. "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 reviewer
Most likely to identify events resulting in patient harm
Fewer ADEs detected compared with patient surveys
Software; trained reviewers
Most likely to identify events resulting in patient harm
Limited availability of software in this setting in the short term
Pharmacist
Good measure of dispensing errors; provides clues to causes of errors
Dependent on availability of staff and time
Health care provider
Can provide clues to the causes of errors
Small numbers involved; should not be used for rate calculations
Health care provider
Can be used to follow up on symptoms, obtain additional information
May be time-consuming if no electronic screening is available
Computerized detection of ADEs is based on the use of screening criteria for triggering events. Techniques used by such systems include examining medication orders for antidotes (indicating a wrong dose or wrong drug) and screening clinical laboratory data for results that exceed critical values. These techniques may be employed at various levels of sophistication (Bates et al., 2003). Once a potential ADE has been identified, clinical review is necessary to confirm whether it was in fact such an event.
Observation of Medication Administration
Since 1960, studies have used nurses to observe medication administration in hospitals because the results provide an accurate measure of how often medication administration errors actually occur (Flynn et al., 2002). Observation involves a trained nurse or other health care profes-
