Error Medication Preventing
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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 Errors: Working to Improve Medication Safety Share Tweet preventing nursing medication errors Linkedin Pin it More sharing options Linkedin Pin it Email Print When Jacquelyn Ley shattered her preventing medication errors in hospitals elbow on the soccer field, her parents set out to find her the best care in Minneapolis. "We drove past five other hospitals to
Preventing Medication Errors Institute Of Medicine
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 surgeon. After a successful three-hour surgery to repair the broken bones, Jacquelyn, who was 9
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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. When she woke up in the middle of the night and checked on her, Jacquelyn was barely breathing. "I called her name, but preventing medication errors a $21 billion opportunity 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 has received nearly 30,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no "typical" medication error, and health professionals, patients, and their families are all involved. Some examples:A physici
Health Search databasePMCAll DatabasesAssemblyBioProjectBioSampleBioSystemsBooksClinVarCloneConserved DomainsdbGaPdbVarESTGeneGenomeGEO DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed HealthSNPSparcleSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch termSearch Advanced Journal list Help Journal ListBr J Clin
Preventing Medication Administration Errors
Pharmacolv.67(6); 2009 JunPMC2723204 Br J Clin Pharmacol. 2009 Jun; 67(6): 651–655. institute of medicine’s july 2006 report preventing medication errors doi: 10.1111/j.1365-2125.2009.03422.xPMCID: PMC2723204Prevention of medication errors: detection and auditGermana Montesi and Alessandro LechiInternal Medicine, University Hospital, preventing medication errors institute of medicine. (2007) Verona, ItalyCorrespondence Dott.ssa Germana Montesi, Medicina Interna C, Policlinico G.B Rossi – P.le L.A. Scuro, 10, 37134 Verona, Italy. Tel: +39-045-8124414 Fax: +39-045-8027465 E-mail: ti.rvinu@isetnom.serolodanamregAuthor information ► Article http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm notes ► Copyright and License information ►Received 2009 Feb 18; Accepted 2009 Mar 18.Copyright Journal compilation © 2009 The British Pharmacological SocietyThis article has been cited by other articles in PMC.AbstractMedication errors have important implications for patient safety, and their identification is a main target in improving clinical practice errors, in order to prevent adverse events.Error https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723204/ detection is the first crucial step. Approaches to this are likely to be different in research and routine care, and the most suitable must be chosen according to the setting.The major methods for detecting medication errors and associated adverse drug-related events are chart review, computerized monitoring, administrative databases, and claims data, using direct observation, incident reporting, and patient monitoring. All of these methods have both advantages and limitations.Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of a culture of safe practice. Combining and comparing data from various and encourages the diffusion of a culture of safe practice sources increases the reliability of the system.Error prevention can be planned by means of retroactive and proactive tools, such as audit and Failure Mode, Effect, and Criticality Analysis (FMECA). Audit is also an educational activity, which promotes high-quality care; it should be carried out regularly. In an audit cycle we can compare what is actually done against reference standards and put in place corrective actio
Health Search databasePMCAll DatabasesAssemblyBioProjectBioSampleBioSystemsBooksClinVarCloneConserved DomainsdbGaPdbVarESTGeneGenomeGEO DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723209/ HealthSNPSparcleSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch termSearch Advanced Journal list Help Journal ListBr J Clin Pharmacolv.67(6); 2009 JunPMC2723209 Br J Clin Pharmacol. 2009 Jun; 67(6): 681–686. doi: 10.1111/j.1365-2125.2009.03427.xPMCID: PMC2723209Medication errors: prevention using information technology systemsAbha AgrawalDepartment of Clinical Medicine and Medical Informatics, State University of New York Downstate, Brooklyn, NY, USACorrespondence medication errors Professor Abha Agrawal, Department of Clinical Medicine and Medical Informatics, State University of New York Downstate, Brooklyn, NY 11203, USA. Tel: +1-718-245-3980 Fax: +1-718-245-5347 E-mail: moc.liamg@ahba.lawargaAuthor information ► Article notes ► Copyright and License information ►Received 2009 Feb 9; Accepted 2009 Mar 18.Copyright Journal compilation © preventing medication errors 2009 The British Pharmacological SocietyThis article has been cited by other articles in PMC.AbstractGiven the high frequency of medication errors with resultant patient harm and cost, their prevention is a worldwide priority for health systems.Systems that use information technology (IT), such as computerized physician order entry, automated dispensing, barcode medication administration, electronic medication reconciliation, and personal health records, are vital components of strategies to prevent medication errors, and a growing body of evidence calls for their widespread implementation.However, important barriers, such as the high costs of such systems, must be addressed through economic incentives and government policies.This paper provides a review of the current state of IT systems in preventing medication errors.Keywords: CPOE, decision support, electronic health record, health information technology, medication errors, patient safetyA substantial body of evidence from international literature points to the r