters for human performance improvement in 2006. The INPO has been using a traditional form of poster; additionally, the Central Research Institute of Electric Power Industry (CRIEPI) developed a type of caution report. The caution report is comprised of a poster name, a serial number, a figure, work situations, the point at issue, and a countermeasure. The preceding posters which KHNP developed in 2006 give a message about specific information related to HE events. However, it is not enough to arouse interest in the effectiveness of the posters because most people are favorably disposed toward a simple poster with many illustrations. Therefore, we stressed the need for worker's receptiveness rather than notification of information

  10. A study on fatigue measurement of operators for human error prevention in NPPs

    Energy Technology Data Exchange (ETDEWEB)

    Ju, Oh Yeon; Il, Jang Tong; Meiling, Luo; Hee, Lee Young [KAERI, Daejeon (Korea, Republic of)


    The identification and the analysis of individual factor of operators, which is one of the various causes of adverse effects in human performance, is not easy in NPPs. There are work types (including shift), environment, personality, qualification, training, education, cognition, fatigue, job stress, workload, etc in individual factors for the operators. Research at the Finnish Institute of Occupational Health (FIOH) reported that a 'burn out (extreme fatigue)' is related to alcohol dependent habits and must be dealt with using a stress management program. USNRC (U.S. Nuclear Regulatory Commission) developed FFD (Fitness for Duty) for improving the task efficiency and preventing human errors. 'Managing Fatigue' of 10CFR26 presented as requirements to control operator fatigue in NPPs. The committee explained that excessive fatigue is due to stressful work environments, working hours, shifts, sleep disorders, and unstable circadian rhythms. In addition, an International Labor Organization (ILO) developed and suggested a checklist to manage fatigue and job stress. In domestic, a systematic evaluation way is presented by the Final Safety Analysis Report (FSAR) chapter 18, Human Factors, in the licensing process. However, it almost focused on the interface design such as HMI (Human Machine Interface), not individual factors. In particular, because our country is in a process of the exporting the NPP to UAE, the development and setting of fatigue management technique is important and urgent to present the technical standard and FFD criteria to UAE. And also, it is anticipated that the domestic regulatory body applies the FFD program as the regulation requirement so that a preparation for that situation is required. In this paper, advanced researches are investigated to find the fatigue measurement and evaluation methods of operators in a high reliability industry. Also, this study tries to review the NRC report and discuss the causal factors and

  11. A study on fatigue measurement of operators for human error prevention in NPPs

    International Nuclear Information System (INIS)

    Ju, Oh Yeon; Il, Jang Tong; Meiling, Luo; Hee, Lee Young


    The identification and the analysis of individual factor of operators, which is one of the various causes of adverse effects in human performance, is not easy in NPPs. There are work types (including shift), environment, personality, qualification, training, education, cognition, fatigue, job stress, workload, etc in individual factors for the operators. Research at the Finnish Institute of Occupational Health (FIOH) reported that a 'burn out (extreme fatigue)' is related to alcohol dependent habits and must be dealt with using a stress management program. USNRC (U.S. Nuclear Regulatory Commission) developed FFD (Fitness for Duty) for improving the task efficiency and preventing human errors. 'Managing Fatigue' of 10CFR26 presented as requirements to control operator fatigue in NPPs. The committee explained that excessive fatigue is due to stressful work environments, working hours, shifts, sleep disorders, and unstable circadian rhythms. In addition, an International Labor Organization (ILO) developed and suggested a checklist to manage fatigue and job stress. In domestic, a systematic evaluation way is presented by the Final Safety Analysis Report (FSAR) chapter 18, Human Factors, in the licensing process. However, it almost focused on the interface design such as HMI (Human Machine Interface), not individual factors. In particular, because our country is in a process of the exporting the NPP to UAE, the development and setting of fatigue management technique is important and urgent to present the technical standard and FFD criteria to UAE. And also, it is anticipated that the domestic regulatory body applies the FFD program as the regulation requirement so that a preparation for that situation is required. In this paper, advanced researches are investigated to find the fatigue measurement and evaluation methods of operators in a high reliability industry. Also, this study tries to review the NRC report and discuss the causal factors and management

  12. Medication errors versus time of admission in a subpopulation of stroke patients undergoing inpatient rehabilitation complications and considerations. (United States)

    Pitts, Eric P


    This study looked at the medication ordering error frequency and the length of inpatient hospital stay in a subpopulation of stroke patients (n-60) as a function of time of patient admission to an inpatient rehabilitation hospital service. A total of 60 inpatient rehabilitation patients, 30 arriving before 4 pm, and 30 arriving after 4 pm, with as admitting diagnosis of stroke were randomly selected from a larger sample (N=426). There was a statistically significant increase in medication ordering errors and the number of inpatient rehabilitation hospital days in the group of patients who arrived after 4 pm.

  13. Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit. (United States)

    Ni, Yizhao; Lingren, Todd; Hall, Eric S; Leonard, Matthew; Melton, Kristin; Kirkendall, Eric S


    Timely identification of medication administration errors (MAEs) promises great benefits for mitigating medication errors and associated harm. Despite previous efforts utilizing computerized methods to monitor medication errors, sustaining effective and accurate detection of MAEs remains challenging. In this study, we developed a real-time MAE detection system and evaluated its performance prior to system integration into institutional workflows. Our prospective observational study included automated MAE detection of 10 high-risk medications and fluids for patients admitted to the neonatal intensive care unit at Cincinnati Children's Hospital Medical Center during a 4-month period. The automated system extracted real-time medication use information from the institutional electronic health records and identified MAEs using logic-based rules and natural language processing techniques. The MAE summary was delivered via a real-time messaging platform to promote reduction of patient exposure to potential harm. System performance was validated using a physician-generated gold standard of MAE events, and results were compared with those of current practice (incident reporting and trigger tools). Physicians identified 116 MAEs from 10 104 medication administrations during the study period. Compared to current practice, the sensitivity with automated MAE detection was improved significantly from 4.3% to 85.3% (P = .009), with a positive predictive value of 78.0%. Furthermore, the system showed potential to reduce patient exposure to harm, from 256 min to 35 min (P patient exposure to potential harm following MAE events.

  14. Risk factors for medication errors in the electronic and manual prescription. (United States)

    Volpe, Cris Renata Grou; Melo, Eveline Maria Magalhães de; Aguiar, Lucas Barbosa de; Pinho, Diana Lúcia Moura; Stival, Marina Morato


    to compare electronic and manual prescriptions of a public hospital of Brasilia, identifying risk factors for the occurrence of medication errors. descriptive-exploratory, comparative and retrospective study. Data collection occurred from July 2012 to January 2013, using an instrument for the review of the information contained in medical records related to the medication process. A total of 190 manual and 199 electronic records composed the sample, with 2027 prescriptions each. compared to the manual prescription, a significant reduction was observed in the risk factors after implantation of the electronic prescription, in items such as "lack of the form of dilution" (71.1% to 22.3%) and "prescription with brand name" (99.5% to 31.5%). Conversely, the risk factors "no check" and "lack of CRM of the prescriber" increased. The lack of the allergy registration and the occurrences related to medication were the same for both groups. generally, the use of the electronic prescription system was associated with a significant reduction in risk factors for medication errors, concerning the following aspects: illegibility, prescription with brand name and presence of essential items that provide a safe and effective prescription. comparar as prescrições eletrônicas e manuais de um hospital público do Distrito Federal, identificando os fatores de risco para ocorrência de erros de medicação. Estudo descritivo-exploratório, comparativo e retrospectivo. A coleta de dados ocorreu no período de julho de 2012 a janeiro de 2013, através de instrumento para revisão das informações referentes ao processo de medicação contidas em prontuários. Integraram a amostra 190 prontuários manuais e 199 eletrônicos, com 2027 prescrições cada. na comparação com a prescrição manual, observou-se redução significativa dos fatores de risco após implantação da eletrônica, em itens como "falta da forma de diluição" (71,1% e 22,3%) e "prescrição com nome comercial" (99

  15. [Medication reconciliation errors according to patient risk and type of physician prescriber identified by prescribing tool used]. (United States)

    Bilbao Gómez-Martino, Cristina; Nieto Sánchez, Ángel; Fernández Pérez, Cristina; Borrego Hernando, Mª Isabel; Martín-Sánchez, Francisco Javier


    To study the frequency of medication reconciliation errors (MREs) in hospitalized patients and explore the profiles of patients at greater risk. To compare the rates of errors in prescriptions written by emergency physicians and ward physicians, who each used a different prescribing tool. Prospective cross-sectional study of a convenience sample of patients admitted to medical, geriatric, and oncology wards over a period of 6 months. A pharmacist undertook the medication reconciliation report, and data were analyzed for possible associations with risk factors or prescriber type (emergency vs ward physician). A total of 148 patients were studied. Emergency physicians had prescribed for 68 (45.9%) and ward physicians for 80 (54.1%). A total of 303 MREs were detected; 113 (76.4%) patients had at least 1 error. No statistically significant differences were found between prescriber types. Factors that conferred risk for a medication error were use polypharmacy (odds ratio [OR], 3.4; 95% CI, 1.2-9.0; P=.016) and multiple chronic conditions in patients under the age of 80 years (OR, 3.9; 95% CI, 1.1-14.7; P=.039). The incidence of MREs is high regardless of whether the prescriber is an emergency or ward physician. The patients who are most at risk are those taking several medications and those under the age of 80 years who have multiple chronic conditions.

