Severity and probability of harm of medication errors intercepted by an emergency department pharmacist

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Abstract

Objectives The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined. Methods The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process. Key findings There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18%), significant (n = 160; 67%) and serious (n = 35; 15%). The final classification of MEs by probability of harm was as follows: none (n = 13; 6%), very low (n = 96; 41%), low (n = 84; 35%), medium (n = 41; 17%) and high (n = 3; 1%). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5%, kappa = 0.35) and probability of harm (agreement = 76.8%, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1%). Conclusions A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm.

Original languageEnglish (US)
Pages (from-to)358-362
Number of pages5
JournalInternational Journal of Pharmacy Practice
Volume19
Issue number5
DOIs
StatePublished - Oct 2011

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Medication Errors
Pharmacists
Hospital Emergency Service
Databases
Patient Harm
Research Personnel
Physicians

Keywords

  • emergency medical services
  • medication errors
  • patient safety

ASJC Scopus subject areas

  • Pharmaceutical Science
  • Health Policy
  • Public Health, Environmental and Occupational Health
  • Pharmacy

Cite this

@article{65793997ce3b4521a49c58e869e6bea4,
title = "Severity and probability of harm of medication errors intercepted by an emergency department pharmacist",
abstract = "Objectives The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined. Methods The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process. Key findings There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18{\%}), significant (n = 160; 67{\%}) and serious (n = 35; 15{\%}). The final classification of MEs by probability of harm was as follows: none (n = 13; 6{\%}), very low (n = 96; 41{\%}), low (n = 84; 35{\%}), medium (n = 41; 17{\%}) and high (n = 3; 1{\%}). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5{\%}, kappa = 0.35) and probability of harm (agreement = 76.8{\%}, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1{\%}). Conclusions A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm.",
keywords = "emergency medical services, medication errors, patient safety",
author = "Patanwala, {Asad E} and Hays, {Daniel P.} and Sanders, {Arthur B} and Erstad, {Brian L}",
year = "2011",
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doi = "10.1111/j.2042-7174.2011.00122.x",
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T1 - Severity and probability of harm of medication errors intercepted by an emergency department pharmacist

AU - Patanwala, Asad E

AU - Hays, Daniel P.

AU - Sanders, Arthur B

AU - Erstad, Brian L

PY - 2011/10

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N2 - Objectives The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined. Methods The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process. Key findings There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18%), significant (n = 160; 67%) and serious (n = 35; 15%). The final classification of MEs by probability of harm was as follows: none (n = 13; 6%), very low (n = 96; 41%), low (n = 84; 35%), medium (n = 41; 17%) and high (n = 3; 1%). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5%, kappa = 0.35) and probability of harm (agreement = 76.8%, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1%). Conclusions A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm.

AB - Objectives The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined. Methods The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process. Key findings There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18%), significant (n = 160; 67%) and serious (n = 35; 15%). The final classification of MEs by probability of harm was as follows: none (n = 13; 6%), very low (n = 96; 41%), low (n = 84; 35%), medium (n = 41; 17%) and high (n = 3; 1%). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5%, kappa = 0.35) and probability of harm (agreement = 76.8%, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1%). Conclusions A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm.

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