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Prevention of

Medical Errors

DANA BARTLETT RN BSN MSN MA

Dana Bartlett is a professional nurse and author His clinical experience includes 16

years of ICU and ER experience and over 20 years of as a poison control center

information specialist Dana has published numerous CE and journal articles written

NCLEX material written textbook chapters and done editing and reviewing for

publishers such as Elsevire Lippincott and Thieme He has written widely on the

subject of toxicology and was recently named a contributing editor toxicology

section for Critical Care Nurse journal He is currently employed at the Connecticut

Poison Control Center and is actively involved in lecturing and mentoring nurses

emergency medical residents and pharmacy students

ABSTRACT

The identification and prevention of medical errors requires the

participation of all members of the health team including patients The

traditional way of coping with medical errors was to assume errors

were the result of individual mistakes such as carelessness and

inattention creating a culture of blame However it has become clear

this approach is not optimal It does not address the root causes of

medical errors system problems it discourages disclosure of errors

and without disclosure errors cannot be prevented Enhancing health

team knowledge levels and the environment of care helps to reduce

the risk of a medical error


Continuing Nursing Education Course Planners

William A Cook PhD Director Douglas Lawrence MA Webmaster

Susan DePasquale MSN FPMHNP-BC Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Lesscom and the continuing nursing education

requirements of the American Nurses Credentialing Centers

Commission on Accreditation for registered nurses It is the policy of

NurseCe4Lesscom to ensure objectivity transparency and best

practice in clinical education for all continuing nursing education (CNE)

activities

Continuing Education Credit Designation

This educational activity is credited for 2 hours Nurses may only claim

credit commensurate with the credit awarded for completion of this

course activity

Statement of Learning Need

The rates of medical errors remain a public health and safety risk Safe

patient care requires all members of the health team and the public to

be educated on how to recognize and prevent a medical error and to

advocate for needed changes to improve the delivery of healthcare


Course Purpose

To provide an overview of medical errors in todayrsquos health care system

and to identify the incidence and causes of medical errors and the risk

factors disposing to medical errors and to provide strategies to

prevent medical errors in the healthcare setting including by patients

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members including Vocational Nurses

and Medical Assistants may obtain a Certificate of Completion)

Course Author amp Planning Team Conflict of Interest Disclosures

Dana Bartlett RN BSN MSN MA William S Cook PhD

Douglas Lawrence MA Susan DePasquale MSN FPMHNP-BC -all have

no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course

Activity Review Information

Reviewed by Susan DePasquale MSN FPMHNP-BC

Release Date 112016 Termination Date 762017

Please take time to complete a self-assessment of knowledge on page 4 sample questions before reading the article

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course


1 True or false A medical error and an adverse event are

identical

a True

b False

2 Diagnostic errors occur when

a an incorrect diagnosis is made

b the diagnosis is changed from the original diagnosis

c given the available data the correct diagnosis should have been

made

d the diagnosis was made more than 72 hours after examination

3 A medication error is defined in part by the words

a preventable and patient harm

b under-dosing and over-dosing

c adverse effect and therapeutic intervention

d avoidable and lack of vigilance

4 A common cause of medication error is

a look-alike and sound-alike drug names

b adult drugs being used for pediatric patients

c patient refusal to accept the drug therapy

d undisclosed use of herbal supplements

5 True or false medical errors should be disclosed to the

patient

a True b False


6 Diagnostic errors are more likely EXCEPT when

a the patient has a complex medical history

b when there are too many diagnostic resources

c patient follow-up is sub-optimal

d time available for diagnosis is limited or perceived to be

limited

7 True or False The healthcare setting is an influencing factor for diagnostic errors such as one that is fast-paced

and stressful

a True

b False

8 A 2014 study showed a __________ error rate in medical dictationtranscription and poor communication in the

form of using non-standard abbreviations and the common use of sound-alike medications has long been known as a

cause of medical errors

a 15

b 25

c 30

d 44

9 Nurses providing teaching about medication to patients

should include key points of points such as

a the purpose for taking a medication

b common side effects interactions

c risk factors of taking the medication

d All of the above


10 Starmer et al (2013) wrote that communication errors

are a leading cause of

a sentinel events

b poor team dynamics

c medication errors

d documentation errors

11 True or False It has been reported that and that improving handoff communication (ie transferring

information about and responsibility for a patient) reduced medical errors from 383 per 100 admissions to 28

a True

b False

12 Patient discharge is

a when medical errors can occur

b less of a risk factor than admission for a medical error

c less of a risk factor for a medical error than patient follow-up

d Both b and c above

13 True or False Equipment failures during anesthesia are relatively uncommon

a True

b False


14 One example of the second strategy to eliminate cognitive

errors involves a common error in the diagnostic process known as

a Time out

b It-Takes-Two

c Anchoring

d Pause

15 Approximately 25 of medication errors that occur in the United States involve

a verbal orders

b name confusion

c hand-written notes

d an inexperienced nurse

Introduction

Medical errors are a significant problem in the healthcare system The

seminal 1999 monograph by The Institute of Medicine (IOM) reported

that between 44000 and 98000 patients die each year in the United

States as a result of a medical error and that 7 of all hospital

admissions experience a serious medication error1 and this disturbing

situation has not changed since then This study module is an excerpt

from a larger course on medical errors that provides nurses with a

review of six types of medical errors 1) Diagnostic errors 2) Falls 3)

Laboratory errors 4) Medication errors 5) Surgical errors and 6)

