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Am J Health Syst Pharm. 2008 Sep 1;65(17):1661-6. doi: 10.2146/ajhp070634.

Severity of medication administration errors detected by a bar-code medication administration system.

Author information

1
Sutter Health Institute for Research and Education, San Francisco, CA 94104, USA. sakowsj@sutterhealth.org

Abstract

PURPOSE:

The severity of medication administration errors detected by a bar-code medication administration (BCMA) system was studied.

METHODS:

A panel of six health care providers reviewed medication administration error scenarios created from BCMA error logs at six community hospitals. Each scenario was rated on the potential to cause patient harm, taking into account the severity of the potential outcome and the probability that the patient would be harmed. A severity score for each error was determined by averaging the individual reviewers' scores.

RESULTS:

The majority of the medication administration errors identified by the BCMA system were judged to be benign; 1% of the errors reviewed were rated as having the potential to result in a severe or life-threatening adverse event, 8% were judged to have the potential to produce moderate adverse effects, and 91% were expected to produce minimal, if any, clinical effects. Medication errors due to a dose being administered when there was no corresponding order in the computer system were significantly more likely to produce moderate or severe outcomes than other types of medication errors. Errors that involved medications designated as high-alert drugs were also more likely to produce moderate or severe adverse events than non-high-alert drugs.

CONCLUSION:

The majority of medication administration errors detected by a BCMA system were judged to be benign and pose minimal safety risks; however, the numbers and severity of medication administration errors that occur despite the use of a BCMA system suggest that there are opportunities to improve these systems and how the information they generate is used.

PMID:
18714114
DOI:
10.2146/ajhp070634
[Indexed for MEDLINE]

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