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Reported medication errors in obstetric inpatients in 1 hospital
James A Little1, Maria B Velazquez, William F Rayburn
1Office of Quality and Outcomes Management, University Hospital, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM, USA. jlittle@salud.unm.edu
Objective:
To describe reported medication errors in the obstetric inpatients in 1 hospital.
Study Design:
We analyzed all errors, reported voluntarily in a nonpunitive manner, from December 1996 to November 2001.
Results:
The 164 medication errors led to 154 class 1 (no harm), 10 class 2 (additional therapy but no additional harm) and 0 class 3 (permanent harm) adverse drug events. Omissions and incorrect timing of drug administration were the most common reasons. The rate of class 1 adverse drug events was lower in labor and delivery than on the ward (0.8 versus 1.4 per 1,000 patient days; P < .05). Excess dosing with intravenous magnesium sulfate was the most common class 2 event.
Conclusion:
Reported medication errors on 1 inpatient obstetric service were very rare and not associated with permanent harm. Reporting these errors may identify system improvements and avoid recurrences.