Medication errors hospital pharmacist perspective

Drugs

Volumn 65, Issue 13, 2005, Pages 1735-1746

  Guchelaar, Henk Jan ^a   Colen, Hadewig B B ^b   Kalmeijer, Mathijs D ^c   Hudson, Patrick T W ^d   Teepe Twiss, Irene M ^a  

^a LEIDEN UNIVERSITY MEDICAL CENTER   (Netherlands)

^b MEDISCH SPECTRUM TWENTE   (Netherlands)

^c ACADEMIC MEDICAL CENTER   (Netherlands)

^d LEIDEN UNIVERSITY   (Netherlands)

Author keywords

[No Author keywords available]

Indexed keywords

ANALGESIC AGENT; ANTICOAGULANT AGENT; ANTIDOTE; ANTIINFECTIVE AGENT; BENZODIAZEPINE; CARDIOVASCULAR AGENT; CENTRAL NERVOUS SYSTEM AGENTS; IMMUNOGLOBULIN; PROTON PUMP INHIBITOR; PSYCHOTROPIC AGENT; VACCINE;

CARDIOVASCULAR DISEASE; CENTRAL NERVOUS SYSTEM DISEASE; CLINICAL TRIAL; COST EFFECTIVENESS ANALYSIS; DRUG CHOICE; DRUG COST; DRUG HYPERSENSITIVITY; DRUG SAFETY; GAS; HEALTH CARE COST; HEMATOLOGIC DISEASE; HOSPITAL PHARMACY; HUMAN; LIVER TOXICITY; MEDICATION ERROR; MORBIDITY; MORTALITY; NEPHROTOXICITY; OIL INDUSTRY; PATIENT CARE; PHARMACIST; PRESCRIPTION; REVIEW; RISK ASSESSMENT; SIDE EFFECT; TOXICITY;

HUMANS; MEDICAL ERRORS; MEDICATION ERRORS; MEDICATION SYSTEMS, HOSPITAL; PHARMACISTS; PHARMACY SERVICE, HOSPITAL; PROFESSIONAL ROLE; QUALITY ASSURANCE, HEALTH CARE; RISK ASSESSMENT; SAFETY;

EID: 24344500808     PISSN: 00126667     EISSN: None     Source Type: Journal    
DOI: 10.2165/00003495-200565130-00001     Document Type: Review

References (49)

