Internal fixation has become a pillar of surgical specialties, yet the evolution of these devices has been relatively short. The first known description of medical management of a fracture was found in the Edwin Smith Papyrus of Ancient Egypt (circa 2600 bc). The first description of internal fixation in the ...

Medication administration is a frequent nursing activity that is prone to error. In this study of 318 self-reported medication incidents (including near misses), very few resulted in patient harm-7% required intervention or prolonged hospitalization or caused temporary harm. Aronson's classification system provided an excellent framework for analysis of the incidents ...

Some medication dosing protocols are logistically complex for traditional physician ordering. The use of computerized physician order entry (CPOE) with templates, or order sets, may be useful to reduce medication administration errors. This study evaluated the rate of medication administration errors using CPOE order sets for N-acetylcysteine (NAC) use in ...

Outpatient pharmacy errors are common, but little is known about their occurrence in Parkinson's disease (PD). We prospectively studied carbidopa/levodopa pharmacy errors in a cohort of PD outpatients. Over 1 year, pharmacy errors occurred in 8/73 (11%) subjects treated with this medication, producing adverse drug events (ADEs) in 7/8 (87.5%) ...

The Veterans Affairs Hypertension Primary Care Longitudinal Cohort (VAHC) was initiated in 2003 as a pilot study designed to link the VA electronic medical record system with individual genetic data. Between June 2003 and December 2004, 1,527 hypertensive participants were recruited. Protected health information (PHI) was extracted from the regional ...

Over 22 million US residents are limited English proficient. Hospitals often call upon untrained persons to interpret. There is a dearth of information on errors in medical interpreting and their impact upon cancer education. We conducted an experimental study of standardized medical interpreting training on interpreting errors in the cancer ...

We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction. Preintervention and postintervention study involving a control ...

There are a variety of factors that make the pediatric population more susceptible to medication errors and potential complications resulting from medication administration including the availability of different dosage forms of the same medication, incorrect dosing, lack of standardized dosing regimen, and organ system maturity. A systematic literature search on ...

To assess the prevalence and characteristics of medication errors (ME) in patients admitted to King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia. Medication errors are documented by the nurses and physicians standard reporting forms (Hospital Based Incident Report). The study was carried out in King Fahd University Hospital, Alkhobar, ...

In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices. We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse ...

BACKGROUND: Although strongly favored by patients and ethically imperative for providers, the disclosure of medical errors to patients remains rare because providers fear that it will trigger lawsuits and jeopardize their reputation. To date little is known how patients might respond to their providers' disclosure of a medical error even ...

The effect of an emergency medicine (EM) clinical pharmacist on medication-error reporting in an emergency department (ED) was studied. The medication-error reports for patients seen at a university's ED between September 1, 2005, and February 28, 2009, were retrospectively reviewed. Errors reported before the addition of an EM pharmacist (from ...

Inappropriate withdrawal or continuation of medication in the perioperative period is associated with an increased risk for adverse events. To reduce this risk, it is important that patients take their regular medication as prescribed. We evaluated this treatment objective by studying the frequency and reasons for errors related to medication ...

Communication errors are a source of preventable medical errors. In high-risk health care settings, identifying the source and addressing root causes can reduce error and improve patient safety. While air medical transport is a high-risk setting, its sources and rates of error have been investigated only within the last several ...

Nighttime and weekend admission has been associated with increased morbidity and mortality and has been linked to a variety of factors. Medication errors in hospitalized patients occur frequently, but the association between error rates and time of day and day of week (weekday vs weekend) has not been extensively studied. ...

Multiplicity in terminology has been suggested as a possible explanation for the variation in the prevalence of medication errors. So far, few empirical studies have challenged this assertion. The objective of this review was, therefore, to describe the extent and characteristics of medication error definitions in hospitals and to consider ...

Medication discrepancies, defined as unexplained variations among drug regimens at care transitions, are common. Some are unintended and cause reconciliation errors that are potentially detrimental for patients. To determine the prevalence of medication discrepancies and reconciliation errors at admission and discharge in hospitalized patients and explore risk factors for reconciliation ...

