title: Medication errors outside healthcare facilities: a national poison centre perspective.
abstract: Medication errors (ME) are a major concern to healthcare systems. Most studies evaluated ME occurring in healthcare facilities; only few focused on ME outside them. The objective was to characterise ME occurring outside healthcare facilities. A prospective observational follow-up study evaluating all ME occurring outside healthcare facilities reported to a national poison information centre during a 5-month period. For each ME case, a detailed questionnaire was filled and a follow-up call was made within 7 days. The collected data included demographics, circumstances, type of error and outcome. Of 1381 consecutive ME cases were included; 97.8% involved a single incident and 88.3% one drug. The main characteristics of the ME were as follows: children younger than 6 years old (58.9%), parents responsible for 55.6% of cases, wrong dose 34.5% and different medication 30.1%. Analgesics (27.4%) and antimicrobials (12.2%) were the most common pharmaceuticals. The main reasons for the ME were look-alike packaging (31.4%) and misunderstood instructions (28%). Most followed up patients (97.1%) were asymptomatic or mildly affected; there was one severe case and no mortality. Most ME occurring outside healthcare facilities are single incidents, involving young children who were administered a wrong dose or medication due to look-alike packaging or misunderstood instructions with asymptomatic or mild outcome. Improved packaging, labelling and patient education are suggested to reduce ME.
authors: Israel Information Poison Center, Rambam Health Care Campus, Haifa, Israel; Clinical Pharmacology and Toxicology Unit, Carmel Medical Center, Haifa, Israel.
authors: Ophir
authors: O
authors: Lavon
authors: Adi
authors: A
authors: Ben-Zeev
authors: Yedidia
authors: Y
authors: Bentur
mesh_terms: D000328:Adult; D002675:Child, Preschool; D004348:Drug Labeling / Q000592:standards; D004349:Drug Packaging / Q000592:standards; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000706:statistics & numerical data*; D011039:Poison Control Centers / Q000706:statistics & numerical data*; D011041:Poisoning / Q000453:epidemiology*; D011446:Prospective Studies; D011795:Surveys and Questionnaires