Medication errors during medical emergencies in a large, tertiary care, academic medical center

Resuscitation

Volumn 83, Issue 4, 2012, Pages 482-487

  Gokhman, Roman ^a,b,c   Seybert, Amy L ^a,b,d   Phrampus, Paul ^d   Darby, Joseph ^a   Kane Gill, Sandra L ^a,b  

^a UNIVERSITY OF PITTSBURGH   (United States)

^b UNIVERSITY OF PITTSBURGH MEDICAL CENTER   (United States)

^c READING HOSPITAL AND MEDICAL CENTER   (United States)

^d UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE   (United States)

Author keywords

Medical Emergency Team; Medication errors; Patient safety

Indexed keywords

ACETYLSALICYLIC ACID; ADRENALIN; AMIODARONE; ATROPINE; CALCIUM CHLORIDE; DILTIAZEM; DIPHENHYDRAMINE; DOPAMINE; ETOMIDATE; FENTANYL; FLUMAZENIL; FUROSEMIDE; GLUCOSE; GLYCERYL TRINITRATE; HEPARIN; HETASTARCH; LIDOCAINE; LORAZEPAM; MAGNESIUM SULFATE; METHYLPREDNISOLONE; METOPROLOL; MIDAZOLAM; MORPHINE; NALOXONE; NORADRENALIN; PARACETAMOL; PHENYLEPHRINE; PHENYTOIN; PROPOFOL; UNINDEXED DRUG;

ADULT; ARTICLE; ASEPSIS; CLINICAL ARTICLE; DISEASE SEVERITY; DRUG INFORMATION; DRUG LABELING; EMERGENCY CARE; FEMALE; HUMAN; INAPPROPRIATE PRESCRIBING; MALE; MEDICAL LITERATURE; MEDICATION ERROR; OBSERVATIONAL STUDY; PRIORITY JOURNAL; PROSPECTIVE STUDY; RAPID RESPONSE TEAM; TERTIARY HEALTH CARE; UNIVERSITY HOSPITAL;

ACADEMIC MEDICAL CENTERS; ADULT; AGED; COHORT STUDIES; DOSE-RESPONSE RELATIONSHIP, DRUG; EMERGENCIES; EMERGENCY SERVICE, HOSPITAL; FEMALE; HOSPITAL MORTALITY; HUMANS; INCIDENCE; MALE; MEDICATION ERRORS; MEDICATION SYSTEMS, HOSPITAL; MIDDLE AGED; NEEDS ASSESSMENT; PATIENT CARE TEAM; PHARMACEUTICAL PREPARATIONS; PROSPECTIVE STUDIES; RISK ASSESSMENT; SAFETY MANAGEMENT; SURVIVAL RATE; UNITED STATES; URBAN POPULATION;

EID: 83555176596     PISSN: 03009572     EISSN: 18731570     Source Type: Journal    
DOI: 10.1016/j.resuscitation.2011.10.001     Document Type: Article

References (30)

1. Barker K.N., Flynn E.A., Pepper G.A., et al. Medication errors observed in 36 Health care facilities. Arch Intern Med 2002, 162:1897-1903.
2. National Coordinating Council on Medication Error Reporting and Prevention. NCC MERP index for categorizing medication errors, at [accessed 01.10.10]. http://www.nccmerp.org/.
3. Cullen D.J., Sweitzer B.J., Bates D.W., et al. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997, 25:1289-1297.
4. Kane-Gill S.L., Kowiatek J.G., Weber R.J. A comparison of voluntarily reported medication errors in intensive care and general care units. Qual Saf Health Care 2010, 19:55-59.
5. Lipshutz A.K.M., Morlock L.L., Shore A.D., et al. Medication errors associated with code situations in U.S. hospitals: direct collateral damage. Jt Comm J Qual Patient Saf 2008, 34:46-56.
6. Zimmer M., Wassmer R., Latasch L., et al. Initiation of risk management: incidence of failures in simulated Emergency Medical Service scenarios. Resuscitation 2010, 81:882-886.
7. Devita M.A., Bellomo R., Hillman K., et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006, 34:2463-2478.
8. Lee A., Bishop G., Hillman K.M., Daffurn K. The medical emergency team. Anaesth Intensive Care 1995, 23:183-186.
9. Barker K.N., McConnell W.E. The problems of detecting medication errors in hospitals. Am J Hosp Pharm 1962, 19:360-369.
10. Ford D.G., Seybert A.L., Smithburger P.L., et al. Impact of simulation-based learning on medication error rates in critically ill patients. Intensive Care Med 2010, 36:1526-1531.
11. Buckley M.S., Erstad B.L., Kopp B.J., et al. Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. Pediatr Crit Care Med 2007, 8:145-152.
12. Stockwell D.C., Kane-Gill S.L. Developing a patient safety surveillance system to identify adverse events in the intensive care unit. Crit Care Med 2010, 38:S117-S125.
13. Santell J.P., Hicks R.W., McMeekin J., et al. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol 2003, 43:760-767.
14. MEDMARX Data Reports. U.S. Pharmacopeia web site, at [accessed 01.09.10]. http://www.usp.org/products/medMarx.
15. Shulman R., Singer M., Goldstone J., et al. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care 2005, 9:R516-R521.
16. Bates D.W., Cullen D.J., Laird N., et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995, 274:29-43.
17. Kane-Gill S., Weber R.J. Principles and practices of medication safety in the ICU. Crit Care Clin 2006, 22:273-290.
18. Kane-Gill S.L., Jacobi J., Rothschild J.M. Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med 2010, 38:S83-S89.
19. Rothschild J.M., Landrigan C.P., Cronin J.W., et al. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005, 33:1694-1700.
20. Kozer E., Seto W., Verjee V., et al. Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. BMJ 2004, 10.1136/bmj.38244.607083.55.
21. Leape L.L., Bates D.W., Cullen D.J., et al. Systems analysis of adverse drug events. JAMA 1995, 274:35-43.
22. Agarwal S., Swanson S., Murphy A., et al. Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios. Pediatrics 2005, 116:e326-e333.
23. Feleke R., Kalynych C.J., Lundblom B., et al. Color coded medication safety system reduces community pediatric emergency nursing medication errors. J Patient Saf 2009, 5:79-85.
24. Leape L.L., Cullen D.J., Clapp M.D., et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999, 282:267-270.
25. Kane S.L., Weber R.J., Dasta J.F. The impact of critical care pharmacists on enhancing patient outcomes. Intensive Care Med 2003, 29:691-698.
26. Wakefield D.S., Broke J., Ward M.M., et al. An exploratory study measuring verbal order content and context. Qual Saf Health Care 2009, 18:169-173.
27. Wakefield D.S., Wakefield B.J. Are verbal orders a threat to patient safety?. Qual Saf Health Care 2009, 18:168.
28. Siegel JD, Rhinehart E, Jackson M, et al. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, [accessed 29.03.11]. http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html.
29. Dolan SA, Barnes S, Cox TR, et al. APIC position paper: safe injection, infusion and medication vial practices in healthcare, [accessed 29.03.11]. http://premierinc.com/safety/topics/safe_injection_practices/Downloads/APIC_SafeInjections_final.pdf.
30. Hutin Y., Hauri A., Chiarello L., et al. Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bull World Health Organ 2003, 81:491-500.