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Medication-Prescribing Errors in a Teaching Hospital: A 9-Year Experience

Medication-Prescribing Errors in a Teaching Hospital: A 9-Year Experience Abstract Background: Improved understanding of medication-prescribing errors should be useful in the design of error prevention strategies. Objective: To report analysis of a 9-year experience with a systematic program of detecting, recording, and evaluating medication-prescribing errors in a teaching hospital. Methods: All medication-prescribing errors with potential for adverse patient outcome detected and averted by staff pharmacists from January 1, 1987, through December 31, 1995, were systematically recorded and analyzed. Errors were evaluated by type of error, medication class involved, prescribing service, potential severity, time of day, and month. Data were analyzed to determine changes in medication-prescribing error frequency and characteristics occurring during the 9-year study period. Results: A total of 11 186 confirmed medication-prescribing errors with potential for adverse patient consequences were detected and averted during the study period. The annual number of errors detected increased from 522 in the index year 1987 to 2115 in 1995. The rate of errors occurring per order written, per admission, and per patient-day, all increased significantly during the study duration (P<.001). Increased error rates were correlated with the number of admissions (P<.001). Antimicrobials, cardiovascular agents, gastrointestinal agents, and narcotics were the most common medication classes involved in errors. The most common type of errors were dosing errors, prescribing medications to which the patient was allergic, and prescribing inappropriate dosage forms. Conclusions: The results of this study suggest there may exist a progressively increasing risk of adverse drug events for hospitalized patients. The increased rate of errors is possibly associated with increases in the intensity of medical care and use of drug therapy. Limited changes in the characteristics of prescribing errors occurred, as similar type errors were found to be repeated with increasing frequency. New errors were encountered as new drug therapies were introduced. Health care practitioners and health care systems must incorporate adequate error reduction, prevention, and detection mechanisms into the routine provision of care.Arch Intern Med. 1997;157:1569-1576 References 1. Brennan TA, Leape LL, Laird N, et al. Incidence of adverse effects and negligence in hospitalized patients: results of the Harvard Medical Practice Study I . N Engl J Med. 1991;324:370-376.Crossref 2. Leape LL, Brennan T, Laird L, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II . N Engl J Med. 1991; 324:377-384.Crossref 3. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention . JAMA. 1995;274:29-34.Crossref 4. Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse events in hospitalized patients . J Gen Intern Med. 1993;8:289-294.Crossref 5. Leape LL, Bates DWE, Cullen DJ, et al. Systems analysis of adverse drug events . JAMA. 1995;274:35-43.Crossref 6. Ferner RE, Whittington RM. Coroner's cases of death due to errors in prescribing or giving medicines or to adverse drug reactions: Birmingham 1986-1991 . J R Soc Med. 1994;87:145-148. 7. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape LL. Relationship between medication errors and adverse drug events . J Gen Intern Med. 1995;10:199-205.Crossref 8. Folli HL, Poole RL, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two childrens hospitals . Pediatrics. 1987;19:719-722. 9. Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital . JAMA. 1990;263:2329-2334.Crossref 10. Lesar TS, Briceland LL, Stein D. Analysis of factors related to medication prescribing errors . JAMA. 1997;277:312-317.Crossref 11. Blum KV, Abel SR, Urbanski CJ, Pierce JM. Medication error prevention by pharmacists . Am J Hosp Pharm. 1988;45:1902-1903. 