HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sakowski, J. Articles by Dozier, K. Search for Related Content PubMed PubMed Citation Articles by Sakowski, J. Articles by Dozier, K.

JULIE SAKOWSKI, PH.D., is Senior Health Services Researcher, Sutter Health Institute for Research and Education, San Francisco, CA, and Assistant Clinical Professor, Department of Clinical Pharmacy, University of California San Francisco, San Francisco. JEFFREY M. NEWMAN, M.D., M.P.h., is Director, Sutter Health Institute for Research and Education, and Adjunct Professor, Institute for Health and Aging, University of California San Francisco. KRYSTIN DOZIER, B.S.N., is Vice President, Clinical Effectiveness, Clinical Integration Department, Sutter Health Institute for Research and Education, Sacramento, CA.

Address correspondence to Dr. Sakowski at the Sutter Health Institute for Research and Education, 345 California Street, Suite 2000, San Francisco, CA 94104 (sakowsj{at}sutterhealth.org).

Purpose. The severity of medication administration errors detected by a bar-code medication administration (BCMA) system was studied. Methods. A panel of six health care providers reviewed medication administration error scenarios created from BCMA error logs at six community hospitals. Each scenario was rated on the potential to cause patient harm, taking into account the severity of the potential outcome and the probability that the patient would be harmed. A severity score for each error was determined by averaging the individual reviewers’ scores. Results. The majority of the medication administration errors identified by the BCMA system were judged to be benign; 1% of the errors reviewed were rated as having the potential to result in a severe or life-threatening adverse event, 8% were judged to have the potential to produce moderate adverse effects, and 91% were expected to produce minimal, if any, clinical effects. Medication errors due to a dose being administered when there was no corresponding order in the computer system were significantly more likely to produce moderate or severe outcomes than other types of medication errors. Errors that involved medications designated as high-alert drugs were also more likely to produce moderate or severe adverse events than non-high-alert drugs. Conclusion. The majority of medication administration errors detected by a BCMA system were judged to be benign and pose minimal safety risks; however, the numbers and severity of medication administration errors that occur despite the use of a BCMA system suggest that there are opportunities to improve these systems and how the information they generate is used. Index terms: Codes; Drug administration; Errors, medication; Hospitals; Quality assurance

 

This article has been cited by other articles:

				J. L. DeYoung, M. E. VanderKooi, and J. F. Barletta Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit Am. J. Health Syst. Pharm., June 15, 2009; 66(12): 1110 - 1115. [Abstract] [Full Text] [PDF]