An urban medical system's exploratory study of medication errors.
Skip G Morelock, Jeffrey D Kirk
PMID 31367446WHAT IT FOUND
No difference in severity was found between a.m. and p.m. shifts.
Most reported errors needed extra monitoring; antibiotics, IV cardiac drugs and analgesics made up 50.1%. IV doses, omitted doses, late doses and overdoses were common.
Key findings
01The study did not find a difference in event severity between a.m. and p.m. shifts; mean magnitude was 2.6 for a.m. and 2.5 for p.m.
02Most events required increased monitoring (46.1%); antibiotics (20%), intravenous cardiac medications (16.9%) and analgesics (13.2%) accounted for 50.1% of errors.
03Omitted doses (22.8%) were the most commonly reported error, and late administration (21.8%) and overdoses (20.8%) accounted for much of the remainder; 76.4% of events involved intravenous administration.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
Read the rest of this summary
You get three full summaries a month, free, and we do not ask for a card. Search, the TL;DRs and your library stay unlimited either way.
What it does not show
The study analysed only medication events that reached the patient and were reported in the hospital event system; near misses were not included, so unrecognised or unreported errors are not captured. It was a retrospective exploratory study in two hospitals in one urban medical system, so the patterns may not apply to other settings. The study describes where and how errors were reported; it does not show why they happened or prove that any change would prevent them. The emergency department error percentage was unexpectedly low, and the authors suspected underrepresentation in that area. The shift analysis compared only a.m. and p.m. shifts, not the specific night shift and weekend staffing concerns raised in the background.
Declared interests
The authors reported no conflict of interest in any phase of the research.
The easy way to misread this
Do not conclude that p.m. shift causes more severe medication errors. Event severity did not differ between a.m. and p.m. shifts, and the study only describes reported errors from one health system without testing any intervention.