Medication errors analyzing

The PIAA conducted a medication-error study in 1993 ° and another in 1999 to analyze high-frequency and severe malpractice claims. The data collected included loss description and causation information, expense and indemnity payments, and the demographics of policyholders, claimants, and institutions. The PIAA companies insured almost 87,000 physicians in the United States, ranging from the smallest to the largest physician-owned malpractice insurers. 

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... 

Prevention of medication errors is the primary objective of the USP Medication Errors Reporting Program. It collects and analyzes potential and actual medication errors submitted by health care practitioners. The program affords health care professionals the opportunity to report medication errors and thereby contribute to improving patient safety by sharing their experiences. 

Medication error information submitted to USP is entered into a nationally recognized repository for medication error reporting. This database serves to track, monitor, and analyze medication errors from a systems-based perspective. The USP develops educational resources and materials to disseminate best practice solutions and error-avoidance strategies to students and practitioners. 

Several methods of analyzing medication errors exist. Two common methods are root cause analysis and failure mode and effects analysis. 

To maintain a national medication error reporting program to collect observations and experiences of healthcare practitioners and to analyze this information with a systems approach in order to draw valid... 

This program has three main characteristics it is voluntary, confidential, and independent. It collects observations and experiences concerning those potential or actual medication errors that healthcare professionals voluntarily report. The information is independently analyzed, with no conflicts of interests nor administrative pressure, and all information is treated confidentially. 

Thus, the process-improvement approach to the safety of the medication-use cycle goes beyond the celebrated cases and first stories to scientifically investigate the system as a whole. Data on near-misses and uncelebrated errors should be analyzed to find hidden flaws and strengths, and to better understand the dynamics of our medication-use system. Scientific investigation of the whole cycle— peeling away the layers of the onion—will reveal latent points of failure and facilitate a redesign that substantially reduces the occurrence of harmful outcomes. 

An analysis of self-reported interventions by hematology-oncology pharmacists and staff was also performed to document pharmaceutical care interventions over a period of approximately 8 months at the Walter Reed Army Medical Center.The interventions were analyzed to determine the types of interventions that are most frequently performed, prescribing errors encountered, medication cost avoidance that resulted from the interventions and types of interventions that are associated with medication cost interventions, and intervention acceptance rate by physicians. Interventions were entered into a personal computer and analyzed using CliniTrend Web Support System software (ASHP). Medication cost avoidance was determined if less medication was used, an equally effective but less costly medication was used, or a medication that could not be reused was not prepared. 

Medical devices such as ventilators, blood chemistry analyzers, patient monitors, infusion pumps, and kidney dialysis machines often have various types of user-interface design-related problems. These problems can negatively affect usability and appeal of a medical device. The following guidelines address these user-interface design problems, in turn reducing device user-interface-related errors [8]. 

This organization was founded in 1989 to monitor anesthesia errors and was expanded to patient incident reporting and monitoring after the findings of the Quality in Australian Health Care Study (QAHCS) in 1995 [9]. Adverse medical events are reported and analyzed through its subsidiary known as Patient Safety International (PSI), using the Advanced Incident Management System (AIMS), a software tool. 

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