Medication errors associated with code situations in U.S. hospitals: Direct and collateral damage

Joint Commission Journal on Quality and Patient Safety

Volumn 34, Issue 1, 2008, Pages 46-56

  Lipshutz, Angela K M ^a,b   Morlock, Laura L ^c   Shore, Andrew D ^a   Hicks, Rodney W ^d,e   Dy, Sydney M ^a,f   Pronovost, Peter J ^a   Winters, Bradford D ^f  

^a JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH   (United States)

^b UNIVERSITY OF CALIFORNIA   (United States)

^c Health Management Programs

^d UNITED STATES PHARMACOPEIA   (United States)

^e TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER   (United States)

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

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; EMERGENCY TREATMENT; HEALTH CARE QUALITY; HOSPITAL; HUMAN; MANDATORY REPORTING; MEDICATION ERROR; METHODOLOGY; QUALITY CONTROL; RESUSCITATION; RISK; STANDARD; STATISTICS; UNITED STATES;

BENCHMARKING; EMERGENCY TREATMENT; HOSPITALS; HUMANS; MANDATORY REPORTING; MEDICATION ERRORS; ODDS RATIO; QUALITY ASSURANCE, HEALTH CARE; RESUSCITATION ORDERS; UNITED STATES;

EID: 38549123441     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/S1553-7250(08)34007-0     Document Type: Article

References (24)

1. Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
2. Clancy T.R.: Medication error prevention: Progress of initiatives. JONAS Healthc Law Ethics Regul 6:3-12, Jan.-Mar. 2004.
3. National Coordinating Council for Medication Error and Prevention: About Medication Errors: What Is a Medication Error? http://www.nccmerp. org/aboutMedErrors.html, (last accessed Nov. 27, 2007).
4. Aspden P., et al.: Preventing Medication Errors (Quality Chasm). Washington, DC.: National Academy Press, 2006.
5. Lubell J., DoBias M.: Medication errors persist: IOM report highlights steps to reduce severity, frequency. Mod Healthc 36:10, Jul. 24, 2006.
6. Rothschild J.M., et al.: Analysis of medication-related malpractice claims: Causes, preventability, and costs. Arch Intern Med 162:2414-2420, Nov. 25, 2002.
7. Hicks R.W., et al.: MEDMARX 5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999-2003. Rockville, MD: USP Center for rhe Advancement of Patient Safety, 2004.
8. American Heart Association: Cardiac Arrest. http://www.american- heart.org/presenter.jhtml?identifier=4481 (last accessed Nov. 27, 2007).
9. American Hospital Association (AHA): 2007 AHA Hospital Statistics. Chicago: AHA, 2006.
10. American Hospital Association: Fast Facts on U.S. Hospitals. http://www.aha.org/aha/resource-center/Statistics-and-Studies/fastfacts.html (last accessed Nov. 27, 2007).
11. Dictionary.com: Code. http://dictionary.reference.com/browse/code (last accessed Nov. 27, 2007).
12. Kozer E., et al.: Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. BMJ 329:132, Dec. 4, 2004.
13. Vardi A., et al.: Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care. Resuscitation 73:400-406, Jun. 2007.
14. Abella B.S., et al.: Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 293:305-310, Jan. 19, 2005.
15. Peberdy M.A., et al.: Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the national registry of cardiopulmonary resuscitation. Resuscitation 58:297-308, Sep. 2003.
16. Eisenberg M.S., Mengert T.J.: Cardiac resuscitation. N Engl J Med 344:1304-1313, Apr. 26, 2001.
17. Strzyzewski N.: Common errors made in resuscitation of respiratory and cardiac arrest. Plast Surg Nurs 26:10-4, Jan.-Mar. 2006.
18. Buist M.D., et al.: Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: Preliminary study. BMJ 324:387-390, Feb. 16, 2002.
19. Winters B.D., et al.: Rapid response systems: A systematic review. Crit Care Med 35:1238-1243, May 2007.
20. Hakim R.B., et al.: Factors associated with do-not-resuscitate orders: Patients' preferences, prognoses, and physicians' judgments. SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Ann Intern Med 25:284-293, Aug. 15, 1996.
21. Needleman J., et al.: Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 346:1715-1722, May 30, 2002.
22. Papiris S., et al.: Clinical review: Severe asthma. Crit Care 6:30-44, Nov. 22, 2001.
23. Cooper C.B., Tashkin D.P.: Recent developments in inhaled therapy in stable chronic obstructive pulmonary disease. BMJ 330:640-644, Mar. 19, 2005.
24. Dhand R.: New frontiers in aerosol delivery during mechanical ventilation. Respir Care 49:666-677, Jun. 2004.