California nurses do not go into the hospital without a buddy nurse who watches their treatment, and particularly their medications. One of my colleagues recently had a young child in for surgery who would have been overdosed on morphine if a family member was not logging every medication dose at the bedside. There have been many retrospective studies of historical data that have clearly identified the problem. Some new studies are prospective. They look at the problem as it is happening, resulting in more accurate measurement of the frequency and severity of the error.
Medication Errors Observed in 36 Health Care Facilities. Arch Intern Med. 2002;162:1897-1903
Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD; Ginette A. Pepper, PhD; David W. Bates, MD, MSc; Robert L. Mikeal, PhD
Background: Medication errors are a national concern.
Objective: To identify the prevalence of medication errors (doses administered differently than ordered).
Design: A prospective cohort study.
Setting: Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado.
Participants: A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication–volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered.
Methods: Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians.
Main Outcome Measure: Medication errors reaching patients.
Results: In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P = .82) or by size (P = .39). Error rates were higher in Colorado than in Georgia (P = .04)
Conclusions: Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.