Interrater agreement with a standard scheme for classifying medication errors

Forrey, Ryan A.; Pedersen, Craig A.; Schneider, Philip J.

doi:10.2146/ajhp060109

Cited by 74 publications

(63 citation statements)

References 6 publications

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“…Several authors advocate it is the most adequate method (Santell et al, 2003;Forrey et al, 2007). However, more data from different institutions need to be collected (in methodologically similar fashion) so that comparisons can be made with the data presently available (Lacasa et al, 2012;Menendez et al, 2012).…”

Section: Resultsmentioning

confidence: 99%

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Dalmolin

Rotta

Goldim

2013

Braz. J. Pharm. Sci.

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Medication errors can be frequent in hospitals; these errors are multidisciplinary and occur at various stages of the drug therapy. The present study evaluated the seriousness, the type and the drugs involved in medication errors reported at the Hospital de Clínicas de Porto Alegre. We analyzed written error reports for 2010-2011. The sample consisted of 165 reports. The errors identified were classified according to seriousness, type and pharmacological class. 114 reports were categorized as actual errors (medication errors) and 51 reports were categorized as potential errors. There were more medication error reports in 2011 compared to 2010, but there was no significant change in the seriousness of the reports. The most common type of error was prescribing error (48.25%). Errors that occurred during the process of drug therapy sometimes generated additional medication errors. In 114 reports of medication errors identified, 122 drugs were cited. The reflection on medication errors, the possibility of harm resulting from these errors, and the methods for error identification and evaluation should include a broad perspective of the aspects involved in the occurrence of errors. Patient safety depends on the process of communication involving errors, on the proper recording of information, and on the monitoring itself.Uniterms: Medication/errors. Drug therapy. Patients/safety. Erros envolvendo medicamentos ocorrem frequentemente em hospitais, possuem natureza multidisciplinar e podem ocorrer nas várias etapas da terapia medicamentosa. O estudo avaliou a seriedade, o tipo e os medicamentos envolvidos nos erros de medicação notificados no Hospital de Clínicas de Porto Alegre. Foram analisadas notificações de erros realizadas por escrito em 2010-2011. A amostra foi composta por 165 notificações. Cento e catorze notificações foram classificadas como erros de fato (erros de medicação) e 51 notificações, como erros potenciais. Apesar de se ter realizado maior número de notificações de erros de medicação em 2011, comparativamente a 2010, não houve alteração significativa no perfil de seriedade destes eventos. O tipo de erro mais frequente foi o de prescrição (48,25%). Os erros ocorridos ao longo do processo geraram, em algumas situações, novos erros de medicação associados. Nas 114 notificações de erros de medicação identificadas citaram-se 122 medicamentos. A reflexão sobre os erros de medicação e a possibilidade de danos decorrentes dos mesmos, assim como dos métodos para a sua identificação e avaliação, deve incluir uma ampla perspectiva dos aspectos envolvidos na sua ocorrência. A segurança dos pacientes depende deste processo de comunicação, do registro adequado das informações e do monitoramento propriamente dito.

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Section: Resultsmentioning

confidence: 99%

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Dalmolin

Rotta

Goldim

2013

Braz. J. Pharm. Sci.

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“…We recommend that these variables be added to reporting systems. And finally, although a good inter-rater agreement in MEDMARX has been established, 23 the definitions of the classification system are still subject to interpretation by the reporter, which can lead to misclassification of error data.…”

Section: Discussionmentioning

confidence: 99%

“…22 Good inter-rater agreement (k ¼ 0.61) has been reported for MEDMARX users. 23 Each error report is standardized and provides information regarding the error's timing, location, error category, node, cause, medication involved, and error type. Facility characteristics captured include bed size, number of doses delivered, ownership, type of facility, and degree of pharmacist availability.…”

Section: Data and Variablesmentioning

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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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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“…The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Medication Errors was adapted and utilized for rating potential harm. 15,16 This nationally recognized NCC MERP harm level taxonomy was chosen because it is widely utilized by hospitals participating in the largest adverse drug event reporting system developed by the United States Pharmacopeia (USP). 17 NCC MERP criteria were collapsed to group errors into three categories:…”

Section: Classification Of Medication Errors and Potential Harm Assesmentioning

confidence: 99%

Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission

et al. 2010

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Interrater agreement with a standard scheme for classifying medication errors

Cited by 74 publications

References 6 publications

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

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

Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission

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