Definition Near Miss Medication Error
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Professional Development Career CenterANCC CertificationMagnet Recognition Program®Work at ANA Practice 2016 Culture of SafetyPublic Health NursingDeliriumNurse StaffingNursing QualityProfessional StandardsCall for near miss medication error reporting Public CommentView More Ethics Code of EthicsEthics Position StatementsAbout The CenterEthics medication error definition joint commission Topics and ArticlesSafetyPersonalized MedicineEnd of Life IssuesView More Health & Safety Healthy Nurse, Healthy Nation™Healthy Work Environment medication error types definitions Policy & Advocacy Professional Issues PanelsPositions and ResolutionsCongress and Federal AgenciesPublic ReportingState Government AffairsANA PACTake ActionView More Member Benefits ANA and State Member BenefitsANA Personal BenefitsFactsheets and ResourcesProfessional medication error definition fda ToolsANA Periodicals Conferences 2017 ANA Annual Conference Join » Home >Practice >Nursing Quality >Advocacy >Institute for Healthcare Improvement >Get Involved >Near Misses Near Misses ^ m d Report Near Misses Adverse Drug Events The Institute for Healthcare Improvement (IHI) refers to adverse drug events (ADEs) as injuries attributable to the use of medications (1). Hospitalized patients
Definition Of Medication Error In Nursing
who experience an ADE are almost twice as likely to die as those without an ADE (2). Death certificate data showed that almost 1,200 hospital deaths in 1993 were due to medication errors. In addition, the incidence of such deaths had more than doubled since 1983 (3). Medication errors are one of the leading causes of injury to hospital patients, and chart reviews reveal that over half of all hospital medication errors occur at the interfaces of care (4). ADEs account for 6.3% of malpractice claims (5). A study of pediatric cancer patients revealed variances between medication orders and information from patient/guardian or prescription labels on the container 30% of the time (6). A multidisciplinary check of medication orders, also for pediatric cancer patients, revealed that 42% of the orders being reviewed needed to be changed (7). According to one estimate, in any given week four out of every five U.S. adults will use prescription medicines, over-the-counter (OTC) drugs, or dietary supplements of some sort,
Professional Development Career CenterANCC CertificationMagnet Recognition Program®Work at ANA Practice 2016 Culture of SafetyPublic
Definition Of Near Miss Accident
Health NursingDeliriumNurse StaffingNursing QualityProfessional StandardsCall for Public CommentView More Ethics definition of near miss incident Code of EthicsEthics Position StatementsAbout The CenterEthics Topics and ArticlesSafetyPersonalized MedicineEnd of Life IssuesView More definition of near miss osha Health & Safety Healthy Nurse, Healthy Nation™Healthy Work Environment Policy & Advocacy Professional Issues PanelsPositions and ResolutionsCongress and Federal AgenciesPublic ReportingState Government AffairsANA PACTake ActionView http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Advocacy/IHCI/GetInvolved/NearMisses.html More Member Benefits ANA and State Member BenefitsANA Personal BenefitsFactsheets and ResourcesProfessional ToolsANA Periodicals Conferences 2017 ANA Annual Conference Join » Home >Practice >Nursing Quality >Advocacy >Institute for Healthcare Improvement >Get Involved >Near Misses Near Misses ^ m d Report Near Misses Adverse Drug Events The Institute for Healthcare Improvement (IHI) http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Advocacy/IHCI/GetInvolved/NearMisses.html refers to adverse drug events (ADEs) as injuries attributable to the use of medications (1). Hospitalized patients who experience an ADE are almost twice as likely to die as those without an ADE (2). Death certificate data showed that almost 1,200 hospital deaths in 1993 were due to medication errors. In addition, the incidence of such deaths had more than doubled since 1983 (3). Medication errors are one of the leading causes of injury to hospital patients, and chart reviews reveal that over half of all hospital medication errors occur at the interfaces of care (4). ADEs account for 6.3% of malpractice claims (5). A study of pediatric cancer patients revealed variances between medication orders and information from patient/guardian or prescription labels on the container 30% of the time (6). A multidisciplinary check of medication orders, also for pediatric cancer patients, revealed that 42% of the orders being review
in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes Steven Crane, MD, Philip D. Sloane, MD, Nancy Elder, http://www.jabfm.org/content/28/4/452.full MD, Lauren Cohen, MA, Natascha Laughtenschlaeger, MD, Kathleen Walsh, BA and Sheryl Zimmerman, PhD From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North medication error Carolina—Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE). Corresponding author: Steven D. Crane, Mountain Area Health Education Center, University of North Carolina—Chapel Hill, 121 Henderson Rd, Asheville, NC 28803 (E-mail: steven.crane{at}msj.org). Next Section Abstract Purpose: Near-miss events represent an opportunity to identify and correct errors that jeopardize patient safety. This study was undertaken to definition of near assess the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them. Methods: We implemented a web-based, anonymous near-miss reporting system into 7 diverse practices, collecting and categorizing all reports. At the end of the study period, we interviewed practice leaders to determine how the near-miss reports were used for quality improvement (QI) in each practice. Results: All 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 QI projects based on the reports. The most frequent events reported were breakdowns in office processes (47.3%); of these, filing errors were most common, with 38% of these errors judged by external coders to be high risk for an adverse event. Electronic medical records were the primary or secondary cause of the error in 7.8% and 14.4% of reported cases, respectively. The pattern of near-miss events across these diverse practices was similar. Conclusions: Anonymous near-miss reporting can be successfully implemented in primary care practices. Near-miss events occur fr