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An analysis of fatal iatrogenic therapeutic errors reported to United States poison centers.
- Source :
-
Clinical toxicology (Philadelphia, Pa.) [Clin Toxicol (Phila)] 2021 Jan; Vol. 59 (1), pp. 53-60. Date of Electronic Publication: 2020 May 28. - Publication Year :
- 2021
-
Abstract
- Objective: This is a descriptive study evaluating fatal iatrogenic and in-hospital medication errors reported to United States poison centers.<br />Methods: A retrospective evaluation of the National Poison Data System from 2000-2017 of all therapeutic errors with a scenario coded as iatrogenic/healthcare professional or occurring in a healthcare facility. Death abstracts were reviewed for details of the exposure and therapeutic error scenarios were recoded or added to the case as appropriate. Cases, where death was considered not related to the exposure, were excluded. Additionally, we created one additional scenario (rate-related) and one additional route of administration (intrathecal) to better describe the cases.<br />Results: A total of 172 cases were evaluated. The majority of the patients were female (52.3%) with a median age of 58.5 years (range: 2 days to 96 years). The most commonly reported medication error was "other incorrect dose" (22.7%) followed by other/unknown error (15.1%). The route of exposure was primarily parenteral (54.9%), followed by ingestion (30.2%), then intrathecal (7.0%). The most common medications were cardiac drugs, chemotherapeutics, opioids, anticoagulants, and sedative-hypnotic/antipsychotics.<br />Conclusions: Iatrogenic and in-hospital medication errors have been studied extensively with goals to reduce their occurrence. Specific controls to prevent incorrect dosing routes, 10-fold overdoses, and incorrect intrathecal administration have been instituted. Despite interventions, all three of these therapeutic errors continued to occur in 2017, suggesting that more preventive controls should be instituted.
- Subjects :
- Adolescent
Adult
Aged
Aged, 80 and over
Child
Child, Preschool
Drug Administration Routes
Drug Interactions
Drug Overdose mortality
Female
Hospital Mortality
Humans
Infant
Infant, Newborn
Male
Middle Aged
Retrospective Studies
Risk Assessment
Risk Factors
Time Factors
United States
Young Adult
Iatrogenic Disease
Inpatients
Medication Errors mortality
Poison Control Centers
Subjects
Details
- Language :
- English
- ISSN :
- 1556-9519
- Volume :
- 59
- Issue :
- 1
- Database :
- MEDLINE
- Journal :
- Clinical toxicology (Philadelphia, Pa.)
- Publication Type :
- Academic Journal
- Accession number :
- 32463298
- Full Text :
- https://doi.org/10.1080/15563650.2020.1766691