Reengineering the medication error reporting system in a hospital can lead to improved reporting of errors, particularly near misses.Jt Comm J Qual Patient Saf. 2014;40;9:398-407.
Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.
McKaig D, Collins C, Elsaid KA. Jt Comm J Qual Patient Saf. 2014;40;9:398-407.
Hospital incident reporting systems are ubiquitous, but many events remain unreported. This pre-post study sought to determine the impact of a reengineered medication error reporting approach. Researchers implemented a Web-based electronic medication error reporting system in concert with a novel work process in which clinical managers perform the first review of the report. The intervention led to increased error reporting, with the majority of errors being near-misses. This finding suggests that under-reporting of medication errors via standard incident reporting mechanisms can be addressed using human factors engineering approaches, which apply to and enhance both the error reporting tool and clinicians' workflow. A past AHRQ WebM&Mperspective discusses how human factors engineering can be used to uncover problems with device design and work processes.
Smart pumps: advanced capabilities and continuous quality improvement.
Vanderveen T. Patient Saf Quality Healthc. January/February 2007.
Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States.
Bonis PA, Pickens GT, Rind DM, Foster DA. Int J Med Inform. 2008;77:745-753.
Medication errors occurring with the use of bar-code administration technology.
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
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For all the right reasons.
Hagland M. Healthc Informatics. 2009;26:40-44.
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