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Quality Update
What an Idea!
In the quest for an error-free drug delivery system, self-reporting currently is the best way to track medication errors. Accurate and unbiased reporting, however, has been especially difficult in the health care environment up to this point, because the fear of blame is still prevalent.
To take fear and bias out of the process, a multidisciplinary group has developed an automated method to report medication errors. The system, called Medication Event Markers (MEM), red-flags mistakes by the type of drug, the time it occurred and the unit where it happened.
Still in its infancy, MEMS is being tested in the Weinberg and surgery intensive care units, because it can pull information from Eclypsis, a point-of-care clinical data system. These medication-event triggers don’t necessarily indicate actual harm to patients, but they are valuable for tracking error trends and highlighting areas for improvement.
A medication-event marker is an automated algorithm that identifies the toxic side effects, or triggers, of an overdose with certain clinical indicators. In setting up the system, the group—intensive care units, pharmacy, nursing, risk management, information technology, the Hopkins Hospital patient safety committee, and the Center for Innovation in Quality Patient Care—focused on medications whose high use and mis-dosage could have devastating consequences for patients. These include narcotics, anticoagulants and insulin.
The system’s mathematical formula takes into account exceptions to the rule.
Implementation of the clinical physician order entry system at Hopkins, scheduled by this autumn, should increase the potential for more widespread use of MEMS.
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