  16. Exploring behavioural determinants relating to health professional reporting of medication errors: a qualitative study using the Theoretical Domains Framework. (United States)

    Alqubaisi, Mai; Tonna, Antonella; Strath, Alison; Stewart, Derek


    Effective and efficient medication reporting processes are essential in promoting patient safety. Few qualitative studies have explored reporting of medication errors by health professionals, and none have made reference to behavioural theories. The objective was to describe and understand the behavioural determinants of health professional reporting of medication errors in the United Arab Emirates (UAE). This was a qualitative study comprising face-to-face, semi-structured interviews within three major medical/surgical hospitals of Abu Dhabi, the UAE. Health professionals were sampled purposively in strata of profession and years of experience. The semi-structured interview schedule focused on behavioural determinants around medication error reporting, facilitators, barriers and experiences. The Theoretical Domains Framework (TDF; a framework of theories of behaviour change) was used as a coding framework. Ethical approval was obtained from a UK university and all participating hospital ethics committees. Data saturation was achieved after interviewing ten nurses, ten pharmacists and nine physicians. Whilst it appeared that patient safety and organisational improvement goals and intentions were behavioural determinants which facilitated reporting, there were key determinants which deterred reporting. These included the beliefs of the consequences of reporting (lack of any feedback following reporting and impacting professional reputation, relationships and career progression), emotions (fear and worry) and issues related to the environmental context (time taken to report). These key behavioural determinants which negatively impact error reporting can facilitate the development of an intervention, centring on organisational safety and reporting culture, to enhance reporting effectiveness and efficiency.

  17. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. (United States)

    Westbrook, Johanna I; Li, Ling; Lehnbom, Elin C; Baysari, Melissa T; Braithwaite, Jeffrey; Burke, Rosemary; Conn, Chris; Day, Richard O


    To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Audit of 3291 patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as 'clinically important'. Two major academic teaching hospitals in Sydney, Australia. Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6-1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0-253.8), but only 13.0/1000 (95% CI: 3.4-22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4-28.4%) contained ≥ 1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation. © The Author 2015. Published by Oxford University Press in association

  18. Impact of automated dispensing cabinets on medication selection and preparation error rates in an emergency department: a prospective and direct observational before-and-after study. (United States)

    Fanning, Laura; Jones, Nick; Manias, Elizabeth


    The implementation of automated dispensing cabinets (ADCs) in healthcare facilities appears to be increasing, in particular within Australian hospital emergency departments (EDs). While the investment in ADCs is on the increase, no studies have specifically investigated the impacts of ADCs on medication selection and preparation error rates in EDs. Our aim was to assess the impact of ADCs on medication selection and preparation error rates in an ED of a tertiary teaching hospital. Pre intervention and post intervention study involving direct observations of nurses completing medication selection and preparation activities before and after the implementation of ADCs in the original and new emergency departments within a 377-bed tertiary teaching hospital in Australia. Medication selection and preparation error rates were calculated and compared between these two periods. Secondary end points included the impact on medication error type and severity. A total of 2087 medication selection and preparations were observed among 808 patients pre and post intervention. Implementation of ADCs in the new ED resulted in a 64.7% (1.96% versus 0.69%, respectively, P = 0.017) reduction in medication selection and preparation errors. All medication error types were reduced in the post intervention study period. There was an insignificant impact on medication error severity as all errors detected were categorised as minor. The implementation of ADCs could reduce medication selection and preparation errors and improve medication safety in an ED setting. © 2015 John Wiley & Sons, Ltd.

  19. Recruitment into diabetes prevention programs: what is the impact of errors in self-reported measures of obesity? (United States)

    Hernan, Andrea; Philpot, Benjamin; Janus, Edward D; Dunbar, James A


    Error in self-reported measures of obesity has been frequently described, but the effect of self-reported error on recruitment into diabetes prevention programs is not well established. The aim of this study was to examine the effect of using self-reported obesity data from the Finnish diabetes risk score (FINDRISC) on recruitment into the Greater Green Triangle Diabetes Prevention Project (GGT DPP). The GGT DPP was a structured group-based lifestyle modification program delivered in primary health care settings in South-Eastern Australia. Between 2004-05, 850 FINDRISC forms were collected during recruitment for the GGT DPP. Eligible individuals, at moderate to high risk of developing diabetes, were invited to undertake baseline tests, including anthropometric measurements performed by specially trained nurses. In addition to errors in calculating total risk scores, accuracy of self-reported data (height, weight, waist circumference (WC) and Body Mass Index (BMI)) from FINDRISCs was compared with baseline data, with impact on participation eligibility presented. Overall, calculation errors impacted on eligibility in 18 cases (2.1%). Of n = 279 GGT DPP participants with measured data, errors (total score calculation, BMI or WC) in self-report were found in n = 90 (32.3%). These errors were equally likely to result in under- or over-reported risk. Under-reporting was more common in those reporting lower risk scores (Spearman-rho = -0.226, p-value recruit participants at moderate to high risk of diabetes, accurately categorising levels of overweight and obesity using self-report data. The results could be generalisable to other diabetes prevention programs using screening tools which include self-reported levels of obesity.

  20. Investigating the Factors Affecting the Occurrence and Reporting of Medication Errors from the Viewpoint of Nurses in Sina Hospital, Tabriz, Iran

    Directory of Open Access Journals (Sweden)

    Massumeh gholizadeh


    Full Text Available Background and objectives: Medication errors can cause serious problems to patients and health system. Initial results of medication errors increase duration of hospitalization and costs. The aim of this study was to determine the reasons of medication errors and the barriers of errors reporting from nurses’ viewpoints. Material and Methods: A cross-sectional descriptive study was conducted in 2013. The study population included all of the nurses working in Tabriz Sina hospital. Study sample was calculated 124 by census method. The data collection tool was questionnaire and data were analyzed using SPSS software version 20 package. Results: In this study, from the viewpoint of nurses, the most important reasons of medication errors included the wrong infusion speed, illegible medication orders, work-related fatigue, noise of ambient and shortages of staff.  Regarding barriers of error reporting, the most important factors were the emphasis of the directors on the person regardless of other factors involved in medication errors and the lake of a clear definition of medication errors. Conclusion: Given the importance of ensuring patient safety, the following corrections can lead to improvement of hospital safety: establishing an effective system for reporting and recording errors, minimizing barriers to reporting by establishing a positive relationship between managers and staff and positive reaction towards reporting error. To reduce medication errors, establishing training classes in relation to drugs information for nurses and continuing evaluation of personnel in the field of drug information using the results of pharmaceutical information in the ward are recommended.

  1. Errors in medicine administration - profile of medicines: knowing and preventing Perfil de medicamentos envueltos en errores de administración: conocer para prevenir Perfil de medicamentos envolvidos com erros de administração: conhecer para prevenir

    Directory of Open Access Journals (Sweden)

    Adriano Max Moreira Reis


    Full Text Available OBJECTIVES: To describe the pharmacological characteristics of medicines involved in administration errors and determine the frequency of errors with potentially dangerous medicines and low therapeutic index, in clinical units of five teaching hospitals, in Brazil. METHODS: Multicentric study, descriptive and exploratory, using the non-participant observation technique (during the administration of 4958 doses of medicines and the anatomical therapeutic chemical classification (ATC. RESULTS: Of that total, 1500 administration errors were identified (30.3%. The administration of pharmacological groups - ATC (cardiovascular system, nervous system, alimentary tract and metabolism system and anti-infectives for systemic use showed a higher frequency of errors. In 13.0% of errors were involved potentially dangerous medicines and in 12.2% medicines with low therapeutic index. CONCLUSION: The knowledge of the pharmacological profile could be an important strategy to be used in the prevention medication errors in health institutions.OBJETIVOS: Describir las características farmacológicas de los medicamentos envueltos en errores de administración y determinar la frecuencia de esos errores en medicamentos potencialmente peligrosos y en los de bajo índice terapéutico, en unidades de clínica médica de cinco hospitales de enseñanza brasileños. MÉTODOS: Estudio multicéntrico, descriptivo-exploratorio utilizando la técnica de observación no participante (durante la administración de 4.958 dosis de medicamentos y la clasificación anatómica terapéutica química (ATC. RESULTADOS: Fueron identificados 1500 errores de administración de medicamentos (30,3%. La administración de los fármacos de los grupos ATC (sistema cardiovascular, sistema nervioso, sistema digestivo y metabolismo, y, anti-infecciosos de uso sistémico presentó mayor frecuencia de errores. En 13,0% de los errores estaban envueltos medicamentos potencialmente peligrosos y en 12

