scholarly journals Medical error reporting software program development and its impact on pediatric units’ reporting medical errors

2019 ◽  
Vol 36 (2) ◽  
Author(s):  
Aysun Unal ◽  
Seyda Seren İntepeler
Keyword(s):  
Blood Transfusion ◽  
Program Development ◽  
Medical Errors ◽  
Medical Error ◽  
Reporting System ◽  
Error Reporting ◽  
Web Based ◽  
Medication Error Reporting ◽  
Anonymous Reporting ◽  
Software Program

Objective: The purpose of this quasi-experimental study was to developing web-based, anonymous reporting system to increase reporting of medication errors, blood transfusion errors and patient falls in pediatric units and to compare the computerized system with the written system already in use at the institution. Methods: This study was conducted in all pediatric units of a research hospital. All physicians and nurses working in these units agreed to participate in the study. All units were visited to introduce the new reporting system. The number and quality of the reports sent on the new system in years 2014 and 2015 were compared to the reports sent the previous year using the written system. Results: There was considerable increase in rates of reporting: 234% increase in medication error reporting rate, and 100% increase in the reports of blood transfusion errors. One of the most important results of this study that near-miss errors were not reported at all while the written system of the study institution was being used, whereas it was the most commonly reported type of errors in the electronic error reporting system. Conclusion: The web-based reporting system, which makes reporting easy, promoted the development of safety culture among doctors and nurses in common language. doi: https://doi.org/10.12669/pjms.36.2.732 How to cite this:Unal A, Intepeler SS. Medical error reporting software program development and its impact on pediatric units’ reporting medical errors. Pak J Med Sci. 2020;36(2):---------. doi: https://doi.org/10.12669/pjms.36.2.732 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

scholarly journals Toward a theoretical approach to medical error reporting system research and design

2006 ◽  
Vol 37 (3) ◽  
pp. 283-295 ◽  
Author(s):  
Ben-Tzion Karsh ◽  
Kamisha Hamilton Escoto ◽  
John W. Beasley ◽  
Richard J. Holden
Keyword(s):  
Theoretical Approach ◽  
Medical Error ◽  
Reporting System ◽  
Error Reporting ◽  
System Research ◽  
Error Reporting System ◽  
Research And Design

Chemotherapy Related Errors in the Pediatric Oncology Unit At a Tertiary Care Institution,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 4197-4197
Author(s):  
Radha Rohatgi ◽  
Sadhna Shankar
Keyword(s):  
Cancer Patients ◽  
Medication Errors ◽  
Pediatric Oncology ◽  
Reporting System ◽  
Conflicts Of Interest ◽  
Tertiary Care ◽  
Error Reporting ◽  
Prescribing Errors ◽  
Medication Error Reporting ◽  
Dispensing Errors

Abstract Abstract 4197 Medication errors are responsible for 98,000 deaths and over almost a million injuries every year according to the Institute of Medicine report published in 1999. Cancer patients often receive complicated chemotherapy regimens which are at risk for errors. Few studies have evaluated the risk of medication errors related to chemotherapy. Majority of these studies are related to adult cancer patients. Studies regarding chemotherapy errors in pediatric patients are limited. The goal of this study was to evaluate the type and severity of errors related to chemotherapy administration in the pediatric oncology inpatient unit and outpatient clinic at a single institution over a 24 month period using a voluntary error reporting system in the institution. WebEnvision is a voluntary electronic reporting system implemented in 2007, that allows staff to anonymously report patient or staff safety incidents. We evaluated all the chemotherapy related WebEnvision reports from June 1, 2009 to May 31, 2011. All reports related to prescribing, dispensing and administering chemotherapy medications were included. Reports related to a supportive care measures were excluded. The reports were reviewed by both authors and graded according to the National Coordinating Council for Medication Error Reporting and Prevention Index for medication errors. The errors were also classified by type as defined by the American Society of Hospital Pharmacists guidelines for preventing medication errors. A total of 1030 reports related to oncology patients were recorded during the study period. Of these, 246 (23.9%) were related to chemotherapy. Thirty nine thousand preparations were dispensed by the chemotherapy pharmacy during the study period. The median number of chemotherapy drugs on orders associated with an error was 2 with a range of 1 to 6. The median length of chemotherapy treatment per order was 3 days with a range of 1 to 56 days. Approximately half (47%) of the errors occurred in patients undergoing treatment for leukemia or lymphoma, 28% for solid tumors, 17% for brain tumors, and 7% for non-malignant hematology patients. Ninety four (38%) errors were attributed to pharmacy, 83 (34%) to the providers, and 51 (20%) to the nurses. Seventy six (31%) were prescribing errors, 41 (16%) were administration errors, 31 (13%) were dispensing errors, and 26 (11%) were transcription errors. Approximately half (44%) of errors were of category B, an error occurred but did not reach the patient. Seventy six (31%) reports were category A, circumstances for error were present but no error occurred. Fifty nine (24%) were category C, an error reached the patient but caused no harm. Three errors reached the patient and could have contributed to harm (category D, F,G). Approximately one in three dispensing errors (32%), one in six prescribing errors (17%) and one in ten (11%) transcription errors reached the patient. Prescribing errors were the most common chemotherapy related errors in this study. One in four of all errors reached the patients. Errors occurred despite an institutional policy of two independent checks by providers, pharmacists, and nurses. More diligence is necessary on part of the person performing the second check on chemotherapy orders. Computerized provider order entry may help reduce chemotherapy related errors. Table1. Types of chemotherapy related errors Types of Errors N (%) Prescribing 76 (31) Delay 58 (23) Administration 41 (16) Dispensing 31 (13) Transcription 26 (11) Monitoring 7 (3) Compliance 4 (2) Omission 3 (1) Total 246 (100) Disclosures: No relevant conflicts of interest to declare.

scholarly journals A Nonpunitive, Computerized System For Improved Reporting of Medical Occurrences

2007 ◽  
Vol 93 (3) ◽  
pp. 29-35
Author(s):  
Dale A. Arroyo
Keyword(s):  
Patient Safety ◽  
Reporting System ◽  
Individual Performance ◽  
Error Reporting ◽  
Safety Program ◽  
Culture Of Safety ◽  
Staff Members ◽  
Anonymous Reporting ◽  
Naval Hospital ◽  
Computerized System

ABSTRACT To improve the patient safety program at the Naval Hospital at Oak Harbor, the facility instituted a new computerized system of reporting errors, incorporating a nonpunitive approach. The new “Culture of Safety” led to a paradigm shift in assessing an individual’s performance, event occurrences and error reporting. Prior to the patient safety initiative, under the then-existing error reporting system, staff members at the Naval Hospital at Oak Harbor were held personally accountable and subject to discipline for errors they committed. Under the Culture of Safety program, most errors are considered preventable and attributable to systems issues. The new reporting system is used to assess systems failures, not individual performance. Staff may input errors and occurrences directly into the computerized database or submit paper reports. Although anonymous reporting is allowed, staff members are encouraged to identify themselves. Reviewers comment on the errors and occurrences reported to help identify trends and develop baselines for quality improvement activities. Ultimately, the appointed physician advisor for performance improvement summarizes what actions are needed to remediate the problem. The new system provides up-to-the-minute information for review, dissemination and action, replacing paper trails and time-consuming meetings that failed to resolve occurrences. Data collected provides feedback to department heads, allowing for monitoring, systems improvement or environmental changes. Aggregate data are tracked, trended and fully disseminated.

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