Preventing adverse events in the pediatric intensive care unit: Prospectively targeting factors that lead to intravenous potassium chloride order errors

Pediatric Critical Care Medicine

Volumn 6, Issue 1, 2005, Pages

  White, Jeanette R M ^a   Veltri, Michael A ^b   Fackler, James C ^a  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b JOHNS HOPKINS HOSPITAL   (United States)

Author keywords

Adverse event; Failure Mode and Effects Analysis; Hyperkalemia; Medical error; Pediatric intensive care; Prospective

Indexed keywords

CREATININE; POTASSIUM CHLORIDE;

ADOLESCENT; ADULT; ARTICLE; CHILD; CHILD CARE; COHORT ANALYSIS; COMPETENCE; CONTINUING EDUCATION; CREATININE BLOOD LEVEL; DRUG FATALITY; DRUG INFUSION; DRUG MONITORING; DRUG SAFETY; DRUG USE; FEMALE; HUMAN; INTENSIVE CARE; JOB PERFORMANCE; MAJOR CLINICAL STUDY; MALE; MEDICATION ERROR; MORBIDITY; PATIENT MONITORING; POTASSIUM BLOOD LEVEL; PRIORITY JOURNAL; QUALITATIVE ANALYSIS; SIDE EFFECT; BLOOD; CHEMICALLY INDUCED DISORDER; HEALTH CARE QUALITY; HOSPITAL ORGANIZATION; HYPERKALEMIA; INCIDENCE; INFANT; INTRAVENOUS DRUG ADMINISTRATION; MEDICAL EDUCATION; MEDICAL STAFF; NEWBORN; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PRESCHOOL CHILD; PRESCRIPTION; PROSPECTIVE STUDY; STANDARD; STATISTICS; TEACHING HOSPITAL;

ADOLESCENT; CHILD; CHILD, PRESCHOOL; DRUG UTILIZATION REVIEW; EDUCATION, MEDICAL, CONTINUING; HOSPITALS, TEACHING; HUMANS; HYPERKALEMIA; INCIDENCE; INFANT; INFANT, NEWBORN; INFUSIONS, INTRAVENOUS; INTENSIVE CARE UNITS, PEDIATRIC; MEDICAL STAFF, HOSPITAL; MEDICATION ERRORS; MEDICATION SYSTEMS, HOSPITAL; PATIENT CARE TEAM; POTASSIUM CHLORIDE; PRESCRIPTIONS, DRUG; PROCESS ASSESSMENT (HEALTH CARE); PROSPECTIVE STUDIES;

EID: 21744451674     PISSN: 15297535     EISSN: None     Source Type: Journal    
DOI: 10.1097/01.PCC.0000149832.76329.90     Document Type: Article

References (28)

1. Kohn LT, Corrigan JM, Donaldson MS (Eds). Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington DC, National Academy Press, 2000
2. Prevention of medication errors in the pediatric inpatient setting. American Academy of Pediatrics. Committee on Drugs and Committee on Hospital Care. Pediatrics 1998; 102:428-430
3. Brennan TA, Leape LL, Laird NM, et al: Incidence of adverse events and negligence in hospitalized patients: Results from the Harvard medical practice study I. N Engl J Med 1991; 324:370-376
4. Cooper JB, Newbower RS, Kitz RJ: An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention and detection. Anesthesiology 1984; 60:34-42
5. Currie M, Mackay P, Morgan C, et al: The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: An analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:596-601
6. Giraud T, Dhainaut JF, Vaxelaire JF, et al: Iatrogenic complications in adult intensive care units: A prospective two-center study. Crit Care Med 1993; 21:40-51
7. Leape LL, Bates DW, Cullen DJ, et al: Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995; 274:35-43
8. Webb RK, Currie M, Morgan CA, et al: The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:520-528
9. Wilson DG, McArtney RG, Newcombe RG, et al: Medication errors in paediatric practice: Insights from a continuous quality improvement approach. Eur J Pediatr 1998; 157:769-774
10. Reason J: Understanding adverse events: Human factors. Qual Health Care 1995; 4:80-89
11. Intravenous potassium predicament. Clin J Oncol Nurs 1997; 1:45-49
12. Medication error prevention-Potassium chloride. Sentinel Event Alert 1998; 1:1-2
13. Phillips SL, Polzin DJ: Clinical disorders of potassium homeostasis. Hyperkalemia and hypokalemia. Vet Clin North Am Small Anim Pract 1998; 28:545-564
14. Borden SL: MEDMARX 2002 Data Report Highlights. 2002. Available at: http://www.usp.org. Accessed December 17, 2003
15. 2003 National Patient Safety Goals. 2003. Available online at http://www.jcaho.org. Accessed December 17, 2003
16. Leape LL: A systems analysis approach to medical error. J Eval Clin Pract 1997; 3:213-222
17. Carroll AE, Tarczy-Hornoch P, O'Reilly E, et al: Resident documentation discrepancies in a neonatal intensive care unit. Pediatrics 2003; 111:976-980
18. Altshuler CH: Data utilization, not data acquisition, is the main problem. Clin Chem 1994; 40:1616-1620
19. Schiff GD, Aggarwal HC, Kumar S, et al: Prescribing potassium despite hyperkalemia: Medication errors uncovered by linking laboratory and pharmacy information systems. Am J Med 2000; 109:494-497
20. Herout PM, Erstad BL: Medication errors involving continuously infused medications in a surgical intensive care unit. Crit Care Med 2004; 32:428-432
21. Rimmer JM, Horn JF, Gennari FJ: Hyperkalemia as a complication of drug therapy. Arch Intern Med 1987; 147:867-869
22. Leape LL, Brennan TA, Laird NM, et al: The nature of adverse events in hospitalized patients: Results from the Harvard medical practice study II. N Engl J Med 1991; 324:377-384
23. Berwick DM: A primer on leading the improvement of systems. BMJ 1996; 312:619-622
24. Leape LL: Error in medicine. JAMA 1994; 272:1851-1857
25. Wasserfallen JB, Butschi AJ, Muff P, et al: Format of medical ordersheet improves security of antibiotics prescription: The experience of an intensive care unit. Crit Care Med 2004; 32:655-659
26. Fijn R, Van den Bemt PM, Chow M, et al: Hospital prescribing errors: Epidemiological assessment of predictors. Br J Clin Pharmacol 2002; 53:326-331
27. Valenstein P, Meier F: Outpatient order accuracy. A College of American Pathologists Q-probes study of requisition order entry accuracy in 660 institutions. Arch Pathol Lab Med 1999; 123:1145-1150
28. Dahl FC, Davis NM: A survey of hospital policies on verbal orders. Hospital Pharmacy 1990; 5:443-447