Medication errors during hospital drug rounds.
Objective--To determine the nature and rate of drug administration errors in one National Health Service hospital. Design--Covert observational survey be tween January and April 1993 of drug rounds with intervention to stop drug administration errors reaching the patient. Setting--Two medical, two surgical, and two medicine for the elderly wards in a former district general hospital, now a NHS trust hospital. Subjects--37 Nurses performing routine single nurse drug rounds. Main measures--Drug administration errors recorded by trained observers. Results--Seventy four drug rounds were observed in which 115 errors occurred during 3312 drug administrations. The overall error rate was 3.5% (95% confidence interval 2.9% to 4.1%). Errors owing to omissions, because the drug had not been supplied or located or the prescription had not been seen, accounted for most (68%, 78) of the errors. Wrong doses accounted for 15% (17) errors, four of which were greater than the prescribed dose. The dose was given within two hours of the time indicated by the prescriber in 98.2% of cases. Conclusion--The observed rate of drug administration errors is too high. It might be reduced by a multidisciplinary review of practices in prescribing, supply, and administration of drugs.
Ridge
K W
KW
Department of Pharmacy, University of Manchester, UK.
Jenkins
D B
DB
Noyce
P R
PR
Barber
N D
ND
D000368:Aged; D006757:Hospital Units; D006779:Hospitals, Public / Q000706:statistics & numerical data; D006801:Humans; D008508:Medication Errors / Q000706:statistics & numerical data*; D009741:Nursing Staff, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D013222:State Medicine; D006113:United Kingdom