Preventing Medication Errors (2007) / Chapter Skim
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Appendix C Medication Errors: Incidence Rates
Appendix C Medication Errors: Incidence Rates
Pages 367-408
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From page 367... ...
INCIDENCE OF MEDICATION ERRORS IN HOSPITAL CARE Selection and Procurement of the Drug by the Pharmacy No studies were identified that specifically identified medication errors of this type. It is possible that these types of errors were included in studies of general medication error rates.
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-- clinical pharmacist directly participating in clinical care 1,400 (Bates et al., 1995a) -- prompted reporting, chart review, review of medication orders Per 1,000 orders -- detection methods 0.61 (Lesar, 2002a)
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. Administration of the Drug As with prescribing error rates, rates of administration errors varied widely in medical and surgical units (See Table C-3)
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-- prompted reports medications Error rates in Per opportunity/dose -- detection method intensive care 3.3 percent (Calabrese et al., 2001) -- direct observation units (ICUs)
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. In another study, carried out in a medical ICU in a French hospital, an administration error rate of 6.6 percent was observed (2,009 medication administration interventions by nurses)
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Carried out in 1993 under the Adverse Drug Events Prevention Study, this study found an overall ADE rate of 6.5 per 100 nonobstetric admissions (or 11.5 ADEs per 1,000 patient-days) ; of these, 28 percent were judged preventable (Bates et al., 1995b)
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From page 373... ...
Prescription and Selection of the Drug for the Patient: Errors of Omission Errors of omission occur when a medication necessary for the appropriate care of hospitalized individuals is not prescribed. After reviewing the published literature on medication errors of omission within acute care, the committee identified three broad categories of studies: studies on treatment of acute coronary syndromes, on antibiotic prophylaxis, and on thrombosis prophylaxis (see Table C-6)
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374 APPENDIX C TABLE C-6 continued Percentage of patients given beta-blockers within 24 hours of hospitalization 66 (Sanborn et al., 2004)
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. Thrombosis Prophylaxis The committee identified nine studies that determined rates of thromboembolic prophylaxis in at-risk hospitalized patients (Campbell et al., 2001; Ageno et al., 2002; Ahmad et al., 2002; Aujesky et al., 2002; Freeman et al., 2002; Learhinan and Alderman, 2003; Scott et al., 2003; Tan and Tan, 2004; Chopard et al., 2005)
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From page 376... ...
. Administration Errors The committee identified a few studies that measured the incidence of medication administration errors in nursing homes (see Table C-7)
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-- direct observation 58 nursing homes identified a mean error rate of 12.2 percent (range 059 percent over the 58 nursing homes) , where an error was defined as a dose administered or omitted that deviates from the physician's orders (Barker et al., 1982)
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. Wrong-time errors were even more prevalent in nursing homes, where the error rate decreased from 35.6 to 6.7 percent when wrong-time errors were excluded (Scott-Cawiezell et al., 2005)
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collected parallel data on 2,557 doses using direct observation, chart review, and voluntary incident reporting. Rates of error detected by the three methods across all study sites (including 24 hospitals and 12 nursing homes)
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The first (Gurwitz et al., 2000) examined the incidence and preventability of ADEs over a 12-month period in long-term residents of 18 nursing homes served by one pharmacy provider in Massachusetts.
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nursing homes, between 24 and 120 ADEs occur annually in the average nursing home (bed size 105)
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. Using judgments of an expert review panel, Ruths and colleagues identified underuse of beneficial therapy in 13 percent of residents in 23 nursing homes in Norway (Ruths et al., 2003)
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. Cross-sectional studies using the SAGE database or MDS data have indicated that 26 percent of nursing home residents overall and 30 percent of those with a cancer diagnosis have daily pain, and approximately 25 percent of these individuals receive no analgesics (Bernabei et al., 1998; Won et al., 1999, 2004)
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INCIDENCE OF MEDICATION ERRORS IN AMBULATORY CARE For the purposes of this study, the committee examined medication error rates in six different settings within the ambulatory care domain: (1) the interface between care settings, for example, from hospital care to outpatient clinic; (2)
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. The Ambulatory Clinic Most studies on medication errors in ambulatory care have focused on prescribing errors (see Table C-11)
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. Overall, there was a medication error rate of 3 percent (306 out of 10,122 orders)
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The remaining 62 percent referred the user to enclosed prescribing information, which in 27 percent of cases was not in fact enclosed. Lack of Medication Monitoring The committee identified only one study of medication monitoring in an ambulatory care setting.
