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According to the Institute of Medicine report, titled “To Err Is Human: Building a Safer Health System”, it was first reported in 1999 that between 44,000 and 98,000 Americans die in hospitals each year due to mistakes in their care.
ORIENTATION PREFERRED NURSE STAFFING NATIONAL PATIENT SAFETY GOAL Improve the accuracy of patient identification Improve the effectiveness of communication. NATIONAL PATIENT SAFETY GOAL Improve the accuracy of patient identification Improve the effectiveness of communication among caregivers Improve the safety of using medications Reduce the Risk of Health care-associated infections Accurately and completely reconcile medications across the continuum of care Patient Safety Goals Improve the accuracy of Patient Identification Use at least two patient identifiers (neither to be the patient’s room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. Patient Safety Goals Improve the effectiveness of communication among caregivers For verbal or telephone orders or for telephonic reporting of critical tests results, verify the complete order or test results by having the person receiving the order or test result “read-back” the complete order or test result. Patient Safety Goals Effective Communication Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Patient Safety Goals Improve the safety of using medications Limited Drug concentrations Many commonly used infusions are provided in pre-mixed, standardized concentrations (dopamine, dobutamine, milrinone, heparin, levofloxacin) Many compounded infusions are mixed in standard concentrations (felnoldopam, diltiazem, nitroprusside) Concentrated Electrolytes Concentrated electrolyte injections (potassium chloride, potassium phosphate, and sodium chloride) are not stored in o made available to patient care areas. Patient Safety Goals Medications must be delivered to the procedure field in an aseptic manner All medications, med containers and other solutions on or off the field should be labeled. Patient Safety Goals Reduce the Risk of Health care-associated Infections Comply with current CDC hand hygiene guidelines. Patient Safety Goals Accurately and completely reconcile medications across the continuum of care Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. Patient Safety Goals Reduce the risk of patient harm resulting from falls Implement a fall reduction program and evaluate the effectiveness of the program.
In the recent readings, the article about HIT (Health Information Technology) reminds me of the area of human errors.
Think about this way, the machine is designed in such a way that buttons, icons and menus are extremely confusing. In this sense, I searched online for some material on human errors, and find the definition for latent errors and active errors (which also occurred in that paper).
Medication errors can be broadly classified as prescribing, dispensing or drug administration errors.
ABSTRACTAn estimated 300 million radiologic procedures are conducted per year in the United States. You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site. The European Medicines Agency’s definition of a medication error, published last year, is “an unintended failure in the treatment process that leads to, or has the potential to lead to, harm to the patient”. James Reason classified errors into two broad categories, based on the observation that intentions are carried out according to formulated plans. This classification leads to ideas about how medication errors may be prevented, as summarised in the table below. Jeffrey Aronson is a clinical pharmacologist, working in the Centre for Evidence Based Medicine in Oxford’s Nuffield Department of Primary Care Health Sciences. As humans we are always susceptible to make errors, but understanding why we make them will help us design systems that decrease the chances of such errors to happen. Eg: The nurse is distracted in her busy shift and gives a medication to her patient which was intended for another patient.
The rule based errors or cognitive errors are very interesting and if you wish to learn more then refer to this brief article by Dr. Latent Errors :   Latent errors are accidents waiting to happen because of defects in the design of the system.
Standardize a list of abbreviations, acronyms, and symbols that are not to be used throughout organization. Concentrated electrolytes are only available in the pharmacy for use in IV fluid preparation.
Medications which are drawn up and given immediately does not leave your hand or sight) do not have to be labeled. Wash hands with soap and water when hands are visibly soiled Decontaminate hands with alcohol-based foam when hands are not visibly soiled Banning of artificial nails in the hospital-setting Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
This process includes a comparison of the medications the organization provides to those on the list.
Assess daily and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to address any identified risks Stickers are placed on chart, patient’s armband, call light and the Kardex is flagged.
As we all know, one of the most popular research topic in healthcare domain is about medical errors (and thus human error).
Specifically, it is very difficult to find the reason behind an error: is it really a human error, or organizational error, or machine error. In this case, the error could attribute to engineers (the designer) instead of machine operator, though it occurred at the stage of operation.
In the author’s sense, latent errors refer to the errors that hide deeply within the organization or operating procedures, which might finally attribute to the engineer, designer, or manager. The relevance of medication and drug administration errors in our everyday practice is an important aspect of medical audit. Drug error in anaesthetic practice: A review of 896 reports from the Australian incident monitoring Study database. Drug administration errors: A prospective survey from three South African teaching hospitals.
