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Jeff Sutherland

Twice the Energy with Half the Stress

Medication Error: Error Rates Double 1996-2000

Medication error rates in hospitals are well known to be the fourth leading cause of death in the United States. Outpatient errors are probably much higher than inpatient errors, although little data exists for outpatient studies in the literature. I have argued for years that the number of unnecessary deaths is increasing every year from medication error because more drugs are given and they have more dramatic impact on the patients physical system. This combined with nursing shortages and underfunding of information techologies to prevent these errors have doubled the rate of medication error from 1996 to 2000 in the study below.

Prescribing Errors Involving Medication Dosage Forms

Timothy S. Lesar, Pharm D

Journal of General Internal Medicine, Volume 17 Issue 8 Page 579 – August 2002

CONTEXT: Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed.

OBJECTIVE: To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms .

DESIGN: Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital.

MAIN OUTCOME MEASURES: Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms.

RESULTS: A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially “fatal or severe” in 3 cases (0.7%), and “serious” in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%).

CONCLUSIONS: Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors.

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