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- Error Reporting and Analysis
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Search results for "Error Reporting and Analysis"
Journal Article > Study
Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.
Call RJ, Burlison JD, Robertson JJ, et al. 2014;165:447-452.
To investigate the utility of a trigger tool in detecting adverse drug events (ADEs) in pediatric hematology and oncology patients, this study compared the tool with a voluntary reporting system. Implementation of the trigger tool led to inclusion of many cases that were not ADEs (false positives). In contrast, voluntary reporting did not identify all ADEs that were found using the trigger tool, implying under-reporting. These results reinforce prior research suggesting that multiple detection methods are needed to comprehensively detect ADEs. The authors advocate for triggers to be refined according to patient population and hospital setting to augment their usefulness. A previous AHRQ WebM&M perspective discusses the role of trigger tools in identifying ADEs and measuring patient safety.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Journal Article > Study
Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.
Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.
Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.