@article{6703, author = {Julius Cuong Pham and Julie L. Story and Rodney W. Hicks and Andrew D. Shore and Laura Morlock and Dickson S. Cheung and Gabor D. Kelen and Peter Pronovost}, title = {National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.}, abstract = {

BACKGROUND: Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors.

STUDY OBJECTIVE: To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States.

METHODS: A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format.

RESULTS: There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time.

CONCLUSION: ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.

}, year = {2011}, journal = {J Emerg Med}, volume = {40}, pages = {485-92}, month = {05/2011}, issn = {0736-4679}, doi = {10.1016/j.jemermed.2008.02.059}, language = {eng}, }