12. Steel K, Gertman PM, Crescenzi C, Anderson J. Iatrogenic illness on a general medical service at a university hospital . N Engl J Med. 1981;304:638-642.Crossref 13. Medication Error Study . Philadelphia, Pa: Physicians Insurers Association of America; 1993. 14. Dubois RW, Brook RH. Preventable deaths: who, how often, why? Ann Intern Med. 1988;109:582-589.Crossref 15. Schiff GD, Hegde HK, LaCloche L, Hryhorczuk DO. Inpatient theophylline toxicity: preventable factors . Ann Intern Med. 1991;114:748-753.Crossref 16. Greenberger PA, Cranberg JA, Ganz M, Hubler GL. A prospective evaluation of elevated serum theophylline concentrations to determine if high concentrations are predictable . Am J Med. 1991;91:67-73.Crossref 17. Wu AW, Folkman S, McPhee S, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094.Crossref 18. Vincer MJ, Murray JM, Yuill A, Allen A, Evans J, Stinson D. Drug errors and incidents in a neonatal intensive care unit . AJDC. 1989;143:737-740. 19. Edgar TA, Le DS, Cousins DD. Experience with a national medication error reporting program . Am J Hosp Pharm. 1994;51:1335-1338. 20. Pearson TF, Pittman DG, Lonley JM, Grapes T, Vigliotti DJ, Mullis SR. Factors associated with preventable adverse drug reactions . Am J Hosp Pharm. 1994; 51:2268-2272. 21. Schumock GT, Guenette AJ, Keys TW, Hutchinson RW. Prescribing errors for patients about to be discharged from a university teaching hospital . Am J Hosp Pharm. 1994;51:2288-2290. 22. Morrill GB, Barreuther C. Screening discharge prescriptions . Am J Hosp Pharm. 1988;45:1904-1905. 23. Chan CY, Maxwell PR, Koger CA, Gamboa CD, Brewer JG. Screening discharge prescriptions on a pediatric ward . Am J Hosp Pharm. 1990;47:2060-2061. 24. Rupp MT, DeYoung M, Schondelmeyer SW. Prescribing problems and pharmacists interactions in community practice . Med Care. 1992;30:926-940.Crossref 25. Beers MH, Ouslander JG, Fingold SF, et al. Inappropriate medication prescribing in skilled nursing facilities . Ann Intern Med. 1992;117:684-689.Crossref 26. Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton J. Psychotropic drug use and the risk of hip fracture . N Engl J Med. 1987;316:363-369.Crossref 27. Einerson TR. Drug related hospital admissions . Ann Pharmacother. 1993;27:832-840. 28. Hawkey CJ, Hodgson S, Norman A, Daneshmend TK, Garner ST. Effect of reactive pharmacy intervention on quality of hospital prescribing . BMJ. 1990;300:986-990.Crossref 29. Epstein M. Calcium antagonists should continue to be used for first-line treatment of hypertension . Arch Intern Med. 1995;155:2150-2156.Crossref 30. Weintraub M, Singh S, Byrne L, Maharaj K, Guttmacher L. Consequences of the 1989 New York State triplicate benzodiazepine prescription regulations . JAMA. 1991;266:2392-2397.Crossref 31. Vitillo J, Lesar T. Preventing medication prescribing errors . Ann Pharmacother. 1991;25:1388-1394. 32. Leape LL. Error in medicine . JAMA. 1994;272:1851-1857.Crossref 33. Lesar TS. Common prescribing errors . Ann Intern Med. 1992;117:537.Crossref 34. Lomaestro BL, Lesar TS. Methotrexate prescribing errors . Ann Intern Med. 1992; 268:2031-2032. 35. Lesar TS. Standardized dosing tables to reduce errors involving high-dose methylprednisolone for acute spinal cord injury . Hosp Pharm. 1994;29:935-938. 36. Lomaestro BL. More on the GUSTO trial . Ann Intern Med. 1994;121:818-819.Crossref 37. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury . ORB Qual Rev Bull. 1993;19:144-149. 38. Classen DC, Pestotnik SL, Evans S, et al. Adverse drug events in hospitalized patients . JAMA. 1997;277:301-306.Crossref 39. Blumenthal D. Making medical errors into 'medical treasures. ' JAMA. 1994;272:1867-1868.Crossref 40. Kahn KL. Above all 'do no harm:' how shall we avoid errors in medicine? JAMA. 1995;274:75-76.Crossref 41. The science of making mistakes . Lancet. 1995:345:871-872.Crossref 42. Ferner RE. Is there a cure for drug errors? BMJ. 1995;311:463-464.Crossref 43. Leape LL. Preventing adverse drug events . Am J Health Syst Pharm. 