Medication Error Rate
Contents |
to download it as a free PDF. Contents Chapter Page of 464 Original Pages Text Pages Get This Book « Previous: Appendix B Glossary of medication error statistics 2015 Terms and Acronyms Page 367 Share Cite Suggested Citation: "Appendix C Medication
Medication Error Definition
Errors: Incidence Rates ." Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies medication errors statistics 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) in three care
Medication Errors In Nursing
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 that specifically identified medication errors medication error rate calculation 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 care 1,400 (Bates et al., 1995a)—prompted reporting, chart review, revi
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
Types Of Medication Errors
are dangerous? Are these evidence based? What drug names are frequently confused? How should
Medication Error Articles
tall man lettering be applied to differentiate look-alike/sound-alike drug names? What is confirmation bias? How do I do an independent medication errors in hospitals 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? https://www.nap.edu/read/11623/chapter/15 What is an FMEA, and how 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 http://www.ismp.org/faq.asp ISMP as a student? Does ISMP have a 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 Aler
Home Food Drugs Medical Devices Radiation-Emitting Products Vaccines, Blood & Biologics Animal http://www.fda.gov/drugs/drugsafety/medicationerrors/ & Veterinary Cosmetics Tobacco Products Drugs Home Drugs Drug Safety http://www.nccmerp.org/statement-medication-error-rates and Availability Medication Errors Medication Errors Related to Drugs Share Tweet Linkedin Pin it More sharing options Linkedin Pin it Email Print Within the Center for Drug Evaluation and Research (CDER), the Division of Medication Error Prevention and Analysis (DMEPA) reviews medication error medication error reports on marketed human drugs including prescription drugs, generic drugs, and over-the-counter drugs. DMEPA uses the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) definition of a medication error. Specifically, a medication error is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication medication error rate is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."DMEPA includes a medication error prevention program staffed with healthcare professionals. Among their many duties, program staff review medication error reports sent to MedWatch, evaluate causality, and analyze the data to provide solutions to reduce the risk of medication errors to industry and others at FDA.Additionally, DMEPA prospectively reviews proprietary names, labeling, packaging, and product design prior to drug approval to help prevent medication errors.Although DMEPA encourages manufacturers to perform their due diligence when naming their drug products and we strive to avoid approving confusing proprietary names for drug products, there are cases of adverse events where a name of a marketed product is identified as a source of confusion and error. Therefore, we continue to encourage healthcare
Drug Event AlgorithmRecommendations / StatementsFor Consumers Statement on Medication Error Rates Statement from NCC MERP Use of Medication Error Rates to Compare Health Care Organizations is of No Value The use of medication error rates to compare health care organizations is not recommended for the following reasons: Differences in culture among health care organizations can lead to significant differences in the reporting of medication errors. Organizations that encourage medication error reporting by providing incentives and resources to report within a non-punitive, continuous quality improvement arena will likely report more medication errors than organizations that wish to conceal errors and punish individuals who are involved in or report errors. Differences in the definition of a medication error among health care organizations can lead to significant differences in the reporting and classification of medication errors. For example, some organizations may only consider actual errors that reach the patient as errors. Other organizations also will include potential errors and errors that do not reach the patient. The latter organizations will likely collect more medication errors, and information from reports of potential errors can sometimes be more useful in prevention efforts than reports of actual errors. Differences in the patient populations served by various health care organizations can lead to significant differences in the number and severity of medication errors occurring among organizations. For example, tertiary care hospitals generally may serve more severely ill patients than rehabilitation hospitals. In addition, the intensity of drug therapies, the types of drugs used, and the methods of drug distribution may be substantially different in these environments, thereby leading to differences in number and types of errors. Differences in the type(s) of reporting and detection systems for medication errors among health care organizations can lead to significant differences in the number of medication errors recorded. Passive reporting systems, relying upon voluntary reports from staff, are known to result in far fewer medication erro