Medication Error Reporting Systems Problems And Solutions
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Medication Error Reporting Form
Institutes of Health.Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for reporting medication errors in nursing Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Show detailsHughes RG, medical error reporting system editor.Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.ContentsSearch term < PrevNext > Chapter 35Error Reporting and DisclosureZane Robinson Wolf; Ronda G. Hughes.Author InformationZane Robinson Wolf;1 Ronda G. Hughes.21 Zane Robinson Wolf, Ph.D., R.N., F.A.A.N., dean and professor, La Salle University School of Nursing
What Is A Systems Approach To Addressing Error?
and Health Sciences. E-mail: ude.ellasal@flow2 Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for Healthcare Research and Quality. E-mail: vog.shh.qrha@sehguH.adnoRBackgroundThis chapter examines reporting of health care errors (e.g., verbal, written, or other form of communication and/or recording of near miss and patient safety events that generally involves some form of reporting system) and these events’ disclosure (e.g., communication of errors to patients and their families), including the ethical aspects of error-reporting mechanisms. The potential benefits of intrainstitutional and Web-based databases might assist nurses and other providers to prevent similar hazards and improve patient safety. Clinicians’ fears of lawsuits and their self-perceptions of incompetence could be dispelled by organizational cultures emphasizing safety rather than blame. This chapter focuses on the assertion that reporting errors that result in patient harm as well as seemin
(description of the safety issue along with error-reduction recommendations) In direct response to reporting medical errors to improve patient safety analysis of specific types of errors and hazards submitted to the when an error occurs, which of the following is a productive response? MERP, ISMP electronically distributed timely, nationwide, hazard alerts to healthcare providers on the following topics:
Medication Error Reporting And Prevention
Fatal events involving concentrated electrolytes (1996) Mix-ups between various protease inhibitors, some new to the market (1996) Change in packaging of Clintec Nutrition 10% amino acid https://www.ncbi.nlm.nih.gov/books/NBK2652/ solution, which has led to mix-ups with look-alike containers of 10% dextrose solution (1996) Errors from confusing dose labeling on Camptosar (irinotecan hydrochloride injection, CPT-11) (The alert leads to labeling changes) (1996) Ambiguous presentation of a cisplatin regimen published in the Journal of Clinical Oncology (The alert leads to correction published in subsequent http://www.ismp.org/about/merpimpact.aspx journal) (1997) Fatal overdoses of cisplatin due to labeling and packaging similarity with carboplatin (The alert leads to labeling and packaging changes) (1997) Fatal events involving magnesium sulfate overdoses (1997) Fatal errors stemming from confusion between lipid-based products (amphotericin B, doxorubicin, daunorubicin) and their conventional counterparts (1998) Repeated warnings about errors from confusing dose labeling on Cerebyx (fosphenytoin) (The alert leads to labeling changes) (1998) Methotrexate overdoses due to inadvertent administration daily instead of weekly (2002) The need for immediate, nationwide replacement of Brethine (terbutaline) ampuls with available vials to avoid potentially fatal mix-ups with look-alike ampuls of Methergine (methylergonovine) (2004) Press releases to the lay and healthcare media (description of the safety issue, error-reduction strategies, and link for additional information) In direct response to analysis of specific types of errors and hazards submitted to the MERP, ISMP electronically distributed timely, nationwide press releases to the lay and healthcare media on the following topics:
Home Food Drugs Medical Devices Radiation-Emitting Products Vaccines, Blood & Biologics Animal & Veterinary Cosmetics Tobacco Products http://www.fda.gov/drugs/drugsafety/medicationerrors/ Drugs Home Drugs Drug Safety 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 reports on marketed human drugs including prescription drugs, generic drugs, and medication error 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 is in the control of the health care professional, patient, or consumer. Such events may be medication error reporting 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 providers, patients and consumers to report all medication errors to MedWatch so that we can be made aware of potential problems related to drug names and the Agency can provide effective in