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Journal articles on the topic 'Reports of errors'

Author: Grafiati

Published: 4 June 2021

Last updated: 1 February 2022

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Leddin, Desmond. "Alpha Errors, Beta Errors and Negative Trials." Canadian Journal of Gastroenterology 2, no. 4 (1988): 147–50. http://dx.doi.org/10.1155/1988/523841.

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Reports of negative trials arc increasing in number as standard therapy for many gastrointestinal diseases is refined. The validity of a negative report depends on the number of patients in the trial, the alpha and bern error and the difference in efficacy which the trial is able to detect. The relationship between these parameters is discussed and a formula given for the calculation of trial size. All reports of negative trials should include not only the number of patients involved and the level of significance of the results but also the beta error and the detectable difference in efficacy of the treatments.

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Mathiowetz, Nancy A. "Errors in Reports of Occupation." Public Opinion Quarterly 56, no. 3 (1992): 352. http://dx.doi.org/10.1086/269327.

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Dalmolin, Gabriella Rejane dos Santos, Eloni Terezinha Rotta, and José Roberto Goldim. "Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital." Brazilian Journal of Pharmaceutical Sciences 49, no. 4 (2013): 793–802. http://dx.doi.org/10.1590/s1984-82502013000400019.

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Medication errors can be frequent in hospitals; these errors are multidisciplinary and occur at various stages of the drug therapy. The present study evaluated the seriousness, the type and the drugs involved in medication errors reported at the Hospital de Clínicas de Porto Alegre. We analyzed written error reports for 2010-2011. The sample consisted of 165 reports. The errors identified were classified according to seriousness, type and pharmacological class. 114 reports were categorized as actual errors (medication errors) and 51 reports were categorized as potential errors. There were more medication error reports in 2011 compared to 2010, but there was no significant change in the seriousness of the reports. The most common type of error was prescribing error (48.25%). Errors that occurred during the process of drug therapy sometimes generated additional medication errors. In 114 reports of medication errors identified, 122 drugs were cited. The reflection on medication errors, the possibility of harm resulting from these errors, and the methods for error identification and evaluation should include a broad perspective of the aspects involved in the occurrence of errors. Patient safety depends on the process of communication involving errors, on the proper recording of information, and on the monitoring itself.

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Dreijer, Albert R., Jeroen Diepstraten, Vera E. Bukkems, et al. "Anticoagulant medication errors in hospitals and primary care: a cross-sectional study." International Journal for Quality in Health Care 31, no. 5 (2018): 346–52. http://dx.doi.org/10.1093/intqhc/mzy177.

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Abstract Objective To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase). Design A cross-sectional study. Setting Medication errors reported to the Central Medication incidents Registration reporting system. Participants Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR. Intervention N/A. Main outcome measure Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline. Results Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline. Conclusions Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.

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Merrick, Joav, and Kenneth Koslowe. "Refractive errors and visual anomalies in Down syndrome." Down Syndrome Research and Practice 6, no. 3 (2001): 131–33. http://dx.doi.org/10.3104/reports.105.

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Rohatgi, Radha, and Sadhna Shankar. "Chemotherapy Related Errors in the Pediatric Oncology Unit At a Tertiary Care Institution,." Blood 118, no. 21 (2011): 4197. http://dx.doi.org/10.1182/blood.v118.21.4197.4197.

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Abstract Abstract 4197 Medication errors are responsible for 98,000 deaths and over almost a million injuries every year according to the Institute of Medicine report published in 1999. Cancer patients often receive complicated chemotherapy regimens which are at risk for errors. Few studies have evaluated the risk of medication errors related to chemotherapy. Majority of these studies are related to adult cancer patients. Studies regarding chemotherapy errors in pediatric patients are limited. The goal of this study was to evaluate the type and severity of errors related to chemotherapy administration in the pediatric oncology inpatient unit and outpatient clinic at a single institution over a 24 month period using a voluntary error reporting system in the institution. WebEnvision is a voluntary electronic reporting system implemented in 2007, that allows staff to anonymously report patient or staff safety incidents. We evaluated all the chemotherapy related WebEnvision reports from June 1, 2009 to May 31, 2011. All reports related to prescribing, dispensing and administering chemotherapy medications were included. Reports related to a supportive care measures were excluded. The reports were reviewed by both authors and graded according to the National Coordinating Council for Medication Error Reporting and Prevention Index for medication errors. The errors were also classified by type as defined by the American Society of Hospital Pharmacists guidelines for preventing medication errors. A total of 1030 reports related to oncology patients were recorded during the study period. Of these, 246 (23.9%) were related to chemotherapy. Thirty nine thousand preparations were dispensed by the chemotherapy pharmacy during the study period. The median number of chemotherapy drugs on orders associated with an error was 2 with a range of 1 to 6. The median length of chemotherapy treatment per order was 3 days with a range of 1 to 56 days. Approximately half (47%) of the errors occurred in patients undergoing treatment for leukemia or lymphoma, 28% for solid tumors, 17% for brain tumors, and 7% for non-malignant hematology patients. Ninety four (38%) errors were attributed to pharmacy, 83 (34%) to the providers, and 51 (20%) to the nurses. Seventy six (31%) were prescribing errors, 41 (16%) were administration errors, 31 (13%) were dispensing errors, and 26 (11%) were transcription errors. Approximately half (44%) of errors were of category B, an error occurred but did not reach the patient. Seventy six (31%) reports were category A, circumstances for error were present but no error occurred. Fifty nine (24%) were category C, an error reached the patient but caused no harm. Three errors reached the patient and could have contributed to harm (category D, F,G). Approximately one in three dispensing errors (32%), one in six prescribing errors (17%) and one in ten (11%) transcription errors reached the patient. Prescribing errors were the most common chemotherapy related errors in this study. One in four of all errors reached the patients. Errors occurred despite an institutional policy of two independent checks by providers, pharmacists, and nurses. More diligence is necessary on part of the person performing the second check on chemotherapy orders. Computerized provider order entry may help reduce chemotherapy related errors. Table1. Types of chemotherapy related errors Types of Errors N (%) Prescribing 76 (31) Delay 58 (23) Administration 41 (16) Dispensing 31 (13) Transcription 26 (11) Monitoring 7 (3) Compliance 4 (2) Omission 3 (1) Total 246 (100) Disclosures: No relevant conflicts of interest to declare.

