Document Detail


Medication Errors During Medical Emergencies in a Large, Tertiary Care, Academic Medical Center.
MedLine Citation:
PMID:  22001000     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
PURPOSE: Evaluate the rate, type and severity of medication errors occurring during Medical Emergency Team (MET) care at a large, tertiary-care, academic medical center. METHODS: A prospective, observational evaluation of 50 patients that required MET care was conducted. Data on medication use were collected using a direct-observation method whereby an observer documented drug information such as drug, dose, frequency, rate of administration and administration technique. Subsequently, a team of three clinicians assessed rate, type and severity of medication errors using definitions consistent with United States Pharmacopeia MEDMARX system. Severity was assessed on a scale of minor, moderate and severe. Results: One hundred eighty six doses were observed for 36 different medications. A total of 296 errors were identified; of these 196 errors (66%) were inappropriate aseptic technique. Of the remaining 100 errors, 46% were prescribing errors, 28% administration technique errors, 14% mislabeling errors, 10% drug preparation errors and 2% improper dose prescribing. Examples included: 1) prescribing errors, 2) administering wrong doses, 3) mislabeling, and 4) wrong administration technique such as not flushing intravenous medication through intravenous access. The rate of medication administration errors was 1.6 errors/dose including aseptic technique and 0.5 errors/dose excluding aseptic technique. A notable portion (14%) of errors were considered at least moderate in severity. CONCLUSIONS: One out of 2 doses were administered in error after errors of using inappropriate aseptic technique were excluded. There is a need for education and systematic changes to prevent medication errors during medical emergencies as an effort to avoid harm.
Authors:
Roman Gokhman; Amy L Seybert; Paul Pharmpus; Joseph Darby; Sandra L Kane-Gill
Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2011-10-13
Journal Detail:
Title:  Resuscitation     Volume:  -     ISSN:  1873-1570     ISO Abbreviation:  -     Publication Date:  2011 Oct 
Date Detail:
Created Date:  2011-10-17     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0332173     Medline TA:  Resuscitation     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Copyright Information:
Copyright © 2011. Published by Elsevier Ireland Ltd.
Affiliation:
Adjunct Assistant Professor, University of Pittsburgh School of Pharmacy, Critical Care Specialist, Medical/Trauma Intensive Care Unit, The Reading Hospital and Medical Center, Sixth Avenue and Spruce Street, West Reading, PA 19611.
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