Medication Errors Observed in 36 Health Care Facilities

Barker, Kenneth N.; Flynn, Elizabeth A.; Pepper, Ginette A.; Bates, David W.; Mikeal, Robert L.

doi:10.1001/archinte.162.16.1897

Cited by 636 publications

(506 citation statements)

References 12 publications

Supporting

Mentioning

430

Contrasting

Unclassified

Order By: Relevance

“…2 Because medication errors represent one of the most common, costly and preventable causes of patient injury in the nursing home setting, the Institute of Medicine has called for a thorough and systematic approach to documenting them. [3][4][5] Voluntary reporting, direct observation, manual chart review, and computerized techniques can be used to detect and document medication errors. 6, 7 However, the majority of nursing home policies and procedures specify the use of voluntary incident reporting, which results in a low frequency of formal reporting.…”

Section: Introductionmentioning

confidence: 99%

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

Handler

Perera

Olshansky

et al. 2007

Journal of the American Medical Directors Association

View full text Add to dashboard Cite

Objectives-To have healthcare professionals in nursing homes identify organizational-level and individual-level modifiable barriers to medication error reporting.Design-Nominal group technique sessions to identify potential barriers, followed by development and administration of a 20-item cross-sectional mailed survey.Participants and Setting-Representatives of 4 professions (physicians, pharmacists, advanced practitioners, and nurses) from 4 independently owned, nonprofit nursing homes that had an average bed size of 150, were affiliated with an academic medical center, and were located in urban and suburban areas.Measurements-Barriers identified in the nominal group technique sessions were used to design a 20-item survey. Survey respondents used 5-point Likert scales to score factors in terms of their likelihood of posing a barrier ("very unlikely" to "very likely") and their modifiability ("not modifiable" to "very modifiable"). Immediate action factors were identified as factors with mean scores of <3.0 on the likelihood and modifiability scales, and represent barriers that should be addressed to increase medication error reporting frequency.Results-In 4 nominal group technique sessions, 28 professionals identified factors to include in the survey. The survey was mailed to all 154 professionals in the 4 nursing homes, and 104 (67.5%) responded. Response rates by facility ranged from 55.8% to 92.9%, and rates by profession ranged from 52.0% for physicians to 100% for pharmacists. Most respondents (75.0%) were women.Corresponding Author: S. M. Handler, MD, MS, Division of Geriatric Medicine, University of Pittsburgh, 3471 Fifth Ave, Suite 500, Pittsburgh, PA 15213, USA, 412-692-2360 (office phone), 412-291-2141 (fax), handlersm@upmc.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Respondents had worked for a mean of 9.8 years in nursing homes and 5.4 years in their current facility. Of 20 survey items, 14 (70%) had scores that categorized them as immediate action factors, 9 (64%) of which were organizational barriers. Of these factors, the 3 considered most modifiable were (1) lack of a readily available medication error reporting system or forms, (2) lack of information on how to report a medication error, and (3) lack of feedback to the reporter or rest of the facility on medication errors that have been reported. NIH Public AccessAuthor Manuscript J Am Med Dir Assoc. Author manuscript; available in PMC 2008 November 1. Conclusions-The study results provide a broad-based perspective of the barriers to medication error reporting in the nursing home setting...

show abstract

Section: Introductionmentioning

confidence: 99%

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

Handler

Perera

Olshansky

et al. 2007

Journal of the American Medical Directors Association

View full text Add to dashboard Cite

show abstract

“…Clinical inertia leads to adverse events just as surely as erroneous injections of certain medications can rapidly lead to death in a fragile hospitalized patient. 4,5 The principal substantive distinction between the adverse events caused by overuse or misuse of therapies, and adverse events attributable to clinical inertia in chronic disease care, is the time frame over which the adverse event occurs. In hospital settings misuse of a therapy may lead to adverse events in minutes to hours.…”

Section: Introductionmentioning

confidence: 99%

Clinical Inertia and Outpatient Medical Errors

O’Connor¹,

Sperl-Hillen²,

Johnson³

et al. 2005

PsycEXTRA Dataset

115

View full text Add to dashboard Cite

Clinical inertia is defined as lack of treatment intensification in a patient not at evidence-based goals for care. Clinical inertia is a major factor that contributes to inadequate chronic disease care in patients with diabetes mellitus, hypertension, dyslipidemias, depression, coronary heart disease, and other conditions. Recent work suggests that clinical inertia related to the management of diabetes, hypertension, and lipid disorders may contribute to up to 80 percent of heart attacks and strokes. Clinical inertia is, therefore, a leading cause of potentially preventable adverse events, disability, death, and excess medical care costs. This paper addresses three specific objectives: (1) to present a conceptual model of clinical inertia that takes into account recent developments in human factors research, cognitive science, and organizational behavior; (2) to operationally define clinical inertia and propose simple clinical protocols that can be used to identify and map its incidence across populations of patients and physicians; and (3) to propose future research to reduce clinical inertia by specifically targeting the root causes of the problem. Ultimately, a better understanding of clinical inertia and the development of specific interventions to reduce it may be a productive strategy to reduce passive errors that contribute to hundreds of thousands of adverse events and tens of thousands of premature deaths annually in the United States.

show abstract

“…Hasta ahora, no tenemos conocimiento de evidencia científica disponible que haya usado esta metodología para este nivel de complejidad en la atención. Otros estudios, con mediciones parciales, han medido la etapa de prescripción (25%-80%) 3,15,26 , o administración (19%-81%) 27,28 , o dispensación (0,06%-31,2%) 10,29,30 .…”

Section: Discussionunclassified

Errores de medicación en el Servicio de Medicina de un hospital de alta complejidad

2014

Rev. méd. Chile

View full text Add to dashboard Cite

show abstract

Medication Errors Observed in 36 Health Care Facilities

Cited by 636 publications

References 12 publications

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

Clinical Inertia and Outpatient Medical Errors

Errores de medicación en el Servicio de Medicina de un hospital de alta complejidad

Contact Info

Product

Resources

About