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Sangwaiya, Minal Jagtiani, Shyla Saini, Michael A. Blake, Keith J. Dreyer, and Mannudeep K. Kalra. "Errare Humanum Est: Frequency of Laterality Errors in Radiology Reports." American Journal of Roentgenology 192, no. 5 (2009): W239—W244. http://dx.doi.org/10.2214/ajr.08.1778.

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Goodyear, Nancy, Bruce K. Ulness, Jennifer L. Prentice, Brad T. Cookson, and Ajit P. Limaye. "Systematic Assessment of Culture Review as a Tool to Assess Errors in the Clinical Microbiology Laboratory." Archives of Pathology & Laboratory Medicine 132, no. 11 (2008): 1792–95. http://dx.doi.org/10.5858/132.11.1792.

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Abstract Context.—Daily supervisory review is a common practice in microbiology laboratories; however, there are no publications describing errors corrected by this practice. Objective.—To determine (1) the correction rates for routinely reviewed positive cultures, (2) the correction rates for negative cultures, and (3) the types of corrections that are found, including the number with potential clinical significance. Design.—We prospectively assessed errors identified during culture report review for all positive (10-month period) and negative (1-month period) cultures at a single, university-based clinical microbiology laboratory in the United States. Errors were classified using predefined categories, and total and per category error rates were determined. A χ2 test was used to assess significant differences between error rates. Results.—A total of 112 108 culture reports were examined; 914 reports required a total of 1043 corrections. Of 101 703 positive culture reports, 786 (0.8%) required 900 corrections, 302 (0.3%) of which were potentially clinically significant. Of 10 405 negative culture reports, 128 (1.2%) required 143 corrections, 5 (0.05%) of which were potentially clinically significant. The rate of potentially clinically significant errors was significantly higher among positive versus negative culture reports (P &lt; .001). Errors from positive culture reports most commonly involved susceptibility (374 [42%]), reporting (275 [31%]), and identification workup (217 [24%]). Most potentially significant errors from positive culture reports involved susceptibility testing (n = 253) and specimens from wound or lower respiratory tract (P &lt; .001). Conclusions.—Review of culture reports from positive cultures from nonsterile sites with special attention to antimicrobial susceptibility testing and reporting would be most likely to detect potentially significant errors within the clinical microbiology laboratory.

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Burks, Jeffrey J. "Accounting Errors in Nonprofit Organizations." Accounting Horizons 29, no. 2 (2015): 341–61. http://dx.doi.org/10.2308/acch-51017.

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SYNOPSIS This study examines the accounting errors committed by public charities as revealed by searching for disclosures of their corrections in auditor reports, financial statements, and footnotes. A sample of 5,511 audited financial statements, predominantly from the years 2006 to 2010, was obtained from GuideStar, a data provider for nonprofits. Public charities report errors at a rate that is 60 percent higher than that of publicly traded corporations, and almost twice as high as that of similar-sized corporations. The errors are commonly errors of omission (i.e., failing to recognize items). The error rate has a strong positive association with internal control deficiencies and a strong negative association with Big 4 and second-tier auditors. Regressions are unable to detect a significant association between the error rate and organization size, type, or portion of the budget devoted to administrative activities. The error corrections often have low visibility in the financial reports issued by public charities; although they are reported in the footnotes of the audited financial statements, they often are not mentioned in auditor reports and in IRS Form 990s. The study improves our understanding of the accounting challenges faced by nonprofits, and may enhance nonprofit financial reporting by helping nonprofit managers and auditors understand the common circumstances and types of errors, and thus what activities to monitor more closely. The study also contributes to the academic literature by comparing the errors of nonprofits to those of corporations, by examining the outcomes of audits conducted by large as well as small auditors, and by advancing our understanding of discrepancies between audited and unaudited financial reports. Data Availability: Data are available from sources identified in the paper.

