Systems Analysis of Adverse Drug Events

Leape, Lucian L.

doi:10.1001/jama.1995.03530010049034

Cited by 1,356 publications

(734 citation statements)

References 0 publications

Supporting

Mentioning

653

Contrasting

Unclassified

Order By: Relevance

“…Complex systems provide multiple opportunities for error. Methods to try to prevent such errors occurring include education, having adequate and standardized protocols that are relevant and easy to follow and regular re-validation of the procedure being performed [12]. However all these methods continue to rely heavily on the individual performing the task; the overall method involved should also be examined to see if it can be simpli®ed and if further safety margins can be introduced into the system.…”

Section: Discussionmentioning

confidence: 99%

Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example

Ferner

Langford

Anton

et al. 2001

Brit J Clinical Pharma

View full text Add to dashboard Cite

Aims The nature and incidence of errors in prescribing and giving medicines have previously been estimated by trained observers, or by retrospective analysis of incidents in which patients have come to harm. We have examined prospectively in routine clinical practice the concentrations of intravenous infusions of a drug (acetylcysteine) which is given according to a complicated dosing schedule. Methods We prospectively collected samples before and, where possible, after the infusion of acetylcysteine in 66 anonymous patients requiring treatment for acetaminophen (paracetamol) overdose in four centres in the United Kingdom. We measured the concentration in each infusion bag, and deduced from the weight of the patient the percentage of the anticipated dose that had actually been given. Results The experimentally determined dose was within 10% of the anticipated dose in 68 of 184 individual bags (37%), and within 20% of the anticipated dose in 112 bags (61%). Doses in 17 bags were more than 50% from the anticipated doses. In three patients, values in all three bags appeared to be systematically wrong by 50% or more; in a further seven cases, individual bags differed by 50% or more from the anticipated value. The median difference between pre-and post-infusion samples was 0% [interquartile range x5.2% to +14.6%], but 9% showed a disparity of greater than t50%. Conclusions Our data suggest that there is large random variation in administered dosage of intravenous infusions. Systematic calculation errors occur in about 5% [95% con®dence interval 2, 8%] of cases, and major errors in drawing up in a further 3% [1, 7%], with inadequate mixing in 9% [4, 14%]. While we have no evidence that patients were adversely affected, and while the regime of administration of the drug studied (acetylcysteine) is complicated, these data suggest that the delivered dose often deviates from the intended dose, and that methods of quality control are needed.

show abstract

Section: Discussionmentioning

confidence: 99%

Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example

Ferner

Langford

Anton

et al. 2001

Brit J Clinical Pharma

View full text Add to dashboard Cite

show abstract

“…This meant that rather than looking at individuals and deeming every incident the result of a single human's failing, it was necessary to dig more deeply into the history of the incident in order to unearth the many factors that may have led to conditions setting the stage for the incident. 11 One author suggests a Swiss cheese model to describe the occurrence of error; many layers in a system work to prevent error and maintain high quality, but when the holes that inevitably appear in each layer happen to line up, an incident results. 10 Looking at the systems behind error helped commercial aviation avoid even a single death in 1998 and, relevant to medicine, allowed anesthesia to reduce a death rate of one in 20,000 two decades ago to one in 200,000 today.…”

Section: A Few Notes On the Science Of Errormentioning

confidence: 99%

Promoting Patient Safety and Preventing Medical Error in Emergency Departments

Schenkel

2000

Academic Emergency Medicine

131

View full text Add to dashboard Cite

Abstract. An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.

show abstract

“…6,[12][13][14] The problem of similarities in drug packaging and ampoule design have been addressed in studies from adverse drug events in hospitals and in anesthesia. 6,15 In anesthesia, the drugs are often prepared and drawn up in syringes some time before they are to be used. This gives the possibility of choosing the wrong ampoule, as well as choosing the wrong syringe, or 'syringe swap'.…”

mentioning

confidence: 99%

Adverse drug errors in anesthesia, and the impact of coloured syringe labels

Fasting

Gisvold

2000

Can J Anesth/J Can Anesth

156

149

View full text Add to dashboard Cite

Purpose: To describe the frequency and pattern of drug errors in clinical anesthesia, and to evaluate whether a change to colour coded syringe labels, along with education, could reduce the problem of drug errors. Methods:We prospectively recorded anesthesia-related information from all anesthetic cases for 36 mo, totally 55,426 procedures. Intraoperative problems, including drug errors, were recorded. After eighteen months we changed to colour coded syringe labels, and the effect of this change and education on drug errors was assessed. Errors were divided into four groups: syringe swap, ampoule swap, other 'wrong drug' errors, and wrong dose errors. The problems were graded into four levels, according to severity.Results: A drug error was recorded in 63 cases (0.11%). There were 28 syringe swaps, and muscle relaxants were erroneously given in 15. There were nine ampoule swaps. There were eight 'other wrong drug' cases, and 18 cases where a wrong dose of the correct drug was given. Three of the drug errors were classified as serious, and 27 were of moderate severity. We found no differences between the two periods except for decreased number of ampoule swaps (P = 0.04).Conclusion: Drug errors are uncommon, and represent a small part of anesthesia problems but still have the potential for serious morbidity. Syringe swaps occurred most often between syringes of equal size, and were not eliminated by colour coding of labels. As muscle relaxant drugs are most commonly involved, and can cause lasting morbidity, special preventive measures should be taken for this group of drugs.Objectif: Décrire les erreurs de médicaments en anesthésie clinique selon leur fréquence et leur nature et éva-luer si une modification de la couleur des étiquettes codées des seringues pouvait, avec une certaine formation, résoudre ce problème. Conclusion : Les erreurs de médicaments sont rares et ne représentent qu'une petite partie des problèmes anesthésiques, mais elles sont toujours potentiellement dangereuses. Les échanges de seringues surviennent le plus souvent entre seringues de même taille et ils ne sont pas réduits par les étiquettes de couleurs codées. Les myorelaxants, le plus souvent en cause, peuvent entraîner une morbidité résiduelle. Des mesures préventives spéciales devaient être envisagées dans ce cas.

show abstract

Systems Analysis of Adverse Drug Events

Cited by 1,356 publications

References 0 publications

Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example

Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example

Promoting Patient Safety and Preventing Medical Error in Emergency Departments

Adverse drug errors in anesthesia, and the impact of coloured syringe labels

Contact Info

Product

Resources

About