Improving patients safety medical errors and adverse events in health care

The topic has received attention from notable physicians in the centuries since.

Improving patients safety medical errors and adverse events in health care

A medication error is an error of commission or omission at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication.

An adverse drug event ADE is defined as harm experienced by a patient as a result of exposure to a medication. As with the more general term adverse eventthe occurrence of an ADE does not necessarily indicate an error or poor quality care.

Preventable adverse drug events result from a medication error that reaches the patient and causes any degree of harm.

It is generally estimated that about half of ADEs are preventable.

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Medication errors that do not cause any harm—either because they are intercepted before reaching the patient or because of luck—are often called potential ADEs.

An ameliorable ADE is one in which the patient experienced harm from a medication that, while not completely preventable, could have been mitigated. Finally, a certain percentage of patients will experience ADEs even when medications are prescribed and administered appropriately; these are considered adverse drug reactions or nonpreventable ADEs and are popularly known as side effects.

For example, the intravenous anticoagulant heparin is considered one of the highest-risk medications used in the inpatient setting.

Improving patients safety medical errors and adverse events in health care

Safe use of heparin requires weight-based dosing and frequent monitoring of tests of the blood's clotting ability, in order to avoid either bleeding complications if the dose is too high or clotting risks if the dose is inadequate.

If a clinician prescribes an incorrect dose of heparin, that would be considered a medication error even if a pharmacist detected the mistake before the dose was dispensed.

If the incorrect dose was dispensed and administered but the patient experienced no clinical consequences, that would be a potential ADE. If an excessively large dose was administered, the overdose was detected by abnormal lab results, but the patient experienced a bleeding complication due to clinicians failing to respond appropriately, that would be considered an ameliorable ADE that is, earlier detection could have reduced the level of harm the patient experienced.

Adverse drugs events are one of the most common preventable adverse events in all settings of care, mostly because of the widespread use of prescription and nonprescription medications.

Clinicians have access to an armamentarium of more than 10, prescription medications, and nearly one-third of adults in the United States take 5 or more medications. Each year, ADEs account for nearlyemergency department visits andhospitalizations. Ambulatory patients may experience ADEs at even higher rates, as illustrated by the dramatic increase in deaths due to opioid medicationswhich has largely taken place outside the hospital.

4 Ways Technology Is Improving Patient Safety

Transitions in care are also a well-documented source of preventable harm related to medications. Polypharmacy—taking more medications than clinically necessary—is likely the strongest risk factor for ADEs.

Elderly patients, who take more medications and are more vulnerable to specific medication adverse effects than younger patients, are particularly vulnerable to ADEs. Pediatric patients are also at heightened risk, especially when hospitalized, since many medications for children must be dosed according to their weight.

Other well-documented patient-specific risk factors include limited health literacy and numeracy the ability to use arithmetic operations for daily tasks. It is important to note that in ambulatory carepatient-level risk factors are probably an underrecognized source of ADEs.

Studies have shown that both caregivers including parents of sick children and patients themselves commit medication administration errors at surprisingly high rates.

Introduction

The Institute for Safe Medication Practices maintains a list of high-alert medications—medications that can cause significant patient harm if used in error. These include medications that have dangerous adverse effects, but also include look-alike and sound-alike medications: The Beers criteriawhich define certain classes of medications as potentially inappropriate for geriatric patients, have traditionally been used to assess medication safety.Improving patient safety and the quality of health care is a national priority in the United States.

1 In , the Institute of Medicine reported that 44, to 98, Americans die each year as a result of medical errors. 2 More recently, at least one author has suggested that estimates of harm are much higher. 3 The majority of these errors. Adverse drug events—harm experienced by a patient as a result of exposure to a medication—are often the result of medication errors and are likely the most common source of preventable harm in both hospitalized and ambulatory patients.

Feb 16,  · The Critical Care Safety Study reported an overall rate of medication errors associated with harm/1, patient-days in medical and coronary-care patients.

In the recent worldwide SEE2 study, the rate of parenteral medication errors was /1, patient-days [ 10 ]. Improving patient safety and the quality of health care is a national priority in the United States.

1 In , the Institute of Medicine reported that 44, to 98, Americans die each year as a result of medical errors. 2 More recently, at least one author has suggested that estimates of harm are much higher. 3 The majority of these errors. an event that results in unintended harm to the patient and is related to the care or services provided to the patients, rather than to the patient's underlying medical conditions incident reports instruments (paper or electronic) used to document occurrences that could have led or did lead to undesirable results.

The terms adverse events, near misses, and medical errors are used in patient safety to refer to events where patients were harmed (or easily could have been). Adverse Events, Near Misses, and Errors. Topics. Resource Type. Patient Safety Primers specifically "adverse outcomes to patients in the course of health care management.

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