Medication errors in the PACU.
A collaborative research group examined seven years of PACU medication errors from the MEDMARX database. Descriptive statistics showed a comparison of medication errors in all ages from pediatric to adult to geriatric groups. Nine categories of medication errors were noted and a total of 3,023 errors were attributed to errors in prescribing, transcribing, dispensing, administering, and monitoring. Harmful errors were present in 5.8% of the sample, which included two patient deaths. Results indicated that errors can occur in any age group. Organizations and institutions should be aware of these occurrences to ensure vigilance at all times and to focus efforts toward avoiding or decreasing such errors. Patient safety and error prevention recommendations are provided.
Hicks
Rodney W
RW
Center for the Advancement of Patient Safety, U.S. Pharmacopeia, 12601 Twinbrook Parkway, Rockville, MD 20852, USA. rh@usp.org
Becker
Shawn C
SC
Windle
Pamela E
PE
Krenzischek
Dina A
DA
D000328:Adult; D016907:Adverse Drug Reaction Reporting Systems; D017677:Age Distribution; D000368:Aged; D002648:Child; D004282:Documentation; D016903:Drug Monitoring; D011307:Drug Prescriptions; D004358:Drug Therapy / Q000379:methods / Q000451:nursing; D064420:Drug-Related Side Effects and Adverse Reactions; D006301:Health Services Needs and Demand; D006801:Humans; D020407:Internet; D008433:Mathematics; D008508:Medication Errors / Q000379:methods / Q000451:nursing / Q000517:prevention & control / Q000706:statistics & numerical data*; D008510:Medication Systems, Hospital / Q000458:organization & administration; D024802:Nurse's Role; D015403:Nursing Evaluation Research; D016528:Postanesthesia Nursing / Q000458:organization & administration*; D011997:Recovery Room / Q000458:organization & administration*; D018570:Risk Assessment; D012307:Risk Factors; D017751:Safety Management / Q000458:organization & administration*; D013597:Systems Analysis; D017749:Total Quality Management; D014481:United States