Medication errors in anesthesia: An 8-year retrospective analysis at an urban university hospital. The effect of barcode-enabled point of care technology on medication administration errors. Incidence of Adverse Drug Events and Potential Adverse Drug Events; Implications for Prevention. Ndagije,Charles Karamagi Drugs - Real World Outcomes. In cardiac catheterization laboratories, radiology, and other diagnostic departments, medications such as contrast media are administered, rates are adjusted for intravenous (IV) fluids, and IV access lines are flushed. This, with the addition of a single word, “unintended”, is the definition that Robin Ferner and I suggested 16 years ago. It encompasses not only therapeutic drugs but also oral contraceptives, vaccines, hormones for replacement therapy, radiographic contrast media, and cells. This also reminds us of the final clause in Reason’s definition, recognising that errors are often intercepted. If the failure was intended, that would constitute a violation, a subject for another time. Either the plan is appropriate but carried out wrongly, resulting in errors that he called slips and lapses, or the plan is inappropriate, leading to errors that he called mistakes.
But an important principle is suggested by the origin of the word “memory”, the Indo-European root [S]MER, which implied being mindful or taking care.
It was then said that more people die from medical errors each year than from breast cancer or from motor vehicle accidents. That is why it is now believed that errors are not made by defective people, but by defective systems. A complete list of the patient’s medication is communicated to the next provider of service when it refers or transfers a patient to another setting, service practitioner, or level of care within or outside the organization. This reading of Health Information Technology listed a whole bunch of fallacies that may occurred in healthcare domain. Just take a very easy example, a common medical error (error in medical domain) is that wrong operation of machine which might cause wrong diagnosis or even death. On the other hand, it could also attribute to organizational error in the following sense: 1.
On the other hand, the active error refers to the mistake committed simply due to the machine operators. Although there have been few case reports of drug administration errors by anesthetists, there is paucity of information regarding medication errors in anesthetic practice in Nigeria. In addition to specific medications that are used in radiology, high-alert medications such as IV sedatives, vasopressors, and blood coagulation modifiers are given in this setting. For example, a prescriber may write a prescription for “digoxin 250 mg”, but whoever is responsible for administering it may recognise the error and correctly administer 250 micrograms instead, preferably after checking with the prescriber. This is potentially confusing, since in common parlance “error” and “mistake” are regarded as synonyms. As if these figures were not staggering enough, a study was published recently in the Journal of Patient Safety that estimated the annual number of medical errors in U.S.

Because one day the attending doesn’t have time to go over every detail about patient care and this unsupervised intern prescribes the wrong medication leading to active error. Some are well defined and described, while some others are kind of vague and not clearly classified. However, does that simply mean it’s a human error (since it’s an error occurred in operation of machine)?
We set out to study the incidence of medication errors among anesthesia practitioners in Kaduna State, North Western Nigeria and to suggest ways to minimize such errors. Nearly 1,000 event reports submitted to the Pennsylvania Patient Safety Authority specifically mentioned medication errors that occurred in care areas providing radiologic services. A more useful approach is Reason’s classification according to whether the error is based on erroneous memory, actions, rules, or knowledge (MARK), as illustrated in the figure. Materials and Methods: A questionnaire-based study was conducted among physician anesthetists and nurse anesthetists working in the major secondary and tertiary hospitals in Kaduna State, North Western Nigeria.
Mato and Fyneface-Ogan working in the South-South region of Nigeria reported 3 cases of drug administration errors in a Teaching hospital.
The administration of wrong drugs and unauthorized drugs was the most commonly reported medication error, followed by wrong-dose errors. With this medical errors stands as the third leading cause of death after myocardial infarction and cancer. The organizational had a failure in job rotation so that information are not perfectly transmitted, which caused the error in machine operation. The data obtained was analyzed using SPSS Version 17.0 and the data presented in relevant charts and tables. Owen International Journal of Obstetric Anesthesia. While contrast agents and radiopharmaceutical products were cited in almost a quarter of all medication error reports, a majority of the drugs listed are used across the spectrum of patient care settings, not just in radiology. Further qualitative analysis of events classified as wrong-rate medication errors in these areas shows no radiologic medications.
Twenty-four (56%) of them admitted to ever having a medication error, and 34 (79%) of them attributed the medication error to problems with drug labeling from manufactures using similar labels for different drugs.
Untoward sequelae resulted in 44% of the patients that were affected by these medication errors and these ranged from cardiac arrest to delayed recovery from anesthesia. Strategies to address these problems include conducting organizational examinations of the medication-use processes in radiology areas to uncover risks that could lead to harmful errors, proactively addressing the plan for the management of the patient’s infusion therapy while they are undergoing a radiologic procedure, and including radiology staff when evaluating and validating the level of training and competency to perform medication administration or related tasks.