  2. Medical students, clinical preventive services, and shared decision-making. (United States)

    Keefe, Carole W; Thompson, Margaret E; Noel, Mary Margaret


    Improving access to preventive care requires addressing patient, provider, and systems barriers. Patients often lack knowledge or are skeptical about the importance of prevention. Physicians feel that they have too little time, are not trained to deliver preventive services, and are concerned about the effectiveness of prevention. We have implemented an educational module in the required family practice clerkship (1) to enhance medical student learning about common clinical preventive services and (2) to teach students how to inform and involve patients in shared decision making about those services. Students are asked to examine available evidence-based information for preventive screening services. They are encouraged to look at the recommendations of various organizations and use such resources as reports from the U.S. Preventive Services Task Force to determine recommendations they want to be knowledgeable about in talking with their patients. For learning shared decision making, students are trained to use a model adapted from Braddock and colleagues(1) to discuss specific screening services and to engage patients in the process of making informed decisions about what is best for their own health. The shared decision making is presented and modeled by faculty, discussed in small groups, and students practice using Web-based cases and simulations. The students are evaluated using formative and summative performance-based assessments as they interact with simulated patients about (1) screening for high blood cholesterol and other lipid abnormalities, (2) screening for colorectal cancer, (3) screening for prostate cancer, and (4) screening for breast cancer. The final student evaluation is a ten-minute, videotaped discussion with a simulated patient about screening for colorectal cancer that is graded against a checklist that focuses primarily on the elements of shared decision making. Our medical students appear quite willing to accept shared decision making as

  3. [Analysis of barriers and legal-ethical opportunities for disclosure and apology for medical errors in Spain]. (United States)

    Giraldo, Priscila; Corbella, Josep; Rodrigo, Carmen; Comas, Mercè; Sala, Maria; Castells, Xavier


    To identify opportunities for disclosing information on medical errors in Spain and issuing an apology, as well as legal-ethical barriers. A cross-sectional study was conducted through a questionnaire sent to health law and bioethics experts (n=46). A total of 39 experts (84.7%) responded that health providers should always disclose adverse events and 38 experts (82.6%) were in favour of issuing an apology. Thirty experts (65.2%) reported that disclosure of errors would not lead to professional liability. The main opportunity for increasing disclosure was by enhancing trust in the physician-patient relationship and the main barrier was fear of the outcomes of disclosing medical errors. There is a broad agreement on the lack of liability following disclosure/apology on adverse events and the need to develop a strategy for disclosure among support for physicians. Copyright © 2015 SESPAS. Published by Elsevier Espana. All rights reserved.

  4. Quality of IT service delivery — Analysis and framework for human error prevention

    KAUST Repository

    Shwartz, L.; Rosu, D.; Loewenstern, D.; Buco, M. J.; Guo, S.; Lavrado, Rafael Coelho; Gupta, M.; De, P.; Madduri, V.; Singh, J. K.


    In this paper, we address the problem of reducing the occurrence of Human Errors that cause service interruptions in IT Service Support and Delivery operations. Analysis of a large volume of service interruption records revealed that more than 21

  5. A survey of mindset theories of intelligence and medical error self-reporting among pediatric housestaff and faculty. (United States)

    Jegathesan, Mithila; Vitberg, Yaffa M; Pusic, Martin V


    Intelligence theory research has illustrated that people hold either "fixed" (intelligence is immutable) or "growth" (intelligence can be improved) mindsets and that these views may affect how people learn throughout their lifetime. Little is known about the mindsets of physicians, and how mindset may affect their lifetime learning and integration of feedback. Our objective was to determine if pediatric physicians are of the "fixed" or "growth" mindset and whether individual mindset affects perception of medical error reporting.  We sent an anonymous electronic survey to pediatric residents and attending pediatricians at a tertiary care pediatric hospital. Respondents completed the "Theories of Intelligence Inventory" which classifies individuals on a 6-point scale ranging from 1 (Fixed Mindset) to 6 (Growth Mindset). Subsequent questions collected data on respondents' recall of medical errors by self or others. We received 176/349 responses (50 %). Participants were equally distributed between mindsets with 84 (49 %) classified as "fixed" and 86 (51 %) as "growth". Residents, fellows and attendings did not differ in terms of mindset. Mindset did not correlate with the small number of reported medical errors. There is no dominant theory of intelligence (mindset) amongst pediatric physicians. The distribution is similar to that seen in the general population. Mindset did not correlate with error reports.

  6. Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm. (United States)

    van de Plas, Afke; Slikkerveer, Mariëlle; Hoen, Saskia; Schrijnemakers, Rick; Driessen, Johanna; de Vries, Frank; van den Bemt, Patricia


    In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined. During baseline measurement, on control versus intervention ward, at least one administration error occurred in 14 (74%) and 6 (46%) administrations with potential risk of harm in 6 (32%) and 1 (8%) administrations. Most administration errors with high potential risk of harm occurred in bolus injections: 8 (57%) versus 2 (67%) bolus injections were injected too fast with a potential risk of harm in 6 (43%) and 1 (33%) bolus injections on control and intervention ward. Implemented improvement strategies, based on major causes of too fast administration of bolus injections, were: Substitution of bolus injections by infusions, education, availability of administration information and drug round tabards. Post intervention, on the control ward in 76 (76%) administrations at least one error was made (RR 1.03; CI95:0.77-1.38), with a potential risk of harm in 14 (14%) administrations (RR 0.45; CI95:0.20-1.02). In 40 (68%) administrations on the intervention ward at least one error occurred (RR 1.47; CI95:0.80-2.71) but no administrations were associated with a potential risk of harm. A shift in wrong duration administration errors from bolus injections to infusions, with a reduction of potential risk of harm, seems to have occurred on the intervention ward. Although data are insufficient to prove an effect, Lean Six Sigma was experienced as a suitable strategy to select tailored improvements. Further studies are required to prove the effect of the strategy on parenteral medication administration errors.

  7. Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era

    Directory of Open Access Journals (Sweden)

    Wang HF


    Full Text Available Hua-fen Wang,1 Jing-fen Jin,1 Xiu-qin Feng,1 Xin Huang,1 Ling-ling Zhu,2 Xiao-ying Zhao,3 Quan Zhou4 1Division of Nursing, 2Geriatric VIP Ward, Division of Nursing, 3Office of Quality Administration, 4Department of Pharmacy, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China Background: Medication errors may occur during prescribing, transcribing, prescription auditing, preparing, dispensing, administration, and monitoring. Medication administration errors (MAEs are those that actually reach patients and remain a threat to patient safety. The Joint Commission International (JCI advocates medication error prevention, but experience in reducing MAEs during the period of before and after JCI accreditation has not been reported. Methods: An intervention study, aimed at reducing MAEs in hospitalized patients, was performed in the Second Affiliated Hospital of Zhejiang University, Hangzhou, People’s Republic of China, during the journey to JCI accreditation and in the post-JCI accreditation era (first half-year of 2011 to first half-year of 2014. Comprehensive interventions included organizational, information technology, educational, and process optimization-based measures. Data mining was performed on MAEs derived from a compulsory electronic reporting system. Results: The number of MAEs continuously decreased from 143 (first half-year of 2012 to 64 (first half-year of 2014, with a decrease in occurrence rate by 60.9% (0.338% versus 0.132%, P<0.05. The number of MAEs related to high-alert medications decreased from 32 (the second half-year of 2011 to 16 (the first half-year of 2014, with a decrease in occurrence rate by 57.9% (0.0787% versus 0.0331%, P<0.05. Omission was the top type of MAE during the first half-year of 2011 to the first half-year of 2014, with a decrease by 50% (40 cases versus 20 cases. Intravenous administration error was the

  8. Voluntary medical male circumcision: an HIV prevention priority for PEPFAR. (United States)

    Reed, Jason Bailey; Njeuhmeli, Emmanuel; Thomas, Anne Goldzier; Bacon, Melanie C; Bailey, Robert; Cherutich, Peter; Curran, Kelly; Dickson, Kim; Farley, Tim; Hankins, Catherine; Hatzold, Karin; Justman, Jessica; Mwandi, Zebedee; Nkinsi, Luke; Ridzon, Renee; Ryan, Caroline; Bock, Naomi


    As the science demonstrating strong evidence for voluntary medical male circumcision (VMMC) for HIV prevention has evolved, the President's Emergency Plan for AIDS Relief (PEPFAR) has collaborated with international agencies, donors, and partner country governments supporting VMMC programming. Mathematical models forecast that quickly reaching a large number of uncircumcised men with VMMC in strategically chosen populations may dramatically reduce community-level HIV incidence and save billions of dollars in HIV care and treatment costs. Because VMMC is a 1-time procedure that confers life-long partial protection against HIV, programs for adult men are vital short-term investments with long-term benefits. VMMC also provides a unique opportunity to reach boys and men with HIV testing and counseling services and referrals for other HIV services, including treatment. After formal recommendations by WHO in 2007, priority countries have pursued expansion of VMMC. More than 1 million males have received VMMC thus far, with the most notable successes coming from Kenya's Nyanza Province. However, a myriad of necessary cultural, political, and ethical considerations have moderated the pace of overall success. Because many millions more uncircumcised men would benefit from VMMC services now, US President Barack Obama committed PEPFAR to provide 4.7 million males with VMMC by 2014. Innovative circumcision methods-such as medical devices that remove the foreskin without injected anesthesia and/or sutures-are being rigorously evaluated. Incorporation of safe innovations into surgical VMMC programs may provide the opportunity to reach more men more quickly with services and dramatically reduce HIV incidence for all.