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Digumarthy, Subba Rao, Rachel Vining, Azadeh Tabari, et al. "Process improvement for reducing side discrepancies in radiology reports." Acta Radiologica Open 7, no. 7-8 (2018): 205846011879472. http://dx.doi.org/10.1177/2058460118794727.

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Background Laterality errors in radiology reports can lead to serious errors in management. Purpose To reduce errors related to side discrepancies in radiology reports from thoracic imaging by 50% over a six-month period with education and voice recognition software tools. Material and Methods All radiology reports at the Thoracic Imaging Division from the fourth quarter of 2016 were reviewed manually for presence of side discrepancies (baseline data). Side discrepancies were defined as a lack of consistency in side labeling of any abnormality in the “Findings” to “Impression” sections of the reports. Process map and Ishikawa fishbone diagram (Microsoft Visio) were created. All thoracic radiologists were educated on side-related errors in radiology reports for plan–design–study–act cycle 1 (PDSA #1). Two weeks later, voice recognition software was configured to capitalize sides (RIGHT and LEFT) in the reports during dictated (PDSA# 2). Radiology reports were analyzed to determine side-discrepancy errors following each PDSA cycle (post-interventional data). Statistical run charts were created using QI Macros statistical software. Results Baseline data revealed 33 side-discrepancy errors in 47,876 reports with an average of 2.5 errors per week (range = 1–8 errors). Following PDSA #1, there were seven errors pertaining to side discrepancies over a two-week period. Errors declined following implementation of PDSA #2 to meet the target of 0.85 side-discrepancy error per week over seven weeks. Conclusion Automated processes (such as capitalization of sides) help reduce left/right errors substantially without affecting reporting turnaround time.

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Williamson, J. A., R. K. Webb, A. Sellen, W. B. Runciman, and J. H. Van Der Walt. "Human Failure: An Analysis of 2000 Incident Reports." Anaesthesia and Intensive Care 21, no. 5 (1993): 678–83. http://dx.doi.org/10.1177/0310057x9302100534.

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Information of relevance to human failure was extracted from the first 2,000 incidents reported to the Australian Incident Monitoring Study (AIMS). All reports were searched for human factors amongst the “factors contributing”, “factors minimising”, and “suggested corrective strategies” categories, and these were classified according to the type of human error with which they were associated. In 83% of the reports elements of human error were scored by reporters. “Knowledge-based errors” contributed directly to about one-quarter of incidents; the outcome of one third of incidents was thought to have been minimised by prior experience or awareness of the potential problems, and in one fifth some strategy to improve knowledge was suggested. Correction of “rule-based errors” or provision of protocols or algorithms were thought, together, to have a potential impact on nearly half of all incidents. Failure to check equipment or the patient contributed to nearly one-quarter of all incidents, and inadequate crisis management contributed to a further I in 8. “Skill-based errors” (slips and lapses) were directly responsible for I in 10 of all incidents, and were thought to make an indirect contribution in up to one quarter. “Technical errors” were responsible for about 1 in 8 incidents. Analysing the relative contribution of each type of error for each type of problem allows the development of rational preventative strategies. Continued efforts must be made to improve the knowledge-base of anaesthetists, but AIMS has shown that there may also be much to gain from directing attention towards eliminating rule-based errors, for promoting the use of protocols, check-lists and crisis management algorithms, and improving anaesthetists’ insight into the factors contributing and circumstances in which slips and lapses may occur. Traditional patterns of behaviour in doctors may also make them more liable to certain types of human error; removing the onus for adhering to standards and approved work practices from the individual to the “system” may lead to more consistent application of the “best practice”.

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Greaney, MB BCh, BAO, FRCA, MSc, FJFICMI, David, Renu Roy, BSP, MSc, RPh, and Conor McDonnell, MD, MB BCh, BAO, FFARCSI. "Opioid-related harm in a quaternary pediatric hospital: A 5-year review." Journal of Opioid Management 16, no. 5 (2020): 375–82. http://dx.doi.org/10.5055/jom.2020.0592.

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Background: Opioid therapy in pediatrics may be particularly prone to error, yet the incidence of opioid-related medication error and harm has not yet been described in the pediatric inpatient setting.Methods: We reviewed a prospectively compiled medication safety database from November 1, 2012 to October 31, 2017. Reports originated from voluntary reporting, hospital code events, naloxone administrations, and reports of unexpected experiences of patient pain. Time, location, error characteristics, drug, route, prescription, error phase, mechanisms, harm, and outcome were collected for all reports. Error and harm were classified by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) system.Results: Over 697 opioid medication safety reports were included during the study period. Opioids were administered at a rate of 79.26 administrations per 100 patient bed days, with morphine and hydromorphone administered at 62 versus 15 administrations per 100 bed days, respectively. Overall error rate was 0.94 errors per 1,000 patient days. Although the absolute rate of error reporting was greater for morphine (0.65 errors reported per 1,000 opioid administrations) than for hydromorphone, the adjusted incidence of harm was 0.211 per 1,000 hydromorphone administrations compared to 0.086 per 1,000 morphine administrations. 47 opioid errors resulted in harm, and administration errors (29) were almost twice as common as prescribing errors (15).Conclusions: We report and aim to establish a comparative reference point for incidence of opioid-related error and harm adjusted for both hospital bed days and total opioid administrations within the pediatric hospital inpatient setting based on the above findings.

