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Medication errors in the outpatient setting: classification and root cause analysis.

Amy L Friedman1, Sarah R Geoghegan, Noelle M Sowers

  • 1Department of Surgery, Yale University School of Medicine, New Haven, CT 06520-8062, USA. amy.friedman@yale.edu

Archives of Surgery (Chicago, Ill. : 1960)
|March 21, 2007
PubMed
Summary
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Medication errors are common in transplant patients, with patients themselves causing most errors. The healthcare system contributes to nearly one-third of these medication safety issues.

Area of Science:

  • Transplant medicine
  • Patient safety
  • Medication management

Background:

  • Medication errors pose a significant risk to patient safety, particularly in complex patient populations.
  • Understanding the root causes of medication errors is crucial for developing effective interventions.

Purpose of the Study:

  • To classify causal factors of medication errors in transplant recipients.
  • To identify opportunities for systematic improvements in prescription medication safety.

Main Methods:

  • A 12-month review of medication lists for liver, kidney, and/or pancreas transplant recipients.
  • Classification of errors into five categories: prescription, delivery, availability, patient, and reporting errors.
  • Root cause analysis to determine the source of errors.

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Main Results:

  • 149 medication errors were identified in 93 patients, with an average of 10.9 medications prescribed per patient.
  • Patient errors constituted the majority (56%), followed by prescription (13%) and delivery errors (13%).
  • The healthcare system was implicated in 27% of errors, with patients identified as the cause in 68%.

Conclusions:

  • Outpatient medication errors are frequent and often undetected in transplant patients, leading to adverse events.
  • A substantial portion of medication errors are linked to the healthcare system, highlighting the need for systemic changes.