. "5 Action Agenda for Health Care Organizations ." Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007.
The following HTML text is provided to enhance online
readability. Many aspects of typography translate only awkwardly to HTML.
Please use the page image
as the authoritative form to ensure accuracy.
Preventing Medication Errors
Resources
Advantages
Disadvantages
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