Majority of the respondents recommended vigilance, double checking of drug labels, and color coding of syringes as ways to minimize medication errors. Fifty structured questionnaires were administered to anesthesia care-givers at 6 hospitals that were selected based on convenience. Radiologic services are provided in a variety of inpatient and outpatient settings but most commonly involve cardiac catheterization, radiology, and nuclear medicine services. Conclusion: Medication errors do occur in the everyday practice of anesthetists in Nigeria as in other countries and can lead to morbidity and mortality in our patients. The total number of eligible respondents was 56, and the 50 respondents that were included in the study were selected on the basis of convenience and availability. These services use medical imaging, such as radiography, computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography, and ultrasound.
Routine audit and reporting of critical incidents including errors in drug administration should be encouraged.
Forty-three questionnaires were returned, and the data obtained was analyzed using SPSS Version 17.0 and the data presented in relevant charts. Pharmacopeia (USP) report on medication errors in radiology1—that pooled error reports to MEDMARX® from 2000 to 2004—revealed that, while medication errors in radiologic services are not more prevalent when compared to other settings, they do have more potential to cause harm. Twelve percent of the medication errors reported by USP in radiologic services resulted in patient harm (“harm” defined as National Coordinating Council for Medication Error Reporting and Prevention [NCC MERP] harm category E or higher) compared to 1.7% of all medication errors. There were 23 physician anesthetists (including consultants and trainees) and 20 nurse anesthetists [Figure 1]. As a patient is being transferred to and from a radiologic care setting, the opportunity for miscommunication and lack of access to patient information sets the stage for errors to occur. Majority of the anesthetists 24 (56%) admitted to ever having a medication error [Figure 3].
Because the care provided to the patient is very much focused on a particular procedure, drugs that were administered pre-examination, or those to be continued postexamination, may not be given sufficient attention.
Certification and training requirements for radiologic staff can vary by setting, state regulations, and institutional policies. Frequently, staff directly dispense and administer medications; however, there is no true standard on how much or what kind of medication-use training they receive. In cardiac catheterization laboratories, radiology, and other diagnostic departments, staff administer medications such as contrast media, adjust rates of IV fluids, and flush IV access lines.
Seventy-nine percent (40) of the anesthetists attributed the medication error to problems of the drugs with similar labeling by the drug manufacturers [Plates 1 and 2].
In reality, these medications are sometimes administered without a radiologist ever actually seeing the patient or the patient’s medical record.
Additionally, there is sometimes no written prescription and no written documentation on a patient’s medication administration record when these drugs are administered.
Other untoward sequelae ranged from sedation, tachycardia, and cardiac arrest to delayed recovery from anesthesia in 19% of the patients [Figure 6].
Because of this, there is very little opportunity for a pharmacist’s involvement in reviewing the orders and screening the patient for allergies, drug-drug interactions, or drug-disease state warnings before the medication is administered.
Majority of the respondents recommend vigilance (9), appropriate and double checking of drug labels (18), and color coding of syringes (7) as ways to minimize medication errors. A Look at the NumbersLittle information in the literature specifically mentions medication errors that occur in the radiologic setting.
It is usually assumed that the higher the response rate, the more likely the results are representative of the population, provided the sampling is appropriate. This survey suggests that the incidence of self-reported drug administration errors by anesthetists in Kaduna State, North Western Nigeria is similar to that in other countries.
Table 2 identifies the top 15 most common drugs mentioned in reports associated with the radiologic unit.
Drug administrations per anesthetic were counted on a random sample of anesthetic records at Green Lane Hospital. When combining the medications listed into their respective class of medications, 28.3% of all medications mentioned are considered high-alert medications, excluding IV contrast agents (which are also high-alert medications). Eighty-nine percent of 66 respondents reported at least one error of drug administration, and 12.5% had actually harmed patients.
Top 15 Medications Involved in Medication Errors in the  Radiologic Care Area (n=15)       Table 3. The perceived value of a Canadian reporting agency for medication errors and improved standards for labels on drug ampoules was also investigated.
Forty (28.4%) of the wrong-drug errors involved mix-ups of the various formulations of technetium, a radiopharmaceutical widely used as a diagnostic aid. They conducted a self-reporting survey mailed to members of the Canadian Anesthesiologists' Society (n = 2,266). Its applications include imaging procedures of the brain, myocardium, lungs, thyroid, and bone.
