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Voluntary Error-Reporting System Ensures Patient Safety

online infusion calculator that reduces medication errors in children undergoing IV infusions (for more information, see http://www.hopkinschildrens.org/pages/news/pressdetails.cfm?newsid=340)

? An online total parenteral nutrition (TPN) calculator, designed to prevent nutrition errors among premature babies in the neonatal intensive care unit, and currently used system-wide for all pediatric patients(for more information, see http://www.hopkinschildrens.org/pages/news/archivedetails.cfm?newsid=172)

Since 2004, Johns Hopkins has implemented a hospital-wide computer reporting system that captures a variety of medication errors, the vast majority of which do not harm a patient but may have the potential to do so if systems are not corrected.

In the study, researchers found that errors occurred in every step of the medication process - from prescribing, to ordering to administering to the patient - and no one area is immune to errors. Physicians, nurses and pharmacists caring for children were equally prone to mistakes, researchers say.

‘One of the more interesting findings was that drug-administering errors, such as giving the patient the wrong drug or the wrong dose or at the wrong time, were quite common,’ Lehmann says. ‘We had focused in the past on ordering errors. This finding made us look for possible interventions on the administration side.’

Researchers reviewed data collected over 19 months via a voluntary error-reporting system that was in use at the Children’s Center from 2001 to 2004. They analyzed all 1,010 medication errors entered into the system between July 2001 and January 2003. Those who filed reports were asked to fill out an online form consisting of multiple choices and then submit a free-text description of the event. To determine the accuracy of the reports, researchers compared the multiple-choice form to the free-text description of the event, finding that the number of actual errors was 899
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