Medication Errors Observed in 36 Health Care Facilities

Abstract

Background: Medication errors are a national concern. Objective: 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 per- cent 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 ad- ministration systems, although varied, is widespread.