How To Calculate Medication Error Rates
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Risk Managv.4(4); 2008 AugPMC2621376 Ther Clin Risk Manag. 2008 Aug; 4(4): 673–679. Published online medication errors 2008 Aug. PMCID: PMC2621376A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, PakistanKhurshid Khowaja,1 Rozmin Nizar,1
Adverse Impact
Rashida J Merchant,2 Jacqueline Dias,3 Irma Bustamante-Gavino,4 and Amina Malik11Division of Nursing Services2Nursing Education Services3Diploma Programme, Nurudin Jivraj Professorship of Nursing, Aga Khan University, Karachi, Pakistan;4The Ahmed Shivji Professorship of Nursing, The Aga Khan University School of Nursing, Karachi, PakistanCorrespondence: Khurschid Khowaja, Division of Nursing Services, ismp Aga Khan, University, PO Box 3500, Karachi 74800, Pakistan, Tel +92 21 486 3600, Fax +92 21 493 4294/+92 21 493 2095, Email ude.uka@ajawohk.dihsruhkAuthor information ► Copyright and License information ►Copyright © 2008 Dove Medical Press Limited. All rights reservedThis article has been cited by other articles in PMC.AbstractIntroduction:Administering medication is one of the high risk areas for any health professional. It is a multidisciplinary process, which begins with the doctor’s prescription, followed by review and provision by a pharmacist, and ends with preparation and administration by a nurse. Several studies have highlighted a high medication incident rate at several healthcare institutions.Methods:Our study design was exploratory and evaluative and used methodological triangulation. Sample size was of two types. First, a convenient sample of 1000 medication dosages to estimate the medication error (95% CI). We took another sample
to download it as a free PDF. Contents Chapter Page of 464 Original Pages Text Pages Get This Book « Previous: Appendix B Glossary of Terms and Acronyms Page 367 Share Cite Suggested Citation: "Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. doi:10.17226/11623. × Save Cancel C Medication Errors: Incidence Rates This appendix reviews estimates of the rates of medication errors and adverse drug events (ADEs) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621376/ in three care settings (hospital, nursing home, and ambulatory care) and in pediatric and psychiatric care. Where possible, error rates for the five stages of the medication-use system and at the interface between care settings are documented separately. INCIDENCE OF MEDICATION ERRORS IN HOSPITAL CARE Selection and Procurement of the Drug by the Pharmacy No studies were identified https://www.nap.edu/read/11623/chapter/15 that specifically identified medication errors of this type. It is possible that these types of errors were included in studies of general medication error rates. Prescription and Selection of the Drug for the Patient: Errors of Commission Rates of prescribing errors (for example, dosing errors, prescribing medications to which the patient was allergic, prescribing inappropriate dosage forms) vary considerably from study to study and are quoted in several different ways—errors per 1,000 admissions, errors per 1,000 orders, errors per 100 opportunities for error, and preventable ADEs per 1,000 admissions (see Table C-1): Page 368 Share Cite Suggested Citation: "Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. doi:10.17226/11623. × Save Cancel TABLE C-1 Hospital Care: Prescription and Selection Errors of Commission Error rates Per 1,000 admissions—detection method 12.3 (Lesar, 2002a)—pharmacist review of written orders 29 (Winterstein et al., 2004)—prompted reporting 52.9 (Lesar et al., 1997)—pharmacist review of written orders 190 (LaPointe and Jollis, 2003)—clinical pharmacist directly participating in clinical
is the definition of a medication error? What are the “ten key elements” of the medication-use system? Won’t medication errors be prevented if nurses just follow the “Five Rights?” What are "high-alert" medications? What abbreviations are dangerous? Are http://www.ismp.org/faq.asp these evidence based? What drug names are frequently confused? How should tall man lettering be applied to differentiate look-alike/sound-alike drug names? What is confirmation bias? How do I do an independent double check? How can I measure culture? Should a healthcare practitioner be disciplined for being involved in an error? How can I assess risk? What is the difference between high-leverage and low-leverage safety strategies? What is an FMEA, and how medication error can I use it? How do I join ISMP? What ISMP resources are available for consumers? Why are standard concentrations safer than using the Rule of 6 for pediatric drips? What tools does ISMP have to satisfy regulatory or insurance network inclusion requirements for community pharmacies to demonstrate participation and knowledge in medication safe practices? Is there a way to get involved with ISMP as a student? Does ISMP have a medication error rate nationally registered student-organization? 1. What is the national medication error rate? What standards are available for benchmarking? A national or other regional medication error rate does not exist. It is not possible to establish a national medication error rate or set a benchmark for medication error rates. Each hospital or organization is different. The rates that are tracked are a measure of the number of reports at a given institution not the actual number of events or the quality of the care given. Most systems for measuring medication errors rely on voluntary reporting of errors and near-miss events. Studies have shown that even in good systems, voluntary reporting only captures the "tip of the iceberg." For this reason, counting reported errors yields limited information about how safe a medication-use process actually is. It is very possible that an institution with a good reporting system, and thus what appears to be a high error "rate," may have a safer system. For more detailed information see Medication Errors, a book available on our website, and the following articles. "If safety is your yardstick, measuring culture from the top down must be a priority" ISMP Medication Safety Alert! March 22, 2007 "Measuring up to medication safety" ISMP Medication Safety Alert! March 10, 2005 "Measuring medicatio