ArticleBMJ quality & safety2012
Adverse drug events caused by serious medication administration errors.
Article in BMJ quality & safety, 2012. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 23 papers, 6 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
23 citing papers in PubMed, 6 syntheses or guidelines pooled it.
- Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta-Analysis.Drug safety · 2022Pooled it
- Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis.PloS one · 2021Pooled it
- An individual patient data meta-analysis on factors associated with adverse drug events in surgical and non-surgical inpatients.British journal of clinical pharmacology · 2015Pooled it
- Interventions for reducing medication errors in children in hospital.The Cochrane database of systematic reviews · 2015Pooled it
- Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence.Drug safety · 2013Pooled it
- The economic burden of inappropriate drug prescribing, lack of adherence and compliance, adverse drug events in older people: a systematic review.Drug safety · 2012Pooled it
- Clinical and economic impact of medication administration errors among neonates in neonatal intensive care units.PloS one · 2024Observational
- Attributes of errors, facilitators, and barriers related to rate control of IV medications: a scoping review.Systematic reviews · 2023Article
- Assessing the severity of medication administration errors identified in an observational study using a valid and reliable method.Journal of pharmaceutical policy and practice · 2023Article
- Pharmacologic Stewardship in a Rural Community Pharmacy.Healthcare (Basel, Switzerland) · 2023Article
- Development and validation of a risk prediction model for medication administration errors among neonates in the neonatal intensive care unit: a study protocol.BMJ paediatrics open · 2023Article
- Eliciting willingness-to-pay to prevent hospital medication administration errors in the UK: a contingent valuation survey.BMJ open · 2022Article
- Magnitude of error: a review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system.European journal of hospital pharmacy : science and practice · 2021Review
- The Generalizability of a Medication Administration Discrepancy Detection System: Quantitative Comparative Analysis.JMIR medical informatics · 2020Article
- Medication transcription errors in hospitalized patient settings: a consensual study in the Palestinian nursing practice.BMC health services research · 2019Observational
- Pneumocystis jirovecii pneumonia (PJP) prophylaxis patterns among patients with rheumatic diseases receiving high-risk immunosuppressant drugs.Seminars in arthritis and rheumatism · 2019Article
- Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit.Journal of the American Medical Informatics Association : JAMIA · 2018Observational
- Medication audit and feedback by a clinical pharmacist decrease medication errors at the PICU: An interrupted time series analysis.Health science reports · 2018Article
- A User-Centered Glucose-Insulin Data Display for the Inpatient Setting.Studies in health technology and informatics · 2017Article
- Standardising analgesic administration for nurses: a prospective intervention study.International journal of clinical pharmacy · 2016Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors.
Funding
Abstract
objectiveTo determine how often serious or life-threatening medication administration errors with the potential to cause harm (potential adverse drug events) result in actual harm (adverse drug events (ADEs)) in the hospital setting.
designRetrospective chart review of clinical events following observed medication administration errors.
backgroundMedication errors are common at the medication administration stage for inpatients. While many errors can cause harm, it is unclear exactly how often.
methodsIn a previous study where 14 041 medication administrations were directly observed, 1271 medication administration errors were discovered, of which 133 had the potential to cause serious or life-threatening harm and were considered serious or life-threatening potential adverse drug events. As a follow-up, clinical reviewers conducted detailed chart review of serious or life-threatening potential ADEs to determine if they caused an ADE. Reviewers assessed severity of the ADE and attribution to the error.
resultsTen (7.5% (95% CI 6.98 to 8.01)) actual ADEs resulted from the 133 serious and life-threatening potential ADEs, of which 6 resulted in significant, three in serious, and one life threatening injury. Therefore 4 (3% (95% CI 2.12 to 3.6)) of serious or life threatening potential ADEs led to serious or life threatening ADEs. Half of the ADEs were caused by dosage or monitoring errors for anti-hypertensives.
conclusionsUnintercepted potential ADEs at the medication administration stage can cause serious patient harm. At hospitals where 6 million doses are administered per year, about 4000 preventable ADEs would be attributable to medication administration errors annually.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.