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Medication errors associated with code situations in U.S. hospitals: direct and collateral damage.

Angela K M Lipshutz1, Laura L Morloc, Andrew D Shore

  • 1University of California, San Francisco, USA.

Joint Commission Journal on Quality and Patient Safety
|February 19, 2008
PubMed
Summary
This summary is machine-generated.

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Medication errors during medical emergencies ("codes") primarily harm others, not the patient in crisis. Collateral damage errors comprised 74% of all code-related medication mistakes.

Area of Science:

  • Medical Safety
  • Clinical Pharmacy
  • Healthcare Management

Background:

  • Medical emergencies, or "code situations," necessitate rapid interventions.
  • Medication errors can occur during these high-stress events.
  • Understanding the types and targets of these errors is crucial for patient safety.

Purpose of the Study:

  • To analyze medication errors occurring during code situations.
  • To differentiate between errors directly affecting patients in codes and those impacting others ("collateral damage").

Main Methods:

  • Retrospective analysis of 842 medication errors.
  • Categorization of errors based on whether they involved the patient directly experiencing the code or resulted in collateral damage.

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Main Results:

  • "Collateral damage" medication errors constituted 74% of all code-related errors.
  • Medication errors directly involving patients experiencing codes accounted for 21%.

Conclusions:

  • The majority of medication errors during code situations impact individuals other than the patient undergoing the emergency.
  • Interventions should address both direct patient errors and the significant issue of collateral medication errors in critical care settings.