Therapeutic errors involving adults in the community setting: nature, causes and outcomes.
OBJECTIVE
To compare the nature of therapeutic errors made by adults in community residential units (CRU) and private homes (Home).


METHODS
This was an analytical case series of therapeutic errors, involving adults, reported to the Victorian Poisons Information Centre (January 2006 to March 2007). The main outcome measures were the nature, causes and outcomes of the errors and actions taken or recommendations for avoidance.


RESULTS
Ninety-seven CRU and 611 Home residents (cases) were enrolled. These groups took 243 (median 2) and 785 (median 1) medications in error, respectively (p<0.001). The medication administrators were predominately staff members (94.8%) and the cases themselves (95.9%), respectively (p<0.001). The CRU cases more frequently had an incorrect medication(s) or another person's medication(s) and the Home cases a double dose or incorrect dose (p<0.001). Wide ranges of medications were taken in error with cardiac and respiratory medications being more common among the Home cases. Four (4.1%, 95% CI 1.3-10.8) CRU and 16 (2.6%, 95% CI 1.6-4.3) Home cases were referred to hospital. No case followed up had a serious outcome. Error cause differed significantly between the groups (p<0.001). Staffing issues and human factors were common within the CRU and Home groups, respectively.


CONCLUSIONS
Therapeutic errors in the community are preventable and differ considerably between the CRU and Home settings.


CONCLUSIONS
Prevention initiatives are indicated with particular attention to CRU staffing, training and procedural issues.
Taylor
David McD
DM
Austin Health, Victoria. David.Taylor@austin.org.au
Robinson
Jeffrey
J
MacLeod
Dawson
D
MacBean
Catherine E
CE
Braitberg
George
G
D000368:Aged; D016009:Chi-Square Distribution; D003153:Community Health Services; D005260:Female; D006701:Home Nursing; D006707:Homes for the Aged; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D009735:Nursing Homes; D012307:Risk Factors; D012646:Self Administration; D018709:Statistics, Nonparametric; D011795:Surveys and Questionnaires