Information de reference pour ce titreAccession Number: | 00134255-201008000-00019.
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Author: | McDowell, Sarah E 1; Mt-Isa, Shahrul 2; Ashby, Deborah 2; Ferner, R E 1
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Institution: | (1)West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK (2)Wolfson Institute of Preventive Medicine, Queen Mary, University of London, London, UK
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Title: | Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis.[Miscellaneous Article]
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Source: | Quality & Safety in Health Care. 19(4):341-345, August 2010.
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Abstract: | Objective: To investigate the overall probability of error in preparing and administering intravenous medicines; to identify at which stage of the process an error is most likely to occur; and to determine the impact of error correction on the error probability.
Design: Systematic review and random-effects Bayesian conditional independence modelling.
Methods: Medline and EMBASE were searched for studies on intravenous medicines. The error rates of each stage were extracted. These, expert estimates, and error rates from generic tasks, were used in a Bayesian conditional independence model to find error 'hot-spots.' The main outcome measure was the probability of at least one error occurring during intravenous therapy.
Results: Nine published studies were identified for inclusion in the systematic review and meta-analysis. The overall probability of making at least one error in intravenous therapy was 0.73 (95% credible interval (CrI) 0.54 to 0.90). If error-checking was introduced at each stage of the process, the overall rate fell to 0.22 (95% CrI 0.14 to 0.31). Errors were most likely in the reconstitution step. Removing the reconstitution step by providing preprepared injections would reduce the overall error rate to 0.17 (95% CrI 0.09 to 0.27).
Conclusions: Intravenous therapy is complex and error-prone. Error-checking at each stage could reduce the error probability. The use of preprepared injections may help by eliminating errors in the reconstitution of drug and diluent. However, it will be important to ensure that benefits are not outweighed by practical disadvantages such as an increase in selection errors.
(C) 2010 BMJ Publishing Group Ltd & Institute for Healthcare Improvement
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Author Keywords: | Medication error; intravenous injections; systematic review.
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Language: | English.
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Document Type: | Error management.
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Journal Subset: | Public Health.
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ISSN: | 1475-3898
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NLM Journal Code: | 101136980
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DOI Number: | https://dx.doi.org/10.1136/qshc....- ouverture dans une nouvelle fenêtre
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