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Morone, Lauren L. "The Observational Error of Automated Wind Reports from Aircraft." Bulletin of the American Meteorological Society 67, no. 2 (1986): 177–85. http://dx.doi.org/10.1175/1520-0477-67.2.177.

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Data collected from aircraft equipped with AIDS (Aircraft Integrated Data System) instrumentation during the Global Weather Experiment year of 1979 are used to estimate the observational error of winds at flight level from this and other aircraft automated wind-reporting systems. Structure functions are computed from reports that are paired using specific criteria. The value of this function extrapolated to zero separation distance is an estimate of twice the random measurement-error variance of the AIDS-measured winds. Component-wind errors computed in this way range from 2.1 to 3.1 m · s−1 for the two months of data examined, January and August 1979. Observational error, specified in optimum-interpolation analyses to allow the analysis to distinguish among observations of differing quality, is composed of both measurement error and the error of unrepresentativeness. The latter type of error is a function of the resolvable scale of the analysis-prediction system. The structure function, which measures the variability of a field as a function of separation distance, includes both of these types of error. If the resolvable scale of an analysis procedure is known, an estimate of the observational error can be computed from the structure function at that particular distance. An observational error of 5.3 m · s−1 was computed for the u and v wind components for a sample resolvable scale of 300 km. The errors computed from the structure functions are compared to colocation statistics from radiosondes. The errors associated with automated wind reports are found to compare favorably with those estimated for radiosonde winds at that level.

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Dunn, Debra. "Incident reports-Correcting processes and reducing errors." AORN Journal 78, no. 2 (2003): 211–33. http://dx.doi.org/10.1016/s0001-2092(06)60772-2.

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Kermode-Scott, Barbara. "US has most reports of medical errors." BMJ 331, no. 7525 (2005): 1100.2. http://dx.doi.org/10.1136/bmj.331.7525.1100-a.

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Mohsin, Syed Umer, Yahya Ibrahim, and Diane Levine. "Teaching medical students to recognise and report errors." BMJ Open Quality 8, no. 2 (2019): e000558. http://dx.doi.org/10.1136/bmjoq-2018-000558.

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BackgroundMedical student error reporting can potentially be increased through patient safety education, culture change and by teaching students how to report errors. There is scant literature on what kinds of errors students see during clinical rotations. The authors developed an intervention to better understand what kinds of errors students see and to train them to identify and report errors.MethodsA safety curriculum was delivered during the Medicine clerkship for the academic year 2015–2016. Prior to the workshop, students completed a preintervention survey to determine whether they had reported a clinical error. Subsequently, they participated in an educational workshop. Facilitated discussions about conditions contributing to errors, types of errors, prevention of errors and importance of reporting followed. Students were required to submit a simulated error report about an error they personally observed. An end-of-year survey was sent to students who participated in the curriculum to determine clinical error reporting frequency.ResultsStudents submitted 282 reports. Near miss errors were seen in 64% and adverse events in 36%. National Quality Forum serious events were reported in 14%, including one death. Recommendations to prevent similar events were weak (62%). Students correctly categorised 93% near miss, 88% adverse events, 67% diagnostic, 81% treatment and 78% preventative errors. On the preintervention survey, 8.5% stated they submitted an error report to their clinical site. On the end-of-year survey, 18% confirmed submitting a formal error report.ConclusionTraining students to recognise and report errors can be successfully integrated into a clinical clerkship and impact clinical error reporting.

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Dinamika, Soraya Grabiella, and Elitaria B. A. Siregar. "A Morphological Error Analysis of Students’ Written Reports on Indonesia’s 2014 Presidential Election." IJEE (Indonesian Journal of English Education) 7, no. 1 (2020): 87–96. http://dx.doi.org/10.15408/ijee.v7i1.16978.

