Recent systematic reviews of medication administration error (MAE) prevalence in healthcare settings found that they were common [8, 9], with one reporting an estimated median of 19.1 % of ‘total opportunities for Medication was misplaced or lost on the ward on occasions [47, 62, 75, 81]. Accessed: 2013 July 2.17. Journal Article › Study The incidence and severity of adverse events affecting patients after discharge from the hospital. http://divxpl.net/medication-error/medication-errors-stories.html
N Engl J Med. 2003;348:1556-1564. The aim of this research was therefore to systematically review and appraise the empirical evidence available relating to the causes of MAEs in hospital settings.Literature Search MethodSearch StrategyThe following electronic databases The response rate was 28%. McBride-Henry K, Foureur M.
JAMA. 2016;316:2115-2125. Knowledge-based mistakes were less frequent (n = 16), with staff explaining that they did not know enough about the medication they were administering [34, 40, 41, 44, 51, 52, 56, 66, 77, 78, Journal Article › Review Medication safety in neonatal care: a review of medication errors among neonates. BMJ Qual Saf. 2013;22(4):278–289.
Transcribing errors were reported but appear to occur mainly in countries where nurses were expected to transcribe physician orders [37, 38, 41, 44]. Problems with policies or procedures were reported on few occasions (n = 6). View More Back to Top PSNET: Patient Safety Network Home Topics Issues WebM&M Cases Perspectives Primers Submit Case CME / CEU Training Catalog Glossary About PSNet Help & FAQ Contact PSNet Medication Errors Articles Barker KN.
BMJ Open. 2016;6:e009052. Medication Errors In Hospitals Statistics Personality-related causes were briefly reported as a lack of assertiveness/confidence  (including when challenging medical staff ), error perception  and conscientiousness .Training and experience. The majority of studies provided insufficient detail of their sampling strategy to determine its nature. To date there is scant evidence to support the notion that double checking reduces the MAE rate .
Vincent C, Taylor-Adams S, Stanhope N. Causes Of Medication Error As discussed previously, specific error examples appear to link poor supervision to violation-type errors and the provoking conditions of inexperience, trusting colleagues and fatigue [34, 40, 42, 43, 45, 63], though McLeod MC, Barber N, Franklin BD. Journal Article › Study A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.
Other well-documented patient-specific risk factors include limited health literacy and numeracy (the ability to use arithmetic operations for daily tasks), both of which are independently associated with ADE risk. check over here Am J Health Syst Pharm. 1995;52(4):390–395. [PubMed]12. doi: 10.1136/bmj.326.7391.684. [PMC free article] [PubMed] [Cross Ref]35. Kale A, Keohane CA, Maviglia S, et al. Medication Errors In Hospitals Articles
ADEs/PADEs are reported by physicians, nurses, pharmacists, patients, medical records/QA personnel or any member of hospital staff. Adverse Drug Reaction (ADR) - is a subset of ADEs that includes any clinical manifestation that is undesired, unintended, or unexpected that is consequent to and caused by the administration of Workload was found to combine with distractions to lead to errors in intravenous administration [34, 40] and with patient acuity, inexperience or local working practice to lead to other errors [42, http://divxpl.net/medication-error/incidence-of-medication-errors-in-hospitals.html delayed delivery of medication from pharmacy).In contrast, interviews/conversations (±direct observation), focus groups or self-reporting methods involving narrative free text responses generally provided a greater variety of MAE causes.
Crit Care Med. 2006;34(2):415–425. Medication Error Definition The system returned: (22) Invalid argument The remote host or network may be down. Please try the request again.
Considering that only a small proportion of included studies predominantly sought to determine the causes of MAEs, and that only five of these used more qualitative methods [34, 40–45, 52, 56], NCBISkip to main contentSkip to navigationResourcesHow ToAbout NCBI AccesskeysMy NCBISign in to NCBISign Out PMC US National Library of Medicine National Institutes of Health Search databasePMCAll DatabasesAssemblyBioProjectBioSampleBioSystemsBooksClinVarCloneConserved DomainsdbGaPdbVarESTGeneGenomeGEO DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web doi: 10.1023/A:1008616622472. [PubMed] [Cross Ref]38. Medication Errors In Nursing Heterogeneity between studies meant that no attempt was made to quantify the frequency of MAE causes; such analyses would mislead readers, as a notion of frequency would be presented that may
J Nurs Care Qual 2004; 19(3):209–17. [PubMed]20. Reason J. Available from URL: http://www.nccmerp.org/pdf/taxo2001-07-31.pdf. weblink Of these few, most do not provide break-down at the individual error level.In light of the strong influence of data collection method on our findings, we did not attempt to infer
Studies have linked nurse staffing levels to negative patient outcomes, including MEs , but this relationship is complex, and further study is required to understand more clearly the role MAEs have Kaushal R, Bates DW, Landrigan C, et al. Journal Article › Study Incidence of adverse drug events and potential adverse drug events: implications for prevention. Studies were included if they were published in English and identified causes in relation to specific errors or near misses that staff members either made themselves or were directly involved with.
doi: 10.2146/ajhp100019. [PubMed] [Cross Ref]24. Reference lists of included articles and relevant review papers were hand searched for additional studies. Journal Article › Study Medicines management, medication errors and adverse medication events in older people referred to a community nursing service: a retrospective observational study. The small number of studies providing insight into the origins of violations suggests that their origins may lie in staff relationships, patient interactions, general workload and institutional policies and procedures.
Whenever an error is identified, it must be documented and the prescriber or nurse administering the medication informed. Am J Health Syst Pharm. 2011;68(3):227–240. Nearly three fourths of respondents differentiated between errors caught and not caught before a medication leaves the pharmacy and between errors caught and not caught before administration to the patient. There is reason to believe criminal activity or criminal intent may be involved in the making or reporting of an ADE.
They are not intended to replace professional judgment. Recent work suggests that violations of medication administration protocols may be more likely in certain circumstances  and that they arise depending on the nurses workload, familiarity with the drug and Transcribing: in a paper-based system, an intermediary (a clerk in the hospital setting, or a pharmacist or pharmacy technician in the outpatient setting) must read and interpret the prescription correctly. In particular, adverse events associated with medication appear among the chief causes of this harm while patients reside in hospitals  and are known to be responsible for a large proportion
More detailed analysis of error accounts by one interview study revealed cases where physical exhaustion was caused by long hours and lack of breaks/food . Pepper GA. When considered with the prominence of medicines supply issues, medication administration can be viewed as the culmination of multiple high-risk processes that complicate nursing practice and place patients in potential danger.Organisational Drugs Real World Outcomes. 2016;3:13-24.
Physical feelings of fatigue, tiredness/sleep deprivation, sickness and general discomfort amongst staff were reported as contributory factors to errors (n = 13) [42, 43, 45, 51, 52, 63–65, 68, 70–72, 82, 86, 88]. Some demonstrated the link between administration errors/violations and their associated error-producing conditions using human error theory [34, 40, 41, 44, 53, 62, 88]. Carlton G, Blegen MA. Journal Article › Study Liquid medication errors and dosing tools: a randomized controlled experiment.