Document Detail


Inpatient medical errors involving glucose-lowering medications and their impact on patients: review of 2,598 incidents from a voluntary electronic error-reporting database.
MedLine Citation:
PMID:  18753094     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: To describe characteristics of inpatient medical errors involving hypoglycemic medications and their impact on patient care. METHODS: We conducted a cross-sectional analysis of medical errors and associated adverse events voluntarily reported by hospital employees and staff in 21 nonprofit, nonfederal health-care organizations in the United States that implemented a Web-based electronic error-reporting system (e-ERS) between August 1, 2000, and December 31, 2005. Persons reporting the errors determined the level of impact on patient care. RESULTS: The median duration of e-ERS use was 3.1 years, and 2,598 inpatient error reports involved insulin or orally administered hypoglycemic agents. Nursing staff provided 59% of the reports; physicians reported <2%. Approximately two-thirds of the errors (1,693 of 2,598) reached the patient. Errors that caused temporary harm necessitating major treatment or that caused permanent harm accounted for 1.5% of reports (40 of 2,598). Insulin was involved in 82% of reports, and orally administered hypoglycemic agents were involved in 18% of all reports (473 of 2,598). Sulfonylureas were implicated in 51.8% of reports involving oral hypoglycemic agents (9.4% of all reports). CONCLUSION: An e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm.
Authors:
Renee E Amori; Anastassios G Pittas; Richard D Siegel; Sanjaya Kumar; Jack S Chen; Suneel Karnam; Sherita H Golden; Deeb N Salem
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists     Volume:  14     ISSN:  1934-2403     ISO Abbreviation:  Endocr Pract     Publication Date:    2008 Jul-Aug
Date Detail:
Created Date:  2008-08-28     Completed Date:  2009-01-14     Revised Date:  2010-02-23    
Medline Journal Info:
Nlm Unique ID:  9607439     Medline TA:  Endocr Pract     Country:  United States    
Other Details:
Languages:  eng     Pagination:  535-42     Citation Subset:  IM    
Affiliation:
Division of Endocrinology, Diabetes, and Metabolism, Tufts-New England Medical Center, Boston, Massachusetts, USA.
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MeSH Terms
Descriptor/Qualifier:
Adverse Drug Reaction Reporting Systems / statistics & numerical data*
Cross-Sectional Studies
Drug Toxicity / epidemiology,  etiology
Humans
Hypoglycemic Agents / adverse effects*
Incidence
Insulin / adverse effects
Medical Errors / statistics & numerical data*
Sulfonylurea Compounds / adverse effects
United States / epidemiology
Chemical
Reg. No./Substance:
0/Hypoglycemic Agents; 0/Sulfonylurea Compounds; 11061-68-0/Insulin
Comments/Corrections
Comment In:
Endocr Pract. 2010 Jan-Feb;16(1):134-5

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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