A variety of approaches are available to monitor and quantify the frequency of medical errors and the harm associated with them. The University HealthSystem Consortium Patient Safety Net provides a categorical, rank-ordered approach for designating harm associated with medical errors but does not lend itself to routine monitoring of change ...

To explore the nurse's role in the process of medication management and identify the challenges associated with safe medication management in contemporary clinical practice. Medication errors have been a long-standing factor affecting consumer safety. The nursing profession has been identified as essential to the promotion of patient safety. A review ...

Errors and the incorrect use of medications are significant sources of risk and harm to children in US hospitals. The risk associated with medication infusions has led to recommendations for the adoption of technologies including computer order physician entry (CPOE) and 'smart' infusion pumps despite a paucity of evidence demonstrating ...

PURPOSE: Although experts advise disclosing medical errors to patients, individual physicians' different levels of knowledge and comfort suggest a gap between recommendations and practice. This study explored pediatric residents' knowledge and attitudes about disclosure. METHOD: In 2006, the authors of this single-center, mixed-methods study surveyed 64 pediatric residents at the ...

OBJECTIVE: To identify and quantify errors and adverse events on an inpatient academic tertiary-care pediatric otolaryngology service, a trigger tool was developed and validated as part of a quality improvement initiative. STUDY DESIGN: Retrospective record review. SETTING: Children's Hospital Boston quality improvement initiative. SUBJECTS AND METHODS: Fifty inpatient admissions were ...

The epidemiology of adverse drug events (ADEs) and medication errors has received little evaluation outside the U.S. and Europe, and extrapolating from these data might not be valid, especially regarding selecting and prioritizing solutions. To assess the incidence and preventability of ADEs and medication errors in Japan. The Japan Adverse ...

The safe prescribing, use, administration, and monitoring of medications are an important component of patient safety efforts and are of particular importance to the obstetrician/gynecologist. Safe use of medications requires a team-based approach focused on medication safety with effective 2-way communication, use of technology to prevent and identify errors, diligent ...

To determine what components of a checklist contribute to effective detection of medication errors at the bedside. High-fidelity simulation study of outpatient chemotherapy administration. Usability laboratory. Nurses from an outpatient chemotherapy unit, who used two different checklists to identify four categories of medication administration errors. Rates of specified types of ...

An Institute of Medicine Report stated there are 98,000 people annually who die due to medication related errors in the United States, and hospitals and other medical institutions are thus being pressed to use technologies to reduce such errors. One approach is to provide a suitable protocol that can cooperate ...

Medication errors are common in many settings and have important ramifications. Although there is growing research on rates and characteristics of medication errors in adult ambulatory settings, less is known about the paediatric ambulatory setting. To assess medication error rates in paediatric patients in ambulatory settings. The authors conducted a ...

To compare determinants for medication errors leading to patient harm with determinants for medication errors without patient harm. A two-way case-control design was used to identify determinants for medication errors without harm (substudy 1) and determinants for medication errors causing harm (substudy 2). Data of patients admitted to five internal ...

The purpose of the study was to evaluate whether a Medication Pass Time Out initiative was effective and sustainable in reducing medication administration errors. A retrospective descriptive method was used for this research, where a structured Medication Pass Time Out program was implemented following staff and physician education. As a ...

Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; ...

OBJECTIVES: To determine the accuracy of medication reconciliation in an internal medicine clinic and to evaluate pharmacist interventions targeted at improving the accuracy of medication reconciliation. DESIGN: Prospective case series. SETTING: Memphis, TN, from October 2007 to March 2008. PATIENTS: 180 adults attending an internal medicine appointment. INTERVENTION: On patient ...

Medication errors are among the most common medical errors and cause significant morbidity and in some cases mortality. The objective of this article is to review the literature on medication errors in psychiatry. We completed a comprehensive search of both peer- and non-peer-reviewed articles that investigated medication errors in psychiatry. ...

Diagnostic errors often result in patient harm. Previous studies have shown that there is large variability in results in different medical specialties. The present study explored diagnostic adverse events (DAEs) across all medical specialties to determine their incidence and to gain insight into their causes and consequences by comparing them ...