Treatment errors The incidence etiology and risk factors of each will

be examined and strategies for their prevention will be discussed


Definitions Associated With Medical Errors

The terminology associated with medical errors can be confusing

adverse events adverse effects errors of commission errors of

omission medical errors near misses preventable adverse effects

and side effects are all frequently mentioned in discussions of medical

errors All of these have some relevance to the discussion of medical

errors but the terms that are important for this module are medical

error and adverse event This module will define a medical error as1

Failure of a planned action to be completed as intended or

the use of a wrong plan to achieve a goal

Medical error

A medical error may result in injury or it may not but the potential for

injury is present Medical errors can be errors of execution or planning

An execution error is one in which a plan of action such as a specific

therapy is considered appropriate and correct but it was not properly

carried out Execution errors can be errors of commission or errors of

omission In the former an incorrect action was done unintentionally

and in the latter the correct action was unintentionally not done A

planning error is one in which the plan of action is not considered

appropriate or correct for the patient2

Adverse event


An adverse event is defined as a preventable medical error that causes

harm to the patient Not all medical errors are adverse events and

medical errors and not all medical errors become adverse events The

differences between a side effect and an adverse event are

predictability severity and consequences

At times the distinction between a side effect and an adverse event

can be blurred A side effect is typically considered to be predictable

minor in severity and often temporary in duration and it will not cause

harm or require treatment An adverse event is typically considered to

be (somewhat) unpredictable moderate to severe possibly

permanent and it may cause harm andor require treatment and

stopping the use of a medication suspected to be causing the adverse

event

Diagnostic Errors

Diagnostic errors are relatively common but when compared to other

medical errors such as falls and medication errors they have received

much less attention and research3 Despite the obvious and immediate

effects of a medical error such as a fall diagnostic errors can be a

significant cause of morbidity and mortality and at times more so than

other types of medical errors4 There is no universally accepted

definition of a diagnostic error This module will define a diagnostic

error as follows5

A diagnostic error has occurred if the wrong diagnosis was made and

1) there was adequate data to suggest the correct diagnosis or 2) the


clinical findings should have prompted the medical provider to do

further evaluation in order to make the proper diagnosis

In essence a diagnostic medical error has happened when it could be

reasonably expected that a competent and experienced medical

provider should have been able to make the correct diagnosis or that

further evaluation and testing should have been ordered in order to

make a correct diagnosis given the clinical findings

The true incidence of diagnostic errors is not known but it is generally

assumed to be approximately 10-156 However the reported

incidence has varied from 1 to 557 and a recent (2014) survey

estimated the incidence of diagnostic errors in the outpatient setting to

be 508 or 12 million adults every year in the United States8 This

wide range can be explained by many factors and some key factors

are outlined in the sections to follow36

Patient population

Consideration of the patient population involves taking into account

the demographics of the persons receiving care and the location where

health care is delivered Diagnostic errors will clearly be more likely if

the patient has a complex medical history and multiple medical

problems Additionally diagnostic errors will be more likely if

diagnostic resources are limited patient follow-up is sub-optimal and

the time available for diagnosis is limited or perceived to be limited

The setting in which health care is delivered is another influencing

factor such as a setting that is particularly fast-paced and stressful

can be predisposed to diagnostic errors Skill and experience level of


the diagnostician is another obvious factor in the accuracy of the

diagnostic process

Data sources

Autopsy reports chart reviews clinical laboratory records and reviews

medical malpractice claims patient and provider surveys peer

reviews simulations and standardized patients and voluntary

reporting have all been used to determine the incidence of diagnostic

errors For this purpose all of these have strengths and weaknesses

and they can all either under-report or over-report the incidence of

diagnostic errors Still these all reveal an incidence of diagnostic

errors that is disturbing

Autopsy studies show an incidence of diagnostic errors of 10-20

The use interpretation or follow-up of laboratory data accounted for

44 of all diagnostic errors There have been study reports that

revealed pediatricians had a diagnostic error of over 50 within one

month of being surveyed the ability of radiologists to detect breast

cancers varied by up to 11 and simulations and standardized

patients have demonstrated a rate of diagnostic accuracy of 25 -

5769-12

Some types of diagnoses are much more difficult to make than others

Patients in their early stages of an illness such as an infection with

HIV or tuberculosis can be very difficult to correctly diagnose The

incidence of these medical errors clearly depends in part on how they

are defined


Causes of diagnostic errors

Research into the root causes of diagnostic errors has suggested that

these errors occur from either a failure of the physiciansrsquo intuitive

reasoning process (ie pattern recognition and memory retrieval) or a

failure of their consciousness reasoning process13 Viewed this way it

is possible to understand in a generalized way how diagnostic errors

occur However it is helpful to look at the specific situational causes of

diagnostic errors

Singh et al (2013) examined diagnostic errors that were made in

primary care settings and five distinct factors were identified as

primary causes of diagnostic errors5

1 Patient related

Singh reported that in 163 of all cases patient related factors

were the primary causes of diagnostic error These factors

included failure of the patient to provide an accurate medical

history failure of the patient to seek help in a timely manner a

communication barrier between the patient and the practitioner

2 Patient-practitioner

An issue between the patient and the practitioner during the

clinical encounter was identified in 789 of all cases of

diagnostic errors Specific problems were errors made by the

clinician during the physical examination failure to review

medical records failure to ask questions needed to make the

diagnosis (ie data gathering) failure to order the appropriate


diagnostic and laboratory tests and failure to take a

comprehensive medical history

3 Diagnostic tests

Incorrect use incorrect interpretation and incorrect follow-up of

diagnostic tests were identified in 137 of all cases of

diagnostic errors

4 Follow-up and tracking

Inadequate follow-up and tracking errors such as failure to

have a follow-up system in place or failure to follow-up


diagnostic errors

5 Referrals

In 195 of all cases diagnostic error mistakes in the referral

process were identified These included failure to contact the

appropriate expert failure to identify when a referral was

needed lack of knowledge that would have helped the

practitioner identify the need for a referral failure to consider

the patientrsquos condition serious enough to require a referral or an

error when taking a medical history

In 437 of all cases in which the correct diagnosis was not made

more than one of the five factors identified above was operative The

researchers noted that in 379 of all cases the failure to correctly

diagnose the patientrsquos problem could have resulted in considerable

harm and in 142 of the cases the patient could have suffered


immediate or inevitable death5 The clinical problems were not highly

complex or unusual pneumonia congestive heart failure acute renal

failure and urinary tract infections were among the diagnoses that

were commonly missed5

The research indicates that practitioner errors involving mistakes in

information gathering and synthesis and reasoning are the most

common cause of diagnostic errors514-17 and this fact could be

dismissed by some as in part inevitable people make mistakes

However the wide variation in the incidence of diagnostic errors clearly

shows that they are not inevitable and that some practitioners are not

making cognitive errors during the diagnostic process The hope is that

the habits and techniques of a successful diagnostic process can be

identified and taught and that the incidence of diagnostic errors could

be reduced Several strategies for doing this have been researched

and will be discussed later in this study module

Patient Falls

Patient falls are very common medical errors and they are one of the

most common adverse events that happen to hospital in-patients18 It

has been estimated that up to 20 of

all in-patients suffer a fall at least

once during a hospital stay19 and the

rate of falls in acute care hospitals

has been reported to be between 13

to 89 per 1000 hospital days20

Joint Commission definition of

a sentinel event

an unexpected occurrence

involving death or serious

injury or psychological injury

