Error Reporting Logic

2008 ◽  
Author(s):  
Ciera Jaspan ◽  
Trisha Quan ◽  
Jonathan Aldrich
Keyword(s):  
Error Reporting

Congress Negotiating Error-Reporting Measure

2005 ◽  
Vol 33 (7) ◽  
pp. 78
Author(s):  
NELLIE BRISTOL
Keyword(s):  
Error Reporting

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy

2021 ◽  
pp. 107815522199431
Author(s):  
Jennifer P Booth ◽  
Julie M Kennerly-Shah ◽  
Amber D Hartman
Keyword(s):  
Cancer Therapy ◽  
Medication Error ◽  
Retrospective Analysis ◽  
Error Reporting ◽  
Single Center ◽  
Medication Error Reporting ◽  
Anti Cancer ◽  
Secondary Endpoints ◽  
Type Frequency

Introduction To describe pharmacist interventions as a result of an independent double check during cognitive order verification of outpatient parenteral anti-cancer therapy. Methods A single-center, retrospective analysis of all individual orders for outpatient, parenteral anti-cancer agents within a hematology/oncology infusion center during a 30 day period was conducted. The primary endpoint was error identification rates during first and second verification. Secondary endpoints included the type, frequency, and severity of errors identified during second verification using a modified National Coordinating Council for Medication Error Reporting and Prevention Index. Results A total of 1970 anti-cancer parenteral orders were screened, from which 1645 received an independent double check and were included. The number of errors identified during first and second verification were 30 (1.8%) and 10 (0.6%) respectively; second verification resulted in a 33.3% increase in corrected errors. The 10 errors identified during second verification included: four rate transcriptions to optimize pump interoperability, three rate and/or volume modifications, two dosage adjustments, and one treatment deferral due to toxicity. The severity was classified as Category A for four (40%), Category C for three (30%), and Category D for three (30%) errors. This correlated to a low capacity for harm for seven (70%) and a serious capacity for three (30%) errors. Conclusions Second verification of outpatient, parenteral anti-cancer medication orders resulted in a 33.3% increase in corrected errors. Three errors detected during second verification were determined to have a serious capacity for harm, supporting the value of independent double checks during pharmacist cognitive order verification.

Trying to Improve Care: The Morbidity and Mortality Conference in a Division of Rheumatology

2014 ◽  
Vol 41 (12) ◽  
pp. 2452-2458 ◽  
Author(s):  
Michelle Batthish ◽  
Shirley M.L. Tse ◽  
Brian M. Feldman ◽  
G. Ross Baker ◽  
Ronald M. Laxer
Keyword(s):  
Adverse Events ◽  
Test Procedure ◽  
Morbidity And Mortality ◽  
Error Reporting ◽  
Descriptive Data ◽  
Medication Error Reporting ◽  
Morbidity And Mortality Conference ◽  
System Improvement ◽  
Sick Children ◽  
Mortality Conference

Objective.To describe the frequency and types of reported adverse events and system improvement recommendations in the Morbidity and Mortality Conference (M&MC) within the Division of Rheumatology at The Hospital for Sick Children, Toronto, Ontario, Canada (SickKids).Methods.A 5-year retrospective review of the M&MC within the Division of Rheumatology at SickKids was completed. Descriptive data including the number and types of events reported were collected. Events were categorized using an adaptation of the National Coordinating Council for Medication Error Reporting and Prevention Index. Recommendations were classified according to the Institute for Safe Medication Practices Canada.Results.Between January 2007 and December 2011, 30 regularly scheduled M&MC were held. Eighty-three cases were reviewed. The most common types of reported events were related to “miscommunication” (34.9%), “treatment/test/procedure” (22.9%), “adverse drug reactions” (12.0%), and “medication errors” (8.4%). Category A events (“an event that has the capacity to cause error”) were the most common with 39.8% of the cases, followed by Category C events (“an event occurred that reached the patient, but did not cause harm”) with 28.9%. Eighty-nine recommendations were made. Over half of these were classified as “information” (58.4%), followed by 11 “rules and policies” recommendations (12.4%). Of the 36 action items generated from these recommendations, most are either complete or ongoing.Conclusion.The M&MC within the Division of Rheumatology reviews a variety of events. Increased reporting of adverse events can lead to system improvements, and has the potential to improve and promote safer healthcare.

Improving patient safety in radiotherapy through error reporting and analysis

Radiography ◽  
2016 ◽  
Vol 22 ◽  
pp. S3-S11 ◽  
Author(s):  
Ú. Findlay ◽  
H. Best ◽  
M. Ottrey
Keyword(s):  
Patient Safety ◽  
Error Reporting

A Comprehensive Quality Assurance Program for Personnel and Procedures in Radiation Oncology: Value of Voluntary Error Reporting and Checklists

2013 ◽  
Vol 86 (2) ◽  
pp. 241-248 ◽  
Author(s):  
John A. Kalapurakal ◽  
Aleksandar Zafirovski ◽  
Jeffery Smith ◽  
Paul Fisher ◽  
Vythialingam Sathiaseelan ◽  
...  
Keyword(s):  
Quality Assurance ◽  
Radiation Oncology ◽  
Error Reporting ◽  
Quality Assurance Program
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