Medication Error Measurement
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Consumers Who Measure Medications At Home Most Often Use Which System?
list Help Journal ListJ Am Med Inform Assocv.15(4); Jul-Aug medication safety for nurses 2008PMC2442267 J Am Med Inform Assoc. 2008 Jul-Aug; 15(4): 461–465. doi: 10.1197/jamia.M2549PMCID: PMC2442267Identifying and Quantifying types of medication errors Medication Errors: Evaluation of Rapidly Discontinued Medication Orders Submitted to a Computerized Physician Order Entry SystemRoss Koppel, PhD, a , b , ∗ Charles E.
Medication Errors In Nursing
Leonard, PharmD, b , c A. Russell Localio, JD, PhD, b , c Abigail Cohen, PhD, b , c Ruthann Auten, BA, b , c and Brian L. Strom, MD, MPH b , c , d aDepartment of Sociology, University of Pennsylvania, Philadelphia, PAbDepartment of Biostatistics and Epidemiology, Center for
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Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PAcCenter for Education and Research on Therapeutics, University of Pennsylvania School of Medicine, Philadelphia, PAdDepartment of Medicine (General Medicine Division), Department of Pharmacology, University of Pennsylvania School of Medicine, Philadelphia, PA.∗Correspondence: Ross Koppel, Ph.D. 813 Pardee Lane, Wyncote, PA 19095 (Email: ude.nnepu.sas@leppokr).Author information ► Article notes ► Copyright and License information ►Received 2007 Jul 6; Accepted 2008 Mar 19.Copyright © 2008, American Medical Informatics AssociationThis article has been cited by other articles in PMC.AbstractAll methods of identifying medication prescribing errors are fraught with inaccuracies and systematic bias. A systematic, efficient, and inexpensive way of measuring and quantifying prescribing errors would be a useful step for reducing them.We ask if rapid discontinuations of prescription-orders–where physicians stop their orders within 2 hours–would be an expedient proxy for prescribing errors?To study this we analyzed CPOE-system medication orders entered
In Username or Email * Password * Forgot Password? Remember Me Don't have an account? Create New Account Home New This Week Measure Summaries By Measure Domain By Measurement Setting By Organization By MeSH Tag In Progress Archive All Summaries Expert Commentaries Matrix Tool Submit Measures Help &About Expert Commentary March 10, 2014 Medication Administration Errors in Hospitals — Challenges and Recommendations for Their Measurement By: Monsey McLeod, MPharm, MSc, PhD, Nick Barber, BPharm, PhD, Bryony Dean Franklin, BPharm, PhD Share Facebook Twitter Linkedin Email Print Read Comments (0) Medication errors are a threat to patient safety. Those that result in patient harm http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442267/ occur in an estimated 1% to 2% of hospital inpatients (1,2) and contribute to an increased hospital stay of 4.6 to 10.3 days for each affected patient. (3–5) While errors may arise at any stage of the medication use process (prescribing, dispensing, administering and monitoring), research suggests prescribing and administration errors account for the largest percentage of all (39% and 38%, respectively). (6) However, medication administration errors (MAEs) https://www.qualitymeasures.ahrq.gov/expert/expert-commentary/47856/medication-administration-errors-in-hospitals---challenges-and-recommendations-for-their-measurement are least likely to be intercepted before they reach the patient. (1,6) This is partly due to the narrow window of opportunity for detecting a MAE, which makes studying MAEs and developing suitable intervention strategies particularly problematic. Since the publication of key reports worldwide, (7–9) several attempts have been made to adapt strategies from high-risk industries, such as aviation, to analyse and reduce risk in healthcare. (10,11) However, there are a number of key differences between such industries and healthcare. (7) First, front-line staff in high-risk industries are usually directly affected when an accident happens, while in the healthcare setting it is typically someone else, i.e., the patient, who is affected. Second, preventable harm in healthcare generally occurs to one patient at a time, rather than groups of patients, making incidents less visible at the organisational level unless a patient suffers severe harm. For MAEs, the problem of visibility is made more challenging by the difficulties of measuring and reporting MAEs in practice. (12,13) In this commentary, we highlight some of the main challenges associated with measuring MAE rates and make suggestions for the development of more practical proxy measures of MAE rates for use in everyday practice by healthcare pro
