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iDoseCheck
Visualize Safety
Jacqueline Ellis, RN, PhDStephanie Langford, RN, MEd
Powered by Clinical Evaluation Online (CEO) Inc
Problem• Drug calculation errors common and deadly
– 5 and 10- fold errors range from 6% to 15% of reported pediatric drug errors– morphine most commonly associated with error
• Specialty pediatric hospitals not immune to errors– 6,000 medication incident reports from SickKids (2004-2009)– 4% were 10-fold errors (240 errors) – patient harm noted in 22 cases– 18 errors were 100-fold overdoses
• Wrong dose errors occur in a global context– UK-study 5,000 incidents involving chemotherapy were analyzed (2003-2008)– 32% were wrong dose, including wrong strength (1600 errors)– 7 fatalities, 9 episodes of moderate harm and 9 episodes of severe harm
resulted from errors
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Problem
• Drug errors end lives and careers • Drug errors cost money • Lack of confidence with
calculations wastes valuable time
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Solutions
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Typical text based calculator
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Value Added Solutions
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Value Added Solutions
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Research ProgramStudy 1 A human factors approach to understanding medication errors related tointravenous morphine administration in a pediatric hospital (2009)
Study 2 Preventing Medication Errors with High Alert Drugs: Testing a Computerized Double Check (2009-211)
Research Team
Business Team
connected networks
relevant experience
contextual knowledge
manage information
people, money
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Vivian Joseph Mathews, BEngJacqueline Ellis, RN, PhDStephanie Langford, RN MEd
Thank YouQuestions?