  9. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative

    National Research Council Canada - National Science Library

    Harris, Daniel M; Westfall, John M; Fernald, Douglas H; Duclos, Christine W; West, David R; Niebauer, Linda; Marr, Linda; Quintela, Javan; Main, Deborah S


    .... This paper presents a mixed methods approach to analyzing narrative error event reports. Mixed methods studies integrate one or more qualitative and quantitative techniques for data collection and analysis...

  10. Nurses' experiences and perspectives on medication safety practices: an explorative qualitative study

    NARCIS (Netherlands)

    Smeulers, Marian; Onderwater, Astrid T.; van Zwieten, Myra C. B.; Vermeulen, Hester


    To explore nurses' experiences with and perspectives on preventing medication administration errors. Insight into nurses' experiences with and perspectives on preventing medication administration errors is important and can be utilised to tailor and implement safety practices. A qualitative

  11. Negligence, genuine error, and litigation

    Directory of Open Access Journals (Sweden)

    Sohn DH


    Full Text Available David H SohnDepartment of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USAAbstract: Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort system in the United States; and review current and future solutions, including medical malpractice reform, alternative dispute resolution, health courts, and no-fault compensation systems. The current political environment favors investigation of non-cap tort reform remedies; investment into more rational oversight systems, such as health courts or no-fault systems may reap both quantitative and qualitative benefits for a less costly and safer health system.Keywords: medical malpractice, tort reform, no fault compensation, alternative dispute resolution, system errors

  12. Integrated system for error prevention in process of drugs used in oncology

    International Nuclear Information System (INIS)

    Soriano Garcia, Jorge L; Lima Perez, Mayte; Gonzalez Gonzalez, Joaquin; Batista Albuerne, Noyde; Rodriguez Lopez, Roberto; Garcia Dieguez, Robin; Gonzalez Duennas, Marta; Ugando, Elizabeth


    Medication mistakes in case of chemotherapy or adjuvant treatment used in any stage of drug application process: prescription, transcription, preparation, dispense or administration, are a frequent cause of side effects of antineoplastic drugs. (Author)

  13. [Measures to prevent patient identification errors in blood collection/physiological function testing utilizing a laboratory information system]. (United States)

    Shimazu, Chisato; Hoshino, Satoshi; Furukawa, Taiji


    We constructed an integrated personal identification workflow chart using both bar code reading and an all in-one laboratory information system. The information system not only handles test data but also the information needed for patient guidance in the laboratory department. The reception terminals at the entrance, displays for patient guidance and patient identification tools at blood-sampling booths are all controlled by the information system. The number of patient identification errors was greatly reduced by the system. However, identification errors have not been abolished in the ultrasound department. After re-evaluation of the patient identification process in this department, we recognized that the major reason for the errors came from excessive identification workflow. Ordinarily, an ultrasound test requires patient identification 3 times, because 3 different systems are required during the entire test process, i.e. ultrasound modality system, laboratory information system and a system for producing reports. We are trying to connect the 3 different systems to develop a one-time identification workflow, but it is not a simple task and has not been completed yet. Utilization of the laboratory information system is effective, but is not yet perfect for patient identification. The most fundamental procedure for patient identification is to ask a person's name even today. Everyday checks in the ordinary workflow and everyone's participation in safety-management activity are important for the prevention of patient identification errors.

  14. Family Perceptions of Medication Administration at School: Errors, Risk Factors, and Consequences (United States)

    Clay, Daniel; Farris, Karen; McCarthy, Ann Marie; Kelly, Michael W.; Howarth, Robyn


    Medications are administered every day in schools across the country. Researchers and clinicians have studied school nurses' and educators' experiences with medication administration, but not the experiences of children or their parents. This study examined medication administration from the child and parent perspectives to (a) determine problems…

  15. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. (United States)

    Vogus, Timothy J; Sutcliffe, Kathleen M


    Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety. Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors. A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004. Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing. Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways. Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.

  16. Ranking of the Causes of Medication Errors in the Viewpoints of Nurses in Selected Hospitals Affiliated With Yazd University of Medical Sciences, Iran

    Directory of Open Access Journals (Sweden)

    Roohollah Askari


    Methods: A cross-sectional study was conducted on 220 nurses working in educational hospitals affiliated to Yazd University of Medical Sciences (Shahid Sadoughi, Shahid Rahnemoon and Afshar Hospitals. Stratified random sampling was used. Required data was gathered by Gladstone questionnaire. Data analysis was done through SPSS 16. Results: The most common causes of medication errors were the failure to match the patients' names with ordered drugs, the ill-considered and unreadable nature of the physicians' orders and the nominal similarity of drugs. Failure to match the patients' names with ordered drugs (3.45 ± 2.85 and the incorrect setting of the infusion device by the nurse (8.81 ± 2.57 had the highest and lowest scores from the viewpoints of nurses. Conclusion: Establishing and implementing electronic drug prescription, in service training for improving nurses' pharmacological knowledge, identifying the main types and causes of drug errors, the teaching of proper prescribing techniques are needed.

  17. "Apologies" from pathologists: why, when, and how to say "sorry" after committing a medical error. (United States)

    Dewar, Rajan; Parkash, Vinita; Forrow, Lachlan; Truog, Robert D


    How pathologists communicate an error is complicated by the absence of a direct physician-patient relationship. Using 2 examples, we elaborate on how other physician colleagues routinely play an intermediary role in our day-to-day transactions and in the communication of a pathologist error to the patient. The concept of a "dual-hybrid" mind-set in the intermediary physician and its role in representing the pathologists' viewpoint adequately is considered. In a dual-hybrid mind-set, the intermediary physician can align with the patients' philosophy and like the patient, consider the smallest deviation from norm to be an error. Alternatively, they might embrace the traditional physician philosophy and communicate only those errors that resulted in a clinically inappropriate outcome. Neither may effectively reflect the pathologists' interests. We propose that pathologists develop strategies to communicate errors that include considerations of meeting with the patients directly. Such interactions promote healing for the patient and are relieving to the well-intentioned pathologist.

  18. Identification and Assessment of Human Errors in Postgraduate Endodontic Students of Kerman University of Medical Sciences by Using the SHERPA Method

    Directory of Open Access Journals (Sweden)

    Saman Dastaran


    Full Text Available Introduction: Human errors are the cause of many accidents, including industrial and medical, therefore finding out an approach for identifying and reducing them is very important. Since no study has been done about human errors in the dental field, this study aimed to identify and assess human errors in postgraduate endodontic students of Kerman University of Medical Sciences by using the SHERPA Method. Methods: This cross-sectional study was performed during year 2014. Data was collected using task observation and interviewing postgraduate endodontic students. Overall, 10 critical tasks, which were most likely to cause harm to patients were determined. Next, Hierarchical Task Analysis (HTA was conducted and human errors in each task were identified by the Systematic Human Error Reduction Prediction Approach (SHERPA technique worksheets. Results: After analyzing the SHERPA worksheets, 90 human errors were identified including (67.7% action errors, (13.3% checking errors, (8.8% selection errors, (5.5% retrieval errors and (4.4% communication errors. As a result, most of them were action errors and less of them were communication errors. Conclusions: The results of the study showed that the highest percentage of errors and the highest level of risk were associated with action errors, therefore, to reduce the occurrence of such errors and limit their consequences, control measures including periodical training of work procedures, providing work check-lists, development of guidelines and establishment of a systematic and standardized reporting system, should be put in place. Regarding the results of this study, the control of recovery errors with the highest percentage of undesirable risk and action errors with the highest frequency of errors should be in the priority of control

  19. Development of Human Factor Management Requirements and Human Error Classification for the Prevention of Railway Accident

    International Nuclear Information System (INIS)

    Kwak, Sang Log; Park, Chan Woo; Shin, Seung Ryoung


    Railway accident analysis results show that accidents cased by human factors are not decreasing, whereas H/W related accidents are steadily decreasing. For the efficient management of human factors, many expertise on design, conditions, safety culture and staffing are required. But current safety management activities on safety critical works are focused on training, due to the limited resource and information. In order to improve railway safety, human factors management requirements for safety critical worker and human error classification is proposed in this report. For this accident analysis, status of safety measure on human factor, safety management system on safety critical worker, current safety planning is analysis

  20. Automated systems help prevent operator error during [reactor] I and C [instrumentation and control] testing

    International Nuclear Information System (INIS)

    Courcoux, R.


