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Medication-prescribing errors in a teaching hospital. A 9-year experience

T S Lesar1, B M Lomaestro, H Pohl

  • 1Albany Medical Center, NY, USA.

Archives of Internal Medicine
|July 28, 1997
PubMed
Summary

Medication prescribing errors in hospitals increased significantly over nine years, posing a growing risk to patients. This highlights the need for robust error reduction and prevention strategies in healthcare systems.

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Area of Science:

  • Pharmacovigilance
  • Health Services Research
  • Patient Safety

Background:

  • Understanding medication prescribing errors is crucial for developing effective prevention strategies.
  • A systematic approach to error detection and analysis can inform healthcare practices.

Purpose of the Study:

  • To analyze a nine-year experience with a systematic program for detecting, recording, and evaluating medication-prescribing errors in a teaching hospital.
  • To identify trends and changes in the frequency and characteristics of these errors over time.

Main Methods:

  • Systematic recording and analysis of all medication-prescribing errors with potential for adverse patient outcomes, averted by staff pharmacists.
  • Evaluation of errors based on type, medication class, prescribing service, potential severity, time of day, and month.

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  • Statistical analysis to determine changes in error frequency and characteristics over the nine-year study period (1987-1995).

    • Main Results:

    • A total of 11,186 medication-prescribing errors were detected and averted.
    • The annual number of detected errors increased significantly from 522 in 1987 to 2115 in 1995.
    • Error rates per order, admission, and patient-day increased significantly, correlated with increased admissions. Common errors involved antimicrobials, cardiovascular agents, and dosing issues.

    Conclusions:

    • Hospitalized patients face a progressively increasing risk of adverse drug events.
    • Increased medical care intensity and drug use likely contribute to rising error rates.
    • Similar error types recurred, and new errors emerged with new therapies, necessitating integrated error reduction mechanisms.