Respondents provided free-text descriptions of medication errors and answered fixed response questions.
Technetium has numerous uses in nuclear medicine, and it is available in more than 60 different products. Surveys from 687 anesthesiologists (30% response rate) revealed that 85% of the participants had experienced at least one drug error or "near miss." Although most errors (1,038) were of minor consequence (98%), four deaths were reported.
The commonest error involved the administration of muscle relaxants instead of a reversal agent. This means that 44.7% (n = 63) of wrong-drug reports involved medications specific to that setting.
The Canadian anesthetists (97.9%) reported that they read the ampoule label "most of the time" although the label color was an important secondary cue.
In most cases, the result of this mix-up does not lead to patient harm; however, it may lead to the rescheduling of the intended test and result in increased cost and loss of productivity. Approximately half of the participants in that study said they would report the error if a reporting program existed, and 84% agreed that improved standards for drug labels would reduce the incidence of error.
Orser and colleagues concluded that most anesthetists in their survey experienced at least one drug error.
In fact, the most common medications listed included insulin and heparin infusions, such as in the following example: The patient has been in radiology since early this morning.

Most errors were of minor consequence; however, serious morbidity and mortality resulted from clearly preventable events.
Apparently, the insulin pump was disconnected before the patient’s arrival in the radiology department.
Their results supported the development of improved standards for drug labels and the establishment of a Canadian reporting program for medication errors. After several hours passed, the radiology technicians made the nurse from the unit aware that the patient would be in the radiology department a while longer. The patient’s companion alerted me in the early afternoon to the fact the patient had an insulin pump and it has been disconnected since this morning, so a blood sugar was obtained. The floor nurse was notified of the patient’s status and that the radiology department does not carry insulin.This example reported to the Authority demonstrates a bigger problem, which is the effect any procedure may have on a patient’s current drug therapy.
It may be difficult to conclude from the results because it doesn't really have a pattern, and the groups are not well represented even though the results have been expressed in percentages. Errors may occur when the infusion pump is restarted by radiology staff or if the pump is off for a prolonged period of time. The interpretation of the findings of this survey is that the higher the year of practice from 5 years upwards, the higher the risk of medication errors.
It would be expected that medication errors that occur in this area would primarily involve problems with medications specifically given for radiologic procedures. However, as indicated in Tables 2 and 3, a majority of the medications involved in errors in radiologic settings were not radiologic medications, such as contrast or radiopharmaceuticals. One patient suffered a cardiac arrest due to wrongful administration of adrenaline instead of oxytocin during a cesarean section; however, she was successfully resuscitated [Figure 6].
Apart from patient morbidity and even death, wrong drug administrations have economic consequences as they may lead to prolongation of the duration of hospital stay.Poor labeling of ampoules and vials was identified as another important cause of drug errors. The following are two examples submitted to the Authority:Patient was consented for MRI with conscious sedation. Strategies described to prevent such errors include improved labeling with clear fonts that emphasize the generic name rather than the proprietary name, [14] using a two-person check when drawing up drugs, and the introduction of bar-coded ampoules with a computer that speaks the name of the drug after it has been scanned before being drawn up. A registered nurse (RN) administered Versed® (midazolam) and fentanyl IV push prior to MRI. The bar code on the bracelet links the patient with his or her electronic health record, which is maintained by the hospital and which contains information about drug therapy and other medical informationEach unit dose of medication (for both prescription and non-prescription drugs) is labeled with a bar codeAt the time the medication is dispensed for a patient, pharmacy staff use a scanner to read the medication's bar code. The computerized database matches this code with the information in the patient's health record, to confirm that the correct medication is being dispensedBefore the medication is administered to the patient, the nurse or other health care provider uses a bedside or portable scanner or reader to scan both the bar code on the patient's identification bracelet and the bar code on the label of the unit-dose package of the medication to be administeredThe computer compares information in the patient's health record with information linked to the medication's bar code.
If there is a match, a confirmation is issued, and the medication, dosage, and time of administration are entered automatically into the patient's electronic health record.
Patient developed respiratory distress and cyanosis for which an airway emergency was called. This process allows such "near misses" to be captured for analysis, so that the institution can address causes in a systematic way.
The patient stabilized and was taken to recovery room and subsequently was transferred to pediatric intermediate care for observation.In addition, analysis of events classified as wrong-rate medication errors in these areas shows not one radiologic medication, and over half of these events involved high-alert medications.
