Clinical incidents medication errors

ADEs and medication errors can be extracted from practice data, incidents reports from health professionals, and patient surveys. Practice data include charts, laboratory, prescription data, and administrative databases, and can be reviewed manually or screened by computer systems to identify signals. A method of ADE and medication error detection and classification has been presented that is feasible and has good reliability (Marimoto et al. 2004). It can be used in various clinical settings to measure and improve medication safety. 

Holley [21] conducted a study of adverse events and medical errors in four hemodialysis units. Incident data are based on reports by the units clinical directors. Among nearly 65,000 dialysis treatments, 88 errors occurred (1 event/ 733 treatments). Infiltration of the hemodialysis access, clotting of the dialysis circuit and omitted medications were common problems. In a surveillance study of dialysis patients in Gran Canaria (Spain), the incidence rate of adverse events was 8.6/100 patient-months [22]. The rate was higher among patients with arteriovenous fistula (9.1/100 patient-months) compared to patients with permanent catheter (2.9/100 patient-months). The preventability of the events is unknown. 

USA) 1995. Phase 1 14 days phase 2 5 days paediatric teaching hospital. Phase 1 2 units (ICU and medical surgical unit). Phase 2 3 units (ICU, medical and surgical units) Following medication order written from prescribing through administration. Also review of medical record, pharmacy s clinical interventions and quality control log, and incident reports. Also review of medication administration record Sample 3312 medication orders Error rate 24/100 orders Administration error 0.15% doses administered... 

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