| A model for medication safety event detection. | |
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MedLine Citation:
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PMID: 20348558 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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BACKGROUND: Hospital medication safety event detection predominantly emphasizes the identification of preventable adverse drug events (ADEs) through self-reports. These relatively rare events only provide insight into patient harm and self-reports identify only a small portion of ADEs. A broader system-focused approach to medication safety event detection that uses an array of event detection methods is recommended. This approach illuminates medication system deficits and supports improvement strategies that can prevent future patient risk. OBJECTIVE: To: (i) describe a system-focused approach to hospital medication safety event detection, and (ii) present a case illustration of approach application. SYSTEM-FOCUSED MODEL AND METHODOLOGY: A three-level medication safety event detection model that ranges from a narrow harm-focused to broader system-focused approach is described. A standardized cross-level methodology to detect medication safety events is presented. CASE ILLUSTRATION: A Level 3 system-focused methodology that incorporated both voluntary and non-voluntary event detection strategies was used in 17 critical care (n = 4), intermediate care (n = 7) and medical-surgical units (n = 6) across two hospitals. A total of 431 events were detected: 78 (18.1%) ADEs and 353 (81.9%) potential ADEs. Of the 353 PADEs, 302 (70.0%) were non-intercepted events. Non-voluntary detection methods yielded the majority of events (367, 85.1%). CONCLUSIONS: The incidence of ADEs was low when compared with non-intercepted PADEs. This was indicative of medication safety system failures that placed patients at risk for potential harm. Non-voluntary detection methods were much more effective at detecting events than traditional self-report methods. |
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Authors:
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Rita A Snyder; Willa Fields |
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Publication Detail:
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Type: Journal Article; Research Support, N.I.H., Extramural Date: 2010-03-27 |
Journal Detail:
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Title: International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua Volume: 22 ISSN: 1464-3677 ISO Abbreviation: Int J Qual Health Care Publication Date: 2010 Jun |
Date Detail:
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Created Date: 2010-05-13 Completed Date: 2010-08-13 Revised Date: 2011-07-28 |
Medline Journal Info:
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Nlm Unique ID: 9434628 Medline TA: Int J Qual Health Care Country: England |
Other Details:
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Languages: eng Pagination: 179-86 Citation Subset: IM |
Affiliation:
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College of Nursing, University of South Carolina, 1601 Greene Street, Columbia, SC 29208-4001, USA. ritsny520@aol.com |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Adverse Drug Reaction Reporting Systems
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organization & administration* Drug Toxicity / epidemiology* Hospital Administration* Humans Incidence Medication Errors / prevention & control* Safety Management / organization & administration* |
| Grant Support | |
ID/Acronym/Agency:
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R01 HS013131/HS/AHRQ HHS |
| Comments/Corrections | |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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