Medication error administration 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. 

That medication errors occur frequently in U.S. hospitals has been well-documented [2-4]. In observation studies done between 1962 and 1995 on the rate of administration errors in a variety of in-patient settings, rates ranged from 0 to 59% [5]. Estimates that medication errors occur in almost 7% of hospitalized patients have been reported [6]. One study found that the frequency of medication errors was 1.4 per admission [4]. When approximately 290,000 medication orders were analyzed, Lesar et al. estimated that there were almost two serious errors for every 1,000 orders written. Based on a review of death certificates, it was estimated that almost 8,000 people died from medication errors in 1993, as opposed to almost 3,000 people in 1983 [3]. Researchers foimd an error rate at tv 0 children s hospitals of 4.7 per 1,000 orders [7]. Several... 

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including prescribing order communication product labeling, packaging, and nomenclature compounding dispensing distribution administration education monitoring and use. 

Since 1992, the Food and Drug Administration has received nearly 30,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no typical medication error, and health professionals, patients, and their families are all involved. Some examples ... 

It s a promising way to automate aspects of medication administration, says Robert Krawisz, former executive director of the National Patient Safety Foundation. The technology s impact at VA hospitals so far has been amazing. The Department of Veterans Affairs (VA) already uses bar codes nationwide in its hospitals, and the result has been a drastic reduction in medication errors. For example, the VA medical center in Topeka, Kan., has reported that bar coding reduced its medication error rate by 86 percent over a nine-year period. 

About the Author Dr. Tipton is Associate Professor of Social and Administrative Pharmaceutical Sciences at the Mylan School of Pharmacy at Duquesne University. Dr. Tipton earned an MBA in marketing and a Ph.D. in management from St. Louis University. Prior to obtaining his degree, he practiced pharmacy for 20 years and was an owner/partner in a four-store pharmacy operation. His current research interests focus on customer service, medication errors, and judgment. Dr. Tipton teaches courses at Duquesne University in management, marketing, and customer service. 

Acts of commission (i.e., prescribing, dispensing, and medication administration errors)... 

Administration errors can also occur with devices used to administer and monitor medications. Metered-dose inhalers, nebulizers, infusion pumps. 

The lack of photoprotection for the drug product during administration may lead to increased/decreased efficacy or increased toxicity of photolabile drugs. These episodes may be categorized as preventable medication errors, in particular, as wrong administration-technique errors (2). On the other hand, superfluous photoprotection measurements represent an unproductive use of nurses time and a waste of materials. 

Reason (21) has described a model for looking at human error that portrays a battle between the sources of error and the system-based defenses against them. This model is often referred to as the "Swiss cheese model" because the defenses against error are displayed as thin layers with holes that are described as latent error in the system. Figure 26.5 demonstrates the model as applied to medication error. Each opportunity for error is defended by the prescriber, pharmacist, nurse, and patient. When a potential error is identified and corrected (e.g., dose error, route of administration error) the event becomes a "near miss" rather than an ADE. In those cases in which the holes in the Swiss cheese line up, a preventable medication error occurs. The Swiss cheese model provides an interesting framework for research in this field. 

Calabrese AD, Erstad BL, Brandi K, Barletta JF, Kane SL, Sherman DS. Medication administration errors in adult patients in the ICU. Intensive Care Med 2001 27 1592-8. 

That medication errors occur frequently in U.S. hospitals has been well documented.In observation studies carried out between 1962 and 1995 on the rate of administration errors in a variety of inpatient settings. 

Name four ways to prevent common medication administration errors. 

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