'Organisational governance'--the systems, processes, behaviours and cultures by which an organisation leads and controls its functions to achieve its objectives--is seen as an important influence on patient safety. The features of 'good' governance remain to be established, partly because the relationship between governance and safety requires more investigation. To describe ...

With the introduction of Computerised Physician Order Entry (CPOE) in routine hospital care, a great deal of effort has been put into refining Clinical Decision Support Systems (CDSS) to identify patients at risk of preventable medication-related harm. This study compared a CPOE with basic CDSS and 16 clinical rules with ...

Medication error reporting is an important measure to prevent medication error incidents in a healthcare system and can serve as an important tool for improving patient safety. This study aimed to investigate attitudes of healthcare professionals (doctors, nurses, and pharmacists) in reporting medication errors. Fifty-six healthcare professionals working at a ...

OBJECTIVES/HYPOTHESIS: Medication errors are a common cause of poor clinical outcomes. Information on perioperative medication errors is scarce. This study was aimed at identifying the nature, cause, and potential remedies for medication errors in otolaryngologic surgery. STUDY DESIGN: Prospective and descriptive. METHODS: Clinicians were incentivized for reporting possible medication errors ...

BACKGROUND: Medication errors are highly prevalent in long-term care facilities and are responsible for preventable injury. Repeat medication errors, or identical events occurring multiple times in the same patient, may be particularly preventable. OBJECTIVES: This study assessed the factors that contribute to repeat medication errors and the association between repeat ...

OBJECTIVE: To evaluate the relationship between burnout and perceived major medical errors among American surgeons. BACKGROUND: Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality. METHODS: Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in June ...

Medication errors represent a failure in the medication use process and can increase morbidity and mortality. The National Coordinating Council for Medication Error Reporting and Prevention maintains a taxonomy that assists in standardized reporting, evaluating, and trending of medication error data. Many emergency departments are overcrowded from the increased responsibility ...

Medical registries are useful to summarize retrospective or prospective data in a fashion that, on interpretation, could result in changes in the standard of care or highlight issues that must be further investigated in the management of certain diseases. Registries involve collection of data and registries are only as good ...

Previous research has established health professionals as secondary victims of medical error, with the identification of a range of emotional and psychological repercussions that may occur as a result of involvement in error.2 3 Due to the vast range of emotional and psychological outcomes, research to date has been inconsistent ...

Each July thousands begin medical residencies and acquire increased responsibility for patient care. Many have suggested that these new medical residents may produce errors and worsen patient outcomes-the so-called "July Effect;" however, we have found no U.S. evidence documenting this effect. Determine whether fatal medication errors spike in July. We ...

Medication errors are common throughout healthcare and result in significant human and financial cost. Prospective studies suggest that the error rate in anaesthesia is around one error in every 133 anaesthetics. There are several categories of medication error ranging from slips and lapses to fixation errors and deliberate violations. Violations ...

BACKGROUND: Given the expanding use of oral chemotherapies, the authors set out to examine errors in the prescribing, dispensing, administration, and monitoring of these drugs. METHODS: Reports were collected of oral chemotherapy-associated medication errors from a medical literature and Internet search and review of reports to the Medication Errors Reporting ...

To describe and evaluate pharmacy students' knowledge of and comfort in communicating, managing, and preventing medication errors. Using a cross-sectional design, a survey instrument was administered to fifth-year pharmacy students. The survey instrument included both open- and close-ended questions to describe and examine factors associated with knowledge and comfort in ...

BACKGROUND: Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR). METHODS: We conducted a before-and-after, quasi-experimental study in ...

OBJECTIVE: Data entry errors may occur in body weights and heights assessed during routine medical care. These errors may affect data quality markedly and create a large number of biologically implausible values. To address this issue, we evaluated the quality of body weight and height measures for children based on ...

BACKGROUND: External reporting of medical errors a adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful ...

The prevalence of medical errors and malpractice claims has been attributed to deficits in error reporting and disclosure. Increasingly, states are adopting error reporting and apology laws to reduce these information gaps thereby instituting error-transparent medical cultures. At the same time, doubts have been expressed about the capacity for legislation ...