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ABSTRACTThis study, conducted at the Department of English Literature of Universitas Sumatera Utara (USU), aimed to investigate the morphological errors made by university students in their report texts on Indonesia’s Presidential Election in 2014. The objectives of this qualitative and descriptive study were to: a) find out the most predominant morphological errors made by the students; b) investigate the sources causing the errors; and c) suggest appropriate remediation for identified morphological errors. In analyzing the data, the Error Analysis theory, espoused by Gass and Selinker (2008), was applied as it provides six systematic procedures in overcoming L2 learning errors. Results of the analysis revealed that the students respectively made significant morphological errors in: a) the use of derivational morphemes with 46 errors (51%); b) the use of inflectional morphemes with 43 errors (47%); and c) the use of affixes with two errors (2%). The morphological error made by the students was caused by two primary sources, the interlanguage and intralanguage errors. To address these problematic areas, the researchers have suggested several pedagogical remediations to follow up.ABSTRAKPenelitian ini bertujuan untuk mengetahui kesalahan morfologi yang dibuat oleh mahasiswa Departemen Sastra Inggris Universitas Sumatera Utara, dalam teks laporan yang mereka tulis tentang Pemilihan Presiden Tahun 2014. Selain itu, penelitian ini bertujuan untuk; a) mencari tahu jenis kesalahan morfologi apa yang paling banyak terjadi; b) mencari tahu sumber penyebab kesalahan; dan c) memberikan langkah-langkah yang sesuai untuk mengatasi kesalahan morfologi. Dalam menganalisis data, teori yang digunakan adalah Teori Analisis Kesalahan yang digubah oleh Gass & Selinker pada tahun 2008, karena teori ini memuat enam prosedur lengkap dalam menangani masalah kesalahan pembelajaran bahasa kedua. Penelitian ini menggunakan pendekatan deskriptif kualitatif. Hasil analisis data mengemukakan bahwa kesalahan yang paling banyak terjadi dalam penggunaan morfem derivasi dengan jumlah 46 kesalahan (51%), diikuti oleh penggunaan morfem infleksional dengan jumlah 43 kesalahan (47%), dan yang paling sedikit adalah penggunaan imbuhan dengan jumlah 2 kesalahan (2%). Ada dua penyebab terjadinya kesalahan morfologi, yaitu kesalahan intrabahasa dan kesalahan interbahasa. Selanjutnya, peneliti menyarankan sejumlah langkah remediasi pedagogik untuk mengatasi kesalahan morfologi. How to Cite: Dinamika, S. G., Siregar, E. B.A.. (2020). A Morphological Error Analysis of Students’ Written Reports on Indonesia’s 2014 Presidential Election. IJEE (Indonesian Journal of English Education), 7(1), 85-94. doi:10.15408/ijee.v7i1.16978

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Bhargava, Divya, and Karen Marais. "Narrative Analysis of Runway Incursion Reports in the National Transportation Safety Board Database To Identify Contributing." Proceedings of the Human Factors and Ergonomics Society Annual Meeting 64, no. 1 (2020): 144–48. http://dx.doi.org/10.1177/1071181320641037.

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A runway incursion occurs when an aircraft, ground vehicle, or a pedestrian is incorrectly present on the runway. This incorrect presence can lead to a collision resulting in fatal injuries and aircraft damage. Despite the aviation community’s measures to reduce incursions, they continue increasing. Most runway incursions are a result of human error. Our limited knowledge of these human errors and their causes is hindering our ability to reduce runway incursions. While previous researchers have analyzed past runway incursions to identify types of human error, we still know little about the causes of these errors. The narratives in the NTSB database often provide detailed information to identify human errors and their causes. In this paper, we analyze the narratives of runway incursion reports in the NTSB database. We use task analysis to map human error to tasks they perform, and map the causes of these errors to the error itself.

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Patra, Anurima, Manthreshwar Premkumar, Shyamkumar N. Keshava, Anuradha Chandramohan, Elizabeth Joseph, and Sridhar Gibikote. "Radiology Reporting Errors: Learning from Report Addenda." Indian Journal of Radiology and Imaging 31, no. 02 (2021): 333–44. http://dx.doi.org/10.1055/s-0041-1734351.

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Abstract Background The addition of new information to a completed radiology report in the form of an “addendum” conveys a variety of information, ranging from less significant typographical errors to serious omissions and misinterpretations. Understanding the reasons for errors and their clinical implications will lead to better clinical governance and radiology practice. Aims This article assesses the common reasons which lead to addenda generation to completed reports and their clinical implications. Subjects and Methods Retrospective study was conducted by reviewing addenda to computed tomography (CT), ultrasound, and magnetic resonance imaging reports between January 2018 to June 2018, to note the frequency and classification of report addenda. Results Rate of addenda generation was 1.1% (n = 1,076) among the 97,003 approved cross-sectional radiology reports. Errors contributed to 71.2% (n = 767) of addenda, most commonly communication (29.3%, n = 316) and observational errors (20.8%, n = 224), and 28.7% were nonerrors aimed at providing additional clinically relevant information. Majority of the addenda (82.3%, n = 886) did not have a significant clinical impact. CT and ultrasound reports accounted for 36.9% (n = 398) and 35.2% (n = 379) share, respectively. A time gap of 1 to 7 days was noted for 46.8% (n = 504) addenda and 37.6% (n = 405) were issued in less than a day. Radiologists with more than 6-year experience created majority (1.5%, n = 456) of addenda. Those which were added to reports generated during emergency hours contributed to 23.2% (n = 250) of the addenda. Conclusion The study has identified the prevalence of report addenda in a radiology practice involving picture archiving and communication system in a tertiary care center in India. The etiology included both errors and non-errors. Results of this audit were used to generate a checklist and put protocols that will help decrease serious radiology misses and common errors.