or the risk thereof The term

sentinel is applied to these

events because they indicate

the need for immediate

investigation and response

and the possibility of serious

systemic errors in the

healthcare facility andor the

delivery of healthcare


Falls can be very serious Between 30-50 of all patient falls result

in an injury and patients who suffer a fall have longer hospital stays

and higher health care costs2021 The Joint Commission considers a fall

that results in death or major permanent loss of function as a result of

injuries sustained in the fall to be a reviewable sentinel event and

fall prevention is one of the Joint Commissionrsquos National Patient Safety

Goals2223 Additionally the World Health Organization (WHO) defines

fall as an event that results in a person coming to rest inadvertently on

the ground or some lower level24

Several risk factors identified with falling exist such as being elderly or

having urinary frequency25 Healthcare teams frequently use

assessment tools to identify patients that are at risk for falling and

there are many screening tools and fall risk algorithms available

through the Center of Disease Control (CDC) website a helpful

resource with multiple fall prevention patient handouts at

httpwwwcdcgovhomeandrecreationalsafetyfallsadultfallshtml

Laboratory Errors

Laboratory medical errors can be divided into three categories pre-

test testing and post-test The incidence of testing performance

errors which are errors that occur with the technical processing of

specimens is comparatively low as standardization of analytical

methods and materials and improved instrumentation have greatly

decreased the incidence of in-laboratory analytical error2829


Most in-laboratory errors involve specimen mis-labeling3031 and the

incidence of inaccurate test performance is very low estimated at

000232 However pre-test and post-test medical errors involving the

clinical laboratory are quite common2829 A ten-year study of

laboratory errors showed that 691 of all laboratory errors occurred

in the pre-test phase 150 in the testing phase and 231 occurred

in the post-test phase33 Pre-test and post-test errors are outlined

below

Pre-test errors

1 Inappropriate ordering of tests ie ordering a test

that has no relevance to the clinical situation

2 Test performance and specimen collection errors such as

improper site preparation specimen contamination improper

performance of the test not using the correct specimen

containers or tubes mislabeling of specimens and performing

a test on the wrong patient

Post-test errors

1 Errors in receiving such as test results being incorrectly

transmitted by the sender test results being incorrectly

recorded by the receiver and test results not transmitted to

the right person or not transmitted in a timely manner

2 Errors in interpretation

3 Errors in follow-up such as failure to check for test results

failure to use test results in a timely manner failure to order

further testing that would be indicate by the previous test

results failure to appropriately use test results to change


therapies and failure to send test results to patients or to

contact them about test results2832

Plebani (2010) noted that laboratory errors could result in mistakes in

digoxin or heparin therapies inappropriate admissions and other

clinical problems33 Additionally 24-30 of laboratory errors had an

effect on patient care and the risk for adverse events from laboratory

errors was 2-12733 Such studies highlight the serious harm to

patients that can occur as a result of laboratory errors

Medication Errors

A medication error is defined in this section as follows

ldquoAny preventable effect that may cause or lead to inappropriate use or

patient harm while the medication is in control of the healthcare

professional patient or consumerrdquo34

Two terms in this definition that should be remembered are

preventable and patient harm indicating that the medication error was

preventable and may have caused or lead to patient harm In this

study module the medication errors presented are divided into four

categories

1 Prescribing

2 Administration or preparation

3 Dispensing

4 Monitoring

Prescribing errors


Prescribing errors include but are not limited to

1 Wrong drug because of drug-drug interactions andor drug

allergies

2 Incorrect dose concentration route or frequency

3 Drug prescribed for the wrong patient

4 Duplicate drugs prescribed

5 The appropriate drug not prescribed

6 The prescription was written illegibly or improper

abbreviations were used

Transcribing errors involve a mistake that was made when the order

was transcribed either in the pharmacy or in a clinical setting

Administration and preparation errors

Administration errors are often the same as prescribing errors and

include

1 Missed doses or doses given at an incorrect time

2 Medication given by someone unauthorized to do so

3 Improper administration technique

4 Incorrect rate of administration

5 Administration of an expired drug

6 Drug prematurely discontinued or administered for too long

7 Duplicate administration ie a double dose

8 Incorrect dosage calculations

9 Failure to document administration of a drug or incorrect

documentation

10 Failure to use medication administration safeguards ie

double checking calculations


11 Failure to comply with medication administration policies ie

leaving medications unattended and not watching a patient

take a medications

12 Improper or incomplete administration directions given to a

patient

Preparation errors are typically a drug improperly constituted or

incorrectly concentrated

Dispensing errors

Dispensing A drug can be dispensed to the wrong patient the drug

may not be dispensed in a timely manner or the wrong drug can be

dispensed

Monitoring errors

Monitoring is a very important part of medication therapy to ensure

the medication is effective tolerated and to make dose adjustments

Safe use of medications like digoxin lithium and warfarin requires

periodic laboratory testing of blood levels and other drugs require

measurement of blood glucose electrolytes or renal function in order

to measure their effectiveness or to detect adverse effects Monitoring

errors includes

1 Not ordering the proper laboratory tests


2 Not responding appropriately to laboratory tests

3 Ordering test but the test are not performed

4 Failure to monitor for drug effectiveness adverse

effects and side effects

Monitoring errors appear to be less common than prescribing

administering and dispensing errors but there is limited data and a

wide variation in monitoring errors has been reported In a 2012

study 6048 prescriptions written by general practitioners showed a

09 rate of monitoring errors35 but a 2009 study of nursing homes

showed a 147 rate of monitoring errors36

Clearly medication errors are not unusual but for several reasons the

exact incidence of medication errors is not known Firstly there is no

universally used system for detecting and reporting medication errors

Self-reporting incident reports chart reviews direct observation and

trigger tools can and have been used as tools for detecting medical

errors but each one yields different results Self-reporting appears to

greatly underestimate medication errors while direct observation

consistently detects a large number of medication errors37 Secondly

the definition of a medication error is a significant influence on the

reported incidence of medication errors

Keers et al (2013) did a systematic review of 91 direct observational

studies of medication errors and found a median error rate of 19637

but if timing errors (ie the medication was not given at the

prescribed time) were excluded the median error rate was 8037

The issue is further complicated by different definitions of timing error


Some of the studies Keers et al reviewed defined a timing error as a

delay of 30 minutes or more while some simply reported timing errors

but did not provide a definition of what a timing error was considered

to be In addition 28 of the 91 research papers either did not define a

medication error or used a definition that was exclusive to the study

Despite the difficulty in determining the true incidence of medication

errors the reviews of the literature and the studies of medication

errors are very instructive Regardless of study design or the definition

of medical error that was used the research consistently shows that

the incidence of medication errors is disturbingly high and that there

are multiple and easily identifiable causes of medication errors

Baumgart-Huckels (2014) et al studied the rate of medication errors

and the causes and consequences of medication errors in a large

teaching hospital over a four-year period38 The use of medication was

divided into a process of five steps

1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring

Medication errors in the 2014 study were categorized as the wrong

patient wrong dose wrong drug wrong dose wrong quantity or a

medication omittednot given Medication errors recorded in the four-

year period amounted to 1591 incidents and most of the errors

occurred during the medication preparation and administration steps


The majority of the medication errors 742 involved more than

one-step in the medication use process and only 258 were detected

early in the process The authors report that 843 of the errors

reached the patients and 88 reached the patient and required

monitoring to confirm no harm or intervention to prevent harm The

authors also reported that inattention was the most common cause of

the medication errors (605) This was followed by work conditions

such as poor staffing and heavy workload (314) Ryan et al (2014)

