title: Learning from error: identifying contributory causes of medication errors in an Australian hospital.
abstract: OBJECTIVE
  To study the clinical contexts contributing to harmful medication errors.
  
  
  METHODS
  A qualitative study using semi-structured interviews was conducted between March and August 2005 at Fremantle Hospital, a 450-bed metropolitan teaching hospital. Twenty-six of 46 staff members (57%) identified by pharmacy staff as having contributed to a significant medication error were interviewed. Interviews were recorded and transcribed for thematic analysis.
  
  
  RESULTS
  Most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. Knowledge-based mistakes (eg, failure to follow a protocol) also contributed to prescribing errors. Errors were more likely to occur during tasks being carried out after hours by busy, distracted staff, often in relation to unfamiliar patients. Communication problems with senior staff and difficulty accessing appropriate drug dosing information contributed to knowledge-based prescribing errors. Several medical staff were unaware they had committed an error until their involvement with our study.
  
  
  CONCLUSIONS
  Contextual factors that contributed to slips, lapses and knowledge-based mistakes in our sample are likely to be widespread in hospitals, and their impact on medication error may be substantial. Staff need training in how to recognise and deal with error-prone clinical situations. Safe prescribing practices (eg, the absolute requirement to acquire information before prescribing unfamiliar drugs) must be emphasised. Improved access to drug information at the point of prescribing, attention to communication barriers, and increasing staffing levels in particular areas are other potential strategies for reducing error.
authors.affiliation: Department of General Medicine, School of Medicine and Pharmacology, University of Western Australia, Fremantle, WA, Australia.
authors.forename: Pamela
authors.initials: P
authors.lastname: Nichols
authors.forename: Tandy-Sue
authors.initials: TS
authors.lastname: Copeland
authors.forename: Ian A
authors.initials: IA
authors.lastname: Craib
authors.forename: Paul
authors.initials: P
authors.lastname: Hopkins
authors.forename: David G
authors.initials: DG
authors.lastname: Bruce
mesh_terms: D001315:Australia; D002983:Clinical Competence; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control; D008510:Medication Systems, Hospital / Q000458:organization & administration*; D010607:Pharmacy Service, Hospital / Q000458:organization & administration; D012307:Risk Factors; D016526:Workload