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 Prescriptions Risk Assessment Self-Assessment Humans 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