1995;52:379-382. 44. American Society of Hospital Pharmacists. Reports. Draft guidelines on preventable medication errors . Am J Hosp Pharm. 1992;49:640-648. 45. American Medical Association Board of Trustees Report. Medication (Drug) Errors in Hospitals . Chicago, Ill: American Medical Association; 1994. Resolution 512, I-93. 46. Johnston ME, Langton KB, Haynes B, Mathieu A. Effects of computer-based clinical decision support systems on clinical performance and patient outcome . Ann Intern Med. 1994;120:135-142.Crossref 47. Bates DW, Kuperman G, Teich JM. Computerized physician order entry and quality of care . Q Manage Health Care. 1994;2:18-27.Crossref 48. Bates DW, O'Neil AC, Boyle D, et al. Potential identifiability and preventability of adverse using information systems . J Am Med Inform Assoc. 1994;1:404-411.Crossref 49. Wyatt J, Walton R. Computer based prescribing . BMJ. 1995;311:1181-1182.Crossref 50. West DW, Levine S, Magram G, et al. Pediatric medication order error rates related to the mode of order transmission . Arch Pediatr Adolesc Med. 1994;148:1322-1326.Crossref 51. Pitterle M, Bond C, Raehl C, Franke T. Hospital and pharmacy characteristics associated with mortality rates in United States hospitals . Pharmacotherapy. 1994; 14:620-630. 52. Bjornsson DC, Hiner WO, Potyk RP, et al. Effect of pharmacists on health care outcomes in hospitalized patients . Am J Hosp Pharm. 1993;50:1875-1884. 53. McKenney JM, Wasserman AD. Effect of advanced pharmaceutical services on the incidence of adverse drug reactions . Am J Hosp Pharm. 1979;36:1691-1697. 54. Haig GM, Kiser LA. Effect of pharmacist participation on a medical team on costs, charges and length of stay . Am J Hosp Pharm. 1991;48:1457-1462. 55. Johnson JA, Bootman JL. Drug related morbidity and mortality: a cost of illness model . Arch Intern Med. 1995;155:1949-1956.Crossref 56. Schneider PJ, Gift MG, Lee Y-P, Rothermich EA, Sill BE. Cost of medication related problems at a university hospital . Am J Health Syst Pharm. 1995;52:2415-2418. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Medication-Prescribing Errors in a Teaching Hospital: A 9-Year Experience

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Publisher
American Medical Association
Copyright
Copyright © 1997 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1997.00440350075007
Publisher site
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Abstract

Abstract Background: Improved understanding of medication-prescribing errors should be useful in the design of error prevention strategies. Objective: To report analysis of a 9-year experience with a systematic program of detecting, recording, and evaluating medication-prescribing errors in a teaching hospital. Methods: All medication-prescribing errors with potential for adverse patient outcome detected and averted by staff pharmacists from January 1, 1987, through December 31, 1995, were systematically recorded and analyzed. Errors were evaluated by type of error, medication class involved, prescribing service, potential severity, time of day, and month. Data were analyzed to determine changes in medication-prescribing error frequency and characteristics occurring during the 9-year study period. Results: A total of 11 186 confirmed medication-prescribing errors with potential for adverse patient consequences were detected and averted during the study period. The annual number of errors detected increased from 522 in the index year 1987 to 2115 in 1995. The rate of errors occurring per order written, per admission, and per patient-day, all increased significantly during the study duration (P<.001). Increased error rates were correlated with the number of admissions (P<.001). Antimicrobials, cardiovascular agents, gastrointestinal agents, and narcotics were the most common medication classes involved in errors. The most common type of errors were dosing errors, prescribing medications to which the patient was allergic, and prescribing inappropriate dosage