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Use of chart and record reviews to detect medication errors in a state psychiatric hospital
Benjamin C Grasso1, Robert Genest, Constance W Jordan
1Institute for Self-Directed Care, 95 India Street, Portland, ME 04101, USA. bgrasso1@maine.rr.com
Objective:
This study compared the effectiveness of using a review team and the usual self-reporting method in detecting different types of medication errors in a state psychiatric hospital.
Methods:
Medication errors were defined by using widely accepted criteria. Rates of prescription, transcription, administration, and dispensing errors were determined, and the risk of harm from each error was rated as high, moderate, or low. A review team was assigned to retrospectively review 31 patient records for prescription, transcription, and administration errors for a total of 1,448 patient-days. Dispensing errors, which can only be determined concurrently, were reported for an equivalent number of patient-days. The error rate was compared with the rate that was determined by the usual method of self-reports from all nursing and medical staff.
Results:
In the 31 charts retrospectively reviewed and the dispensing events concurrently reviewed, the team detected a total of 2,194 medication errors, whereas a total of nine errors were self-reported for the same patient group. Administration errors accounted for more than half of the total (66 percent), followed by transcription errors (23 percent), prescription errors (11 percent), and dispensing errors (less than 1 percent). Nineteen percent of errors were rated as having a low risk of harm, 23 percent as having a moderate risk, and 58 percent as having a high risk.
Conclusions:
Use of a review team should be considered as a method for detecting and reporting medication errors.
Insights
A review team significantly outperformed self-reporting in detecting medication errors, identifying over 2,000 errors compared to just nine. This highlights the review team
Area of Science:
- Healthcare Quality Improvement
- Patient Safety Research
- Medication Error Analysis
Background:
- Medication errors pose a significant risk to patient safety in healthcare settings.
- Traditional self-reporting methods may underestimate the true incidence of medication errors.
- Effective detection strategies are crucial for improving medication safety.
Purpose of the Study:
- To compare the effectiveness of a review team versus self-reporting in identifying medication errors.
- To determine the types and frequency of medication errors in a state psychiatric hospital.
- To assess the risk of harm associated with detected medication errors.
Main Methods:
- A review team retrospectively analyzed 31 patient records (1,448 patient-days) for prescription, transcription, and administration errors.
- Dispensing errors were concurrently reported for an equivalent number of patient-days.
- Medication error rates and risk of harm were compared between the review team and self-reporting methods.
Main Results:
- The review team identified 2,194 medication errors, while self-reporting identified only nine.
- Administration errors constituted the majority (66%) of detected errors.
- A substantial proportion of errors (58%) were rated as high risk for patient harm.
Conclusions:
- A dedicated review team is a more effective method for detecting medication errors than self-reporting.
- The findings underscore the need for robust systems to capture the full spectrum of medication errors.
- Implementing review teams can enhance medication safety initiatives in psychiatric hospitals.