Medication Errors Observed in 36 Health Care Facilities

AUTHORS:

Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD; Ginette A. Pepper, PhD; David W. Bates, MD, MSc; Robert L. Mikeal, PhD

BACKGROUND:

Medication errors are a national concern.

OBJECTIVES:

To identify the prevalence of medication errors (doses administered differently than ordered).

DESIGN:

A prospective cohort study.

SETTING:

Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado.

PARTICIPANTS:

A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication–volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered.

METHODS:

Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians.

MAIN OUTCOME MEASURE:

Medication errors reaching patients.

RESULTS:

In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P = .82) or by size (P = .39). Error rates were higher in Colorado than in Georgia (P = .04)

CONCLUSIONS:

Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.

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