Medication Errors: Picking Up the Pieces

By Coleman, Imelda C | Drug Topics, March 15, 1999 | Go to article overview

Medication Errors: Picking Up the Pieces


Coleman, Imelda C, Drug Topics


Dedication errors, always considered unacceptable, likely occur more frequently than they are reported. That's due, in part, to the fact that many health-care workers, fearing retribution, are hesitant to report errors.

When errors occur, organizations must have systems in place to handle the consequences for the patients, the caregiver, and the institution. This article addresses these issues and also looks at some basic error-prevention methods.

Understanding why errors occur-the psychological process involved as well as the system that led to them-helps reduce errors. But when errors-even seemingly trivial ones-are not reported, a valuable source for error prevention is lost. The most common error-reporting methods include anonymous selfreports, incident reports, the critical-incident technique, and the disguised-observation technique.

As methods for revealing medication errors become more sophisticated, the true scope of the problem becomes clearer. It has resulted so far in the discovery that error frequency is high. Studies performed during the early 1980s detected an average of one medication error per patient per day. As unit dosing and awareness of the causal factors of medication errors emerge, more recent studies show the average error rate to be two to three per patient per week. To earn the trust of patients, health-care professionals need to put forth every effort to identify and eliminate this preventable source of harm.

The National Coordinating Council for Medication Error Reporting (Table 1) defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a health-care professional, patient, or consumer." Most research on the frequency of errors occurring in health care focuses on medication errors with regard to hospitalized patients. The ASHP estimates that about one out of every 100 doses of medication administered to patients is in error.

With managed care, a patient's length of stay in the hospital went from an average of 9.7 days in 1987 to 7.4 days in 1995, surveys reveal. This has resulted in an increased intensity of care provided per day; a nineyear study showed a doubling in the daily medication orders. In 1993, David W. Bates et al. reported a correlation between the increased number of orders and a higher rate of medication errors; the larger number of medication orders and shorter hospital stay have served to diminish the amount of time available for considering drug therapy issues and for monitoring the effect of therapy prior to discharge.

Adverse drug events

Medication errors (see Table 2) may lead to adverse drug events. Bates et al. have defined an adverse drug event (ADE) as "injury resulting from medical intervention related to a drug." Some medication errors result in an ADE, but most do not. In a 1995 study, Lucian L. Leape et al. found that 70 of 247 ADEs were due to medication errors; of these, 39% were attributable to physician ordering, and 38% resulted from nurse administration. The remaining errors were due to transcription errors or pharmacy dispensing.

The Harvard Medical Practice study surveyed 30,000 hospitalizations in several New York hospitals. They found that 3.7% of the patients experienced a serious, disabling adverse event during hospitalization-the single most common cause of injury (19%) being an adverse drug event.

Medication errors

There are three major steps between diagnosing a patient and administering medication in a hospital setting: the written statement describing the medication and dosage, the dispensing of the medication, and administration of the medication to the patient. Several studies have focused on the errors unique to each stage.

Point-of-entry errors

Point-of-entry errors (POEs) include errors that involve prescribing, ordering medications, or transcribing orders. …

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