forms. Conclusions: The results of this study suggest there may exist a progressively increasing risk of adverse drug events for hospitalized patients. The increased rate of errors is possibly associated with increases in the intensity of medical care and use of drug therapy. Limited changes in the characteristics of prescribing errors occurred, as similar type errors were found to be repeated with increasing frequency. New errors were encountered as new drug therapies were introduced. Health care practitioners and health care systems must incorporate adequate error reduction, prevention, and detection mechanisms into the routine provision of care.Arch Intern Med. 1997;157:1569-1576 References 1. Brennan TA, Leape LL, Laird N, et al. Incidence of adverse effects and negligence in hospitalized patients: results of the Harvard Medical Practice Study I . N Engl J Med. 1991;324:370-376.Crossref 2. Leape LL, Brennan T, Laird L, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II . N Engl J Med. 1991; 324:377-384.Crossref 3. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention . JAMA. 1995;274:29-34.Crossref 4. Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse events in hospitalized patients . J Gen Intern Med. 1993;8:289-294.Crossref 5. Leape LL, Bates DWE, Cullen DJ, et al. Systems analysis of adverse drug events . JAMA. 1995;274:35-43.Crossref 6. Ferner RE, Whittington RM. Coroner's cases of death due to errors in prescribing or giving medicines or to adverse drug reactions: Birmingham 1986-1991 . J R Soc Med. 1994;87:145-148. 7. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape LL. Relationship between medication errors and adverse drug events . J Gen Intern Med. 1995;10:199-205.Crossref 8. Folli HL, Poole RL, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two childrens hospitals . Pediatrics. 1987;19:719-722. 9. Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital . JAMA. 1990;263:2329-2334.Crossref 10. Lesar TS, Briceland LL, Stein D. Analysis of factors related to medication prescribing errors . JAMA. 1997;277:312-317.Crossref 11. Blum KV, Abel SR, Urbanski CJ, Pierce JM. Medication error prevention by pharmacists . Am J Hosp Pharm. 1988;45:1902-1903. 12. Steel K, Gertman PM, Crescenzi C, Anderson J. Iatrogenic illness on a general medical service at a university hospital . N Engl J Med. 1981;304:638-642.Crossref 13. Medication Error Study . Philadelphia, Pa: Physicians Insurers Association of America; 1993. 14. Dubois RW, Brook RH. Preventable deaths: who, how often, why? Ann Intern Med. 1988;109:582-589.Crossref 15. Schiff GD, Hegde HK, LaCloche L, Hryhorczuk DO. Inpatient theophylline toxicity: preventable factors . Ann Intern Med. 1991;114:748-753.Crossref 16. Greenberger PA, Cranberg JA, Ganz M, Hubler GL. A prospective evaluation of elevated serum theophylline concentrations to determine if high concentrations are predictable . Am J Med. 1991;91:67-73.Crossref 17. Wu AW, Folkman S, McPhee S, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094.Crossref 18. Vincer MJ, Murray JM, Yuill A, Allen A, Evans J, Stinson D. Drug errors and incidents in a neonatal intensive care unit . AJDC. 1989;143:737-740. 19. Edgar TA, Le DS, Cousins DD. Experience with a national medication error reporting program . Am J Hosp Pharm. 1994;51:1335-1338. 20. Pearson TF, Pittman DG, Lonley JM, Grapes T, Vigliotti DJ, Mullis SR. Factors associated with preventable adverse drug reactions . Am J Hosp Pharm. 1994; 51:2268-2272. 21. Schumock GT, Guenette AJ, Keys TW, Hutchinson RW. Prescribing errors for patients about to be discharged from a university teaching hospital . Am J Hosp Pharm. 1994;51:2288-2290. 22. Morrill GB, Barreuther C. Screening discharge prescriptions . Am J Hosp Pharm. 1988;45:1904-1905. 23. Chan CY, Maxwell PR, Koger CA, Gamboa CD, Brewer JG. Screening discharge prescriptions on a pediatric ward . Am J Hosp Pharm. 1990;47:2060-2061. 