Trained reviewers

Detects more events than self-reports (Flynn et al., 2002)

More time-consuming if computer-generated signals are unavailable

Trained observers (nurses, pharmacists)

Detects greatest number of medication administration errors (Flynn et al., 2002); identifies clues to causes of errors that may not be found with other methods

Focuses on administration errors

All providers, report monitoring system and staff

With sufficient data, can identify error and ADE trends; description of event can help trained staff find cause

Detects small percentage of events

Trained staff to conduct interviews

In addition to advantages of voluntary self-report, they can be performed during attending rounds and nurse shift changes

Detects small percentage of events

To increase the strength of the evidence that errors truly are being reduced (or are increasing), additional, more robust error detection methods are needed.

Chart Review

Chart review to identify medication errors involves looking for events in patient documentation that indicate a medication error may have occurred, for example, a change in mental status, a new rash or diarrhea, or orders for antidotes. Chart review is an effective way of finding medication errors and ADEs, but is costly to perform and requires special training for the chart reviewers. Recently, chart review has begun to make use of an ADE trigger tool designed by the Institute for Healthcare Improvement (Rozich et al., 2003), which is based on the automated surveillance methodology created at LDS Hospital, Salt Lake City (Classen et al., 1991). Such ADE trigger tools do not require computerized technology and have been used successfully to demonstrate the benefits of low-cost error prevention

The National Academies of Sciences, Engineering, and Medicine
500 Fifth St. N.W. | Washington, D.C. 20001

Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement