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Journal Article > Study
Prevalence of medication administration errors in two medical units with automated prescription and dispensing.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-78.
Technological solutions such as computerized provider order entry (CPOE) hold promise for reducing medication errors at the prescribing and dispensing stage, but patients may still be harmed by incorrect administration of medications, which have been shown to be disturbingly common in prior studies. Conducted at an academic hospital in Spain that had an established CPOE system, this study found an overall administration error rate of 22%, consistent with prior studies. The hospital in question did not have a barcoding medication administration system. Combining barcoding with CPOE in a closed-loop system has been shown to significantly reduce the overall medication error rate.
Cases & Commentaries
Workaround Error
- Web M&M
Tess Pape, PhD, RN, CNOR; February 2006
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
Journal Article > Study
Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center.
Rochais E, Atkinson S, Guilbeault M, Bussières JF. J Pharm Pract. 2014;27:150-157.
Nurses felt that the introduction of automated dispensing cabinets improved medication safety and made their work easier.
Journal Article > Commentary
Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project.
Harding AD. Am J Nurs. 2012;112:26-35.
This commentary details how one hospital successfully increased use of smart pumps to improve medication safety.
Newspaper/Magazine Article
Guidelines for timely medication administration: response to the CMS "30-minute rule."
ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.
This article reports results from a survey on the Centers for Medicare & Medicaid Services "30-minute rule" and provides a set of revised guidelines.
Newspaper/Magazine Article
CMS 30-minute rule for drug administration needs revision.
ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.
This piece highlights nurses' responses to a national survey that explored problems associated with the Centers for Medicare and Medicaid Services (CMS) medication administration timing requirement.
Journal Article > Study
Impact of barcode medication administration technology on how nurses spend their time providing patient care.
Poon EG, Keohane CA, Bane A, et al. J Nurs Adm. 2008;38:541-549.
Implementation of a barcode medication administration system was associated with an increase in the time nurses spent in direct patient care and did not increase the amount of time devoted to medication administration. Proper integration of information technology into provider workflow was the subject of a Joint Commission Sentinel Event Alert.
Journal Article > Commentary
Automated dispensing cabinets.
Gaunt MJ, Johnston J, Davis MM. Am J Nurs. 2007;107:27-28.
Drawing on Patient Safety Authority reports, this commentary discusses common errors with automated dispensing cabinets and offers tips for safer use of these systems.
Journal Article > Study
Effects of technological interventions on the safety of a medication-use system.
Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Am J Health Syst Pharm. 2007;64:90-96.
The authors implemented technologies supporting safe medication use and observed improved patient identification, decreased turnaround time for orders, and increased accuracy of medication administration.
Audiovisual
Preventing fatal heparin overdoses.
Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.
This video story reviews a high-profile medication error and suggests actions to prevent similar incidents from occurring.
Cases & Commentaries
Cups of Error
- Web M&M
Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN; May 2006
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.