Medication errors observed in 36 health care facilities.
BACKGROUND
Medication errors are a national concern.


OBJECTIVE
To identify the prevalence of medication errors (doses administered differently than ordered).


METHODS
A prospective cohort study.


METHODS
Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado.


METHODS
A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication-volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered.


METHODS
Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians.


METHODS
Medication errors reaching patients.


RESULTS
In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P =.82) or by size (P =.39). Error rates were higher in Colorado than in Georgia (P =.04)


CONCLUSIONS
Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.
Barker
Kenneth N
KN
Center for Research on Pharmacy Operations and Designs, School of Pharmacy, Auburn University, 128 Miller Hall, Auburn, AL 36849-5506, USA. barkekn@auburn.edu
Flynn
Elizabeth A
EA
Pepper
Ginette A
GA
Bates
David W
DW
Mikeal
Robert L
RL
D000068:Accreditation; D015331:Cohort Studies; D003120:Colorado; D005845:Georgia; D006302:Health Services Research / Q000379:methods; D006761:Hospitals / Q000145:classification / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D008508:Medication Errors / Q000706:statistics & numerical data*; D008509:Medication Systems / Q000592:standards* / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital / Q000592:standards / Q000706:statistics & numerical data; D009740:Nursing Staff; D010595:Pharmacists; D010607:Pharmacy Service, Hospital / Q000592:standards / Q000706:statistics & numerical data; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000379:methods; D015203:Reproducibility of Results; D012866:Skilled Nursing Facilities / Q000145:classification / Q000592:standards* / Q000706:statistics & numerical data; D014481:United States