Patterns in nursing home medication errors: Disproportionality analysis as a novel method to identify quality improvement opportunities

Pharmacoepidemiology and Drug Safety

Volumn 19, Issue 10, 2010, Pages 1087-1094

  Hansen, Richard A ^a   Cornell, Portia Y ^b   Ryan, Patrick B ^a   Williams, Charlotte E ^c   Pierson, Stephanie ^c   Greene, Sandra B ^b,c  

^a University of North Carolina   (United States)

^b IL   (United States)

^c UNIVERSITY OF NORTH CAROLINA   (United States)

Author keywords

Data interpretation; Drug safety; Healthcare quality; Medication error; Nursing homes

Indexed keywords

ALPRAZOLAM; ATENOLOL; CLONIDINE; ENALAPRIL MALEATE; ESOMEPRAZOLE; FENTANYL; FOLIC ACID; FUROSEMIDE; HYDROCODONE BITARTRATE PLUS PARACETAMOL; LORAZEPAM; MORPHINE; NITROFURANTOIN; OXYCODONE; POTASSIUM CHLORIDE; RISPERIDONE; VANCOMYCIN; WARFARIN;

ARTICLE; DRUG SAFETY; HEALTH CARE QUALITY; HUMAN; MEDICATION ERROR; NURSING HOME; PATIENT SAFETY; PRIORITY JOURNAL; RETROSPECTIVE STUDY; UNITED STATES;

ADVERSE DRUG REACTION REPORTING SYSTEMS; DRUG TOXICITY; HUMANS; INTERNET; MEDICATION ERRORS; NURSING HOMES; PHARMACEUTICAL PREPARATIONS; QUALITY ASSURANCE, HEALTH CARE; QUALITY IMPROVEMENT; RISK MANAGEMENT;

EID: 79251513281     PISSN: 10538569     EISSN: 10991557     Source Type: Journal    
DOI: 10.1002/pds.2024     Document Type: Article

References (31)

1. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med 2002; 162: 1897-1903.
2. Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000; 109: 87-94.
3. Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med 1997; 157: 2089-2096.
4. Greene SB, Williams CE, Hansen RA, et al. Medication errors in nursing homes: a state's experience implementing a reporting system. J Patient Saf 2005; 1: 181-189.
5. Hansen RA, Greene SB, Williams CE, et al. Types of medication errors in North Carolina nursing homes: a target for quality improvement. Am J Geriatr Pharmacother 2006; 4: 52-61.
6. Pierson S, Hansen R, Greene S, et al. Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system. Qual Saf Health Care 2007; 16: 297-302.
7. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000; 320: 759-763.
8. Smetzer JL, Vaida AJ, Cohen MR, et al. Findings from the ISMP Medication Safety Self-Assessment for hospitals. Jt Comm J Qual Saf 2003; 29: 586-597.
9. Wood KE, Nash DB. Mandatory state-based error-reporting systems: current and future prospects. Am J Med Qual 2005; 20: 297-303.
10. Wysowski DK, Swartz L. Adverse drug event surveillance and drug withdrawals in the United States, 1969-2002: the importance of reporting suspected reactions. Arch Intern Med 2005; 165: 1363-1369.
11. Savage SW, Schneider PJ, Pedersen CA. Utility of an online medication-error-reporting system. Am J Health Syst Pharm 2005; 62: 2265-2270.
12. Rask K. Impact of a statewide reporting system on eedication error reduction. J Patient Saf 2006; 2: 116-123.
13. Zhan C, Smith SR, Keyes MA, et al. How useful are voluntary medication error reports? The case of warfarin-related medication errors. Jt Comm J Qual Patient Saf 2008; 34: 36-45.
14. Leape LL. Reporting of adverse events. N Engl J Med 2002; 347: 1633- 1638.
15. Santell JP, Hicks RW, McMeekin J, Cousins DD. Medication errors: Experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol 2003; 43: 760-767.
16. Hicks RW, Cousins DD, Williams RL. Selected medication-error data from USP's MEDMARX program for 2002. Am J Health Syst Pharm 2004; 61: 993-1000.
17. Hicks RW, Becker SC, Cousins DD. Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX program. J Pediatr Nurs 2006; 21: 290-298.
18. Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med 2008.
19. Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med 2007; 22: 755-761.
20. Uribe CL, Schweikhart SB, Pathak DS, et al. Perceived barriers to medical-error reporting: an exploratory investigation. J Healthc Manag 2002; 47: 263-279.
21. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 1999; 5: 13-21.
22. Almenoff J, Tonning JM, Gould AL, et al. Perspectives on the use of data mining in pharmaco-vigilance. Drug Saf 2005; 28: 981-1007.
23. Hauben M, Madigan D, Gerrits CM, et al. The role of data mining in pharmacovigilance. Expert Opin Drug Saf 2005; 4: 929-948.
24. Evans SJ, Waller PC, Davis S. Use of proportional reporting ratios (PRRs) for signal generation from spontaneous adverse drug reaction reports. Pharmacoepidemiol Drug Saf 2001; 10: 483-486.
25. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). NCC MERP index for categorizing medication errors. Available at http://nccmerp.org (accessed 20 October 2009).
26. van Puijenbroek EP, Bate A, Leufkens HG, et al. A comparison of measures of disproportionality for signal detection in spontaneous reporting systems for adverse drug reactions. Pharmacoepidemiol Drug Saf 2002; 11: 3-10.
27. van Puijenbroek EP, Bate A, Leufkens HGM, et al. A comparison of measures of disproportionality for signal detection in spon-taneous reporting systems for adverse drug reactions. Pharma-coepidemiol Drug Saf 2002; 11: 3-10.
28. Sirio CA, Keyser DJ, Norman H, Weber RJ, Muto CA. Shared learning and the drive to improve patient safety: lessons learned from the Pittsburgh regional healthcare initiative. In Advances in Patient Safety: From Research to Implementation, Vol. 3. Agency for Healthcare Research and Quality: Rockville, MD, 2005.
29. Pronovost P. Using incident reporting to improve patient safety: a conceptual model. J Patient Saf 2007; 3: 27-33.
30. Amoore J, Ingram P. Quality improvement report: learning from adverse incidents involving medical devices. BMJ 2002; 325: 272- 275.
31. Anderson JG, Ramanujam R, Hensel D, et al. The need for organizational change in patient safety initiatives. Int J Med Inform 2006; 75: 809-817.