Preventing Medication Errors (2007) / Chapter Skim
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Part I Understanding the Causes and Costs of Medication Errors
Part I Understanding the Causes and Costs of Medication Errors
Pages 43-49
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From page 43... ...
, illustrates the complexity of the health care system and the medication-use process and the interrelatedness of the factors involved in medication safety and quality. In 1996, a Denver hospital acknowledged that a medication error had led to the death of a day-old infant, born to a mother with a prior history of syphilis.
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From page 44... ...
The nurses knew that, while having been taught that only clear liquids can be injected IV, certain milky-looking substances, such as lipid-based drug products, can be given IV. Therefore, they did not recognize the problem with giving penicillin G benzathine, a milky-white substance, IV.
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From page 45... ...
The analysis presented during the trial had a powerful influence on the jury, which acquitted the nurse in the one case that was tried. The lesson learned from this case study is that we must look beyond blaming individuals and focus on the multiple underlying system failures that shape individual behavior and create the conditions under which medication errors occur.
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From page 46... ...
46 PREVENTING MEDICATION ERRORS TABLE I-1 Latent and Active Failures Associated with Key Elements of the Medication-Use System, Denver Case Study Key Element Latent Failures Active Failures 1. Prescribing Phase Patient Information · Incomplete clinical infor- · Decision made to treat mation on prior treatment infant for congenital and current status of syphilis.
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From page 47... ...
PART I UNDERSTANDING THE CAUSES AND COSTS 47 TABLE I-1 continued Key Element Latent Failures Active Failures 2. Ordering Phase Drug Information · Insufficient drug informa- · Misread both health tion (rarely used in prac- department recommenda tice, nonformulary drug)
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From page 48... ...
4. Drug Administration Phase Drug Information · Insufficient drug informa- · Misunderstood benzathine tion about various forms to be brand name for of penicillin G (never used aqueous penicillin G
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From page 49... ...
1998. Lessons from the Denver medication error/criminal negligence case: Look beyond blaming individuals.
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