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Using the Medical Emergency Team to Supplement an Existing Adverse Drug Event Reporting Framework
Author(s) -
Van De Vreede Melita,
Leong Tim
Publication year - 2007
Publication title -
journal of pharmacy practice and research
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.222
H-Index - 22
eISSN - 2055-2335
pISSN - 1445-937X
DOI - 10.1002/j.2055-2335.2007.tb00743.x
Subject(s) - medicine , medical record , medical emergency , medication error , documentation , emergency medicine , adverse drug event , adverse effect , patient safety , intervention (counseling) , near miss , adverse drug reaction , drug , health care , nursing , psychiatry , forensic engineering , computer science , engineering , economics , programming language , economic growth
ABSTRACT Background The medical emergency team (MET) provides early intervention when a patient deteriorates. The cause of the deterioration is subsequently documented. There is no specific documentation if the cause is related to a medication error. Aim To introduce a process to ensure medication errors identified via MET calls are notified to the quality use of medicines (QUM) manager so they can be included in the continuous quality improvement program. Method A retrospective medical record review of MET calls over one month was undertaken to detect calls related to medication errors. The MET data management process was then modified to include medication as a contributing factor for reporting such events. Reports of MET calls due to medication errors were sent monthly to the QUM manager and these patients' medical records were reviewed to confirm if a medication error occurred. If so, the details of this error and whether it has been reported on the hospital reporting system were determined. Results The baseline review in July 2005 identified 108 confirmed MET calls, 4 of which were definitely and 5 possibly related to medication errors. 2 of the confirmed medication errors were precipitated by omitted doses. In March 2006, the improved system started and in the first 4 months, review of the 12 calls notified by the MET identified that 4 were due to medication errors. 2 of these had not been reported on Riskman. The medical record review also identified one adverse drug reaction which had not been reported and a near‐miss involving IV potassium chloride that would otherwise not have been detected. Conclusion The introduced process identified MET calls due to medication errors that would otherwise have been missed.