Severity of medication administration errors detected by a bar-code medication administration system

American Journal of Health-System Pharmacy

Volumn 65, Issue 17, 2008, Pages 1661-1666

  Sakowski, Julie ^a,b   Newman, Jeffrey M ^a,b   Dozier, Krystin ^a  

^a SUTTER HEALTH   (United States)

^b UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

Codes; Drug administration; Errors, medication; Hospitals; Quality assurance

Indexed keywords

ANTICOAGULANT AGENT; ISOPHANE INSULIN; LIDOCAINE; METOPROLOL TARTRATE; NARCOTIC AGENT; POTASSIUM CHLORIDE;

BAR CODE MEDICATION ADMINISTRATION SYSTEM; COMMUNITY HOSPITAL; DISEASE SEVERITY; DRUG DOSE ESCALATION; HARM REDUCTION; HEALTH CARE MANAGEMENT; HEALTH CARE PERSONNEL; HUMAN; MAJOR CLINICAL STUDY; MEDICATION ERROR; PRIORITY JOURNAL; QUALITY CONTROL; REVIEW; SAFETY; SCORING SYSTEM;

EID: 51649085556     PISSN: 10792082     EISSN: None     Source Type: Journal    
DOI: 10.2146/ajhp070634     Document Type: Review

References (36)

1. Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. JAMA. 1995; 274:29-34.
2. Bates DW. Frequency, consequences and prevention of adverse drug events. J Qual Clin Pract. 1999; 19:13-7.
3. Aspden P, Wolcott JA, Bootman JL et al., eds. Preventing medication errors: quality chasm series. Washington, DC: National Academies Press; 2007.
4. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
5. Migdial K. Medication errors: the scope of the problem. www.ahrq.gov/qual/ errback.htm (accessed 2004 Nov 9).
6. Elixhauser A, Owens P. Adverse drug events in U.S. hospitals, 2004. www. hcup-us.ahrq.gov/reports/statbriefs/ sb29.pdf (accessed 2007 Aug 23).
7. Agency for Healthcare Research and Quality. Medical errors and patient safety initiatives. www.ahrq.gov/qual/errorsix. htm#doc (accessed 2007 Aug 23).
8. Institute for Healthcare Improvement. Medication systems for patient safety. www.ihi.org/IHI/Topics/PatientSafety/ MedicationSystems/ (accessed 2007 Aug 23).
9. Joint Commission. 2008 National Patient Safety Goals - hospital program. www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/08_hap_ npsgs.htm (accessed 2008 May 20).
10. Ioannidis JP, Lau J. Evidence on interventions to reduce medical errors: an overview and recommendations for future research. J Gen Intern Med. 2001; 16: 325-34.
11. Kaushal R, Bates DW. Information technology and medication safety: what is the benefit? Qual Saf Health Care. 2002; 11:261-5.
12. 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; 163:1409-16.
13. Mahoney CD, Berard-Collins CM, Coleman R et al. Effects of an integrated clinical information system on medication safety in a multi-hospital setting. Am J Health-Syst Pharm. 2007; 64:1969-77.
14. Oren E, Shaffer ER, Guglielmo BJ. Impact of emerging technologies on medication errors and adverse drug events. Am J Health-Syst Pharm. 2003; 60:1447-58.
15. Nebeker JR, Hoffman JM, Weir CR et al. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med 2005; 165:1111-6.
16. Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc. 2002; 9:540-53.
17. Weant KA, Cook AM, Armistead JA. Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry. Am J Health-Syst Pharm. 2007; 64:526-30.
18. Cina J, Fanikos J, Mitton P et al. Medication errors in a pharmacy-based barcode-repackaging center. Am J Health-Syst Pharm. 2006; 63:165-8.
19. Johnson CL, Carlson RA, Tucker CL et al. Using BCMA software to improve patient safety in Veterans Administration medical centers. J Healthc Inf Manag. 2002; 16(1):46-51.
20. Larrabee S, Brown MM. Recognizing the institutional benefits of bar-code point-of-care technology. Jt Comm J Qual Saf 2003; 29:345-53.
21. Rough S, Ludwig B, Wilson E. Improving the medication administration process: the impact of point of care bar code medication scanning technology. www. ashpadvantage.com/bestpractices/2003_ papers/rough.htm (accessed 2005 Feb 17).
22. Sakowski J, Leonard T, Colburn S et al. Using a bar-coded medication administration system to prevent medication errors in a community hospital network. Am J Health-Syst Pharm. 2005; 62:2619-25.
23. Lawton G, Shields A. Bar-code verification of medication administration in a small hospital. Am J Health-Syst Pharm. 2005; 62:2413-5.
24. Paoletti RD, Suess TM, Lesko MG et al. Using bar-code technology and medication observation methodology for safer medication administration. Am J Health-Syst Pharm. 2007; 64:536-43.
25. Bates DW, Boyle DL, Vliet MB et al. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995; 10:199-205.
26. Bond CA, Raehl CL, Franke T. Medication errors in United States hospitals. Pharmacotherapy. 2001; 21:1023-36.
27. Dean BS, Barber ND. A validated, reliable method of scoring the severity of medication errors. Am J Health-Syst Pharm. 1999; 56:57-62.
28. Taxis K, Dean B, Barber N. The validation of an existing method of scoring the severity of medication administration errors for use in Germany. Pharm World Sci. 2002; 24:236-9.
29. Tissot E, Cornette C, Demoly P et al. Medication errors at the administration stage in an intensive care unit. Intensive Care Med. 1999; 25:353-9.
30. Morimoto T, Gandhi TK, Seger AC et al. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care. 2004; 13: 306-14.
31. Institute for Safe Medication Practices. List of high-alert medications. www.ismp.org/MSAarticles/highalert. htm (accessed 2005 Feb 18).
32. 'High-alert' medications and patient safety. Int J Qual Health Care. 2001; 13: 339-40.
33. Joint Commission. High-alert medications and patient safety. www. jointcommission.org/SentinelEvents/ SentinelEventAlert/sea_11.htm (accessed 2008 May 20).
34. Dean B, Schachter M, Vincent C et al. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002; 11:340-4.
35. Continued Progress: Hospital Use of Information Technology: American Hospital Association; February, 2007.
36. Senst BL, Achusim LE, Genest RP, et al. Practical approach to determining costs and frequency of adverse drug events in a health care network. American Journal of Health-system Pharmacy. June 15, 2001; 58:1126-1132.