We found a match
Your institution may have access to this item. Find your institution then sign in to continue.
- Title
Does critical incident reporting contribute to medication error prevention?
- Authors
Frey, Bernhard; Buettiker, Vera; Hug, Maja I; Waldvogel, Katharina; Gessler, Peter; Ghelfi, Daniela; Hodler, Catherine; Baenziger, Oskar
- Abstract
Medication-related critical incidents (CIs) comprise harmful and potentially harmful events. The aim of CI monitoring is quality improvement through system changes. In a prospective survey, we analysed our drug-related CIs of the year 2001 with an emphasis on how they contributed to system changes. A voluntary, anonymous, non-punitive CI reporting was used. The study was performed in a multidisciplinary, 23-bed, neonatal-paediatric intensive care unit (ICU). CI severity was graded: minor (no interventions required), moderate (requiring routine therapy, available outside the ICU), major (need for therapeutic interventions specific to the ICU). There were 284 drug-related CIs, 76% (95% confidence interval 71%-81%) of minor, 19% of moderate and 5% of major severity. A total of 24 CIs were potentially life threatening (if not detected). Some 27% of CIs were intercepted, 17% before preparation and 10% before administration of the drug to the patient. There was a negative correlation between median delay (from CI to detection) and mean severity of the different drug classes involved (P = 0.027). As to the impact on quality, 46 CIs were followed by system changes and 63% (95% confidence interval 49%-77%) of these CIs were of minor severity. Examples of system changes are: double checking for potentially harmful drugs, standardised prescription form and contact to the national drug control agency regarding misleading drug labels.
- Publication
European journal of pediatrics, 2002, Vol 161, Issue 11, p594
- ISSN
0340-6199
- Publication type
Journal Article
- DOI
10.1007/s00431-002-1055-0