    On a nuclear steam supply system, even a minor failure can involve actuation of the whole reactor protection system (RPS). To reduce the likelihood of human error leading to unwanted trips during the maintenance of instrumentation and control systems, Framatome has been developing and installing various automated testing systems. Such automated systems are particularly helpful when periodic tests with a potential for RPS actuation have to be carried out, or when the test is on the critical path for the refuelling outage. The Sensitive Channel Programme described is an example of the sort of work that has been done. (author)

  1. Reduction of errors in radiotherapy: the E.F.O.M.P. approach (European federation of organisations for medical physics)

    International Nuclear Information System (INIS)

    Van Kleffens, H.; Van der Putten, W.


    This article is devoted to the study of the current situation of the training and education in medical physics in Europe, through the new perspectives and recommendations of the European federation of organisations for medical physics (E.F.O.M.P.). E.F.O.M.P. recommends to its members to institute a degree course on five years ( master degree in medical physics) followed by two years of specialization in medical physics leading to a title of qualified medical physicist. The question about the time to get this diploma is not solved (10 or 13 years) and could constitute a brake at the improvement of the quality because of the lack of qualified medical physicists. E.F.O.M.P. recommends to its members to integrate a module on safety and risk analysis at the training for students in medical physics, in order to reduce the errors in the field of health cares in general and in radiotherapy in particular. (N.C.)

  2. Sistema integrado de prevención de errores en el proceso de utilización de medicamentos en oncología Integrated system for error prevention in process of drugs used in Oncology

    Directory of Open Access Journals (Sweden)

    Jorge L. Soriano García


    Full Text Available Justificación: Los errores de la medicación en la quimioterapia o la medicación adyuvante que se utilice en cualquier etapa del proceso de utilización del medicamento: prescripción, trascripción, preparación, dispensación o administración son una causa frecuente de eventos adversos de los fármacos antineoplásicos. Métodos: La fuente principal de información la constituyeron las reuniones de análisis de la implementación del programa de garantía de calidad en oncología médica en el marco del servicio y la revisión de la literatura médica publicada desde 1995 hasta enero del 2006 aparecida en MEDLINE. La estrategia de búsqueda se condujo bajo los términos “medication errors” and “chemotherapy”. Un número adicional de búsquedas se realizaron bajo los términos: “safety patient”; “antineoplastic drugs”; “preventing medication errors” y se combinaron entre sí. Resultados: Se expone la experiencia del trabajo del servicio de oncología del Hospital Clinicoquirúrgico. “Hermanos Ameijeiras” en la implementación de una estrategia de trabajo en la prevención de errores en las fases del proceso de utilización del medicamento en oncología desde el año 2000 hasta la fecha; se han introducido como aspectos novedosos: hoja de tratamiento de quimioterapia, indicaciones estandarizadas en hojas preimpresas, tablas de diluciones de fármacos, nuevos sistemas organizativos de enfermería y hojas de reporte de toxicidad por el paciente. La aplicación de la estrategia propuesta implica un incremento de la calidad de vida, en el índice de respuesta del tumor a la quimioterapia antineoplásica y en la supervivencia global de los pacientes. Contribuye a la reducción de los gastos sanitarios directos (disminución de las complicaciones y los tratamientos que de ello se deriva, tiempo real del personal en las diferentes fases del proceso de utilización del medicamento y el consumo de citostáticos y los gastos

  3. Effective use of pre-job briefing as tool for the prevention of human error

    International Nuclear Information System (INIS)

    Schlump, Ansgar


    There is a fundamental demand to minimise the risks for workers and facilities while executing maintenance work. To ensure that facilities are secure and reliable, any deviation from normal operation behaviour has to be avoided. Accurate planning is the basis for minimising mistakes and making work more secure. All workers involved should understand how the work should be done and what is expected to avoid human errors. Especially in nuclear power plants, the human performance tools (HPT) have proved to be an effective instrument to minimise human errors. These human performance tools consist of numerous different tools that complement each other (e.g. pre-job briefing). The safety culture of the plants is also characterised by these tools. The choice of using the right HP-Tool is often a difficult task for the work planer. On the one hand, he wants to avoid mistakes during the execution of work but on the other hand he does not want to irritate the workers with unnecessary requirements. The proposed concept uses a simple risk analysis to take into account the complexity of the task, the experience of the past and the consequences of failure in to account. One main result of this risk analysis is a recommendation of the detailing of the pre-job briefing, to reduce the risks for the involved staff to a minimum.

  4. Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients. (United States)

    Vélez-Díaz-Pallarés, Manuel; Delgado-Silveira, Eva; Carretero-Accame, María Emilia; Bermejo-Vicedo, Teresa


    To identify actions to reduce medication errors in the process of drug prescription, validation and dispensing, and to evaluate the impact of their implementation. A Health Care Failure Mode and Effect Analysis (HFMEA) was supported by a before-and-after medication error study to measure the actual impact on error rate after the implementation of corrective actions in the process of drug prescription, validation and dispensing in wards equipped with computerised physician order entry (CPOE) and unit-dose distribution system (788 beds out of 1080) in a Spanish university hospital. The error study was carried out by two observers who reviewed medication orders on a daily basis to register prescription errors by physicians and validation errors by pharmacists. Drugs dispensed in the unit-dose trolleys were reviewed for dispensing errors. Error rates were expressed as the number of errors for each process divided by the total opportunities for error in that process times 100. A reduction in prescription errors was achieved by providing training for prescribers on CPOE, updating prescription procedures, improving clinical decision support and automating the software connection to the hospital census (relative risk reduction (RRR), 22.0%; 95% CI 12.1% to 31.8%). Validation errors were reduced after optimising time spent in educating pharmacy residents on patient safety, developing standardised validation procedures and improving aspects of the software's database (RRR, 19.4%; 95% CI 2.3% to 36.5%). Two actions reduced dispensing errors: reorganising the process of filling trolleys and drawing up a protocol for drug pharmacy checking before delivery (RRR, 38.5%; 95% CI 14.1% to 62.9%). HFMEA facilitated the identification of actions aimed at reducing medication errors in a healthcare setting, as the implementation of several of these led to a reduction in errors in the process of drug prescription, validation and dispensing.

  5. Treatment errors resulting from use of lasers and IPL by medical laypersons: results of a nationwide survey. (United States)

    Hammes, Stefan; Karsai, Syrus; Metelmann, Hans-Robert; Pohl, Laura; Kaiser, Kathrine; Park, Bo-Hyun; Raulin, Christian


    The demand for hair and tattoo removal with laser and IPL technology (intense pulsed light technology) is continually increasing. Nowadays these treatments are often carried out by medical laypersons without medical supervision in franchise companies, wellness facilities, cosmetic institutes and hair or tattoo studios. This is the first survey is to document and discuss this issue and its effects on public health. Fifty patients affected by treatment errors caused by medical laypersons with laser and IPL applications were evaluated in this retrospective study. We used a standardized questionnaire with accompanying photographic documentation. Among the reports there were some missing or no longer traceable parameters, which is why 7 cases could not be evaluated. The following complications occurred, with possible multiple answers: 81.4% pigmentation changes, 25.6% scars, 14% textural changes and 4.6% incorrect information. The sources of error (multiple answers possible) were the following: 62.8% excessively high energy, 39.5% wrong device for the indication, 20.9% treatment of patients with darker skin or marked tanning, 7% no cooling, and 4.6% incorrect information. The causes of malpractice suggest insufficient training, inadequate diagnostic abilities, and promising unrealistic results. Direct supervision by a medical specialist, comprehensive experience in laser therapy, and compliance with quality guidelines are prerequisites for safe laser and IPL treatments. Legal measures to make such changes mandatory are urgently needed. © The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin.