Know Governance Job Openings Login to PA-PSRS About PA-PSRS Data Interface Facility Reporting Information Login to PassKey About PassKey Advisory Library Patient and Consumer Tips Press Releases Healthcare-Associated Infections Brochures Related Organization Links The http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/mar6(1)/Pages/10.aspx Authority in the News Driving Change Patient Safety Tools Calendar Public Meetings http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048644.htm ADDRESS: Patient Safety Authority 333 Market Street Lobby Level Harrisburg, PA 17120 Phone: 717-346-0469 Fax: 717-346-1090 SearchAdvanced Search Medication Errors: Significance of Accurate Patient Weights Pa Patient Saf Advis 2009 Mar;6(1):10-5. * Correction (Pa Patient Saf Advis 2010 Sep;7[3]:112.)ABSTRACTA patient’s weight is important information because it is often medication error used to calculate the appropriate medication dose. When medication errors arise due to inaccurate or unknown patient weights, the dose of a prescribed medication could be significantly different from what is appropriate. Nearly 480 event reports submitted to the Pennsylvania Patient Safety Authority specifically mentioned medication errors that resulted from breakdowns during the process of obtaining, documenting, and/or communicating patient weights. Analysis reveals that medication error measurement 67.2% of the events reached the patient. The unit mentioned most frequently in reports was the emergency department. All the frequently mentioned medications can be dosed based on a patient’s weight (i.e., weight-based dosing), and 5 of the top 10 medications are high-alert medications. Breakdowns described in reports most frequently involved failures to obtain accurate patient weight measurements. Once a value was obtained, errors arose from misuse of that value. Examples include problems when patients arrive at a hospital and are not weighed, leading to estimates of patient weights; assumptions that documented weights are current and/or accurate; and documentation breakdowns (e.g., the patient is weighed in pounds, but the weight is erroneously documented as kilograms). Strategies to address these problems include providing all units with the necessary equipment to weigh patients, weighing every patient during triage or admission to facilities, and weighing patients and documenting patient weights only in kilograms. Patient information helps practitioners select appropriate medications, doses, and routes of administration.1 One vital piece of patient-specific information, the patient weight, is especially important because it is often used to calculate the appropriate dose of a medication (e.g., mg
Home Food Drugs Medical Devices Radiation-Emitting Products Vaccines, Blood & Biologics Animal & Veterinary Cosmetics Tobacco Products For Consumers Home For Consumers Consumer Updates Avoiding Medication Mistakes Share Tweet Linkedin Pin it More sharing options Linkedin Pin it Email Print On This Page: Examples of Medication Errors FDA's Role NOTE: Go to "6 Tips to Avoid Medication Mistakes" for more easy steps you can follow. A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient. Since 2000, the Food and Drug Administration (FDA) has received more than 95,000 reports of medication errors. FDA reviews reports that come to MedWatch, the agency's adverse event reporting program. "These reports are voluntary, so the number of actual medication errors is believed to be higher," says Carol Holquist, R.Ph., Director of the Division of Medication Error Prevention and Analysis in FDA's Center for Drug Evaluation and Research. FDA works with many partners to track medication errors, including the U.S. Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP). "Every report received through the USP/ISMP Voluntary Medication Error Reporting Program (MERP) automatically gets sent to FDA's MedWatch program," says Mike Cohen, R.Ph., Sc.D., President of ISMP. "It takes a cooperative approach to monitor errors, evaluate them, and educate the public about strategies to keep errors from happening again." Medication errors occur for a variety of reasons. For example, miscommunication of drug orders can involve poor handwriting, confusion between drugs with similar names, poor packaging design, and confusion of metric or other dosing units. "Medication errors usually occur because of multiple, complex factors," says Holquist. "All parts of the health care system—including health professionals and patients—have a role to play in preventing medication errors." back to top Examples of Medication Errors Misuse of Tussionex Prescription Cough Medicine: On March 11, 2008, FDA informed health care professionals about adverse events and deaths in children and adults who have taken Tussionex Pennkinetic Extended-Release Suspension (Tussionex). Tussionex is a l