also examined the prevalence and causes of prescribing errors made

by trainee physicians39 A prescribing error was defined as

ldquoOne which occurs when as a result of a prescribing decision or

prescription writing process there is an unintentional significant

reduction in the probability of treatment being timely and

effective or an increase in the risk of harm when compared with

generally accepted practicersquorsquo39

A total of 44276 prescriptions were examined and the error rate was

75 The most common prescribing order error is omission such as

when a medication was not ordered but should have been Doses that

were too low or too high were also common however fortunately

prescribing medications that would result in a harmful interaction and

prescribing a medication for the wrong patient were uncommon which

accounted respectively for 15 and 05 of the errors

Ryan et al (2014) identified that prescribing errors were ldquoof frequent

and of complex causationrdquo The authors also found that the work

environment and the lack of knowledge of medications by health staff

were the most common causes of the medication prescribing errors It


is interesting to note that a potential cause of a prescribing error was

due to the physiciansrsquo perception that if they made a prescribing error

it was likely to be detected by other physicians or hospital staff and

the error corrected before a medication administration error occurred

Honey et al (2014) also studied 2491 prescriptions that were written

by medical residents and found a prescribing error rate of 58840

Doses that were too high too low or of unclear quantity were the

most common prescribing errors which accounted respectively for

being 173 138 and 127 of the errors made The study was of

pediatric patients and the relatively high rate of dosage errors were

presumed to be because drug dosages for children are more frequently

based on body weight than drug dosaging for adults thus more

proneness to human error of drug dosing calculations made by the

prescriber

Beardsley et al (2013) examined the medical records of all patients

who had been discharged from a general medical practice Patient

records were examined for a period of 60 days prior to discharge and

for a period of 60 days after discharge41 The authors found

prescribing errors in 345 of the pre-discharge records and in 17 of

the post-discharge records Medication omission and dosage errors

were the most common and 3 of the errors were considered to be

serious such as

the route of administration could have led to severe toxicity

the dose was 4-10 times the normal and the drug had a low

therapeutic index


the dose was too low and the patient had a serious condition

the dose was too high and led to a blood level that was

potentially toxic

The risks of medication errors increase if the patient is very young

very old has complex medical problems or is taking multiple

medications The risk for medication errors has also been associated

with specific drugs The United States Pharmacopeia published a list of

medications that were commonly involved in medication errors42

MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14

The list above was similar to one published by Grissinger in 200743

which is outlined in the table below

MEDICATION NAME MEDICATION ERROR


Insulin

Anticoagulants

Amoxicillin

Aspirin

Trimethoprim-sulfamethoxazole

Hydrocodoneacetaminophen

Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13

Desai et al (2013) in a study of medications errors that occurred in

nursing homes and residential facilities found that anxiolytics

sedativeshypnotics anti-diabetic agents anticoagulants

anticonvulsants and ophthalmic preparations were ldquofrequently and

disproportionately involved in errors in nursing homes ldquo and ldquo

certain drug classes are more likely to be involved in medication errors

in nursing home patients regardless of the extent of their userdquo44

Other Medical Errors

There are other medical errors noted in the literature which would be

outside the scope of this study This includes a wide body of research

and literature on surgical and other treatment errors in healthcare

settings

Surgical errors

Major complications occur in 3-16 of all surgical procedures and

the rate of permanent disability or death from surgery has been


reported to be 04-845 Each year in the United States there are

over 70 million applications of anesthesia52 and errors are inevitable

Equipment failures during anesthesia are relatively uncommon Most

involve a disconnection or misconnection of the breathing circuit and

the rate of these errors has been estimated to range from 006 to

0753 however these types of errors account for approximately

20 of all critical anesthesia events54 The incidence of medication

errors in the practice of anesthesia has been reported to be 1 in every

13000 administrations55

Antibiotics inhalation gases local anesthetics muscle relaxers

opiates and vasoactive drugs are the medications most commonly

involved in anesthesia medication errors56 Failure to read labels or

misreading labels distractions carelessness and inattention lack of

vigilance stress and poor communication are the root causes of

anesthesia medication errors and they usually result in a missed

dose an incorrect dose improper drug substitution omission double

dosing or the use of an incorrect route57

Treatment errors

Other treatment errors are those errors that occur during the

performance of an operation test or procedure1 The following list

includes examples of treatment errors and is not all-inclusive

Administering blood and blood products

Advanced monitoring ie intracranial pressure monitoring

Intravenous insertions

Nasogastric tube insertions

Phlebotomy


Urinary catheterization

Surgical errors have been closely studied to help health teams identify

mistakes most likely to happen The basic types of errors that can be

made when nurses are performing a procedure such as collecting a

specimen or doing a treatment during post-operative care are errors

identified during planning performance and follow-up The root causes

of treatment errors involve human factors and system factors

Prevention Of Medical Errors

Human factors and system factors are the root causes of medical

errors but there are certain ways in which people perform and that

healthcare systems are organized which are the specific causes of

medical errors These human and system factors are discussed below

Fragmentation

The use of multiple medical specialists or medical systems to care for

one individual is a large contributor to errors Information does not

always follow patients there is no one place that knows all about one

patientrsquos health Fragmented health services are largely responsible for

health care information not being centralized

One medical provider caring for all of a patientrsquos medical needs is not

the norm in todayrsquos health care setting Fragmentation leads to

duplicate medications and services which is not only costly but

increases the risk of a medical error An individual with diabetes heart

failure prostate cancer and depression could be seeing six providers

including an endocrinologist cardiologist urologist oncologist


psychiatrist and a primary care provider The increasing use of

hospitalists is another piece of the health care system that leads to

fragmentation

The hospitalist is a medical provider specializing in the care of the

patient who is admitted to the hospital These providers are experts in

caring for hospitalized patients but they are not primary care

providers and the lack of familiarity with the patient and (perhaps)

incomplete access to a patientrsquos medical history can be a source of

errors Fragmentation can also be a result of the use of different

pharmacies and hospitals

Time constraints

Health care takes place at a rapid pace Each day providers are seeing

a large volume of patients pharmacists are filling a large number of

prescriptions and nurses are often caring for more patients than they

should Many health care providers are overworked They need to work

fast to meet the demands of administrators patients and the financial

bottom line When people are working quickly - perhaps too quickly -

the risk of errors is increased Nurses often report that they do not

have enough time to properly perform their work

Poor communication

Poor communication is often identified as a major cause of medical

errors Communication errors are common and can happen anywhere

within the healthcare system For example a 2014 study showed a

30 error rate in medical dictationtranscription59 and poor


communication in the form of using non-standard abbreviations and

the common use of sound-alike medications has long been known as a


Starmer et al (2013) wrote that communication errors are a leading

cause of sentinel events and that improving handoff communication

(ie transferring information about and responsibility for a patient)

