Tracking computer-based error reports improves patient safety, Hopkins s...( of the reports researchers compared th...),Health

of the reports, researchers compared the multiple-choice form to the free-text description of the event, finding that the number of actual errors was 899, meaning that a slight over-reporting occurred. This was because certain errors were classified into more than one category. However, the overall distribution of errors by type was accurate.

Of the 1,010 originally reported errors, 173 (17 percent) were near-miss errors, which researchers describe as an error that didn't harm the patient but would likely cause serious harm if it occurred again. A typical near-miss scenario would involve a physician prescribing the wrong dose, followed by a pharmacist dispensing the wrong dose, but a nurse catching the error before giving the wrong dose to the patient.

Of the 1,010, 38 percent (379 errors) did not reach the patient, half (511) reached the patient but no treatment or increased monitoring was required, 10 percent (103) reached the patient and required increased monitoring, 2 percent (17) reached the patient and required additional treatment or prolonged hospital stay. None was fatal or caused serious harm.

Nearly one-third were prescribing errors, one-quarter were dispensing errors, 38 percent were administering errors, and 8 percent were documentation errors. Half of all errors occurred in children under 6.

Most errors occurred with anti-infective medications, such as antibiotics or antivirals (17 percent), followed by pain relievers and sedatives (15 percent), antihistamines for allergies (15 percent), nutritional supplements and vitamins (11 percent), gastrointestinal medications (8 percent), cardiovascular medications (7 percent) and hormonal medications (6 percent). Authors on the paper are Miller, Lehmann and John Clark, Pharm. D., of the Department of Pediatric Pharmacy.

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Contact: Katerina Pesheva
epeshev1@jhmi.edu
410-516-4996
Johns Hopkins Medical Institutions
21-Jun-2006

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