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Related Experiment Videos

Experience with a national medication error reporting program

T A Edgar1, D S Lee, D D Cousins

  • 1Practitioner's Reporting Network, United States Pharmacopeial Convention, Inc. (USP), Rockville, MD 20852.

American Journal of Hospital Pharmacy
|May 15, 1994
PubMed
Summary
This summary is machine-generated.

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A national database captured 568 medication errors from 1991-1993. Product issues caused most errors, while cognitive factors led to fatalities, highlighting the need for reporting programs.

Area of Science:

  • Pharmacovigilance
  • Patient Safety
  • Health Informatics

Background:

  • Medication errors pose a significant risk to patient safety.
  • Voluntary reporting systems are crucial for identifying and mitigating these errors.
  • The United States Pharmacopeial Convention (USP) and Institute for Safe Medication Practices (ISMP) collect and analyze medication error data.

Purpose of the Study:

  • To summarize actual and potential medication errors reported to a national database between August 1991 and April 1993.
  • To identify common causes, contributing factors, and drugs involved in medication errors.
  • To assess the role of product problems and cognitive errors in medication errors.

Main Methods:

  • Analysis of 568 voluntary medication error reports submitted to the USP.

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  • Classification of errors into potential, actual-intercepted, and actual-transpired categories.
  • Identification of implicated healthcare professionals, involved medications, and contributing factors.

    • Main Results:

    • 406 actual and 162 potential medication errors were reported.
    • Nurses, pharmacists, and physicians were most frequently implicated.
    • Heparin, lidocaine, epinephrine, and potassium chloride were the most common drugs involved in errors.
    • Product problems (e.g., packaging, labeling) were the leading cause of errors, while cognitive errors were primary in fatalities.
    • Lidocaine was associated with the highest number of fatalities.

    Conclusions:

    • A national medication error reporting program provides valuable feedback to healthcare practitioners and manufacturers.
    • Understanding error patterns can inform strategies to improve medication safety.
    • Addressing both product-related and cognitive factors is essential for reducing medication errors.