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. Although telephone prescription errors in the community pharmacy setting have raised concern about patient safety, the committee could only find one study addressing this topic.
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The medication error rate did not differ significantly by pharmacy type or city. This dispensing error rate indicates that there are approximately 4 errors per 250 prescriptions per pharmacy per day, translating to an estimated 51.5 million errors during the filling of 3 billion prescriptions each year.
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A 2001 study analyzed the medication usage of 6,718 elderly home care patients and found that 30 percent had experienced potential medication errors when either the Home Health criteria (Brown et al., 1998) or the Beers criteria (Beers et al., 1992; Beers, 1997)
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reported sharing their medication with someone else. The School Setting The committee found no studies on medication error rates in the school setting.
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, the fact that children are much less able than adults to double-check their own medications in any setting, and the wide range of appropriate doses for any medication based on the child's size, children are uniquely vulnerable to medication errors. Accurate pediatric medication administration requires accurate weights; proper conversion of pounds to kilograms; the correct choice of appropriate preparations
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. Using a broader definition of medication error, a French study reported a higher error rate -- 24 percent (937 prescribing errors out of 3,943 orders)
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prior to the implementation of computerized physician order entry (CPOE) (Cordero et al., 2004)
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for all types of medication in an inpatient setting (Kaushal et al., 2001) ; 23 TABLE C-19 Hospital Pediatric Care: Preparation and Dispensing Errors Error rates Errors per 1,000 patients -- detection method 5 (Kaushal et al., 2001)
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. Pediatric Care in the Ambulatory and Emergency Department Setting The majority of pediatric medication error studies identified by the committee were focused on hospitalized patients.
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. Of the two emergency department studies, one focused on global estimates of prescription and administration errors in this setting, and the other on medication errors with respect to antipyretics (see Table C-23)
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INCIDENCE OF MEDICATION ERRORS IN PSYCHIATRIC CARE Many studies of medication errors associated with psychotropic medication were conducted as part of either larger general medicalsurgical studies or ADE-reporting databases or were limited to geriatric populations in settings not restricted to psychiatric care, such as nursing homes and ambulatory clinics. General MedicalSurgical Studies An 18-month study in a tertiary care hospital used computerized monitoring to identify 701 ADEs, including 18 due to psychotropic drugs (2.4 percent)
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TABLE C-25 Psychiatric Care: Medication Errors Prescribing errors Errors per 1,000 patient-days -- detection method 165 (Grasso et al., 2003) -- chart review Transcription errors Errors per 1,000 patient-days -- detection method 334 (Grasso et al., 2003)
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From page 400... ...
These include the selection and procurement of medications, monitoring of the effectiveness of medications in all care settings, medication use in schools, medication use in psychiatric care, and the use of over-the-counter and complementary and alternative medications. The committee concludes that still greater effort is needed in all care settings to identify the incidence of medication errors -- both to measure the extent and scope of such errors and to assess the impact of error prevention strategies.
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1982. Medication errors in nursing homes and small hospitals.
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1987. Drug-related problems in nursing homes: Medication errors.
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2004. Impact of computerized physician order entry on clinical practice in a newborn intensive care unit.
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2000. Incidence and preventability of adverse drug events in nursing homes.
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2006, in press. Assessing appropriateness of pain medication prescribing practices in nursing homes.
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1995. Epidemiology of adverse drug events in the nursing home setting.
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2005. Level of nursing credential and interruptions: What is the impact on nursing home medication administration accuracy?
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2003. Prescribing indicators for evaluating drug use in nursing homes.
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