  6. Sleep Disturbance and Short Sleep as Risk Factors for Depression and Perceived Medical Errors in First-Year Residents. (United States)

    Kalmbach, David A; Arnedt, J Todd; Song, Peter X; Guille, Constance; Sen, Srijan


    While short and poor quality sleep among training physicians has long been recognized as problematic, the longitudinal relationships among sleep, work hours, mood, and work performance are not well understood. Here, we prospectively characterize the risk of depression and medical errors based on preinternship sleep disturbance, internship-related sleep duration, and duty hours. Survey data from 1215 nondepressed interns were collected at preinternship baseline, then 3 and 6 months into internship. We examined how preinternship sleep quality and internship sleep and work hours affected risk of depression at 3 months, per the Patient Health Questionnaire 9. We then examined the impact of sleep loss and work hours on depression persistence from 3 to 6 months. Finally, we compared self-reported errors among interns based on nightly sleep duration (≤6 hr vs. >6 hr), weekly work hours (Poorly sleeping trainees obtained less sleep and were at elevated risk of depression in the first months of internship. Short sleep (≤6 hr nightly) during internship mediated the relationship between sleep disturbance and depression risk, and sleep loss led to a chronic course for depression. Depression rates were highest among interns with both sleep disturbance and short sleep. Elevated medical error rates were reported by physicians sleeping ≤6 hr per night, working ≥ 70 weekly hours, and who were acutely or chronically depressed. Sleep disturbance and internship-enforced short sleep increase risk of depression development and chronicity and medical errors. Interventions targeting sleep problems prior to and during residency hold promise for curbing depression rates and improving patient care. © Sleep Research Society 2017. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail

  7. Preanalytical errors in medical laboratories: a review of the available methodologies of data collection and analysis. (United States)

    West, Jamie; Atherton, Jennifer; Costelloe, Seán J; Pourmahram, Ghazaleh; Stretton, Adam; Cornes, Michael


    Preanalytical errors have previously been shown to contribute a significant proportion of errors in laboratory processes and contribute to a number of patient safety risks. Accreditation against ISO 15189:2012 requires that laboratory Quality Management Systems consider the impact of preanalytical processes in areas such as the identification and control of non-conformances, continual improvement, internal audit and quality indicators. Previous studies have shown that there is a wide variation in the definition, repertoire and collection methods for preanalytical quality indicators. The International Federation of Clinical Chemistry Working Group on Laboratory Errors and Patient Safety has defined a number of quality indicators for the preanalytical stage, and the adoption of harmonized definitions will support interlaboratory comparisons and continual improvement. There are a variety of data collection methods, including audit, manual recording processes, incident reporting mechanisms and laboratory information systems. Quality management processes such as benchmarking, statistical process control, Pareto analysis and failure mode and effect analysis can be used to review data and should be incorporated into clinical governance mechanisms. In this paper, The Association for Clinical Biochemistry and Laboratory Medicine PreAnalytical Specialist Interest Group review the various data collection methods available. Our recommendation is the use of the laboratory information management systems as a recording mechanism for preanalytical errors as this provides the easiest and most standardized mechanism of data capture.


    Directory of Open Access Journals (Sweden)

    Ahmed Al Kuwaiti


    Full Text Available Medication errors will affect the patient safety and quality of healthcare. The aim of this study is to analyze the effect of Six Sigma (DMAIC methodology in reducing medication errors in the outpatient pharmacy of King Fahd Hospital of the University, Saudi Arabia. It was conducted through the five phases of Define, Measure, Analyze, Improve, Control (DMAIC model using various quality tools. The goal was fixed as to reduce medication errors in an outpatient pharmacy by 20%. After implementation of improvement strategies, there was a marked reduction of defects and also improvement of their sigma rating. Especially, Parts per million (PPM of prescription/data entry errors reduced from 56,000 to 5,000 and its sigma rating improved from 3.09 to 4.08. This study concluded that the Six Sigma (DMAIC methodology is found to be more significant in reducing medication errors and ensuring patient safety.

  9. MMI design of K-CPS for preventing human errors and enhancing convenient operation

    International Nuclear Information System (INIS)

    Sung, Chan Ho; Jung, Yeon Sub; Oh, Eoung Se; Shin, Young Chul; Lee, Yong Kwan


    In order to supplement defects of paper procedure, reduce human errors and enhance convenient operation, computer-based procedure system is being developed. CPS (Computerized Procedure System) including human-factor engineering design concept for KNGR (Korean Next Generation Reactor) has been also developed with the same object. K-CPS(KNGR CPS) has higher level of automation than paper procedure. It is fully integrated with control and monitoring systems. Combining statements and relevant components, which changes dynamically according to plant status enhances readability of procedure. This paper shows general design criteria on computer-based procedure system, the MMI design characteristics of K-CPS and the results of suitability evaluation for K-CPS by operator

  10. Interprofessional conflict and medical errors: results of a national multi-specialty survey of hospital residents in the US. (United States)

    Baldwin, Dewitt C; Daugherty, Steven R


    Clear communication is considered the sine qua non of effective teamwork. Breakdowns in communication resulting from interprofessional conflict are believed to potentiate errors in the care of patients, although there is little supportive empirical evidence. In 1999, we surveyed a national, multi-specialty sample of 6,106 residents (64.2% response rate). Three questions inquired about "serious conflict" with another staff member. Residents were also asked whether they had made a "significant medical error" (SME) during their current year of training, and whether this resulted in an "adverse patient outcome" (APO). Just over 20% (n = 722) reported "serious conflict" with another staff member. Ten percent involved another resident, 8.3% supervisory faculty, and 8.9% nursing staff. Of the 2,813 residents reporting no conflict with other professional colleagues, 669, or 23.8%, recorded having made an SME, with 3.4% APOs. By contrast, the 523 residents who reported conflict with at least one other professional had 36.4% SMEs and 8.3% APOs. For the 187 reporting conflict with two or more other professionals, the SME rate was 51%, with 16% APOs. The empirical association between interprofessional conflict and medical errors is both alarming and intriguing, although the exact nature of this relationship cannot currently be determined from these data. Several theoretical constructs are advanced to assist our thinking about this complex issue.

  11. Enhanced error related negativity amplitude in medication-naïve, comorbidity-free obsessive compulsive disorder. (United States)

    Nawani, Hema; Narayanaswamy, Janardhanan C; Basavaraju, Shrinivasa; Bose, Anushree; Mahavir Agarwal, Sri; Venkatasubramanian, Ganesan; Janardhan Reddy, Y C


    Error monitoring and response inhibition is a key cognitive deficit in obsessive-compulsive disorder (OCD). Frontal midline regions such as the cingulate cortex and pre-supplementary motor area are considered critical brain substrates of this deficit. Electrophysiological equivalent of the above dysfunction is a fronto-central event related potential (ERP) which occurs after an error called the error related negativity (ERN). In this study, we sought to compare the ERN parameters between medication-naïve, comorbidity-free subjects with OCD and healthy controls (HC). Age, sex and handedness matched subjects with medication-naïve, comorbidity-free OCD (N = 16) and Healthy Controls (N = 17) performed a modified version of the flanker task while EEG was acquired for ERN. EEG signals were recorded from the electrodes FCz and Cz. Clinical severity of OCD was assessed using the Yale Brown Obsessive Compulsive Scale. The subjects with OCD had significantly greater ERN amplitude at Cz and FCz. There were no significant correlations between ERN measures and illness severity measures. Overactive performance monitoring as evidenced by enhanced ERN amplitude could be considered as a biomarker for OCD. Copyright © 2017 Elsevier B.V. All rights reserved.

  12. The underreporting of medication errors: A retrospective and comparative root cause analysis in an acute mental health unit over a 3-year period. (United States)

    Morrison, Maeve; Cope, Vicki; Murray, Melanie


    Medication errors remain a commonly reported clinical incident in health care as highlighted by the World Health Organization's focus to reduce medication-related harm. This retrospective quantitative analysis examined medication errors reported by staff using an electronic Clinical Incident Management System (CIMS) during a 3-year period from April 2014 to April 2017 at a metropolitan mental health ward in Western Australia. The aim of the project was to identify types of medication errors and the context in which they occur and to consider recourse so that medication errors can be reduced. Data were retrieved from the Clinical Incident Management System database and concerned medication incidents from categorized tiers within the system. Areas requiring improvement were identified, and the quality of the documented data captured in the database was reviewed for themes pertaining to medication errors. Content analysis provided insight into the following issues: (i) frequency of problem, (ii) when the problem was detected, and (iii) characteristics of the error (classification of drug/s, where the error occurred, what time the error occurred, what day of the week it occurred, and patient outcome). Data were compared to the state-wide results published in the Your Safety in Our Hands (2016) report. Results indicated several areas upon which quality improvement activities could be focused. These include the following: structural changes; changes to policy and practice; changes to individual responsibilities; improving workplace culture to counteract underreporting of medication errors; and improvement in safety and quality administration of medications within a mental health setting. © 2018 Australian College of Mental Health Nurses Inc.

