title: Medication errors during medical emergencies in a large, tertiary care, academic medical center.
abstract: OBJECTIVE
  Evaluate the rate, type and severity of medication errors occurring during Medical Emergency Team (MET) care at a large, tertiary-care, academic medical center.
  
  
  METHODS
  A prospective, observational evaluation of 50 patients that required MET care was conducted. Data on medication use were collected using a direct-observation method whereby an observer documented drug information such as drug, dose, frequency, rate of administration and administration technique. Subsequently, a team of three clinicians assessed rate, type and severity of medication errors using definitions consistent with United States Pharmacopeia MEDMARX system. Severity was assessed on a scale of minor, moderate and severe.
  
  
  RESULTS
  One hundred eighty six doses were observed for 36 different medications. A total of 296 errors were identified; of these 196 errors (66%) were inappropriate aseptic technique. Of the remaining 100 errors, 46% were prescribing errors, 28% administration technique errors, 14% mislabeling errors, 10% drug preparation errors and 2% improper dose prescribing. Examples included: (1) prescribing errors, (2) administering wrong doses, (3) mislabeling, and (4) wrong administration technique such as not flushing intravenous medication through intravenous access. The rate of medication administration errors was 1.6 errors/dose including aseptic technique and 0.5 errors/dose excluding aseptic technique. A notable portion (14%) of errors was considered at least moderate in severity.
  
  
  CONCLUSIONS
  One out of 2 doses was administered in error after errors of using inappropriate aseptic technique were excluded. There is a need for education and systematic changes to prevent medication errors during medical emergencies as an effort to avoid harm.
authors: Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, 15213, USA.
authors: Roman
authors: R
authors: Gokhman
authors: Amy L
authors: AL
authors: Seybert
authors: Paul
authors: P
authors: Phrampus
authors: Joseph
authors: J
authors: Darby
authors: Sandra L
authors: SL
authors: Kane-Gill
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004305:Dose-Response Relationship, Drug; D064420:Drug-Related Side Effects and Adverse Reactions; D004630:Emergencies; D004636:Emergency Service, Hospital; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D015994:Incidence; D008297:Male; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008510:Medication Systems, Hospital / Q000592:standards* / Q000639:trends; D008875:Middle Aged; D020380:Needs Assessment; D010348:Patient Care Team; D011446:Prospective Studies; D018570:Risk Assessment; D017751:Safety Management; D015996:Survival Rate; D014481:United States; D014505:Urban Population