Related Experiment Videos
Medication errors observed in 36 health care facilities.
Kenneth N Barker1, Elizabeth A Flynn, Ginette A Pepper
1Center for Research on Pharmacy Operations and Designs, School of Pharmacy, Auburn University, 128 Miller Hall, Auburn, AL 36849-5506, USA. barkekn@auburn.edu
Archives of Internal Medicine
|August 28, 2002
Summary
Medication errors are frequent, with nearly 1 in 5 doses administered incorrectly in hospitals and skilled nursing facilities. A significant percentage of these errors pose potential harm, highlighting widespread issues in medication administration systems.
Area of Science:
- Healthcare Quality
- Patient Safety
- Pharmacology
Background:
- Medication errors represent a significant national concern within healthcare systems.
- Ensuring accurate medication administration is critical for patient safety and treatment efficacy.
Purpose of the Study:
- To determine the prevalence of medication errors, defined as doses administered differently than prescribed.
- To identify the types and potential clinical significance of medication administration discrepancies.
Main Methods:
- A prospective cohort study was conducted across 36 healthcare institutions (accredited hospitals, non-accredited hospitals, and skilled nursing facilities) in Georgia and Colorado.
- Nurses administered medication doses during a 1- to 4-day observation period, with errors identified through direct observation and verified by a research pharmacist.
- An expert panel of physicians assessed the clinical significance of observed medication errors.
Main Results:
- A high prevalence of medication errors was observed, with 19% of all doses administered incorrectly (605/3216).
- The most common errors included wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%).
- Error rates did not significantly differ by institution type or size, but were higher in Colorado than Georgia (P=.04).
Conclusions:
- Medication errors are common, affecting nearly one in five doses in typical healthcare settings.
- Approximately 7% of medication errors were deemed potentially harmful, indicating a substantial risk to patients.
- The findings underscore the widespread and systemic nature of problems within medication administration systems.