Preventing Medication Errors (2007) / Chapter Skim
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1 Introduction
1 Introduction
Pages 25-42
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identified medication errors as the most common type of error in health care and attributed several thousand deaths to medication-related events. The report had an immediate impact.
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. The article also pointed to the accelerated implementation of clinical information systems that can help reduce medication errors.
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Betsy received the wrong dose of cyclophosphamide. The correct dose was 1,000 milligrams (mg)
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. MEASURES TO IMPROVE MEDICATION SAFETY Efforts to improve medication safety are made at all levels of the health care system: by helping the patient avoid medication errors; by organizing
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Since 1994 the Institute for Safe Medication Practices has provided guidance on eliminating medication errors through newsletters, journal articles, and communications with health care professionals and regulatory authorities. In 1996 the National Coordinating Council for Medication Error Reduction and Prevention began publishing a series of recommendations on strategies for reducing medication errors (NCCMERP, 2005)
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, which may include suggestions or default values for drug doses and checks for drug allergies, drug laboratory values, and drug drug interactions; automated dispensing systems that dispense medications electronically in a controlled fashion and track medication use; bar coding for positive identification of patients, prescriptions, and medications; and computerized adverse drug event monitors that search patient databases for data that may indicate the occurrence of such an event. Creating Health Care Organizations That Foster Safe Care The full benefits of technologies for preventing medication errors will not be achieved unless a culture of safety is created within health care organizations that are adequately staffed with professionals whose knowledge, skills, and ethics make them capable of overseeing the medication management of patients who are vulnerable and unable to manage their medications knowledgeably themselves (IOM, 2004)
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. Fifty 2The discussion here, as well as elsewhere in the report, draws on a paper commissioned by the committee: "Trends in Medication Use: Implications for Medication Errors," by Brent Petty, MD, The Johns Hopkins Hospital.
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. One critical implication of these figures relevant to this study is that efforts to control health care costs at the federal and state levels and within health care organizations mean that any new investments, including investments in medication safety, will need to be thoroughly justified.
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The IOM convened the Committee on Identifying and Preventing Medication Errors to conduct this study, with the following charge: · To develop a fuller understanding of drug safety and quality issues through the conduct of an evidence-based review of the literature, case studies and analysis. This review will consider the nature and causes of medication errors; their impact on patients; and the differences in causation, impact and prevention across multiple dimensions of health care delivery including patient populations, care settings, clinicians, and institutional cultures.
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· To provide guidance to consumers, providers, payers, and other key stakeholders on high-priority strategies to achieve both short-term and long-term drug safety goals, to elucidate the goals and expected results of such initiatives and support the business case for them, and to identify critical success factors and key levers for achieving success. · To assess opportunities and key impediments to broad nationwide implementation of medication error reductions, and to provide guidance to policy-makers and government agencies in promoting a national agenda for medication error reduction.
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The term medication encompasses three broad categories of products -- prescription and nonprescription drugs and dietary supplements -- all regulated by the FDA (see Chapter 2)
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Errors Potential Preventable Adverse Drug Adverse Drug Events Events FIGURE 1-1 Relationship among medication errors, adverse drug events, and potential adverse drug events. SOURCE: Gandhi et al., 2000.
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However, most medication errors do not cause harm. Some do cause harm and are either potential adverse drug events or preventable adverse drug events (see Figure 1-1)
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As a result, drug safety researchers coined the term adverse drug event to include both adverse drug reactions (which are nonpreventable) , and preventable adverse drug events (Bates et al., 1995b)
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REPORT OVERVIEW Part I of this report addresses the causes, incidence, and costs of medication errors. By way of background, it begins with a case study illustrating how medication errors can arise through a combination of organizational and individual failures.
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1995a. Relationship between medication errors and adverse drug events.
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2005. The incidence of adverse drug events in two large academic long-term care facilities.
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2003. Prevention of medication errors in the pediatric inpatient setting.
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