Chapter 11: Error Prevention Strategies and Staff Education

2012 ◽  
Vol 1 (2) ◽  
pp. 54 ◽  
Author(s):  
Luigi Brunetti ◽  
Dong-Churl Suh

Background: Medication errors are a significant public health concern.  Although significant advances have been made, errors are still relatively common and represent an opportunity for healthcare improvement.Methodology/Principal Findings: Since the publication of To Err is Human, medication errors have been under tremendous scrutiny.  Organizations have moved towards a non-punitive approach to evaluating errors.  This approach to medication errors has aided in identifying common pathways to medication errors and improving understanding regarding the anatomy of a medication error.  As a result, prevention strategies have been developed to target common themes contributing to errors.  Error prevention strategies may target common contributors of medication errors, broadly grouped as performance lapses, lack of knowledge, and lack or failure of safety systems.  Strategies to thwart medication errors range from process improvement to integration of technology in the health care environment.Conclusions/Significance:  Organizations should devote resources to address medication error prevention strategies in an effort to improve patient outcomes and decrease morbidity and mortality associated with medication errors.


Author(s):  
Mario Pohl ◽  
Uwe Bielke ◽  
Rainer Börret ◽  
Rolf Rascher ◽  
Olga Kukso

2018 ◽  
Vol 9 (11) ◽  
pp. 609-617 ◽  
Author(s):  
Nadine Matti ◽  
Minh-Nha R. Nguyen ◽  
Cassandra Mosel ◽  
Luke E. Grzeskowiak

Background: Medication errors are common in neonatal care and can lead to significant harm. We sought to explore utilization of various medication error prevention strategies across Australian and New Zealand neonatal units (NNUs) through a clinical practice survey. Methods: An electronic survey was distributed in October 2016 to relevant staff at each of the 29 level III NNUs identified as members of the Australian and New Zealand Neonatal Network (ANZNN). The survey contained questions relating to a range of medication error prevention strategies identified from a previous systematic review on the topic. The evaluated interventions targeted different aspects of the medication-use process including prescribing, evaluation/checking of orders by clinical pharmacists, transmission, preparation and dispensing of orders, storage of medications, and medication administration. Results: From the 20 respondents, the evidence-based strategies most commonly utilized were use of smart pumps ( n = 18; 90%), and ward-based clinical pharmacists ( n = 17; 85%). Interventions least commonly utilized included barcode scanning with medication administration ( n = 0; 0%), electronic prescribing and clinical decision support ( n = 1; 5%), and dedicated medication administration nurse ( n = 2; 10%). The total number of evidence-based medication error prevention strategies utilized in each NNU ranged from 2 to 10 (median = 7), 10 of 16 strategies were utilized by less than 50% of NNUs. Conclusion: While evidence supports utilization of a number of medication error prevention strategies, these appear inconsistently utilized across current practice settings.


2018 ◽  
Vol 24 (3) ◽  
pp. 45 ◽  
Author(s):  
Institute for Safe Medication Practices

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