Drug errors: Consequences, mechanisms, and avoidance

British Journal of Anaesthesia

Volumn 105, Issue 1, 2010, Pages 76-82

  Glavin, R J ^a  

^a VICTORIA INFIRMARY   (United Kingdom)

Author keywords

attitude of health personnel; medical errors; medication errors prevention and control; medication errors psychology; risk management standards

Indexed keywords

ANALGESIC AGENT; ANTIANGINA PECTORIS AGENT; ANTIINFECTIVE AGENT; BRONCHODILATING AGENT; CORTICOSTEROID; GENTAMICIN; MORPHINE; NORADRENALIN;

ALLERGY; ANESTHESIA; ANESTHESIST; DRUG SAFETY; HEALTH CARE POLICY; HEALTH PERSONNEL ATTITUDE; HOSPITAL ADMISSION; HUMAN; MEDICATION ERROR; PRIORITY JOURNAL; PROSPECTIVE STUDY; REVIEW;

EID: 77953851506     PISSN: 00070912     EISSN: 14716771     Source Type: Journal    
DOI: 10.1093/bja/aeq131     Document Type: Review

References (32)

1. Phillips DP, Christenfeld N, Glynn LM. Increase in US medicationerror deaths between 1983 and 1993. Lancet 1998; 351: 643-644
2. Bates DW, Spell N, Cullen DJ et al. The costs of adverse drug events in hospitalised patients. Adverse Drug Events Prevention Study Group. J Am Med Assoc 1997; 277: 307-311
3. The National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP: The First Ten Years 'Defining the Problem and Developing Solutions', 2005; 4
4. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Institute of Medicine. Washington, DC: National Academy Press, 2007; 28
5. WHO. International drug monitoring: the role of national centres. World Health Organ Tech Rep Ser 1972; 498: 1-25
6. Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis and management. Lancet 2000; 356: 1255-1259
7. Sanghera IS, Franklin BD, Dhillon S. The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in a UK intensive care unit. Anaesthesia 2007; 62: 53-61
8. Dornan T, Ashcroft D, Heathfield H et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP Study. General Medical Council, 2009. Available from http://www.gmc-uk.org/about/research/ research-commissioned.asp (accessed March 29, 2010)
9. Catchpole K, Bell MDD, Johnson S. Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System. Anaesthesia 2008; 63: 340-346
10. Abeysekera A, Bergman IJ, Kluger MT, Short TG. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia 2005; 60: 220-227
11. Orser BA, Byrick R. Anesthesia-related medication error: time to take action. Can J Anaesth 2004; 51: 756-760
12. Thomas AN, Panchagnula U. Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency. Anaesthesia 2008; 63: 726-733
13. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care 2001; 29: 494-500
14. Llewellyn RL, Gordon PC, Wheatcroft D et al. Drug administration errors: a prospective study survey from three South African teaching hospitals. Anaesth Intensive Care 2009; 37: 93-98
15. Bates DW. Medication errors-how common are they and what can be done to prevent them. Drug Saf 1996; 15: 303-310
16. Reason J. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Farnham: Ashgate Publishing, 2008; 29-47
17. van Beuzekom M, Boer F, Akerboom S, Hudson P. Patient safety: latent risk factors. Br J Anaesth 2010; 105: 52-59
18. Amalberti R, Vincent C, Auroy Y et al. Violations and migrations in health care: a framework for understanding and management. Qual Saf Health Care 2006; 15: i66-i71
19. Reason J. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Farnham: Ashgate Publishing, 2008; 69-103
20. Lowe CM. Accidents waiting to happen: the contribution of latent conditions to patient safety. Qual Saf Health Care 2006; 15: i72-i75
21. Aitken H. A nice cup of tea. Anaesthesia News 2009; 260: 9-10
22. Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidencebased strategies for preventing drug errors during anaesthesia. Anaesthesia 2004; 59: 493-504
23. Merry AF, Webster CS, Connell H. A new infusion syringe label system designed to reduce task complexity during drug preparation. Anaesthesia 2007; 62: 486-491
24. Borycki EM, Kushniruk AW, Keay L, Kuo A. A framework for diagnosing and identifying where technology-induced errors come from. In: Buescart R, Hackl W, Nohr C, eds. Detection and Prevention of Adverse Drug Events. Amsterdam: IOS Press, 2009; 181-187
25. Leroy N, Luyckx M, Lecocq P, Marcilly R, Beuscart-Zephir M-C. Contribution of human factors for the review of automatically detected ADE. In: Buescart R, Hackl W, Nohr C, eds. Detection and Prevention of Adverse Drug Events. Amsterdam: IOS Press, 2009; 170-180
26. National Patient Safety Agency. Seven steps to patient safety: the full reference guide. 2004; 11. Available from http://www.nrls. npsa.nhs.uk/ resources/collections/seven-steps-to-patient-safety/ (accessed April 24, 2010)
27. National Patient Safety Agency. Seven steps to patient safety: the full reference guide. 2004; 17-18. Available from http://www.nrls. npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/ (accessed April 24, 2010)
28. Edmondson A. Psychological Safety and learning behaviour in work teams. Admin Sci Quart 1999; 44: 350-383
29. Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. J Nurs Manag 2009; 17: 679-697
30. Runciman WB, Williamson JAH, Deakin A et al. An integrated framework for safety quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care 2006; 15: i82-i90
31. Mahajan RP. Critical incident reporting and learning. Br J Anaesth 2010; 105: 69-75
32. National Patient Safety Agency. Seven steps to patient safety: an overview guide for NHS staff. 2004; 23. Available from http://www. nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patientsafety/ (accessed April 24, 2010)