Category H Medication Error
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for Medication Error Reporting and Prevention (NCCMERP) has released a document recommending steps needed to correct error-prone aspects of prescription writing. It medication error in nursing includes a recommendation that prescription communications include the medication's purpose as
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a way to help prevent medication dispensing errors. The document also addresses illegibility of prescriptions and medication error stories medication orders and contains a list of dangerous abbreviations, developed in cooperation with ISMP, that should never be used in prescription writing. While the ideas will be
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familiar to many health care practitioners, the NCCMERP action adds a new level of importance since the group is represented by major professional organizations and regulatory authorities such as USP, FDA, AMA, APhA, ANA, AHA, PhRMA, JC and NABP. In a second action, NCCMERP also began promoting a new medication error categorization index. The medication error statistics index was designed to help health care professionals track medication errors consistently and systematically by establishing severity levels to provide a focus for improvement efforts. The new index, based on one designed by Hartwig et al (Hartwig SC et al. A severity-indexed, incident-report based medication-error reporting program. Am J Hosp Pharm. 1991;48:2611-6) appears below. Medication Error Index for Categorizing Errors TYPE OF ERROR/ CATEGORY RESULT NO ERROR Category A Circumstances or events that have the capacity to cause error ERROR, NO HARM Category B An error occurred but the medication did not reach the patient Category C An error occurred that reached the patient but did not cause patient harm Category D An error occurred that resulted in the need for increased patient monitoring but no patient harm ERROR, HARM Category E An error occurred that resulted in the need for treatment or intervention and caused temporary patient harm Category F An error occurred that resulted in initial or prolonged hospita
A medication error is any incorrect or wrongful administration of a medication, such as a mistake in dosage or route of administration, failure to prescribe or administer the correct
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drug or formulation for a particular disease or condition, use of outdated
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drugs, failure to observe the correct time for administration of the drug, or lack of awareness of adverse effects medication error reporting of certain drug combinations. Causes of medication error may include difficulty in reading handwritten orders, confusion about different drugs with similar names, and lack of information about a patient's drug allergies https://www.ismp.org/newsletters/acutecare/articles/19960911.asp or sensitivities. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) has organized medication errors into four major groupings encompassing a total of nine categories (categories A through I): No Error Category A: Circumstances or events that have the capacity to cause error Error, No Harm Category B: An error occurred but the error did not reach the patient http://rx-wiki.org/index.php?title=Medication_errors (An "error of omission" does reach the patient) Category C: An error occurred that reached the patient but did not cause patient harm Category D: An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm Error, Harm Category E: An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention Category F: An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization Category G: An error occurred that may have contributed to or resulted in permanent patient harm Category H: An error occurred that required intervention necessary to sustain life Error, Death Category I: An error occurred that may have contributed to or resulted in the patient’s death Contents 1 Prescription error facts 2 Causes of errors 3 Error reporting 4 Error prevention 5 See also 6 References Prescription error facts The following are some sobering facts related to medication errors. The Institute of Medicine (IOM) estimate