Most Common Medication Error In Hospital
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What Information Must Be Included In An Incident Report Regarding A Medication Error?
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Different Types Of Medication Errors
Issues WebM&M Cases Perspectives Primers Submit Case CME / CEU examples of medication errors in nursing Training Catalog Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial Team Technical most common medical errors or mistakes Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Patient Safety Primer Last Updated: March 2015 Medication Errors Topics Resource Type Patient http://www.medicinenet.com/script/main/art.asp?articlekey=55234 Safety Primers Safety Target Medication Errors/Preventable Adverse Drug Events Look-Alike, Sound-Alike Drugs More Share Facebook Twitter Linkedin Email Print Background and definitions Prescription medication use is widespread, complex, and increasingly risky. Clinicians have access to an armamentarium of more than 10,000 prescription medications, and nearly one-third of adults in the United States https://psnet.ahrq.gov/primers/primer/23/medication-errors take 5 or more medications. Advances in clinical therapeutics have undoubtedly resulted in major improvements in health for patients with many diseases, but these benefits have also been accompanied by increased risks. An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication, and ADEs account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. ADEs affect nearly 5% of hospitalized patients, making them one of the most common types of inpatient errors; ambulatory patients may experience ADEs at even higher rates. Transitions in care are also a well-documented source of preventable harm related to medications. As with the more general term adverse event, the occurrence of an ADE does not necessarily indicate an error or poor quality care. A medication error refers to an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medica
Home Food Drugs Medical Devices Radiation-Emitting Products Vaccines, Blood & Biologics Animal & Veterinary Cosmetics Tobacco Products Drugs Home Drugs Resources for You Information for Consumers (Drugs) Strategies to Reduce Medication http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm Errors: Working to Improve Medication Safety Share Tweet Linkedin Pin it More sharing options Linkedin Pin it Email Print When Jacquelyn Ley shattered her elbow on the soccer field, her parents set out to find her the best care in Minneapolis. "We 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 medication error surgeon. After a successful three-hour surgery to 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. of medication errors When she woke up in the middle of the night and 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
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