  13. Prevention of hospital payment errors and implications for case management: a study of nine hospitals with a high proportion of short-term admissions over time. (United States)

    Hightower, Rebecca E


    Since the publication of the first analysis of Medicare payment error rates in 1998, the Office of Inspector General and the Centers for Medicare & Medicaid Services have focused resources on Medicare payment error prevention programs, now referred to as the Hospital Payment Monitoring Program. The purpose of the Hospital Payment Monitoring Program is to educate providers of Medicare Part A services in strategies to improve medical record documentation and decrease the potential for payment errors through appropriate claims completion. Although the payment error rates by state (and dollars paid in error) have decreased significantly, opportunities for improvement remain as demonstrated in this study of nine hospitals with a high proportion of short-term admissions over time. Previous studies by the Quality Improvement Organization had focused on inpatient stays of 1 day or less, a primary target due to the large amount of Medicare dollars spent on these admissions. Random review of Louisiana Medicare admissions revealed persistent medical record documentation and process issues regardless of length of stay as well as the opportunity for significant future savings to the Medicare Trust Fund. The purpose of this study was to determine whether opportunities for improvement in reduction of payment error continue to exist for inpatient admissions of greater than 1 day, despite focused education provided by Louisiana Health Care Review, the Louisiana Medicare Quality Improvement Organization, from 1999 to 2005, and to work individually with the nine selected hospitals to assist them in reducing the number of unnecessary short-term admissions and billing errors in each hospital by a minimum of 50% by the end of the study period. Inpatient Short-Term Acute Care Hospitals. A sample of claims for short-term stays (defined as an inpatient admission with a length of stay of 3 days or less excluding deaths, interim bills for those still a patient and those who left against

  14. Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol. (United States)

    Westbrook, J I; Li, L; Raban, M Z; Baysari, M T; Mumford, V; Prgomet, M; Georgiou, A; Kim, T; Lake, R; McCullagh, C; Dalla-Pozza, L; Karnon, J; O'Brien, T A; Ambler, G; Day, R; Cowell, C T; Gazarian, M; Worthington, R; Lehmann, C U; White, L; Barbaric, D; Gardo, A; Kelly, M; Kennedy, P


    Medication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults. Electronic medication management (eMM) systems are heralded as a highly effective intervention to reduce adverse drug events (ADEs), yet internationally evidence of their effectiveness in paediatric populations is limited. This study will assess the effectiveness of an eMM system to reduce medication errors, ADEs and length of stay (LOS). The study will also investigate system impact on clinical work processes. A stepped-wedge cluster randomised controlled trial (SWCRCT) will measure changes pre-eMM and post-eMM system implementation in prescribing and medication administration error (MAE) rates, potential and actual ADEs, and average LOS. In stage 1, 8 wards within the first paediatric hospital will be randomised to receive the eMM system 1 week apart. In stage 2, the second paediatric hospital will randomise implementation of a modified eMM and outcomes will be assessed. Prescribing errors will be identified through record reviews, and MAEs through direct observation of nurses and record reviews. Actual and potential severity will be assigned. Outcomes will be assessed at the patient-level using mixed models, taking into account correlation of admissions within wards and multiple admissions for the same patient, with adjustment for potential confounders. Interviews and direct observation of clinicians will investigate the effects of the system on workflow. Data from site 1 will be used to develop improvements in the eMM and implemented at site 2, where the SWCRCT design will be repeated (stage 2). The research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospitals Network and Macquarie University. Results will be reported through academic journals and seminar and conference presentations. Australian New Zealand

  15. Argumentative reasoning and taxonomic analysis for the identification of medical errors


    Doumbouya , Mamadou Bilo; Kamsu-Foguem , Bernard; Kenfack , Hugues; Foguem , Clovis


    International audience; Telemedicine consists of the use of information and communication technologies (ICTs) in the practice of medicine. The massive digitalisation of the society is changing the behaviour of ordinary people even in medical sectors. The impact of digitisation is also having impacts on teleexpertise, where a medical professional can remotely ask some advices through the use of ICTs to provide treatment to a patient in critical conditions in remote environment. However, someti...

  16. The effect of the TIM program (Transfer ICU Medication reconciliation) on medication transfer errors in two Dutch intensive care units : Design of a prospective 8-month observational study with a before and after period

    NARCIS (Netherlands)

    B.E. Bosma (Bertha); E. Meuwese (Edmé); S.S. Tan (Siok Swan); J. van Bommel (Jasper); Melief, P.H.G.J. (Piet Herman Gerard Jan); N.G.M. Hunfeld (Nicola); P.M.L.A. van den Bemt (Patricia)


    markdownabstract__Background:__ The transfer of patients to and from the Intensive Care Unit (ICU) is prone to medication errors. The aim of the present study is to determine whether the number of medication errors at ICU admission and discharge and the associated potential harm and costs are

  17. Learning Through Experience: Influence of Formal and Informal Training on Medical Error Disclosure Skills in Residents. (United States)

    Wong, Brian M; Coffey, Maitreya; Nousiainen, Markku T; Brydges, Ryan; McDonald-Blumer, Heather; Atkinson, Adelle; Levinson, Wendy; Stroud, Lynfa


    Residents' attitudes toward error disclosure have improved over time. It is unclear whether this has been accompanied by improvements in disclosure skills. To measure the disclosure skills of internal medicine (IM), paediatrics, and orthopaedic surgery residents, and to explore resident perceptions of formal versus informal training in preparing them for disclosure in real-world practice. We assessed residents' error disclosure skills using a structured role play with a standardized patient in 2012-2013. We compared disclosure skills across programs using analysis of variance. We conducted a multiple linear regression, including data from a historical cohort of IM residents from 2005, to investigate the influence of predictor variables on performance: training program, cohort year, and prior disclosure training and experience. We conducted a qualitative descriptive analysis of data from semistructured interviews with residents to explore resident perceptions of formal versus informal disclosure training. In a comparison of disclosure skills for 49 residents, there was no difference in overall performance across specialties (4.1 to 4.4 of 5, P  = .19). In regression analysis, only the current cohort was significantly associated with skill: current residents performed better than a historical cohort of 42 IM residents ( P  formal (workshops, morbidity and mortality rounds) and informal (role modeling, debriefing) activities in preparation for disclosure in real-world practice. Residents across specialties have similar skills in disclosure of errors. Residents identified role modeling and a strong local patient safety culture as key facilitators for disclosure.

  18. A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. (United States)

    Gallagher, Thomas H


    After a life-threatening complication of an injection for neck pain several years ago, Ms W experienced a wrong-site surgery to remove a squamous cell lesion from her nose, followed by pain, distress, and shaken trust in clinicians. Her experience highlights the challenges of communicating with patients after errors. Harmful medical errors occur relatively frequently. Gaps exist between patients' expectations for disclosure and apology and physicians' ability to deliver disclosures well. This discrepancy reflects clinicians' fear of litigation, concern that disclosure might harm patients, and lack of confidence in disclosure skills. Many institutions are developing disclosure programs, and some are reporting success in coupling disclosures with early offers of compensation to patients. However, much has yet to be learned about effective disclosure strategies. Important future developments include increased emphasis on institutions' responsibility for disclosure, involving trainees and other team members in disclosure, and strengthening the relationship between disclosure and quality improvement.

  19. Snip and prevent! Medically performed circumcision – a strategy for ...

    African Journals Online (AJOL)

    ... prevent urinary tract and sexually transmitted infections, and for the treatment of phimosis. .... possible that this view might change, given the latest evidence from the ... clearance for circumference loss and cellulite reduction! The VelaShape ...

  20. Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods. (United States)

    Raab, Stephen S; Andrew-Jaja, Carey; Condel, Jennifer L; Dabbs, David J


    The objective of the study was to determine whether the Toyota production system process improves Papanicolaou test quality and patient safety. An 8-month nonconcurrent cohort study that included 464 case and 639 control women who had a Papanicolaou test was performed. Office workflow was redesigned using Toyota production system methods by introducing a 1-by-1 continuous flow process. We measured the frequency of Papanicolaou tests without a transformation zone component, follow-up and Bethesda System diagnostic frequency of atypical squamous cells of undetermined significance, and diagnostic error frequency. After the intervention, the percentage of Papanicolaou tests lacking a transformation zone component decreased from 9.9% to 4.7% (P = .001). The percentage of Papanicolaou tests with a diagnosis of atypical squamous cells of undetermined significance decreased from 7.8% to 3.9% (P = .007). The frequency of error per correlating cytologic-histologic specimen pair decreased from 9.52% to 7.84%. The introduction of the Toyota production system process resulted in improved Papanicolaou test quality.

