Medication Errors Associated with Code Situations in U.S. Hospitals: Direct and Collateral Damage

Lipshutz, Angela; Morlock, Laura L.; Shore, Andrew D.; Hicks, Rodney W.; Dy, Sydney M.; Pronovost, Peter J.; Winters, Bradford D.

doi:10.1016/s1553-7250(08)34007-0

Cited by 27 publications

(51 citation statements)

References 14 publications

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“…Other articles were excluded for the following reasons: 852 were not deemed code related as defined for this review, 4 were review articles, 10 were editorials or letters to the editor, 11 were intervention studies, 9 involved the prehospital setting, 2 were evaluations of errors other than medication errors, and 1 did not quantify the medication errors mentioned. The included studies [4][5][6][7][8][9] are summarized in Table 1. Both authors (A.H.F.…”

Section: Methodsmentioning

confidence: 99%

“…4,9 Various approaches have been used to study these errors, including database mining, simulations, and observational studies.…”

Section: Frequency Of Medication Errors During Emergent Code Situationsmentioning

confidence: 99%

“…The first study 4 in which investigators used database mining to quantify and analyze medication errors during code situations was a review of code-related medication errors reported to MED-MARX, a national, voluntary, anonymous medication-error reporting system currently maintained by the United States Pharmacopeia. Among 1 043 939 errors in the database from 834 health care facilities, a code situation was identified as a contributing factor in 0.22% (2288).…”

Section: Database Miningmentioning

confidence: 99%

“…Among 1 043 939 errors in the database from 834 health care facilities, a code situation was identified as a contributing factor in 0.22% (2288). Surprisingly, the majority of errors identified (74%) involved patients other than the patient being resuscitated, a phenomenon Lipshutz et al 4 termed "collateral damage." The most common type of error reported in the patient not having a code-related situation was error of omission, most likely due to alterations in workload and insufficient staffing for a given situation.…”

Section: Database Miningmentioning

confidence: 99%

“…Autonomic medications and sedative hypnotics accounted for almost 40% of errors that occurred during the resuscitation attempt that affected the patient being resuscitated. 4 One proposal made by the investigators 4 to reduce medication errors in code situations included reducing the number of code situations, certainly something that rapid response teams have done in recent years. 10 In a second study on resuscitation system errors and survival, Ornato et al 5 analyzed the American Heart Association Get With the Guidelines National Registry of Cardiopulmonary Resuscitation, a database created in 2000 to collect data and create guidelines for inpatient cardiopulmonary resuscitation for hospitals throughout the United States.…”

Section: Database Miningmentioning

confidence: 99%

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Medication Errors in Cardiopulmonary Arrest and Code-Related Situations

Flannery

Parli

2016

American Journal of Critical Care

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) was searched to identify relevant published studies on the overall frequency, types, and examples of medication errors during medical emergencies involving cardiopulmonary resuscitation and related situations, and the breakdown by type of error. The overall frequency of medication errors during medical emergencies, specifically situations related to resuscitation, is highly variable. Medication errors during such emergencies, particularly cardiopulmonary resuscitation and surrounding events, are not well characterized in the literature but may be more frequent than previously thought. Depending on whether research methods included database mining, simulation, or prospective observation of clinical practice, reported occurrence of medication errors during cardiopulmonary resuscitation and surrounding events has ranged from less than 1% to 50%. Because of the chaos of the resuscitation environment, errors in prescribing, dosing, preparing, labeling, and administering drugs are prone to occur. System-based strategies, such as infusion pump policies and code cart management, as well as personal strategies exist to minimize medication errors during emergency situations.

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Section: Methodsmentioning

confidence: 99%

“…4,9 Various approaches have been used to study these errors, including database mining, simulations, and observational studies.…”

Section: Frequency Of Medication Errors During Emergent Code Situationsmentioning

confidence: 99%

Section: Database Miningmentioning

confidence: 99%

Section: Database Miningmentioning

confidence: 99%

Section: Database Miningmentioning

confidence: 99%

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Medication Errors in Cardiopulmonary Arrest and Code-Related Situations

Flannery

Parli

2016

American Journal of Critical Care

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Survey of national practices for postgraduate year two critical care and emergency medicine pharmacy residency emergency response training

Philips

Cycz

Liu

et al. 2023

J Am Coll Clin Pharm

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IntroductionMedical emergency response within the hospital involves an interdisciplinary team, including pharmacists. Pharmacist involvement in these teams has increased over time due to published benefits of their involvement. Development of emergency response skills may start during pharmacy residency, although limited data suggest how this is best implemented.ObjectivesLimited data evaluate post‐graduate year 2 (PGY2) pharmacy resident training for emergency response, as well as PGY2 program values for this in screening/ranking candidates, which may help post‐graduate year one (PGY1) pharmacy residents identify residency programs that are a good fit for their career goals.MethodsA list of PGY2 critical care (CC) and emergency medicine (EM) programs were identified. The questionnaire included program demographics, characteristics of PGY2 emergency response training, and PGY2 residency program values of PGY1 emergency response exposure for screening and ranking applicants for their programs. A Fisher's exact test was used to compare differences between CC and EM programs for these outcomes.ResultsA total of 85 complete responses were analyzed (response rate by all identified programs: CC = 36.4%; EM = 32.1%). Emergency response training was often with both core and longitudinal experiences (72.9%), although differed by type of program (p < 0.001). Both CC and EM programs considered PGY1 pharmacy resident exposure to emergency response in screening candidates (33.9% and 57.7%, respectively), as well as ranking candidates (22% and 38.5%, respectively). For CC programs, both Advanced Cardiovascular Life Support certification and quantity of PGY1 emergency response ranked as the most important characteristics, while EM programs ranked quantity as the most important.ConclusionThe results of this survey indicate heterogeneity in PGY2 CC and EM emergency response training. PGY1 applicants for these programs should consider their experience with emergency response as a potential factor in identifying an appropriate program for their training.

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