Overnight and Postcall Errors in Medication Orders

Objective: To compare the error rates in medication orders by physicians who were off call, on overnight call, and postcall. Methods: This was a retrospective review of inpatient medication orders, pharmacy records, and resident physician work schedules in a university‐affiliated community teaching hospital with residency programs in emergency medicine, family practice, internal medicine, obstetrics, pediatrics, and surgery. The authors calculated error rates, odds ratios (ORs), and 95% confidence intervals (95% CIs) for physicians during April 2000. Results: In 8,195 medication orders, there were 177 errors (2.16% overall error rate). There was an increased error rate for overnight and postcall orders (2.71%, OR 1.44, 95% CI = 1.06 to 1.95) in comparison to orders written by off‐call physicians (1.90%). Error rates were significantly higher on the medical/surgical wards during the overnight (3.91%, OR 1.89, 95% CI = 1.22 to 2.92) and postcall (3.41%, OR 1.64, 95% CI = 1.10 to 2.43) periods compared with the off‐call (2.11%) period, and postgraduate year 1 (PGY1) physicians had a higher overnight error rate (4.23%, OR 2.28, 95% CI = 1.44 to 3.61). Error rates were also higher on the medical/surgical wards compared with critical care units (2.62% vs. 1.22%, OR 2.17, 95% CI = 1.48 to 3.18). The PGY1 physicians had error rates similar to those of the PGY2–5 physicians when off call, but were significantly higher on overnight call (4.23% vs. 0.52%, OR 8.47, 95% CI = 2.00 to 35.82). Conclusions: Medication‐ordering error rates were higher for overnight and postcall physicians, particularly on the general medical/surgical wards, and in PGY1 physicians during the overnight period.     

持续质量改进程序减少输血前标本差错的应用研究

目的探讨持续质量改进程序(continuous quality improvement,CQI)对减少输血前标本差错的效果。方法统计2007年7月~2011年3月我科收到的输血前血液标本169599份,其中2007年7月~2009年6月79115份(实施CQI前),2009年7月~2011年3月90484份(实施CQI后)。对所有标本实施两次ABO血型验证。自2009年7月起,针对错误标识和错误采集的标本采取CQI过程,比较实施CQI前后的错误标识标本和校正的错误采集标本比例。结果实施CQI后,错误标识标本比例从1/290增加到1/207,但随着时间进展而逐渐下降;校正的错误采集标本比例从1/1485降至1/4133,并维持在较低水平。结论实施CQI有助于改进标本采集过程,减少标本采集错误。     

Profiles in Patient Safety: Medication Errors in the Emergency Department

Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here.     

品管圈活动在降低住院患者口服药漏发率中的研究

目的 探索品管圈活动在降低住院患者口服药漏发率中应用效果.方法 运用品管圈的管理方法,找出住院患者口服药漏发原因,进行分析、讨论、制定改进措施及效果评价.结果 开展品管圈活动前住院患者口服药漏发率为15.99%,目标值为6.95%,活动后降至1.72%,病人满意度由原来的82%上升至95%,差异有统计学意义(P<0.01).结论 开展品管圈活动,优化发药流程,改善不规范护理行为,能有效降低住院患者口服药漏发率,减少药物浪费,确保患者服药到口,保证用药安全,提高患者满意度.     

Medication Errors in the Management of Anaphylaxis in a Pediatric Emergency Department

Background

Despite the publication of recent guidelines for anaphylaxis management, many studies show that physicians are still not at ease with the management of anaphylaxis.

Objectives

To evaluate the rate and severity of medication errors before and after implementation of a standard order form for anaphylaxis management.

Methods

A before-and-after study was conducted. All children <18 years of age presenting to a tertiary care pediatric hospital Emergency Department with anaphylaxis between September 2007 and November 2010 were included. Patients were divided into two groups according to intervention (Pre and Post). Intervention consisted of the implementation of a standard order form (SOF) for anaphylaxis management. The post-intervention group was further sub-divided into SOF+ (when the SOF was used) and SOF− (when the SOF was not used).

Results

A total of 96 medical charts were reviewed. There were 31 patients in Pre and 65 in Post (29 in SOF+ and 36 in SOF−). A total of 243 drugs were ordered. Thirty-five percent (85/243) of these orders contained at least one medication error. Fifty-five percent (47/85) were dosage errors. The rate of medication errors was the same between Pre and Post (60% vs. 59%, p = 0.95). However, the rate of dosage errors was significantly reduced when the SOF was used (21% in SOF+ vs. 50% in Pre, p = 0.02 and 21% in SOF+ vs. 50% in SOF−, p = 0.02).

Conclusions

Medication errors in the management of anaphylaxis were frequent. Use of an SOF significantly reduced the rate of dosage errors.