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Mc Donnell, Conor. "Opioid Medication Errors in Pediatric Practice: Four years’ Experience of Voluntary Safety Reporting." Pain Research and Management 16, no. 2 (2011): 93–98. http://dx.doi.org/10.1155/2011/739359.

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BACKGROUND: Opioids are the most common source of drug error that leads to harm in pediatric hospitals.OBJECTIVE: To undertake a comprehensive review of experience with voluntary safety reports describing pediatric opioid medication errors at The Hospital for Sick Children (Toronto, Ontario), and to characterize the specific opioids involved, severity and type of error described, hospital location and time of day that the error occurred.METHODS: All medication-related safety reports submitted to an anonymous, voluntary electronic safety reporting database in a university-affiliated pediatric hospital during the first four years of its use were examined. A database of opioid error reports was created for further analysis.RESULTS: A total of 5935 medication-related safety reports were collected, 507 of which described opioids. Morphine was the most frequently reported opioid, administration was the most frequently reported stage of the medication process (192 errors) and surgical wards were the location from which opioid error was most frequently reported (128 reports). Twenty-two reports described patient harm requiring urgent treatment and intervention. Errors with codeine or hydromorphone resulted in the most significant harm reported. A total of 162 reports described problems with inappropriate opioid disposal, missing opioids, or incorrect opioid counts and checks.CONCLUSIONS: Future opportunities for improvement in opioid safety should focus on morphine, opioid administration errors in general, the safe disposal of opioids in the hospital environment and the identification of pain as an adverse event.

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Cohen, Michael R. "Clinicians Often Unaware of Colchicine Dose Limits; What is a “Bolus?”; Drug Information Leaflets can Help Prevent Errors." Hospital Pharmacy 37, no. 4 (2002): 355–56. http://dx.doi.org/10.1177/001857870203700402.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "FDA Advise-ERR: Deaths Associated with IV Colchicine; PCA Means Patient-Controlled Analgesia." Hospital Pharmacy 37, no. 5 (2002): 460–566. http://dx.doi.org/10.1177/001857870203700502.

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Cohen, Michael R. "Beware of Erroneous Daily Oral Methotrexate Dosing; Sound-Alike Names: Diprivan and Ditropan how Many Viokase? Indicate mEq of Potassium or Sodium when Phosphorous Supplements are Prescribed." Hospital Pharmacy 37, no. 6 (2002): 586–93. http://dx.doi.org/10.1177/001857870203700610.

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These medication errors have occurred in health care facilities at least once. They will happen again–perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "USP-Proposed Changes in Neuromuscular Blocker Package Labeling Will Help Prevent Errors; Important Check: Why Are “Missing Doses” Missing?; Information Technology Department Has Important Role in Preventing Medication Errors; Caution about Name Similarity: Avinza and Invanz." Hospital Pharmacy 37, no. 7 (2002): 708–62. http://dx.doi.org/10.1177/001857870203700708.

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Cohen, Michael R. "More on Avoiding Opiate Toxicity with PCA by Proxy; Brand Name Arixtra (Fondaparinux) Confused with Laboratory Test for Anti-Factor Xa; Avoid “AD” as an Abbreviation for “Right Ear”." Hospital Pharmacy 37, no. 8 (2002): 807–12. http://dx.doi.org/10.1177/001857870203700809.

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Cohen, Michael R. "Ensure Proper Mixing of Dual-Chamber Bags; Do Recruiters and Telemarketers Contribute to Dispensing Errors?; Wrong Dose Recognized, Not Returned, and Eventually Administered; Pediatric Medication Error Prevention Guidelines Published by ISMP and PPAG; Nonproprietary Names Also Involved in Errors." Hospital Pharmacy 37, no. 9 (2002): 911–1000. http://dx.doi.org/10.1177/001857870203700910.

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Cohen, Michael R. "Check Crash Cart Drug Concentrations for Broselow Tape Compatibility; Different Dosage Forms of Same Drug May Not Share the Same Monograph in the PDR; Mifepristone Confused with Misoprostol; A Nurse “Nose” How to Differentiate Products." Hospital Pharmacy 37, no. 10 (2002): 1037–38. http://dx.doi.org/10.1177/001857870203701008.

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Cohen, Michael R. "Involving Nonclinical Departments in Patient Safety Discussions can Reduce the Risk of Serious Errors; “40 of K” is Not OK; NDC Number ID of Compounded Prescription Ingredient Leads to Error; Topamax-Toprol XL Mix-Up." Hospital Pharmacy 37, no. 11 (2002): 1140–46. http://dx.doi.org/10.1177/001857870203701108.

