Prescribing errors that cause harm
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Rider, Briana B., author Guant, Michael J., author Grissinger, Mathew, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, September 2016
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Medication Errors -- adverse effects Medication Errors -- prevention & control Medication Errors -- statistics & numerical data Medical Order Entry Systems Patient safety Risk Management Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- Errors that occur in the prescribing phase of the medication use process are less likely to reach the patient and cause harm because of the opportunity to intercept the error in the phases of transcribing, dispensing, administering, and monitoring. However, some prescribing errors make their way through the entire medication use process, reach the patient, and cause harm. A query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) database revealed 811 Serious Events (harm score E through I) associated with reported prescribing errors that occurred from July 2004 through June 2016. Nearly 5% (4.7%, n = 38) of these errors required intervention to sustain life or contributed to or resulted in the patient's death. The most common types of events reported were wrong dose/overdosage (32.2%, n = 261), monitoring error/documented allergy (14.5%, n = 118), dose omission (14.3%, n = 116), and wrong patient (4.4%, n = 36). Recommended system-based risk reduction strategies include optimizing computerized prescriber order entry with clinical decision support to facilitate screening for drug-related problems; and developing well-designed standard order sets.
- 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 81-91))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101693067 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101693067