Medication errors detecting

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. 

Detecting the incidence and type of adverse drug events (ADEs) and medication errors is important for improving the quality of health care delivery. Problems include missing dose, wrong dose, frequency, and route errors. The consequence (ADE) of the errors depends on medication and patient factors as described previously. Some of these problems are organisational and related to chart order system and prescribing. 

Braithwaite RS, DeVita MA, Mahidhara R, et al. 2004. Use of medical emergency team (MET) responses to detect medical errors. QualSaf Health Care 13 255—9. 

Signal detection. Catastrophic medication errors should not be a surprise. Routine and noncatas-trophic errors foreshadow the inevitable. 

Detects and reports medication errors accurately and in a timely manner. 

Much of the knowledge developed about medication errors and ADEs has depended on the ability of individual pharmacists to detect problems and take an active part in resolving them. The increasing use of complex medication regimens has drawn attention to the number of iatrogenic medication errors and ADEs, as well as their associated costs. Pharmacists must work to reduce predisposing factors so that safety can be enhanced and costs reduced. A new practice model as an adjunct to evidence-based medicine practices must be created to prevent medication errors and ADEs, and to let others outside the pharmacy know that we are ready to lend our expertise and energy to this critical endeavor. 

Chart review involves researchers reviewing prescriptions, prescribing charts or computer-prescribing records to identify medication errors. It is widely used for detecting prescribing errors however, it relies on the clinical skills of researchers to detect the error, and inter-observer difference (inter-rater reliability) can be problematic when different... 

The chart review and observation are process-based methods for detecting errors. Most of these process errors , however, do not cause harm, so these methods are not cost-effective for the study of the harmful outcomes of medication errors. 

Table 3.1 Studies that used spontaneous reporting as method of detecting medication errors of all types in paediatrics...

Organisations still frequently rely on retrospective techniques such as incident reporting and complaints to drive safety management [21] and healthcare has been slow and sporadic in adopting predictive safety assessment techniques to detect medical error [22]. Twenty two percent of people in the UK believe, when asked, that they have been the victim of medical error [23]. Nevertheless continually striving to protect patients at vulnerable points in their lives is stiU clearly the right thing to do and a move from reactive to proactive risk reduction wiU surely pay dividends in the future. 

The attention given to patient safety did, I think it is fair to say, aimoy some of those who had worked in quality improvement for decades. Certainly, one can detect a note of irritation in some of the papers pointing out that some safety concepts and the new understanding were simply a reworking of longstanding quality improvement ideas. If safety is a core dimension of quality, did we need to invent patient safety at all Timothy Hofer, Eve Kerr and Rodney Hayward pose the essential question in a paper written in 2000, critiquing the concept of medical error ... 

REPRINTED FROM INTERNATIONAL JOURNAL OF MEDICAL INFORMATICS, KENTON T. UNRUH AND WANDA PRATT. "PATIENTS AS ACTORS THE PATIENT S ROLE IN DETECTING, PREVENTING, AND RECOVERING FROM MEDICAL ERRORS". 76, [236-244], 2007, WITH PERMISSION FROM ELSEVIER)... 

Unruh, K.T. and Pratt, W. (2007) Patients as actors the patient s role in detecting, preventing, and recovering from medical errors. International Journal of Medical Informatics, 76(Suppl. 1), S236-S244. 

Kopp, B. J., et al.. Medication Errors and Adverse Drug Events in an Intensive Care Unit Direct Observation Approach for Detection, Critical Care Medicine, Vol. 34, No. 2,2006, pp. 415-425. 

Blame is rarely an appropriate response to a medical error. Of course there are rare situations where blame is appropriate for example, criminal behavior, insubordination, or refusal to respond to feedback. But these behaviors are rare and seldom the cause of preventable adverse events. On the other hand, a culture of blame is an exceedingly common problem in healthcare and frequently contributes to adverse events by impeding detection, investigation, and remedy. Every effort should be made to eliminate blame from healthcare s culture. 

In conclusion, planning a method comparison study to achieve a given power for detection of medically notable differences should be considered. In this way, a method comparison study is likely to be conclusive either the null hypothesis of no difference is accepted, or the presence of a relevant difference is established. Otherwise, a statistically nonsignificant slope deviation from unity or intercept deviation from zero or both may either imply that the null hypothesis is true, or be an example of a Type II error (i.e., an overlooked real difference of medical importance). 

Linnet K. Choosing quality control systems to detect maximum medically allowable analytical errors. Clin Chem 1989 35 284-8. 

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