Does critical incident reporting contribute to medication error prevention?

Frey, Bernhard; Buettiker, V; Hug, Maja I.; Waldvogel, Katharina; Gessler, Peter; Ghelfi, Daniela; Hodler, Catherine; Baenziger, Oskar

doi:10.1007/s00431-002-1055-0

Cited by 75 publications

(74 citation statements)

References 25 publications

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“…8,15,18,27 Our results likely reflect the frequent use of these medications in the NICU. One definition of risk indicates that risk is directly proportional to frequency of occurrence and to harm.…”

Section: Discussionmentioning

confidence: 68%

“…[9][10][11] Neonates are a particularly vulnerable population and may be at further risk of harm from medication errors because of changing body size, weight-based dosages, off-label drug usage, availability of stock solutions in a variety of concentrations, inability to communicate with providers, and changing developmental systems affecting drug absorption, distribution, metabolism, and excretion. [12][13][14][15][16][17][18] For example, the necessary calculations involved in the ordering of medications and in the dilution of stock drugs in the NICU place these patients at risk for harm from 10-to 100-fold dosing errors. 19 Nevertheless, the understanding of medication errors affecting the care of the neonate is in its early stages, thus hampering efforts to identify targets for intervention in preventing these errors.…”

Section: Introductionmentioning

confidence: 99%

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NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

et al. 2009

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Objective: To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).Study Design: A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified w 2 test was used for analysis.Result: 6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P ¼ 0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/ delivery device failures were more likely to be harmful (Pp0.05). Conclusion:Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

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Section: Discussionmentioning

confidence: 68%

Section: Introductionmentioning

confidence: 99%

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

et al. 2009

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“…Transcription errors were not commonly reported within paediatric studies, with only three articles acknowledging their incidence [Frey et al 2000[Frey et al , 2002Fortescue et al 2003]. These types of errors made up 5.8% of all medication errors, and included: punctuation mistakes (i.e.…”

Section: Paediatricmentioning

confidence: 99%

“…writing '3' instead of '0.3'), omission of medication, wrong unit of measurement (i.e. g instead of mg) and incorrect doses [Frey et al 2000[Frey et al , 2002Fortescue et al 2003]. …”

Section: Paediatricmentioning

confidence: 99%

“…Anticoagulants [Frey et al 2002] Anticoagulants: Warfarin [Calabrese et al 2001;Winterstein et al 2004;Jennane et al 2011;Zeraatchi et al 2013] Anticoagulants: Warfarin [Picone et al 2008;Ernawati et al 2014] Anticonvulsants [Wong et al 2009] Anticonvulsants [Winterstein et al 2004] Sedatives: Midazolam [Frey et al 2002] Sedatives [Wong et al 2009] Benzodiazepines: Lorazepam, Midazolam [Calabrese et al 2001;Jennane et al 2011] Benzodiazepines: Alprazolam, Lorazepam [Picone et al 2008; García-Aparicio and Herrero-Herrero, 2013]…”

Section: A-pinch-listed Medicationmentioning

confidence: 99%

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Medication safety in neonatal care: a review of medication errors among neonates

Krzyżaniak

Bajorek

2016

Therapeutic Advances in Drug Safety

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Objective: The objective of this study was to describe the medication errors in hospitalized patients, comparing those in neonates with medication errors across the age spectrum. Method: In tier 1, PubMed, Embase and Google Scholar were searched, using selected MeSH terms relating to hospitalized paediatric, adult and elderly populations. Tier 2 involved a search of the same electronic databases for literature relating to hospitalized neonatal patients. Results: A total of 58 articles were reviewed. Medication errors were well documented in each patient group. Overall, prescribing and administration errors were most commonly identified across each population, and mostly related to errors in dosing. Errors due to patient misidentification and overdosing were particularly prevalent in neonates, with 47% of administration errors involving at least tenfold overdoses. Unique errors were identified in elderly patients, comprising duplication of therapy and unnecessary prescribing of medicines. Overall, the medicines most frequently identified with error across each patient group included: heparin, antibiotics, insulin, morphine and parenteral nutrition. While neonatal patients experience the same types of medication errors as other hospitalized patients, the medication-use process within this group is more complex and has greater consequences resulting from error. Suggested strategies to help overcome medication error most commonly involved the integration of a clinical pharmacist into the treating team. Conclusion: This review highlights that each step of the medication-use process is prone to error across the age spectrum. Further research is required to develop targeted strategies relevant to specific patient groups that integrate key pharmacy services into wards.

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Reporting and Disclosing Medical Errors

Garbutt¹,

Brownstein²,

Klein³

et al. 2007

Arch Pediatr Adolesc Med

121

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Objective: To characterize pediatricians' attitudes and experiences regarding communicating about errors with the hospital and patients' families.Design: Cross-sectional survey.Setting: St Louis, Mo, and Seattle, Wash.Participants: University-affiliated hospital and community pediatricians and pediatric residents. Results: Four hundred thirty-nine pediatric attending physicians and 118 residents participated (62% response rate). Most respondents had been involved in an error (39%, serious; 72%, minor; 61%, near miss; 7%, none). Respondents endorsed reporting errors to the hospital (97%, serious; 90%, minor; 82%, near miss), but only 39% thought that current error reporting systems were adequate. Most pediatricians had used a formal error reporting mechanism, such as an incident report (65%), but many also used informal reporting mechanisms, such as telling a supervisor (47%) or senior physician (38%), and discussed errors with colleagues (72%). Respondents endorsed disclosing errors to patients' families (99%, serious; 90%, minor; 39%, near miss), and many had done so (36%, serious; 52%, minor). Residents were more likely than attending physicians to believe that disclosing a serious error would be difficult (96% vs 86%; P=.004) and to want disclosure training (69% vs 56%; P =.03). Conclusions:Pediatricians are willing to report errors to hospitals and disclose errors to patients' families but believe current reporting systems are inadequate and struggle with error disclosure. Improving error reporting systems and encouraging physicians to report near misses, as well as providing training in error disclosure, could help prevent future errors and increase patient trust.

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Does critical incident reporting contribute to medication error prevention?

Cited by 75 publications

References 25 publications

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

Medication safety in neonatal care: a review of medication errors among neonates

Reporting and Disclosing Medical Errors

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