Implementation Of Monitoring Programs Can Reduce And Prevent Mistakes
In June 2006 the medical journal Quality & Safety in Healthcare published an article, "Computer based medication error reporting: insights and implications", that demonstrated drug errors can and do occur at all points in the medication process.
Medical researchers, led by Marlene Miller and Christoph Lehmann, analyzed 19 months of data from a voluntary medication error reporting system in use at the Johns Hopkins Children's Center from 2001 to 2004.
As regards where the drug error occurred during the medication process, they found:
- 30% were prescribing errors;
- 24% were dispensing errors;
- 41% were administration errors; and,
- 6% were documentation errors.
Analyzing their data by drug type, the researchers observed:
- 17% of the errors occurred with antibiotics or anti-virals;
- 15% with pain relievers and sedatives;
- 11% with nutritional supplements;
- 8% with gastrointestinal medications; and,
- 7% with cardiovascular medications.
A June 26, 2006 UPI news article provided some perspective from one of the authors, Dr. Lehmann, who said: "Error reporting is only as good as the actual changes that are made as a result of it." The UPI article went on to report:
"In response to those findings, [the Johns Hopkins Children's Center] has created several programs to reduce and prevent such errors, including a computerized ordering tool for pediatric chemotherapy, an online infusion calculator for IV infusions, and an online total parenteral nutrition calculator for premature babies."
Significantly, this team of medical researchers led by Dr. Miller and Dr. Lehman determined that half of all medication errors at the Johns Hopkins facility during the study period occurred in children under six-years of age.
(Posted by: Tom Lamb)