Omission of high-alert medications: a hidden danger
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Grissinger, Matthew, author Alghamdi, Dalia, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, December 2014
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Drug Prescriptions Drug Therapy -- statistics & numerical data Medication Errors -- prevention & control Infusion Pumps Infusions, Intravenous Medical Order Entry Systems Patient safety Pharmaceutical Preparations -- administration & dosage Risk Management Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- A drug omission occurs when a patient does not receive a medication that has been ordered or when a medication has not been ordered despite being appropriate for an underlying condition. Over 2,700 medication errors categorized as drug omissions involving more than 500 different medications were reported to the Pennsylvania Patient Safety Authority from January 1, 2013, through April 30, 2013. Antibiotics (19.7%) and medications used for respiratory therapy (11.5%) were the most common medications cited in reports. More than 21% of reports involved at least one high-alert medication. A majority of omissions with high-alert medications occurred during the administration process (52.9%), followed by occurrence during the transcription (22.9%) and prescribing (12.0%) processes. Most administration omissions involved a medication intended to be given by an intravenous (IV) route (32.9%) or by other injectable routes (38.0%). The most commonly cited types of omissions involving an IV high-alert medication included IV infusions that were not started, IV tubing that was not connected or was clamped, and IV infusion pumps that were not turned on or were turned off. Risk reduction strategies include developing a consistent administration process for IV medication setup, tracing IV lines, and using healthcare technology fully and properly.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (pages 149-155)).
- NLM Unique ID:
- 101648354 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101648354