Error Medication Prevention
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Medication Errors In Nursing
When Jacquelyn Ley shattered her elbow on the soccer field, her parents set out to find her the best care in Minneapolis. "We reducing medication errors drove past five other hospitals to get to the one we wanted," says Carol Ley, M.D., an occupational health physician. Her husband, an orthopedic surgeon, made sure Jacquelyn got the right surgeon. After a successful three-hour surgery to medication error prevention for healthcare providers repair the broken bones, Jacquelyn, who was 9 at the time, received the pain medicine morphine through a pump and was hooked up to a heart monitor, breathing monitor, and blood oxygen monitor. Her recovery was going so well that doctors decided to turn off the morphine pump and to forgo regular checks of her vital signs.Carol Ley slept in her daughter's hospital room that night. When she woke up in the middle of the night and
Pharmacy Medication Error Prevention
checked on her, Jacquelyn was barely breathing. "I called her name, but she wouldn't respond," she says. "I shook her and called for help." The morphine pump hadn't been shut down, but had accidentally been turned up high. The narcotic flooded Jacquelyn's body. She survived the overdose, but it was a close call. "If three more hours had gone by, I don't think Jacquelyn would have survived," Ley says. "Fortunately, I woke up."Ley was pleased with the way the hospital handled the error. "They came right out and said the morphine pump was incorrectly programmed, they told me the steps they were going to take to make sure Jacquelyn was OK, and they also told me what they were going to do to make sure this kind of mistake won't happen again. And that's very important to me." The hospital began using pumps that are easier to use and revamped nurses' training. Ley believes there were many contributors to the error, including the fact that it was Labor Day weekend and there were staff shortages. "It goes to show that this can happen to anyone, anywhere," says Ley, who now chairs the board of the National Patient Safety Foundation.Multiple FactorsSince 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
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Health Search databasePMCAll DatabasesAssemblyBioProjectBioSampleBioSystemsBooksClinVarCloneConserved https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723209/ DomainsdbGaPdbVarESTGeneGenomeGEO DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed HealthSNPSparcleSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch termSearch Advanced Journal list Help Journal ListBr J Clin Pharmacolv.67(6); 2009 JunPMC2723209 Br J Clin Pharmacol. 2009 Jun; 67(6): 681–686. doi: 10.1111/j.1365-2125.2009.03427.xPMCID: PMC2723209Medication errors: prevention using medication error information technology systemsAbha AgrawalDepartment of Clinical Medicine and Medical Informatics, State University of New York Downstate, Brooklyn, NY, USACorrespondence Professor Abha Agrawal, Department of Clinical Medicine and Medical Informatics, State University of New York Downstate, Brooklyn, medication error prevention NY 11203, USA. Tel: +1-718-245-3980 Fax: +1-718-245-5347 E-mail: moc.liamg@ahba.lawargaAuthor information ► Article notes ► Copyright and License information ►Received 2009 Feb 9; Accepted 2009 Mar 18.Copyright Journal compilation © 2009 The British Pharmacological SocietyThis article has been cited by other articles in PMC.AbstractGiven the high frequency of medication errors with resultant patient harm and cost, their prevention is a worldwide priority for health systems.Systems that use information technology (IT), such as computerized physician order entry, automated dispensing, barcode medication administration, electronic medication reconciliation, and personal health records, are vital components of strategies to prevent medication errors, and a growing body of evidence calls for their widespread implementation.However, im
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