  1. Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making. (United States)

    Weiner, Saul J; Schwartz, Alan; Yudkowsky, Rachel; Schiff, Gordon D; Weaver, Frances M; Goldberg, Julie; Weiss, Kevin B


    Clinical decision making requires 2 distinct cognitive skills: the ability to classify patients' conditions into diagnostic and management categories that permit the application of research evidence and the ability to individualize or-more specifically-to contextualize care for patients whose circumstances and needs require variation from the standard approach to care. The purpose of this study was to develop and test a methodology for measuring physicians' performance at contextualizing care and compare it to their performance at planning biomedically appropriate care. First, the authors drafted 3 cases, each with 4 variations, 3 of which are embedded with biomedical and/or contextual information that is essential to planning care. Once the cases were validated as instruments for assessing physician performance, 54 internal medicine residents were then presented with opportunities to make these preidentified biomedical or contextual errors, and data were collected on information elicitation and error making. The case validation process was successful in that, in the final iteration, the physicians who received the contextual variant of cases proposed an alternate plan of care to those who received the baseline variant 100% of the time. The subsequent piloting of these validated cases unmasked previously unmeasured differences in physician performance at contextualizing care. The findings, which reflect the performance characteristics of the study population, are presented. This pilot study demonstrates a methodology for measuring physician performance at contextualizing care and illustrates the contribution of such information to an overall assessment of physician practice.

  2. Escape Excel: A tool for preventing gene symbol and accession conversion errors. (United States)

    Welsh, Eric A; Stewart, Paul A; Kuenzi, Brent M; Eschrich, James A


    Microsoft Excel automatically converts certain gene symbols, database accessions, and other alphanumeric text into dates, scientific notation, and other numerical representations. These conversions lead to subsequent, irreversible, corruption of the imported text. A recent survey of popular genomic literature estimates that one-fifth of all papers with supplementary gene lists suffer from this issue. Here, we present an open-source tool, Escape Excel, which prevents these erroneous conversions by generating an escaped text file that can be safely imported into Excel. Escape Excel is implemented in a variety of formats (, including a command line based Perl script, a Windows-only Excel Add-In, an OS X drag-and-drop application, a simple web-server, and as a Galaxy web environment interface. Test server implementations are accessible as a Galaxy interface ( and simple non-Galaxy web server ( Escape Excel detects and escapes a wide variety of problematic text strings so that they are not erroneously converted into other representations upon importation into Excel. Examples of problematic strings include date-like strings, time-like strings, leading zeroes in front of numbers, and long numeric and alphanumeric identifiers that should not be automatically converted into scientific notation. It is hoped that greater awareness of these potential data corruption issues, together with diligent escaping of text files prior to importation into Excel, will help to reduce the amount of Excel-corrupted data in scientific analyses and publications.

  3. Identifying subassemblies by ultrasound to prevent fuel handling error in sodium fast reactors: First test performed in water

    International Nuclear Information System (INIS)

    Paumel, Kevin; Lhuillier, Christian


    Identifying subassemblies by ultrasound is a method that is being considered to prevent handling errors in sodium fast reactors. It is based on the reading of a code (aligned notches) engraved on the subassembly head by an emitting/receiving ultrasonic sensor. This reading is carried out in sodium with high temperature transducers. The resulting one-dimensional C-scan can be likened to a binary code expressing the subassembly type and number. The first test performed in water investigated two parameters: width and depth of the notches. The code remained legible for notches as thin as 1.6 mm wide. The impact of the depth seems minor in the range under investigation. (authors)

  4. Nurses' systems thinking competency, medical error reporting, and the occurrence of adverse events: a cross-sectional study. (United States)

    Hwang, Jee-In; Park, Hyeoun-Ae


    Healthcare professionals' systems thinking is emphasized for patient safety. To report nurses' systems thinking competency, and its relationship with medical error reporting and the occurrence of adverse events. A cross-sectional survey using a previously validated Systems Thinking Scale (STS), was conducted. Nurses from two teaching hospitals were invited to participate in the survey. There were 407 (60.3%) completed surveys. The mean STS score was 54.5 (SD 7.3) out of 80. Nurses with higher STS scores were more likely to report medical errors (odds ratio (OR) = 1.05; 95% confidence interval (CI) = 1.02-1.08) and were less likely to be involved in the occurrence of adverse events (OR = 0.96; 95% CI = 0.93-0.98). Nurses showed moderate systems thinking competency. Systems thinking was a significant factor associated with patient safety. Impact Statement: The findings of this study highlight the importance of enhancing nurses' systems thinking capacity to promote patient safety.

  5. ٍEffective factors on the Incidence of medication errors from the nursing staff perspective in various department of Fasa Hospital

    Directory of Open Access Journals (Sweden)

    Mostafa Bizhani


    Full Text Available  Background and Objective: The incidence of medical errors is deemed one of the unavoidable cases of serious threats to the health and safety of patients. This study aimed to determine the factors influencing medication errors from the perspective of the nursing staff. Materials and Methods: This descriptive -analytic study recruited 80 nurses working in various wards in Fasa Hospital. The nurses were selected via the availability sampling method, and their perspective on factors affecting medication errors was gathered using a questionnaire designed for this study. The data were analyzed with SPSS-15 software.   Results: The most important causes of medication errors were work fatigue, low nurse-to-patient ratio, long working hours, high density of work in units, and doing other tasks. Other variables such as age and gender as well as factors effective on the incidence of medication errors are mentioned in the full text. Conclusion: From the nurses’ standpoint, workload and the patient-to-nurse ratio were the most significant factors leading to medication errors.

  6. Towards more reliable automated multi-dose dispensing: retrospective follow-up study on medication dose errors and product defects. (United States)

    Palttala, Iida; Heinämäki, Jyrki; Honkanen, Outi; Suominen, Risto; Antikainen, Osmo; Hirvonen, Jouni; Yliruusi, Jouko


    To date, little is known on applicability of different types of pharmaceutical dosage forms in an automated high-speed multi-dose dispensing process. The purpose of the present study was to identify and further investigate various process-induced and/or product-related limitations associated with multi-dose dispensing process. The rates of product defects and dose dispensing errors in automated multi-dose dispensing were retrospectively investigated during a 6-months follow-up period. The study was based on the analysis of process data of totally nine automated high-speed multi-dose dispensing systems. Special attention was paid to the dependence of multi-dose dispensing errors/product defects and pharmaceutical tablet properties (such as shape, dimensions, weight, scored lines, coatings, etc.) to profile the most suitable forms of tablets for automated dose dispensing systems. The relationship between the risk of errors in dose dispensing and tablet characteristics were visualized by creating a principal component analysis (PCA) model for the outcome of dispensed tablets. The two most common process-induced failures identified in the multi-dose dispensing are predisposal of tablet defects and unexpected product transitions in the medication cassette (dose dispensing error). The tablet defects are product-dependent failures, while the tablet transitions are dependent on automated multi-dose dispensing systems used. The occurrence of tablet defects is approximately twice as common as tablet transitions. Optimal tablet preparation for the high-speed multi-dose dispensing would be a round-shaped, relatively small/middle-sized, film-coated tablet without any scored line. Commercial tablet products can be profiled and classified based on their suitability to a high-speed multi-dose dispensing process.

  7. A web-based team-oriented medical error communication assessment tool: development, preliminary reliability, validity, and user ratings. (United States)

    Kim, Sara; Brock, Doug; Prouty, Carolyn D; Odegard, Peggy Soule; Shannon, Sarah E; Robins, Lynne; Boggs, Jim G; Clark, Fiona J; Gallagher, Thomas


    Multiple-choice exams are not well suited for assessing communication skills. Standardized patient assessments are costly and patient and peer assessments are often biased. Web-based assessment using video content offers the possibility of reliable, valid, and cost-efficient means for measuring complex communication skills, including interprofessional communication. We report development of the Web-based Team-Oriented Medical Error Communication Assessment Tool, which uses videotaped cases for assessing skills in error disclosure and team communication. Steps in development included (a) defining communication behaviors, (b) creating scenarios, (c) developing scripts, (d) filming video with professional actors, and (e) writing assessment questions targeting team communication during planning and error disclosure. Using valid data from 78 participants in the intervention group, coefficient alpha estimates of internal consistency were calculated based on the Likert-scale questions and ranged from α=.79 to α=.89 for each set of 7 Likert-type discussion/planning items and from α=.70 to α=.86 for each set of 8 Likert-type disclosure items. The preliminary test-retest Pearson correlation based on the scores of the intervention group was r=.59 for discussion/planning and r=.25 for error disclosure sections, respectively. Content validity was established through reliance on empirically driven published principles of effective disclosure as well as integration of expert views across all aspects of the development process. In addition, data from 122 medicine and surgical physicians and nurses showed high ratings for video quality (4.3 of 5.0), acting (4.3), and case content (4.5). Web assessment of communication skills appears promising. Physicians and nurses across specialties respond favorably to the tool.

  8. Learning without Borders: A Review of the Implementation of Medical Error Reporting in Médecins Sans Frontières.

    Directory of Open Access Journals (Sweden)

    Leslie Shanks

    Full Text Available To analyse the results from the first 3 years of implementation of a