2.50
Hdl Handle:
http://hdl.handle.net/10755/160022
Type:
Presentation
Title:
Evaluating Near Miss Medication Errors
Abstract:
Evaluating Near Miss Medication Errors
Conference Sponsor:Midwest Nursing Research Society
Conference Year:2006
Author:Buchman, Debra, PhD, RN, CNS
P.I. Institution Name:Medical University of Ohio
Title:Associate Professor
Contact Address:College of Nursing, 6012 Hawthorne Dr., Sylvania, OH, 43560, USA
Contact Telephone:419 383-6736
According to the Institute of Medicine (1999), approximately 98,000 deaths that occur annually in hospitals are the result of preventable events and most errors result in less or no harm. Every reported near-miss error is an opportunity to learn and correct system failures before harm reaches the patient (Mutter, 2003; Jones, Cochran, Hicks and Mueller, 2004). The purposes of this pilot study were to determine what proportion of medication errors reported over a three month period in a midwestern teaching hospital could be classified as ônear missö and to evaluate all of the ônear-missö errors to determine the most common types and characteristics. Reason's (1992) theory of human error was used to provide a framework for this study. All reported medication errors were assigned to one of the categories defined by the National Coordinating Council for Medication Error Reporting and Prevention (2001). Near miss were all errors in Category A (capacity to cause error) or B (error occurred but did not reach the patient). Each error was also typed as an error in prescribing, transcribing, dispensing or administering. A total of 440 medication errors were evaluated and 63% (n=277) were near-miss errors. As anticipated, near miss errors most frequently occurred during prescription (75%, n = 208), whereas all other errors most frequently occurred during administration (62%, n = 101). Evaluation of near miss prescribing errors revealed that the most frequent error was incorrect dose/frequency (35%, n = 78) and unclear orders (17%, n = 37). These results support the use of a CPOE and a bar coding system, however only a very small percentage of American healthcare institutions have these systems in place. The immediate challenge is to identify interventions that can reduce near miss errors until the more expensive technological solutions can be implemented. [Poster Presentation]
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Midwest Nursing Research Society

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleEvaluating Near Miss Medication Errorsen_GB
dc.identifier.urihttp://hdl.handle.net/10755/160022-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Evaluating Near Miss Medication Errors</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Midwest Nursing Research Society</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2006</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Buchman, Debra, PhD, RN, CNS</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Medical University of Ohio</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Associate Professor</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">College of Nursing, 6012 Hawthorne Dr., Sylvania, OH, 43560, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">419 383-6736</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">dbuchman@meduohio.edu</td></tr><tr><td colspan="2" class="item-abstract">According to the Institute of Medicine (1999), approximately 98,000 deaths that occur annually in hospitals are the result of preventable events and most errors result in less or no harm. Every reported near-miss error is an opportunity to learn and correct system failures before harm reaches the patient (Mutter, 2003; Jones, Cochran, Hicks and Mueller, 2004). The purposes of this pilot study were to determine what proportion of medication errors reported over a three month period in a midwestern teaching hospital could be classified as &ocirc;near miss&ouml; and to evaluate all of the &ocirc;near-miss&ouml; errors to determine the most common types and characteristics. Reason's (1992) theory of human error was used to provide a framework for this study. All reported medication errors were assigned to one of the categories defined by the National Coordinating Council for Medication Error Reporting and Prevention (2001). Near miss were all errors in Category A (capacity to cause error) or B (error occurred but did not reach the patient). Each error was also typed as an error in prescribing, transcribing, dispensing or administering. A total of 440 medication errors were evaluated and 63% (n=277) were near-miss errors. As anticipated, near miss errors most frequently occurred during prescription (75%, n = 208), whereas all other errors most frequently occurred during administration (62%, n = 101). Evaluation of near miss prescribing errors revealed that the most frequent error was incorrect dose/frequency (35%, n = 78) and unclear orders (17%, n = 37). These results support the use of a CPOE and a bar coding system, however only a very small percentage of American healthcare institutions have these systems in place. The immediate challenge is to identify interventions that can reduce near miss errors until the more expensive technological solutions can be implemented. [Poster Presentation]</td></tr></table>en_GB
dc.date.available2011-10-26T22:33:11Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T22:33:11Z-
dc.description.sponsorshipMidwest Nursing Research Societyen_GB
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