reduced medical errors from 383 per 100 admissions to 18360 Poor

communication is also an issue between healthcare providers and

patients Good listening requires that the health care provider listen

fully and hear their patient In addition to listening health care

providers need to communicate information accurately and simply

Lack of knowledge

Both researchers and healthcare professionals often identify lack of

knowledge as a major cause of medical errors and lack of knowledge

affects all parts of the healthcare delivery process They also note that

there is a lack of resources andor time for increasing knowledge

Healthcare setting

Emergency rooms intensive care units and the operating room are

high-risk areas for medical errors The health acuity of the patients

(intensive care and emergency room) sudden and unexpected

increases in patient census (emergency room) and the use of

anesthesia and the need for strict adherence to infection control

protocols (operating room) all contribute to an increased incidence of

medical errors in these settings of patient care


Admission and discharge to the hospital are common times in which

medical errors occur A medical provider who is unfamiliar with the

patientrsquos medical history often admits the patient to the hospital and

the patient is often in hisher most vulnerable condition at the time of

admission Discharge requires patient teaching perhaps many new

medications that the patient must take and follow-up care these are

multiple opportunities for mistakes to be made and medical errors to

occur

Medical Errors And Reduction Strategies

Reducing the number of medical errors is an important part of

improving the American health care system There is a three-tier

approach to reducing the number of errors The first is an overall

improvement in the health care system Currently there is a national

focus with health care leaders working to collect data enhance

knowledge to reduce the number of medical errors The second is an

effort on each individual health care provider to provide safe and

effective care Lastly each patient needs to be an active consumer of

health care Some specific interventions that can be used to reduce

types of medical errors will be presented first in this section followed

by a short discussion on helping patients prevent medical errors

Diagnostic errors

Thammasitboon and Cutrer (2013) categorized diagnostic errors and

found cognitive mistakes that were common to many diagnostic

errors63 Their strategies to eliminate cognitive error and improve

diagnostic accuracy focused on three areas The first strategy was


expanding clinical expertise which is simply involves identifying the

gaps in the knowledge base and to try to eliminate them The second

strategy is to avoid cognitive processing errors and this is subtler the

authors described eight cognitive errors that can cause a diagnostic

error and strategies for correcting them

One example of the second strategy to eliminate cognitive errors

involves a common error in the diagnostic process known as

anchoring which involves the clinician staying with the original

diagnosis despite evidence to the contrary In order to correct or

reduce anchoring clinicians can be trained to consciously use de-

biasing techniques to periodically re-evaluate evidence and to pause

during the diagnostic process and to re-examine their assumptions In

the final strategy to eliminate cognitive errors wrong diagnoses can be

avoided by reducing the cognitive burden This can be achieved

through appropriate requests for consultations (ie another medical

specialist or ancillary health service) the use of checklists or by team

consensus or decision-making

Medication error prevention

The causes of medication errors are complex and there are many

possible approaches to the problem A simple and effective way to

avoid medication errors is through the use of the eight rights of

medication administration These eight rights of medication

administration include

1 Right patient

All healthcare facilities have a procedure for identifying patients

The minimum number of identifiers is two and the patient must


be correctly identified in person and on all medication orders

Making sure the nurse is giving a medication to the right patient

is largely a matter of communication

2 Right drug

The medication and the order must be checked against one

another to make sure that the right drug will be given Also

before giving a drug that is new for a patient the nurse should

re-check drug allergies re-check possible drug-drug-

interactions and make sure that at some time the patient has

been asked about herhis use of herbal supplements

3 Right dose

The right dose should be checked using current references with

the pharmacy or an appropriate staff member as secondary

resources Nurses should be aware of common dosing errors

such as a 10-fold increase in dose and calculations should be

double-checked

4 Right route

These are important questions a prudent nurse would want to

consider related to patient status and the right route The nurse

should always check to see that the route is correct

5 Right time


The nurse should always check to see when the last medication

dose was given to make sure that it is not being administered

too early or too late

6 Right documentation

Proper documentation should include the time and route of

administration and if needed the patientrsquos vital signs before

and after medication administration

7 Right reason

A medication should be appropriate for the patient and for the

clinical condition it is supposed to treat and nurses have a

responsibility to check this information before giving a drug

8 Right response

The definition of a drug is a substance that is given to prevent or

treat an illness and which has a measurable effect In order to

avoid medication errors nurses should have a basic

understanding of how a drug works and how its effectiveness

can be measured or monitored

Two other preventive strategies for avoiding medication errors are 1)

