Relationship between medication errors and adverse drug events

AUTHORS:

David W. Bates, Deborah L Boyle, Martha B. Vander Vliet, James Schneider and Lucian Leape

OBJECTIVES:

To evaluate the frequency of medication errors using a multidisciplinary approach, to classify these errors by type, and to determine how often medication errors are associated with adverse drug events (ADEs) and potential ADEs.

DESIGN:

Medication errors were detected using self-report by pharmacists, nurse review of all patient charts, and review of all medication sheets. Incidents that were thought to represent ADEs or potential ADEs were identified through spontaneous reporting from nursing or pharmacy personnel, solicited reporting from nurses, and daily chart review by the study nurse. Incidents were subsequently classified by two independent reviewers as ADEs or potential ADEs.

SETTING:

Three medical units at an urban tertiary care hospital.

PARTICIPANTS:

A cohort of 379 consecutive admissions during a 51-day period (1,704 patient-days).

INTERVENTIONS:

None.

MAIN OUTCOME MEASURE:

Over the study period, 10,070 medication orders were written, and 530 medications errors were identified (5.3 errors/100 orders), for a mean of 0.3 medication errors per patient-day, or 1.4 per admission. Of the medication errors, 53% involved at least one missing dose of a medication; 15% involved other dose errors, 8% frequency errors, and 5% route errors. During the same period, 25 ADEs and 35 potential ADEs were found. Of the 25 ADEs, five (20%) were associated with medication errors; all were judged preventable. Thus, five of 530 medication errors (0.9%) resulted in ADEs. Physician computer order entry could have prevented 84% of non-missing dose medication errors, 86% of potential ADEs, and 60% of preventable ADEs.

CONCLUSIONS:

Medication errors are common, although relatively few result in ADEs. However, those that do are preventable, many through physician computer order entry.

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