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Committee on quality of health care in America; Institute of Medicine. Washington, DC: National Academy Press, 1999
2. Department of Health. Building a safer NHS for patients: improving medication safety. London: The Stationery Office, 2001
3. Audit Commission. A spoonful of sugar: medicines management in NHS hospitals. London: Audit Commission Publications, 2001
4. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324 (6): 377-84
5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324 (6): 370-6
6. Australian Council for Safety and Quality in Health Care. Improving medication safety: report of a medication safety workshop, July 2001 [online]. Available from URL: http:// www.safetyandquality.org [Accessed 2005 Jun 13]
7. Chan M, Nicklason F, Vial JH. Adverse drug events as a cause of hospital admission in the elderly. Intern Med J 2001; 31 (4): 199-205
8. National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) [online]. Available from URL: www.nccmerp.org [Accessed 2005 Jun 13]
9. Busse DK, Wright DJ. Classification and analysis of incidents in complex medical environments. Top Health Inf Manage 2000; 20 (4): 1-11
10. Beijer HJ, de Blaey CJ. Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci 2002; 24 (2): 46-54
11. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279 (15): 1200-5
12. Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA 1997; 277 (4): 301-6
13. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348 (25): 2526-34
14. Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998; 5 (3): 305-14
15. Silverman JB, Stapinski CD, Huber C, et al. Computer-based system for preventing adverse drug events. Am J Health Syst Pharm 2004; 61 (15): 1599-603
16. Kanjanarat P, Winterstein AG, Johns TE, et al. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 2003; 60 (17): 1750-9
17. Hudson PTW. Applying the lessons of high risk industries to health care. Qual Saf Health Care 2003; 12 Suppl. 1: i7-21
18. Reason J. Human error: models and management. BMJ 2000; 320 (7237): 768-70
19. van der Graaf GC, Milne D, Primrose M. HSE cases: some lessons learned. Exploration and Production Newsletter. The Hague: Shell International, 1996
20. Hudson PTW, Guchelaar H-J. Risk assessment in clinical pharmacy. Pharm World Sci 2003; 25 (3): 98-103
21. Gawande A. Complications. New York: Metropolitan Books, Henry Holt and Company, 2002
22. Molmans BHE, Kalmeijer MD, Reitsma RB, et al. Invloed van een electronisch voorschrijfsysteem op medicatiegerelateerde foutmeldingen. Pharm Weekbl Ziekenhuisfarmacie 2004; 139 (47): 1547-9
23. Denig P, Haaijer-Ruskamp FM. Therapeutic decision making of physicians. Pharm Weekbl Sci 1992; 14 (1): 9-15
24. Schumock GT, Walton SM, Park HY, et al. Factors that influence prescribing decisions. Ann Pharmacother 2004; 38 (4): 557-62
25. Studdert DM, Mello MM, Brennan TA. Financial conflicts of interest in physicians' relationships with the pharmaceutical industry: self-regulation in the shadow of federal prosecution. N Engl J Med 2004; 351 (18): 1891-900
26. Silverman JB, Stapinski CD, Churchill WD, et al. Multifaceted approach to reducing preventable adverse drug events. Am J Health Syst Pharm 2003; 60: 582-6
27. Janknegt R, Steenhoek A. The System of Objectified Judgement Analysis (SOJA): a tool in rational drug selection for formulary inclusion. Drugs 1997; 53 (4): 550-62
28. Pedersen CA, Schneider PH, Santell JP. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing - 2001. Am J Health Syst Pharm 2001; 58: 2251-66
29. Wade WE, Spruill WJ, Taylor AT, et al. The expanding role of pharmacy and therapeutics committees: the 1990s and beyond. Pharmacoeconomics 1996; 10 (2): 123-8
30. Weekes LM, Brooks C. Drug and therapeutics committees in Australia: expected and actual performance. Br J Clin Pharmacol 1996; 42 (5): 551-7
31. Fijn R, Brouwers JRBJ, Knaap RJ, et al. Drug and therapeutics (D&T) committees in Dutch hospitals: a nation-wide survey of structure, activities, and drug selection procedures. Br J Clin Pharmacol 1999; 48 (2): 239-46
32. Fijn R, Lenderink AW, Egberts AC, et al. Assessment of indicator for hospital drug formulary non-adherence. Eur J Clin Pharmacol 2001; 57 (9): 677-84
33. Kweekel DM, le Cessie S, Guchelaar HJ, et al. Outcomes of an antimicrobial control program in a Dutch hospital. Am J Health Syst Pharm 2004; 61 (16): 1702-6
34. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280 (15): 1311-6
35. Guchelaar HJ, Kalmeijer MD. The potential role of computerisation and information technology in improving prescribing in hospitals. Pharm World Sci 2003; 25 (3): 83-7
36. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003; 163 (12): 1409-16
37. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999; 6 (4): 313-21
38. Weingart SN, Toth M, Sands DZ, et al. Physicians' decisions to override computerized drug alerts in primary care. Arch Intern Med 2003; 163 (21): 2625-31
39. Hsieh TC, Kuperman GJ, Jaggi T, et al. Characteristics and consequences of drug-allergy alert overrides in a computerized physician order entry system. J Am Med Inform Assoc 2004; 11 (6): 482-91
40. Oren E, Shaffer ER, Guglielmo BJ. Impact of emerging technologies on medication errors and adverse drug events. Am J Health Syst Pharm 2003; 60 (14): 1447-58
41. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293 (10): 1197-203
42. Kalmeijer MD, Holtzer W, van Dongen R, et al. Implementation of a computerized physician medication order entry system at the Academic Medical Centre in Amsterdam. Pharm World Sci 2003; 25 (3): 88-93
43. Colen HB, Neef C, Schuring RW. Identification and verification of critical performance dimensions: phase 1 of systematic process redesign of drug distribution. Pharm World Sci 2003; 25 (3): 118-25
44. Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Qual Saf Health Care 2003; 12 (5): 343-7
45. Poley MJ, Bouwmans CA, Hanff LM, et al. Efficiency of different systems for medication distribution in an academic children's hospital in The Netherlands. Pharm World Sci 2004; 26 (2): 83-9
46. Lewis RF, editor. The impact of information technology on patient safety. Chicago (IL): Healthcare Information and Management Systems Society, 2002
47. Lenderink BW, Egberts TC. Closing the loop of the medication use process using electronic medication administration registration. Pharm World Sci 2004; 26 (4): 185-90
48. Leape LL, Cullen DJ, Dempsey Clapp M, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 281 (3): 267-70
49. Kucukarslan SN, Peters M, Mlynarek M, et al. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med 2003; 163: 2014-8