Therapeutic Advances in Drug Safety · 2019 · 21 citations · 26 references
Health ProfessionsEmergency MedicineMethod ValidationPatient SafetyProcess ValidationMedication ErrorsMedication Order VerificationMedication SafetyError Prevention WorkflowHuman Factors EngineeringMedication Administration Error PreventionMedication Administration VerificationMedication Error PreventionMedication Safety ImprovementMedication Safety SystemsRoot Cause Determination
Lack of verification is often cited as a root cause of medication errors; however, medication errors occur in spite of conventional verification practices and it appears that human factors engineering (HFE) can inform the design of a more effective method. To this end, an HFE-driven process was designed and implemented in an urban, Midwestern emergency medical service agency. Medication error data were collected over a 54-month period, 27 months before and after implementation. A decrease in the average monthly error rate was realized for all medications administered (49.0%) during the post-intervention time period. The average monthly error rate for fentanyl, a commonly administered analgesic, demonstrated a 71.1% error rate decrease. This study is the first to evaluate the effectiveness of a team-based cross-check process for medication verification to prevent errors in the prehospital setting.
26
Human error: models and management
James Reason · BMJ · 2000 · 5.4K citations · Full text
Social Sciences, Human Resource Management, Organizational Behavior +12
Lucian L. Leape · JAMA · 1994 · 1.4K citations