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Cases & Commentaries
- Web M&M
Jeffrey M. Pearl, MD; Nancy E. Donaldson RN, DNSc; July-August 2005
A nurse preparing a patient for transfer out of the ICU discovers the guidewire used for central line placement (1 week earlier) still in the patient's leg vein.
Journal Article > Study
Kaushal R, Bates DW, Landrigan C, et al. JAMA. 2001;285:2114-2120.
This prospective cohort study aimed to describe the epidemiology of medication errors by determining prevalence rates, comparing them to existing rates in adult hospitals, and analyzing the major error types captured. Using data from nearly 11,000 medication orders, investigators reported a 5.7% medication error rate and less than 2% adverse drug event (ADE) rate—findings similar to those in adult settings. The rate of potential ADEs, however, was higher in this study population. Results include detailed description of the error types, the point at which the error occurred in the medication administration process, and the severity of the events. The authors discuss potential areas for intervention, such as computerized provider order entry (CPOE) with decision support and greater collaboration with clinical pharmacists.