Color code is an internationally accepted safety measure for drugs, and this is used by drug manufacturing companies. Standardization of this safety measure by practicing anesthetists will help prevent drug errors.Majority of the respondents in our study recommend that correct labeling of drugs vials and ampoules and also syringe labeling will reduce the cases of medication errors [Figure 7]. These problems include misprogrammed infusion pumps, infusions that were stopped for the radiologic test but not restarted, tubing misconnections, and wrong-patient errors. Anesthetists are responsible for labeling the syringes they use, and this should be done with utmost care and vigilance.The administration of drugs to patients is a complex process, which at its simplest involves prescription, preparation, and finally administering the drug itself. The following reports illustrate these problems:The patient arrived to the intensive care unit (ICU) from the cardiac catheterization lab. In the operating room, anesthetists are unique in that a single practitioner is usually responsible for all parts of the process often without any formal checking maneuvers required. When the patient returned from ultrasound, the infusion was found to be no longer running and clamped. In other areas of medical practice, several individuals may be involved, and checking mechanisms are usually more robust.
It is, therefore, important that as anesthetists, we demonstrate that we are practicing safely.From this study, the drugs most commonly administered erroneously are pancuronium instead of suxamethonium, atropine instead of ergometrine, or adrenaline instead of oxytocin and vice versa. A subclavian catheter and tracheostomy were present and all of the ports had similar injection valves.
The syringe swap or vial swap of suxamethonium chloride for pancuronium was a common mistake often made by the respondents. This is similar to the findings by Bowdle, [19] in which a wide variety of drugs were involved in errors such as inhalational agents, opioids, muscle relaxants, and vasoactive agents.
Patient was then pulled out of the MRI and discovered that contrast had been injected into tracheostomy cuff with a rupture of the balloon. Succinylcholine was involved in 35 cases (17 percent), and epinephrine was involved in 17 cases (8 percent). In that study, drugs that were interchanged with epinephrine were ephedrine (two cases), pitocin (three cases), and hydralazine (one case). They validated the recommendations using reports of drug errors collected in a previous study. Following a preliminary investigation, it was determined that an inpatient was in x-ray around the same time the ED patient was in the ED, and for unknown reasons the inpatient’s IV was connected to the ED patient. These aspects of minimizing errors drug administration are necessary in order to maintain a high level of safety. A review of the data submitted to the Authority reveals 126 reports (13%) where breakdowns in obtaining and using patient information occurred, including the following case examples:Patient presented to the ED with abdominal pain and vomiting. Also, the data obtained is 'self-reported' by the respondents, and it is possible that some of the reports may be biased. It may, therefore, be difficult to conclude from these results because some aspects do not really have a pattern and the groups are not well represented. Majority of anesthetists will administer a wrong drug at some time or another in their career. The patient's creatine came back at a critical level and contrast should not have been given.A nurse gave a verbal order for a heparin dose to be given IV push and the physician assisting with the heart catheterization did not know that the heparin was already administered. An important minority of such incidents may cause significant patient morbidity or mortality. Mechanisms for reporting such incidents should be put in place to identify possible causes and implement measures to prevent further incidents.
The patient developed a hematoma at the catheter site and required blood products.A patient received a dosage of IV contrast for a CT scan administered by CT technicians without checking the lab values of the patient’s BUN and Cr before administering the contrast. Prospective, randomized studies investigating the incidence of medication errors and strategies to decrease the incidences of wrong drug administration are needed.
The physician was notified and stated [the intent to] hydrate the patient.A four-year-old patient underwent a Cardiolite® (technetium Tc99m sestamibi) cardiac imaging scan. Reduction in the incidence of medication errors is an important aspect of patient safety, and vigilance remains the watchword in the safe conduct of anesthesia. A routine audit of the records discovered that the dose was based on 50 kg and not the patient’s weight of 50 lbs. Upon internal review, it was discovered that the weight was obtained verbally by the technician and then forwarded to the pharmacy for nuclear medicine. Risk Reduction StrategiesHealthcare facilities should identify the error risks currently present in cardiac catheterization laboratories, radiology, and other diagnostic departments and take steps to implement risk reduction strategies. Ultimately, the responsibility for patient safety falls to the licensed medical professional supervising the technician.Include radiology staff when evaluating and validating the level of training and competency to perform medication administration or related tasks.
Keep technicians in the information loop regarding safe medication administration practices by providing in-service education.11Organizations need to carefully consider current and recent patient information before ordering, dispensing, and administering any medication in this setting that may affect the procedure. MEDMARX® data report: a chartbook of 2000-2004 findings from intensive care units and radiologic services.
Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. Incidence, risk factors, and clinical course of acute renal insufficiency after cardiac catheterization in patients 70 years of age or older.

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