National Study on the Frequency, Types, Causes, and Consequences of Voluntarily Reported Emergency Department Medication Errors
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- 作者：Julius Cuong Pham MD ; † ; ; ; Julie L. Story MD ; Rodney W. Hicks MPA ; MSN ; ARNP‡ ; ; Andrew D. Shore PHD§ ; ; Laura L. Morlock PHD ; Dickson S. Cheung MD ; Gabor D. Kelen MD ; Peter J. Pronovost MD ; PHD† ; ; ¶ ;
- 关键词：medication errors ; Emergency Department ; patient safety
- 刊名：Journal of Emergency Medicine
- 出版年：2011
- 出版时间：May 2011
- 年：2011
- 卷：40
- 期：5
- 页码：485-492
- 全文大小：236 K
文摘
Background: Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. Study Objective: To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. Methods: A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. Results: There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24 % of errors, nurses for 54 % . Errors most commonly occurred in the administration phase (36 % ). The most common type of error was improper dose/quantity (18 % ). Leading causes were not following procedure/protocol (17 % ), and poor communication (11 % ), whereas contributing factors were distractions (7.5 % ), emergency situations (4.1 % ), and workload increase (3.4 % ). Computerized provider order entry caused 2.5 % of errors. Harm resulted in 3 % of errors. Actions taken as a result of the error included informing the staff member who committed the error (26 % ), enhancing communication (26 % ), and providing additional training (12 % ). Patients or family members were notified about medication errors 2.7 % of the time. Conclusion: ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.