awareness of look-alike and sound-alike drugs and 2) using

abbreviations properly Approximately 25 of medication errors that

occur in the United States involve name confusion67 and these errors

have the potential to cause great harm Several websites include The

United States Pharmcopeia and The Institute for Safe Medication


Practices which can be accessed by nurses Regarding proper use of

abbreviations each healthcare facility should have a list of acceptable

abbreviations and nurses should know where the list is and what it

contains

Commonly used abbreviations related to medication administration

that can be used mistakenly or misidentified are ones such as U (or

u) intended to mean unit but easily mistaken for a 0 or 4 SC intended

to mean subcutaneous but easily mistaken for SL (sublingual) and

QOD intended to mean every other day but easily mistaken as QD

(every day) if it is written sloppily The Institute for Safe Medication

practices has a list of dangerous abbreviations and dose designations

on its website at

httpwwwismporgnewslettersacutecarearticlesdangerousabbrev

asp

Avoiding surgical errors

There are many approaches to avoiding medical errors involving

surgery but one of the simplest and most commonly used is the World

Health Organization (WHO) Surgical Safety Checklist This can be

viewed on the WHO website at

httpwwwwhointpatientsafetysafesurgeryss_checklisten

The Surgical Safety Checklist has three components the sign in the

time out and the sign out These three components correspond to

before anesthesia before skin incision and the post-operative period


Prevention of treatment errors

Methods for preventing treatment errors are essentially the same as

those used for preventing the other medical errors that been discussed

previously These methods include health team members having a

good knowledge base good communication and team adherence to

the healthcare facilityrsquos protocols

Preventing Medical Errors Helping The Patient

Medical errors by patients especially medication errors are very

common and may cause serious harm Acetaminophen is very popular

and very safe when taken in therapeutic amounts However in recent

years acetaminophen overdose has been the leading cause of acute

liver injury in the United States68 and many of these cases are not

deliberate overdoses done with the intent to cause self-harm but

therapeutic mistakes made by the lay public69

Teaching patients about medication safety is an important of

preventing medication errors Prescribers nurses and pharmacists

should spend time teaching patients about their medications

Nurses providing teaching about medication to patients should

encourage them to write this information down Key points of patient

teaching and medication administration and safety should include such

concerns as the purpose for taking a medication and common side

effects interactions and risks that require ongoing monitoring

Disclosure Of Medical Errors


Medical errors should be disclosed to the patient and if appropriate to

family members Disclosure of an error is difficult but it is vital for the

patientrsquos physical and emotional wellbeing Disclosure of an error is

also vital for the well being of the healthcare system as acknowledging

errors is the first step in correcting them

In many jurisdictions the disclosure of medical errors is mandatory and

most health care facilities have or should have a policy that outlines

how and by who a medical error should be disclosed This policy

should be reviewed before a medical error is disclosed

Summary

The prevention of medical errors is not easy Hospitals and other

healthcare facilities are complex organizations and the work

environment is fast-paced There is significant external and internal

pressure on staff to perform the work correctly which requires

experience and specialized knowledge The traditional culture of blame

has made it hard to disclose errors and learn from them However

other organizations that share many of these stresses such as the

airlines are remarkably error free They have done this by a

commitment to preventing errors and not reacting to errors If safe

patient care is the goal perhaps modeling other public service

industries that have successfully reduced errors is the way for the

healthcare industry moving forward


Please take time to help NurseCe4Lesscom course planners

evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the

article and providing feedback in the online course evaluation

Completing the study questions is optional and is NOT a course requirement


identical

a True

b False





made














patient

a True b False






limited

7 True or False The healthcare setting is an influencing

factor for diagnostic errors such as one that is fast-paced and stressful

c True

d False

8 A 2014 study showed a __________ error rate in medical

dictationtranscription and poor communication in the form of using non-standard abbreviations and the common

use of sound-alike medications has long been known as a


a 15

b 25

c 30

d 44







d All of the above

10 Starmer et al (2013) wrote that communication errors are a leading cause of

a sentinel events


c medication errors




a True

b False







13 True or False Equipment failures during anesthesia are

relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section

The reference section of in-text citations include published works

intended as helpful material for further reading Unpublished works

and personal communications are not included in this section although

may appear within the study text

1 Kohn LT Corrigan JM Donaldson MS eds To err is human Building

a safer health system Committee on Quality Health Care in America

Institute of Medicine National Academy press Washington DC 2000

2 Garrouste-Orgeas M Philippart F P Bruel C Max A Lau N Misset

B Overview of medical errors and adverse events Annals of Intensive

Care 2012 Published online February 16 2012

3 Zwaan L Schiff GD Singh H Advancing the research agenda for

diagnostic error reduction BMJ Quality amp Safety 201322ii52-ii57

4 Zwaan l De Bruijne MC Wagner C et al Patient record review on

the incidence consequences and causes of diagnostic adverse events

Archives of Internal Medicine 2010170-1015-1021

5 Singh H Giardina TD Meyer AND Forjuoh SN Reis MD Thomas E

Types and origins of diagnostic errors in primary care settings JAMA

Internal Medicine 2013173418-425

6 Graber ML The incidence of diagnostic error in medicine BMJ

Quality amp Safety 201322ii21-ii27

7 Berner ES Graber ML Overconfidence as a cause of diagnostic

error American Journal of Medicine 20081252-53

8 Singh H Meyer AND Thomas EJ The frequency of diagnostic errors

in outpatient care observational studies involving US adult

populations BMJ Quality amp Safety 201401-5


9 Schiff GD Hasan O Kim S et al Diagnostic error in medicine

analysis of 583 physician-reported errors Archives of Internal

Medicine 20091691881-1887

10 Singh H Thomas EJ Wilson L et al Errors of diagnosis in pediatric

practice a multisite survey Pediatrics 2010126-70-79

11 Beam CA Lyade PM Sullivan DC Variability in the interpretation of

screening mammograms by US radiologists Findings from a national

sample Archives of Internal Medicine 1996156209-213

12 Kostopoulou O OudhoffJ Nath R et al Predictors of diagnostic

accuracy and safe management in difficult diagnostic problems in

family medicine Medical Decision Making 200828688-680

13 Norman G Sherbino J Dore K et al The etiology of diagnostic

errors A controlled trial of System 1 versus System 2 reasoning

Academic Medicine 201489277-284

14 Zwaan L Thijs A Wagner C van der Waal G Timmmermans DR

Relating faults in diagnostic reasoning with diagnostic and patient

harm Academic Medicine 201287149-156


error in medicine American Journal of Medicine 2008121S2-S3

16 Nendaz M Perrier A Diagnostic errors and flaws in clinical

reasoning mechanisms and prevention in practice Swiss Medicine

Weekly 2012 Oct 23142w13706

17 Graber ML Franklin N Gordon R Diagnostic error in internal

medicine Archives of Internal Medicine 20051651493-1499

18 DiBardino D Cohen ER Didwania A Meta-analysis

multidisciplinary fall prevention strategies in the acute patient care

population Journal of Hospital Medicine 20127497-503


19 Tung EE Newman JS Fall prevention in hospitalized patients

Hospital Medicine Clinics 20143e189-e201

20 Miake-Lye IM Hempel S Ganz DA Shekelle PG Inpatient fall

prevention programs as a patient safety strategy a systematic review

Annals of Internal Medicine 2013158390-396

21 Tzeng H-M Yin C-Y Perceived top 10 highly effective interventions

to prevent adult inpatient fall injuries by specialty area A multihospital

nurse survey Applied Nursing Research 2014 April 29 [Epub ahead

of print]