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Cohen, Michael R. "Use Your Preadmission Process to Enhance Safety;Beware of Drug Names that End in the Letter “L”; It Doesn't Pay to Play the Percentages." Hospital Pharmacy 37, no. 12 (2002): 1257–61. http://dx.doi.org/10.1177/001857870203701208.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Use Metric Weight to Express Liquid Doses;Tuberculin Syringe Confused with Insulin Syringe;Duragesic Patch Abuse." Hospital Pharmacy 38, no. 1 (2003): 14–15. http://dx.doi.org/10.1177/001857870303800108.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Prevent Mix-ups between Vaccines and Neuromuscular Blockers;Confusing Haemophilus b Conjugate Vaccine with Influenza Vaccine;Proliferation of Insulin Combination Products Increases Opportunity for Errors." Hospital Pharmacy 38, no. 2 (2003): 109–10. http://dx.doi.org/10.1177/001857870303800209.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "With Levothyroxine, Be Careful where you Put the Decimal; It Should Go without Saying: Successful Weight-Based Programs Require a Weight; Don't Confuse Varicella Virus Vaccine with Varicella-Zoster Immune Globulin." Hospital Pharmacy 38, no. 3 (2003): 196–296. http://dx.doi.org/10.1177/001857870303800309.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Look-Alike Names and Packages Are at the Root of Most Stocking Errors in Automated Dispensing Cabinets Use Caution when Reconstituting Synagis (Palivizumab) Intrathecal Vincristine Fatal Once More Fellowship in Medication Safety Medication Safety Videos Available Free via the Internet." Hospital Pharmacy 38, no. 4 (2003): 312–13. http://dx.doi.org/10.1177/001857870303800402.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Sometimes Things Get Lost in Translation New Color Code for 25 Gauge Safety Needles may Lead to Confusion and Errors New Tools that Address Pharmacy Issues Related to Patient Safety Intra-arterial Lines Can Unwittingly Furnish a Route for Medications Intended for IV Administration." Hospital Pharmacy 38, no. 5 (2003): 412–15. http://dx.doi.org/10.1177/001857870303800508.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Ephedrine–Epinephrine Mix-Ups Nurse Computer Order Entry Leads to Error Precisely Wrong." Hospital Pharmacy 38, no. 7 (2003): 629–31. http://dx.doi.org/10.1177/001857870303800708.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers‘ names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Will CDC-Recommended Vaccine Abbreviations Reduce the Risk of Misinterpretation? Unintended Discontinuation of Drugs a Patch or Oral Therapy? Oral Vancomycin Does Not Treat Systemic Infections." Hospital Pharmacy 38, no. 8 (2003): 726–29. http://dx.doi.org/10.1177/001857870303800808.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Callahan, Christopher M., Wanzhu Tu, Timothy E. Stump, Daniel O. Clark, Kathleen T. Unroe, and Hugh C. Hendrie. "Errors in Self-Reports of Health Services Use." Alzheimer Disease & Associated Disorders 29, no. 1 (2015): 75–81. http://dx.doi.org/10.1097/wad.0000000000000048.

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Callahan, Christopher M., and Hugh C. Hendrie. "Errors in Self-Reports of Health Services Use." Alzheimer Disease & Associated Disorders 29, no. 4 (2015): 364–65. http://dx.doi.org/10.1097/wad.0000000000000110.

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Thompson, Cheryl A. "Technology hasn’t eliminated medication errors yet, USP reports." American Journal of Health-System Pharmacy 62, no. 3 (2005): 243–45. http://dx.doi.org/10.1093/ajhp/62.3.243.

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McCarthy, Claudine. "Avoid common errors in Title IX investigations, reports." Student Affairs Today 21, no. 2 (2018): 1–5. http://dx.doi.org/10.1002/say.30467.

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Smith, Janette. "Avoiding vaccination errors: learning from reports of ‘misuse’." Practice Nursing 23, no. 3 (2012): 142–45. http://dx.doi.org/10.12968/pnur.2012.23.3.142.

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Amato, Mary G., Alejandra Salazar, Thu-Trang T. Hickman, et al. "Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors." Journal of the American Medical Informatics Association 24, no. 2 (2016): 316–22. http://dx.doi.org/10.1093/jamia/ocw125.

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Objective: To examine medication errors potentially related to computerized prescriber order entry (CPOE) and refine a previously published taxonomy to classify them. Materials and Methods: We reviewed all patient safety medication reports that occurred in the medication ordering phase from 6 sites participating in a United States Food and Drug Administration–sponsored project examining CPOE safety. Two pharmacists independently reviewed each report to confirm whether the error occurred in the ordering/prescribing phase and was related to CPOE. For those related to CPOE, we assessed whether CPOE facilitated (actively contributed to) the error or failed to prevent the error (did not directly cause it, but optimal systems could have potentially prevented it). A previously developed taxonomy was iteratively refined to classify the reports. Results: Of 2522 medication error reports, 1308 (51.9%) were related to CPOE. Of these, CPOE facilitated the error in 171 (13.1%) and potentially could have prevented the error in 1137 (86.9%). The most frequent categories of “what happened to the patient” were delays in medication reaching the patient, potentially receiving duplicate drugs, or receiving a higher dose than indicated. The most frequent categories for “what happened in CPOE” included orders not routed to or received at the intended location, wrong dose ordered, and duplicate orders. Variations were seen in the format, categorization, and quality of reports, resulting in error causation being assignable in only 403 instances (31%). Discussion and Conclusion: Errors related to CPOE commonly involved transmission errors, erroneous dosing, and duplicate orders. More standardized safety reporting using a common taxonomy could help health care systems and vendors learn and implement prevention strategies.

