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.
Center for Research on Pharmacy Operations and Designs, School of Pharmacy, Auburn University, 128 Miller Hall, Auburn, AL 36849-5506, USA. barkekn@auburn.edu
Kenneth N
KN
Barker
Elizabeth A
EA
Flynn
Ginette A
GA
Pepper
David W
DW
Bates
Robert L
RL
Mikeal
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