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What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system.

Westbrook JI, Li L, Lehnbom EC, Baysari MT, Braithwaite J, Burke R, Conn C, Day RO - Int J Qual Health Care (2015)

Bottom Line: Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates.This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals.New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

View Article: PubMed Central - PubMed

Affiliation: Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney 2109, Australia.

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Distribution of (a) prescribing errors observed by researchers, and detected and reported by clinical staff; (b) clinically important prescribing errors observed by researchers, and detected and reported by clinical staff.
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MZU098F1: Distribution of (a) prescribing errors observed by researchers, and detected and reported by clinical staff; (b) clinically important prescribing errors observed by researchers, and detected and reported by clinical staff.

Mentions: Of the clinically important prescribing errors identified at audit, 21.9% (n = 118) had been detected, of which seven had an incident form. Table 2 presents a summary of the rates at which prescribing errors were identified at audit, detected by staff and reported to the incident systems, by hospital. Figure 1a shows the distribution of prescribing errors identified, detected and reported and Fig. 1b shows this information for clinically important prescribing errors.Figure 1


What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system.

Westbrook JI, Li L, Lehnbom EC, Baysari MT, Braithwaite J, Burke R, Conn C, Day RO - Int J Qual Health Care (2015)

Distribution of (a) prescribing errors observed by researchers, and detected and reported by clinical staff; (b) clinically important prescribing errors observed by researchers, and detected and reported by clinical staff.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4340271&req=5

MZU098F1: Distribution of (a) prescribing errors observed by researchers, and detected and reported by clinical staff; (b) clinically important prescribing errors observed by researchers, and detected and reported by clinical staff.
Mentions: Of the clinically important prescribing errors identified at audit, 21.9% (n = 118) had been detected, of which seven had an incident form. Table 2 presents a summary of the rates at which prescribing errors were identified at audit, detected by staff and reported to the incident systems, by hospital. Figure 1a shows the distribution of prescribing errors identified, detected and reported and Fig. 1b shows this information for clinically important prescribing errors.Figure 1

Bottom Line: Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates.This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals.New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

View Article: PubMed Central - PubMed

Affiliation: Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney 2109, Australia.

Show MeSH