Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Grissinger, Matthew. Dabliz, Rabih. Pennsylvania. Patient Safety Authority. ECRI (Organization) Institute for Safe Medication Practices.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2011
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Mandatory Reporting Medication Errors -- prevention & control Surgicenters -- organization & administration Anti-Bacterial Agents -- administration & dosage Drug Hypersensitivity Drug Labeling Ophthalmic Solutions -- administration & dosage Risk Management Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- Pennsylvania ambulatory surgery facilities (ASFs) submitted 502 medication error reports to the Pennsylvania Patient Safety Authority from June 28, 2004, through December 31, 2010. The most common types of medication errors reported by ASFs to the Authority included drug omission, wrong drug, and monitoring error/documented allergy. The predominant routes of administration associated with wrong-drug errors were intravenous (IV) and ophthalmic. More than one-third of IV wrong-drug errors involved high-alert medications. Unlike previously reported confusion between eye drops of similar pharmacologic categories, three-quarters of wrong-drug errors involving ophthalmic products were mix-ups between eye drops of different pharmacologic categories. Strategies to prevent wrong-drug errors, especially for high-alert medications in the perioperative area, can be prioritized to prevent harm to patients undergoing procedures in ASFs, such as requiring labels on all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field; differentiating look-alike products by highlighting distinguishing information on the label; and purchasing eye drops within a class from different manufacturers.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101570807 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101570807