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. 2002 Sep;11(3):258–260. doi: 10.1136/qhc.11.3.258

Learning from prescribing errors

B Dean
PMCID: PMC1743641  PMID: 12486991

Abstract



 The importance of learning from medical error has recently received increasing emphasis. This paper focuses on prescribing errors and argues that, while learning from prescribing errors is a laudable goal, there are currently barriers that can prevent this occurring. Learning from errors can take place on an individual level, at a team level, and across an organisation. Barriers to learning from prescribing errors include the non-discovery of many prescribing errors, lack of feedback to the prescriber when errors are discovered by other healthcare professionals, and a culture that does not encourage reflection on errors together with why they occurred and how they can be prevented. Changes are needed in both systems and culture to provide an environment in which lessons can be learnt from errors and put into practice.

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Selected References

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  1. Arndt M. Nurses' medication errors. J Adv Nurs. 1994 Mar;19(3):519–526. doi: 10.1111/j.1365-2648.1994.tb01116.x. [DOI] [PubMed] [Google Scholar]
  2. Baker H. M. Rules outside the rules for administration of medication: a study in New South Wales, Australia. Image J Nurs Sch. 1997;29(2):155–158. doi: 10.1111/j.1547-5069.1997.tb01549.x. [DOI] [PubMed] [Google Scholar]
  3. Bates D. W., Cullen D. J., Laird N., Petersen L. A., Small S. D., Servi D., Laffel G., Sweitzer B. J., Shea B. F., Hallisey R. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):29–34. [PubMed] [Google Scholar]
  4. Calliari D. The relationship between a calculation test given in nursing orientation and medication errors. J Contin Educ Nurs. 1995 Jan-Feb;26(1):11–14. doi: 10.3928/0022-0124-19950101-05. [DOI] [PubMed] [Google Scholar]
  5. Dean B., Barber N. Validity and reliability of observational methods for studying medication administration errors. Am J Health Syst Pharm. 2001 Jan 1;58(1):54–59. doi: 10.1093/ajhp/58.1.54. [DOI] [PubMed] [Google Scholar]
  6. Dean B. Learning from prescribing errors. Qual Saf Health Care. 2002 Sep;11(3):258–260. doi: 10.1136/qhc.11.3.258. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Dean Bryony, Schachter Mike, Vincent Charles, Barber Nick. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002 Apr 20;359(9315):1373–1378. doi: 10.1016/S0140-6736(02)08350-2. [DOI] [PubMed] [Google Scholar]
  8. Folli H. L., Poole R. L., Benitz W. E., Russo J. C. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics. 1987 May;79(5):718–722. [PubMed] [Google Scholar]
  9. Gladstone J. Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J Adv Nurs. 1995 Oct;22(4):628–637. doi: 10.1046/j.1365-2648.1995.22040628.x. [DOI] [PubMed] [Google Scholar]
  10. Hall K. W., Ebbeling P., Brown B., Shwortz I. A retrospective-prospective study of medication errors: basis for an ongoing monitoring program. Can J Hosp Pharm. 1985 Oct;38(5):141-3, 146. [PubMed] [Google Scholar]
  11. Leape L. L., Bates D. W., Cullen D. J., Cooper J., Demonaco H. J., Gallivan T., Hallisey R., Ives J., Laird N., Laffel G. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):35–43. [PubMed] [Google Scholar]
  12. Leape L. L., Brennan T. A., Laird N., Lawthers A. G., Localio A. R., Barnes B. A., Hebert L., Newhouse J. P., Weiler P. C., Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991 Feb 7;324(6):377–384. doi: 10.1056/NEJM199102073240605. [DOI] [PubMed] [Google Scholar]
  13. Lesar T. S., Briceland L. L., Delcoure K., Parmalee J. C., Masta-Gornic V., Pohl H. Medication prescribing errors in a teaching hospital. JAMA. 1990 May 2;263(17):2329–2334. [PubMed] [Google Scholar]
  14. Neale G., Woloshynowych M., Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med. 2001 Jul;94(7):322–330. doi: 10.1177/014107680109400702. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Raz T., Kraus G. P. Prediction of medication error probability based on patient characteristics. Qual Assur Health Care. 1989;1(4):207–216. doi: 10.1093/intqhc/1.4.207. [DOI] [PubMed] [Google Scholar]
  16. Roseman C., Booker J. M. Workload and environmental factors in hospital medication errors. Nurs Res. 1995 Jul-Aug;44(4):226–230. [PubMed] [Google Scholar]
  17. Stanhope N., Vincent C., Taylor-Adams S. E., O'Connor A. M., Beard R. W. Applying human factors methods to clinical risk management in obstetrics. Br J Obstet Gynaecol. 1997 Nov;104(11):1225–1232. doi: 10.1111/j.1471-0528.1997.tb10967.x. [DOI] [PubMed] [Google Scholar]
  18. Vincent C., Neale G., Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001 Mar 3;322(7285):517–519. doi: 10.1136/bmj.322.7285.517. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Vincent C., Taylor-Adams S., Chapman E. J., Hewett D., Prior S., Strange P., Tizzard A. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000 Mar 18;320(7237):777–781. doi: 10.1136/bmj.320.7237.777. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Walters J. A. Nurses' perceptions of reportable medication errors and factors that contribute to their occurrence. Appl Nurs Res. 1992 May;5(2):86–88. doi: 10.1016/s0897-1897(05)80019-9. [DOI] [PubMed] [Google Scholar]
  21. West D. W., Levine S., Magram G., MacCorkle A. H., Thomas P., Upp K. Pediatric medication order error rates related to the mode of order transmission. Arch Pediatr Adolesc Med. 1994 Dec;148(12):1322–1326. doi: 10.1001/archpedi.1994.02170120084016. [DOI] [PubMed] [Google Scholar]
  22. Wilson R. M., Runciman W. B., Gibberd R. W., Harrison B. T., Newby L., Hamilton J. D. The Quality in Australian Health Care Study. Med J Aust. 1995 Nov 6;163(9):458–471. doi: 10.5694/j.1326-5377.1995.tb124691.x. [DOI] [PubMed] [Google Scholar]

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