| Medication errors--new approaches to prevention. | |
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MedLine Citation:
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PMID: 21518115 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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Medication errors in pediatric anesthesia represent an important risk to children. Concerted action to reduce harm from this cause is overdue. An understanding of the genesis of avoidable adverse drug events may facilitate the development of effective countermeasures to the events or their effects. Errors include those involving the automatic system of cognition and those involving the reflective system. Errors and violations are distinct, but violations often predispose to error. The system of medication administration is complex, and many aspects of it are conducive to error. Evidence-based practices to reduce the risk of medication error in general include those encompassed by the following recommendations: systematic countermeasures should be used to decrease the number of drug administration errors in anesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimized according to agreed standards; syringes should always be labeled; formal organization of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered. Dosage errors are particularly common in pediatric patients. Causes that should be addressed include a lack of pediatric formulations and/or presentations of medication that necessitates dilution before administration or the use of intravenous formulations for oral administration in children, a frequent failure to obtain accurate weights for patients and a paucity of pharmacokinetic and pharmacodynamic data. Technological innovations, including the use of bar codes and various cognitive aids, may facilitate compliance with these recommendations. Improved medication safety requires a system-wide strategy standardized at least to the level of the institution; it is the responsibility of institutional leadership to introduce such strategies and of individual practitioners to engage in them. |
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Authors:
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Alan F Merry; Brian J Anderson |
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Publication Detail:
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Type: Journal Article; Review Date: 2011-04-25 |
Journal Detail:
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Title: Paediatric anaesthesia Volume: 21 ISSN: 1460-9592 ISO Abbreviation: Paediatr Anaesth Publication Date: 2011 Jul |
Date Detail:
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Created Date: 2011-06-01 Completed Date: 2011-09-28 Revised Date: 2011-11-08 |
Medline Journal Info:
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Nlm Unique ID: 9206575 Medline TA: Paediatr Anaesth Country: France |
Other Details:
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Languages: eng Pagination: 743-53 Citation Subset: IM |
Copyright Information:
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© 2011 Blackwell Publishing Ltd. |
Affiliation:
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Department of Anaesthesiology, University of Auckland, and Auckland City Hospital, Auckland, New Zealand. a.merry@auckland.ac.nz |
Export Citation:
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APA/MLA Format Download EndNote Download BibTex |
| MeSH Terms | |
Descriptor/Qualifier:
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Anesthesia
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adverse effects*,
standards* Anesthesiology / instrumentation Anesthetics / administration & dosage, adverse effects, chemistry Child Drug Labeling Humans Medication Errors / prevention & control*, statistics & numerical data Pediatrics / standards* Risk Management Safety Syringes Technology |
| Chemical | |
Reg. No./Substance:
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0/Anesthetics |
| Comments/Corrections | |
Comment In:
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Paediatr Anaesth. 2011 Nov;21(11):1170-1
[PMID:
21966968
]
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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