2.50
Hdl Handle:
http://hdl.handle.net/10755/160586
Type:
Presentation
Title:
Patient Safety: Reporting Falls and Medication Administration Errors
Abstract:
Patient Safety: Reporting Falls and Medication Administration Errors
Conference Sponsor:Midwest Nursing Research Society
Conference Year:2002
Author:Pepper, Ginette, PhD
P.I. Institution Name:University of Colorado Health Science Center
Title:Associate Professor
Contact Address:School of Nursing, 4200 East 9th Avenue, C288-20, Denver, CO, 80262, USA
Contact Telephone:303.315.5767
To address patient safety threats directly affected by nursing care, accurate detection and identification of associated active and latent failures in the system are essential. Occurrence reports are the most accessible and widely used measure of medication administration errors and falls. Researchers suggest as few as 10% of recognized medication administration errors are reported in hospitals, while accuracy of reporting patient falls has not been studied. Conceptualized within Reason's accident theory, the purpose of this study was to obtain nurses' perceptions of the proportion of medication administration errors and falls that are reported, reasons that these adverse occurrences were not reported, and reasons these adverse occurrences happen. This descriptive study involved quality data from hospitals (N=10) and survey of nurses (N=227) on 25 adult units in these hospitals. Three hospitals had been part of a consortium working to improve quality management processes. Nurses in the consortium hospitals (N=86) reported that 63% of medication errors and 82% of falls were reported, while nurses working in the non-consortium hospitals (N=141) reported that 52% or medication errors and 78% of falls were reported. The medication error rate based on adverse occurrence reports was also greater for consortium hospitals, although the patient fall rates did not differ. Both groups perceived that nurses do not report adverse events for both personal and administrative reasons. Nurses reported that the primary reasons (besides transcription error and physician handwriting) that medication errors occurred included distractions and interruptions, volume of medications, and problems with delivery from pharmacy. The primary reasons for patient falls were patient condition, staffing, and medications. Employment in a consortium hospital was associated with agreement that personal factors (r=.25; p<.001), rather than administrative factors (r=.07; p=.74) hinder reporting. It was concluded that focus on quality management may enhance occurrence reporting.
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.titlePatient Safety: Reporting Falls and Medication Administration Errorsen_GB
dc.identifier.urihttp://hdl.handle.net/10755/160586-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Patient Safety: Reporting Falls and Medication Administration 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">2002</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Pepper, Ginette, PhD</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">University of Colorado Health Science Center</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">School of Nursing, 4200 East 9th Avenue, C288-20, Denver, CO, 80262, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">303.315.5767</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">Ginny.Pepper@UCHSC.edu</td></tr><tr><td colspan="2" class="item-abstract">To address patient safety threats directly affected by nursing care, accurate detection and identification of associated active and latent failures in the system are essential. Occurrence reports are the most accessible and widely used measure of medication administration errors and falls. Researchers suggest as few as 10% of recognized medication administration errors are reported in hospitals, while accuracy of reporting patient falls has not been studied. Conceptualized within Reason's accident theory, the purpose of this study was to obtain nurses' perceptions of the proportion of medication administration errors and falls that are reported, reasons that these adverse occurrences were not reported, and reasons these adverse occurrences happen. This descriptive study involved quality data from hospitals (N=10) and survey of nurses (N=227) on 25 adult units in these hospitals. Three hospitals had been part of a consortium working to improve quality management processes. Nurses in the consortium hospitals (N=86) reported that 63% of medication errors and 82% of falls were reported, while nurses working in the non-consortium hospitals (N=141) reported that 52% or medication errors and 78% of falls were reported. The medication error rate based on adverse occurrence reports was also greater for consortium hospitals, although the patient fall rates did not differ. Both groups perceived that nurses do not report adverse events for both personal and administrative reasons. Nurses reported that the primary reasons (besides transcription error and physician handwriting) that medication errors occurred included distractions and interruptions, volume of medications, and problems with delivery from pharmacy. The primary reasons for patient falls were patient condition, staffing, and medications. Employment in a consortium hospital was associated with agreement that personal factors (r=.25; p&lt;.001), rather than administrative factors (r=.07; p=.74) hinder reporting. It was concluded that focus on quality management may enhance occurrence reporting.</td></tr></table>en_GB
dc.date.available2011-10-26T23:05:09Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T23:05:09Z-
dc.description.sponsorshipMidwest Nursing Research Societyen_GB
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