To err is human, but human error rates and patient
safety systems in hospitals can be improved by asking
nurses, physicians and other staff to report medication
errors and log them into a computer database, according to
a study from the
Hopkins Children's Center. Voluntary error-reporting
systems are not new, but few studies have looked at the
accuracy of the reporting and its impact, the Johns Hopkins
"Our goal was to explore the validity of this
voluntary error-reporting system and whether frontline
reporters were capturing the essence of the actual errors
that occurred," said author Marlene Miller, director of
quality and safety initiatives for the Children's Center.
"There were some incorrect reports, but the overall trends
were accurate, which allows us to say that this reporting
system is a reliable index of problematic areas." The
findings are reported in the June issue of Quality & Safety
Miller emphasizes that error data are valuable only if
consistently monitored for patterns and used to create
safety checks that prevent common errors from happening
Co-author Christoph Lehmann, director of clinical
information technology at the Children's Center, said,
"Error reporting is only as good as the actual changes that
are made as a result of it."
Noting that identifying and fixing potential medical
errors is at the core of the Children's Center patient
safety program, Lehmann said that "monitoring voluntary
error reports has led to the creation of several programs
that reduce and prevent medication errors." Among these:
A computerized ordering tool for
pediatric chemotherapy that reduces medication errors in
children undergoing cancer treatment.
An online infusion calculator that
reduces medication errors in children undergoing IV
An online total parenteral
nutrition calculator, designed to prevent nutrition errors
among premature babies in the neonatal intensive care unit,
and currently used systemwide for all pediatric
Since 2004, Johns Hopkins has implemented a
hospitalwide computer reporting system that captures a
variety of medication errors, the vast majority of which do
not harm a patient but may have the potential to do so if
systems are not corrected.
In the study, researchers found that errors occurred
in every step of the medication process — from
prescribing, to ordering to administering to the patient
— and that no one area is immune to errors.
Physicians, nurses and pharmacists caring for children were
equally prone to mistakes.
"One of the more interesting findings was that
drug-administering errors, such as giving the patient the
wrong drug or the wrong dose or at the wrong time, were
quite common," Lehmann said. "We had focused in the past on
ordering errors. This finding made us look for possible
interventions on the administration side."
Researchers reviewed data collected over 19 months via
a voluntary error-reporting system that was in use at the
Children's Center from 2001 to 2004. They analyzed all
1,010 medication errors entered into the system between
July 2001 and January 2003. Those who filed reports were
asked to fill out an online form consisting of multiple
choices and then submit a free-text description of the
event. To determine the accuracy 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, and 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, of the Department of Pediatric Pharmacy.