Errors in the medication process: Frequency, type, and potential

Aarhus University Hospital, Department of Quality improvement and Patient Safety, Aarhus, Denmark.
International Journal for Quality in Health Care (Impact Factor: 1.76). 03/2005; 17(1):15-22. DOI: 10.1093/intqhc/mzi015
Source: PubMed


To investigate the frequency, type, and consequences of medication errors in more stages of the medication process, including discharge summaries.
A cross-sectional study using three methods to detect errors in the medication process: direct observations, unannounced control visits, and chart reviews. With the exception of errors in discharge summaries all potential medication error consequences were evaluated by physicians and pharmacists.
A randomly selected medical and surgical department at Aarhus University Hospital, Denmark.
Eligible in-hospital patients aged 18 or over (n = 64), physicians prescribing drugs and nurses dispensing and administering drugs.
Frequency, type, and potential clinical consequences of all detected errors compared with the total number of opportunities for error.
We detected a total of 1065 errors in 2467 opportunities for errors (43%). In worst case scenario 20-30% of all evaluated medication errors were assessed as potential adverse drug events. In each stage the frequency of medication errors were-ordering: 167/433 (39%), transcription: 310/558 (56%), dispensing: 22/538 (4%), administration: 166/412 (41%), and finally discharge summaries: 401/526 (76%). The most common types of error throughout the medication process were: lack of drug form, unordered drug, omission of drug/dose, and lack of identity control.
There is a need for quality improvement, as almost 50% of all errors in doses and prescriptions in the medication process were caused by missing actions. We assume that the number of errors could be reduced by simple changes of existing procedures or by implementing automated technologies in the medication process.

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    • "than previous studies. In previous two survey studies the medication error rates were reported as 42.1% and 43 % (Lisby et al., 2005; Mrayyon et al., 2007). In another survey reporting errors from nurse's perspective showed that the error rate was 64.5% (Cheragi et al., 2013). "
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    • "In emergency of Hospital A, the prescriptions on which the dose was not mentioned counted as 43.9% as compared to 1% in emergency department of Hospital B, probably due to e-prescribing in this department. In a study, the most common types of error throughout the medication process were: lack of drug form, unordered drug, and omission of drug/dose [18]. A small percentage (0.6–7.5%) of under dose can be seen in both hospitals prescriptions, this may lead to incomplete treatment and the patients usually need extra visits to hospitals. "
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    • "In detecting problems in the medication process, a direct observation method has been found to be a more efficient and accurate method than reviewing charts and incident reports (Flynn et al., 2002). This method was quite similar to a previous structured observation study conducted in Aarhus University Hospital's medical and surgical wards (Lisby et al., 2005), which also revealed information concerning the lack of patients' identification. However, unlike that study, we identified work environmental and nurse-related factors that could be associated with patient identification. "
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