22 Joint Commission Sentinel Events CAMCH January 2013

Retrieved June 27 2014 from

httpwwwjointcommissionorgassets16CAMCAH_2012_Update2_

23_SEpdf

23 Joint Commission National Patient Safety Goals 2014 Retrieved

June 27 2014 from

httpwwwjointcommissionorgstandards_informationnpsgsaspx

24 World Health Oorganization Violence and Injury Prevention Falls


httpwwwwhointviolence_injury_preventionother_injuryfallsen

25 eMedicine (No author listed) Risk of falls in elderly hospitalized

patients eMedicine Retrieved June 27 2014 from

httpreferencemedscapecomcalculatorfall-risk-elderly-

hospitalized

26 Degelau J Belz M Bungum L Flavin PL Harper C Leys K et al

Institute for Clinical Systems Improvement (ICSI) Prevention of falls

(acute care) Health care protocol Bloomington (MN) Institute for

Clinical Systems Improvement (ICSI) April 2012


27 Oliver D Healy F Falls risk prediction tools for hospital inpatients

do they work Nursing Times 200910518-21

28 Thammasitboon S Thammasitbon S Singhal G System-related

factors contributing to diagnostic errors Current Problems in Pediatric

amp Adolescent Health Care 201343242-247

29 Plebani M Sciavoelli l Aita A Padoan A Chiozza ML Quality

indicators to detect pre-analytical errors in laboratory testing Clinical

Chimca Acta 201443244-48

30 Nakleh RE Idowu O Souers RJ Meier FA Bekeris LG Mislabeling

of cases specimens blocks and slides a college of American

pathologists study of 136 institutions Archives of Pathology amp

Laboratory Medicine 2011135969-974

31 Lippi G Blanckaert N Bonini P et al Causes consequences

detection and prevention of identification errors in laboratory

diagnostics Clinical Chemistry and Laboratory Medicine 200947142-

153

32 Plebani M The detection and prevention of errors in laboratory

medicine Annals of Clinical Biochemistry 201047101-110

33 Carraro P Plebani M Errors in a stat laboratory types and

frequencies 10 years later Clinical Chemistry 2007531338-1342

34 Food and Drug Administration Medication errors August 8 2013


httpwwwfdagovDrugsDrugSafetyMedicationErrorsdefaulthtm

35 Avery AA Ghaleb M Barber N et al The prevalence and nature of

prescribing and monitoring errors in English general practice a

retrospective case note review British Journal of General Practice

201363e543-e553


36 Barber ND Alldred DP Raynor DK et al Cares homesrsquo use of

medicine study prevalence causes and potential harm of medication

errors in care homes for older people Quality amp Safety in Health Care

200918 341-346

37 Keers RN Williams SD Cooke J Ashcroft DM Prevalence of

medication administration errors in healthcare settings A systematic

review of direct observation studies Annals of Pharmacotherapy

201347237-256

38 Baumgart-Huckels S Manser T Identifying medication error chains

from critical incident reports A new analytic approach Journal of

Clinical Pharmacology 2014201-10

39 Ryan C Ross S Davey P et al Prevalence and causes of

prescribing errors The Prescribing Outcomes for Trainee Doctors

Engaged in Clinical Training (PROTECT) Study PLOS ONE 2014-

9e798021-19

40 Honey BL Bray WMJ Gomez MR Condren M Frequency of

prescribing errors by medical residents in various training programs

Journal of Patient Safety 2014001-5

41 Beardsley JR Schomberg RH Heatherly SJ Williams BS

Implementation of a standardized time out process to reduce the

prescribing errors at discharge Hospital Pharmacy 20134839-47

42 Hahn KL The top 10 medication errors and how to avoid them

Medscape Pharmacist May 16 2007 Retrieved June 30 2014 from

httpwwwmedscapeorgviewarticle556487

43 Grissinger M Top 10 adverse drug reactions and medication errors

Program and abstracts of the American Pharmacists Association 2007

Annual Meeting March 16-19 2007 Atlanta Georgia


44 Desai RJ Williams CE Greene SB Pierson S Caprio AJ Hansen

RA Exploratory evaluation of medication classes most commonly

involved in nursing home errors Journal of the American Medical

Directors Association 201314403-408

45 Panesar SS Noble DJ Mirza SB et al Can the surgical checklist

reduce the rate of wrong site surgery in orthopaedics - can the

checklist help Supporting evidence from an analysis of a national

patient reporting system Journal of Othopaedic surgery and Research

2011618-24

46 Vishwanath S Rao AR Motiwala H Karim OMA Wrong site

surgery How can we stop it Urology Annals 2014657-62

47 Collins SJ Newhouse SR Porter J Talsma A Effectiveness of the

surgical safety checklist in correcting errors A literature review

applying Reasonrsquos Swiss Cheese Model AORN J 201410065-79

48 No authors listed Prevention of wrong-site and wrong-patient

surgical errors Prescrire International 20132214-16

49 Sharma G Bigelow J Retained foreign bodies a serious threat in

the Indian operating room Annals of Medical amp Health Science

Research 2014430-37

50 Anderson DE Watts BV Application of an engineering problem

solving methodology to address persistent problems in patient safety

a case study on retained surgical sponges after surgery Journal of

Patient Safety 20139134-139

51 Stawicki SP Evans DC Cipolla J et al Retained surgical foreign

bodies A comprehensive review of risks and preventive strategies

Scandinavian Journal of Surgery 2009988ndash17

52 Sanford TJ Jr Anesthesia In Doherty GM ed Current Diagnosis

and Treatment Surgery McGraw-Hill New York NY


2010httpacbsagepubcomonlineuchceducgiijlinklinkType=ABS

TampjournalCode=clinchemampresid=5371338

53 Mehta SP Eisenkraft JB Posner KL Domino KB Patient injuries

from anesthesia gas delivery equipment a closed claims update

Anesthesiology 2013119788-795

54 Cassidy CJ Smith A Arnot-Smith J Critical incident reports

concerning anesthetic equipment Analysis of the UK National

Reporting and Learning System (NLRS) data from 200mdash2008

Anaesthesia 201166879-888

55 Merry AF Shipp DH Lowinger JS The contribution of labeling to

safe medication administration in anaesthetic practice Best Practice

Research in Clinical Anaesthesiology 201125145-159

56 Cooper L Nossaman B Medication errors in anesthesia A review

International Anesthesiology Clinics 2013511-12

57 Cooper L Digiovanni N Schultz L Taylor AM Nossaman AB

Influences observed on incidence and reporting of medication errors in

anesthesia Canadian Journal of Anesthesia 201259562ndash570

httpovidsptxovidcomonlineuchcedusp-

3120bovidwebcgiLink+Set+Ref=00004311-201305110-

000027C00002690_2012_59_562_cooper_influences_7c00004311

-201305110-0000223xpointer28id28R10-

229297c207c7covftdb7campP=47ampS=AAHHFPKGGBDDLEBD

NCMKADFBAOAEAA00ampWebLinkReturn=Full+Text3dL7cSsh2223

7c07c00004311-201305110-00002

58 Reason J Human errors Models and management BMJ

2000320768-770

59 David GC Chand D Sankaranarayanan B Error rates in physician


dictation quality assurance and medical record production

International Journal of Health Care Quality Assurance 20142799-

110

60 Starmer AJ Sectish TC Simon DW et al Rates of medical errors

and preventable adverse events among hospitalized children following

implementation of a resident handoff bundle Journal of The American

Medical Association 20133102262-2270

61 Runciman WB Webb RK Lee R et al System failure an analysis

of 2000 incident reports Anaesthesia and Intensive Care

199321684ndash95

62 Reason J Safety in the operating theatre ndash Part 2 human error

and organizational failure Quality amp Safety in Health Care

20051455-60

63 Thammasitboon S Cutrer WB Diagnostic decision-making

strategies to improve diagnosis Current Problems in Pediatric amp

Adolescent Health Care 201343232-241

64 Hempel S Newberry S Wang Z Hospital fall prevention a

systematic review of implementation components adherence and

effectiveness Journal of the American Geriatric Society 201361483-

494

65 Shi C Interventions for preventing falls in older people in care

facilities and hospitals Orthopedic Nursing 20143348-49


prevention programs as a patient safety strategy Annals of Internal

Medicine 201358(Pt 2)390-396

67 Ostini R Roughead EE Kirkpatrick CMJ Monteith GR Tett SE

Quality use of medications ndash medication safety issues in naming look-


alike sound-alike medication names International Journal of

Pharmacy Practice 201220349-357

68 Khandelwal N James LP Sanders C Larson AM Lee WM Acute

Liver Failure Study Group Unrecognized acetaminophen toxicity as a

cause of indeterminate acute liver failure Hepatology 201153567-

576

69 Alhelail MA Hoppe JA Rhyee SH Heard KJ Clinical course of

repeated supratherapeutic ingestion of acetaminophen Clinical

Toxicology 201149(2)108-112

70 Lipira LE Gallagher TH Disclosure of adverse events and errors in

surgical care Challenges and strategies for improvement World

Journal of Surgery 2014 Apr 24 [Epub ahead of print]


