Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention

Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention

Collection:
Health Policy and Services Research
Series Title(s):
Pennsylvania patient safety advisory
Author(s):
Yang, Annie, author
Grissinger, Matthew, author
Contributor(s):
Pennsylvania. Patient Safety Authority, issuing body.
ECRI (Organization), issuing body.
Institute for Safe Medication Practices, issuing body.
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, [2013]
Language(s):
English
Format:
Text
Subject(s):
Electronic Prescribing
Medical Order Entry Systems
Medication Errors -- prevention & control
Medication Errors -- statistics & numerical data
Medication Systems, Hospital
Patient Identification Systems
Pennsylvania
United States
Genre(s):
Technical Report
Abstract:
During the period of July 1, 2011, through December 31, 2011, 813 wrong-patient medication errors were reported to the Pennsylvania Patient Safety Authority. These reports were analyzed to classify the events by node, related processes, possible causes, and contributing factors and to detect trends and noteworthy cases. Errors most often occurred during transcribing (38.3%, n = 311) and administration (43.4%, n = 353) and least during dispensing (5.2%, n = 42). Anti-infectives, opioids, and anticoagulants were the most common types of medications associated with wrong-patient events. While multiple factors may have contributed to each event, the most common were two patients being prescribed the same medication, improper verification of patient identification, and similar room numbers. Important risk reduction strategies include ensuring proper storage of medications and patient-specific documents, utilizing healthcare technology fully, limiting verbal orders, and improving patient verification throughout the medication-use process.
Copyright:
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
Extent:
1 online resource (1 PDF file (pages 41-49))
Illustrations:
Illustrations
NLM Unique ID:
101609908 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/101609908