title: An in-depth analysis of medication errors in hospitalized patients with HIV.
abstract: BACKGROUND
  It is well recognized that medication errors occur and can affect success in treating patients with HIV/AIDS. However, little information is available describing the prevalence, nature, and causes of medication errors.
  
  
  OBJECTIVE
  To determine the incidence of combination antiretroviral therapy (ART)- and opportunistic infection (OI)-related medication errors and describe the nature and cause(s) of errors to guide future interventions.
  
  
  METHODS
  A daily antiretroviral utilization report was used to identify adults who were receiving ART and had been admitted to a tertiary care teaching hospital during 2 consecutive months in 2005. Patients' charts, medication profiles, and medication administration records were reviewed for medication errors such as improper dosing, interactions, drug omissions, and missing doses. Once identified, etiology and cause were further investigated through provider interviews. An interdisciplinary team reviewed each case to establish validity of the error, severity, and cause.
  
  
  RESULTS
  Sixty-nine combined ART- and OI-related medication errors were identified in 20 of 26 (77%) evaluated patients, with 2.7 medication errors per patient. Fifty-four percent of the errors occurred within the first 24 hours after admission. Inadequate medication reconciliation on admission caused 21 of 37 (57%) admission-related errors. The most prevalent error types included missing doses (20%), underdosing (13%), overdosing (13%), therapy omission (13%), and drug-drug interaction (12%). The primary cause of errors was provider lack of knowledge.
  
  
  CONCLUSIONS
  Prospective investigation of medication errors provided in-depth insight into the diverse nature of HIV-related medication errors, risk factors, and potential preventive strategies. System changes such as hard stops in the clinical decision support software and improved medication reconciliation training, and changes in cart-fill time could prevent specific types of errors. Further studies are warranted to evaluate the impact of various strategies for preventing medication errors in the HIV population.
authors.affiliation: College of Pharmacy, University of Florida, Gainesville, FL, USA. snyder@cop.ufl.edu
authors.forename: Ann M
authors.initials: AM
authors.lastname: Snyder
authors.forename: Kenneth
authors.initials: K
authors.lastname: Klinker
authors.forename: Joanne J
authors.initials: JJ
authors.lastname: Orrick
authors.forename: Jennifer
authors.initials: J
authors.lastname: Janelle
authors.forename: Almut G
authors.initials: AG
authors.lastname: Winterstein
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy*; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D004347:Drug Interactions; D011307:Drug Prescriptions; D015658:HIV Infections / Q000188:drug therapy*; D006760:Hospitalization; D006801:Humans; D057970:Inappropriate Prescribing; D008508:Medication Errors / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012307:Risk Factors
chemical_list: D044966:Anti-Retroviral Agents