The information presented in this course is intended solely for the use of healthcare

professionals taking this course for credit from NurseCe4Lesscom

The information is designed to assist healthcare professionals including nurses in

addressing issues associated with healthcare

The information provided in this course is general in nature and is not designed to

address any specific situation This publication in no way absolves facilities of their

responsibility for the appropriate orientation of healthcare professionals

Hospitals or other organizations using this publication as a part of their own

orientation processes should review the contents of this publication to ensure

accuracy and compliance before using this publication

Hospitals and facilities that use this publication agree to defend and indemnify and

shall hold NurseCe4Lesscom including its parent(s) subsidiaries affiliates

officersdirectors and employees from liability resulting from the use of this

publication

The contents of this publication may not be reproduced without written permission

from NurseCe4Lesscom


Continuing Nursing Education Course Planners

William A Cook PhD Director Douglas Lawrence MA Webmaster

Susan DePasquale MSN FPMHNP-BC Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Lesscom and the continuing nursing education

requirements of the American Nurses Credentialing Centers

Commission on Accreditation for registered nurses It is the policy of

NurseCe4Lesscom to ensure objectivity transparency and best

practice in clinical education for all continuing nursing education (CNE)

activities

Continuing Education Credit Designation

This educational activity is credited for 2 hours Nurses may only claim

credit commensurate with the credit awarded for completion of this

course activity

Statement of Learning Need

The rates of medical errors remain a public health and safety risk Safe

patient care requires all members of the health team and the public to

be educated on how to recognize and prevent a medical error and to

advocate for needed changes to improve the delivery of healthcare


Course Purpose





Target Audience







no disclosures










identical

a True

b False





made













patient

a True b False







limited


and stressful

a True

b False




a 15

b 25

c 30

d 44






d All of the above




a sentinel events


c medication errors




a True

b False







a True

b False




a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Introduction























Medical error










Adverse event














event

Diagnostic Errors








error as follows5


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication




Course Purpose





Target Audience







no disclosures










identical

a True

b False





made













patient

a True b False







limited


and stressful

a True

b False




a 15

b 25

c 30

d 44






d All of the above




a sentinel events


c medication errors




a True

b False







a True

b False




a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Introduction























Medical error










Adverse event














event

Diagnostic Errors








error as follows5


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication





identical

a True

b False





made













patient

a True b False







limited


and stressful

a True

b False




a 15

b 25

c 30

d 44






d All of the above




a sentinel events


c medication errors




a True

b False







a True

b False




a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Introduction























Medical error










Adverse event














event

Diagnostic Errors








error as follows5


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication









limited


and stressful

a True

b False




a 15

b 25

c 30

d 44






d All of the above




a sentinel events


c medication errors




a True

b False







a True

b False




a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Introduction























Medical error










Adverse event














event

Diagnostic Errors








error as follows5


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication






a sentinel events


c medication errors




a True

b False







a True

b False




a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Introduction























Medical error










Adverse event














event

Diagnostic Errors








error as follows5


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication






a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Introduction























Medical error










Adverse event














event

Diagnostic Errors








error as follows5


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication














Medical error










Adverse event














event

Diagnostic Errors








error as follows5


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication
















event

Diagnostic Errors








error as follows5


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication


















Patient population













diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication





diagnostic process

Data sources
















5769-12





are defined









diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication











diagnostic errors




1 Patient related
















3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication






3 Diagnostic tests



diagnostic errors





diagnostic errors

5 Referrals





























Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication



















Patient Falls










a sentinel event






























Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication




















Laboratory Errors















below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication











below

Pre-test errors








Post-test errors



















Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication












Medication Errors









categories

1 Prescribing


3 Dispensing

4 Monitoring

Prescribing errors




allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication






allergies











include










documentation






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication






take a medications


patient



Dispensing errors



dispensed

Monitoring errors







errors includes












































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication













































1 Prescribing

2 Transcribing

3 Preparation

4 Administration

5 Monitoring















































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication












































prescriber








serious such as



therapeutic index




potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication






potentially toxic






MEDICATION NAME

MEDICATION ERROR

Insulin

Morphine

Potassium chloride

Albuterol

Heparin

Vancomycin

Cefazolin

Acetaminophen

Warfarin

Furosemide

4

23

22

18

17

16

16

16

14

14





Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication




Insulin

Anticoagulants

Amoxicillin

Aspirin



Ibuprofen

Acetaminophen

Cephalexin

Penicillin

8

62

43

25

22

22

21

18

16

13












settings

Surgical errors





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication





















Treatment errors








Phlebotomy














Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication
















Fragmentation















fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication






fragmentation








Time constraints









Poor communication

















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication















Lack of knowledge





Healthcare setting
















occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication











occur













Diagnostic errors





























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication



























1 Right patient







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication







2 Right drug







3 Right dose





double-checked

4 Right route




5 Right time









7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication











7 Right reason




8 Right response
















contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication







contains








on its website at


asp












































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication





































Summary



















identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication









identical

a True

b False





made














patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication





patient

a True b False






limited



c True

d False





a 15

b 25

c 30

d 44







d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication









d All of the above


a sentinel events


c medication errors




a True

b False








relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication





relatively uncommon

a True

b False



a Time out

b It-Takes-Two

c Anchoring

d Pause


a verbal orders

b name confusion



Correct Answers

1 b

2 c

3 a

4 a

5 a

6 b

7 a

8 c

9 d

10 a

11 b

12 a

13 a

14 c

15 b


References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication




References Section





























Medicine 20091691881-1887



















Weekly 2012 Oct 23142w13706















of print]




23_SEpdf


June 27 2014 from








hospitalized





















153











201363e543-e553





200918 341-346




201347237-256







9e798021-19






















2011618-24










Research 2014430-37































-201305110-0000223xpointer28id28R10-



7c07c00004311-201305110-00002


2000320768-770





110







199321684ndash95



20051455-60







494





Medicine 201358(Pt 2)390-396









576



Toxicology 201149(2)108-112


















publication






Medicine 20091691881-1887



















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