Adverse drug events caused by serious medication administration errors.

Area of Science:

• Patient Safety
• Pharmacovigilance
• Healthcare Quality Improvement

Background:

• Medication administration errors are frequent in hospitals.
• The rate at which these errors cause actual harm is not well-established.
• Serious potential adverse drug events (ADEs) require further investigation into their outcomes.

Purpose of the Study:

• To quantify the incidence of actual harm resulting from serious or life-threatening potential adverse drug events (ADEs) during hospital medication administration.
• To assess the severity and attribution of harm caused by medication administration errors.

Main Methods:

• Retrospective chart review of clinical events following observed medication administration errors.
• Analysis of 133 serious or life-threatening potential ADEs identified from a prior study of 14,041 observed medication administrations.
• Clinical reviewers assessed ADE severity and causal attribution to the error.

Main Results:

• Ten (7.5%) actual ADEs occurred from 133 serious potential ADEs.
• Of these, 4 (3%) resulted in serious or life-threatening harm.
• Dosage or monitoring errors for anti-hypertensives accounted for half of the ADEs.

Conclusions:

• Unintercepted medication administration errors can lead to significant patient harm.
• Hospitals administering 6 million doses annually may experience around 4000 preventable ADEs from administration errors.
• These findings underscore the critical need for enhanced medication safety measures at the administration stage.