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Cohen, Michael R. "Dose Confusion with Phosphorus-Containing Products Improper Mixing with Insulin Pens Counseling Patients on Proper Use of Measuring Devices “EDTA” Mix-Ups Modification of Percocet Nomenclature." Hospital Pharmacy 35, no. 2 (2000): 128–33. http://dx.doi.org/10.1177/001857870003500208.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute of Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 1-800-233-7767 (1-800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writer's names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Misidentification of Alphanumeric Characters Confusion between Sufenta and Sublimaze Fortune 500 Company Benefit Plans Adopting Computerized Physician Order Entry Standards." Hospital Pharmacy 35, no. 3 (2000): 234–36. http://dx.doi.org/10.1177/001857870003500310.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute of Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 1-800-233-7767 (1-800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writer's names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Making it Easier for Nurses to Identify Patients before Administering Medications Cafcit Label Easy to Misread Preventing Misunderstandings When Accepting Oral Requests for Drug Information Caution: 30 mL Vials of Topical and Injectable Adrenalin are Nearly Identical." Hospital Pharmacy 35, no. 5 (2000): 486–88. http://dx.doi.org/10.1177/001857870003500507.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute of Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 1-800-233-7767 (1-800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writer's names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "• Oral Feeding Formula Confused with Beta-Blocker/• Look-Alike Products from Bedford Laboratories/• Fatal Error with Simultaneous Low-Molecular-Weight and IV Heparins." Hospital Pharmacy 36, no. 3 (2001): 250–54. http://dx.doi.org/10.1177/001857870103600303.

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These medication errors have occurred in health care facilities at least once. They will happen again–perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 1-800-233-7767 (1-800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "• Drug Shortages Lead to Medication Errors; •Dispense from the Pharmacy, Not from Central Supply; •Use of Symbols Increases Medication Error Risk." Hospital Pharmacy 36, no. 5 (2001): 494–96. http://dx.doi.org/10.1177/001857870103600504.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 1-800-233-7767 (1-800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "•Confusion Possible between Colazal and Clozaril;•Failure to Adjust Dose of Amphotericin B When Route Changed from Oral to IV;•Fentanyl Transdermal System Unsafe in Inexperienced Hands." Hospital Pharmacy 36, no. 7 (2001): 729–30. http://dx.doi.org/10.1177/001857870103600705.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 1-800-233-7767 (1-800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Cohen, Michael R. "Another Purpose for “Purpose” Look-Alike Unit-Dose Containers Mixed up Misinterpretation of Sliding-Scale Insulin Dose." Hospital Pharmacy 36, no. 12 (2001): 1132–33. http://dx.doi.org/10.1177/001857870103601203.

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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 1-800-233-7767 (1-800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

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Kane, M. P., K. Fessele, J. Gordilis-Perez, et al. "Medication safety in cancer clinical trials: An analysis of medication error reports at a comprehensive cancer center." Journal of Clinical Oncology 25, no. 18_suppl (2007): 6547. http://dx.doi.org/10.1200/jco.2007.25.18_suppl.6547.

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6547 Background: Although medication errors comprise 10–25% of all medical errors, little is known concerning the occurrence or types of medication errors occurring while treating patients on a clinical trial. Therefore, we retrospectively reviewed the medication errors reported in patients enrolled on clinical trials at our center. Methods: As part of a multidisciplinary continuous quality improvement project, from January 2003 through December 2006, we collected voluntary reports of medication errors in adult and pediatric patients on clinical trials involving both oral and intravenous chemotherapy. All reports were classified prospectively regarding clinical trial involvement, severity category (A to I) per the National Coordination Council on Medical Error Reporting and Prevention, type, cause, and where in the medication use process the error occurred. Results: There were 163 reports involving patients treated on clinical trials. The most common errors were those corrected prior to reaching the patient in 68% of events (Category A&B), while 31% reached the patient but did not result in harm (Category C&D), with 1% resulting in temporary patient harm (Category E&F). The most common type of errors were prescribing (66%), improper dose (42%), and omission errors (9%). Not following an institutional procedure or the protocol was the primary cause for these errors (39%), followed by the written order (30%), and poor communication involving both the healthcare team and the patient (26%). The processes where the errors initiated were in prescribing 47%, administration 10%, dispensing 6%, and monitoring 5%. Conclusion: Medication errors do occur in clinical trials, however the majority of these are corrected prior to reaching the patient or do not result in harm. Not following an institutional procedure or the protocol was the most common cause of error. This is most likely due to the protocol procedures differing from existing standards of care. Protocol-specific education through the Centralized Education and Training Service, a shared resource within our cancer center, addresses this issue enhancing the quality and safety of clinical trials through the education and training of healthcare professionals. No significant financial relationships to disclose.

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