24. Rupp MT, DeYoung M, Schondelmeyer SW. Prescribing problems and pharmacists interactions in community practice . Med Care. 1992;30:926-940.Crossref 25. Beers MH, Ouslander JG, Fingold SF, et al. Inappropriate medication prescribing in skilled nursing facilities . Ann Intern Med. 1992;117:684-689.Crossref 26. Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton J. Psychotropic drug use and the risk of hip fracture . N Engl J Med. 1987;316:363-369.Crossref 27. Einerson TR. Drug related hospital admissions . Ann Pharmacother. 1993;27:832-840. 28. Hawkey CJ, Hodgson S, Norman A, Daneshmend TK, Garner ST. Effect of reactive pharmacy intervention on quality of hospital prescribing . BMJ. 1990;300:986-990.Crossref 29. Epstein M. Calcium antagonists should continue to be used for first-line treatment of hypertension . Arch Intern Med. 1995;155:2150-2156.Crossref 30. Weintraub M, Singh S, Byrne L, Maharaj K, Guttmacher L. Consequences of the 1989 New York State triplicate benzodiazepine prescription regulations . JAMA. 1991;266:2392-2397.Crossref 31. Vitillo J, Lesar T. Preventing medication prescribing errors . Ann Pharmacother. 1991;25:1388-1394. 32. Leape LL. Error in medicine . JAMA. 1994;272:1851-1857.Crossref 33. Lesar TS. Common prescribing errors . Ann Intern Med. 1992;117:537.Crossref 34. Lomaestro BL, Lesar TS. Methotrexate prescribing errors . Ann Intern Med. 1992; 268:2031-2032. 35. Lesar TS. Standardized dosing tables to reduce errors involving high-dose methylprednisolone for acute spinal cord injury . Hosp Pharm. 1994;29:935-938. 36. Lomaestro BL. More on the GUSTO trial . Ann Intern Med. 1994;121:818-819.Crossref 37. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury . ORB Qual Rev Bull. 1993;19:144-149. 38. Classen DC, Pestotnik SL, Evans S, et al. Adverse drug events in hospitalized patients . JAMA. 1997;277:301-306.Crossref 39. Blumenthal D. Making medical errors into 'medical treasures. ' JAMA. 1994;272:1867-1868.Crossref 40. Kahn KL. Above all 'do no harm:' how shall we avoid errors in medicine? JAMA. 1995;274:75-76.Crossref 41. The science of making mistakes . Lancet. 1995:345:871-872.Crossref 42. Ferner RE. Is there a cure for drug errors? BMJ. 1995;311:463-464.Crossref 43. Leape LL. Preventing adverse drug events . Am J Health Syst Pharm. 1995;52:379-382. 44. American Society of Hospital Pharmacists. Reports. Draft guidelines on preventable medication errors . Am J Hosp Pharm. 1992;49:640-648. 45. American Medical Association Board of Trustees Report. Medication (Drug) Errors in Hospitals . Chicago, Ill: American Medical Association; 1994. Resolution 512, I-93. 46. Johnston ME, Langton KB, Haynes B, Mathieu A. Effects of computer-based clinical decision support systems on clinical performance and patient outcome . Ann Intern Med. 1994;120:135-142.Crossref 47. Bates DW, Kuperman G, Teich JM. Computerized physician order entry and quality of care . Q Manage Health Care. 1994;2:18-27.Crossref 48. Bates DW, O'Neil AC, Boyle D, et al. Potential identifiability and preventability of adverse using information systems . J Am Med Inform Assoc. 1994;1:404-411.Crossref 49. Wyatt J, Walton R. Computer based prescribing . BMJ. 1995;311:1181-1182.Crossref 50. West DW, Levine S, Magram G, et al. Pediatric medication order error rates related to the mode of order transmission . Arch Pediatr Adolesc Med. 1994;148:1322-1326.Crossref 51. Pitterle M, Bond C, Raehl C, Franke T. Hospital and pharmacy characteristics associated with mortality rates in United States hospitals . Pharmacotherapy. 1994; 14:620-630. 52. Bjornsson DC, Hiner WO, Potyk RP, et al. Effect of pharmacists on health care outcomes in hospitalized patients . Am J Hosp Pharm. 1993;50:1875-1884. 53. McKenney JM, Wasserman AD. Effect of advanced pharmaceutical services on the incidence of adverse drug reactions . Am J Hosp Pharm. 1979;36:1691-1697. 54. Haig GM, Kiser LA. Effect of pharmacist participation on a medical team on costs, charges and length of stay . Am J Hosp Pharm. 1991;48:1457-1462. 55. Johnson JA, Bootman JL. Drug related morbidity and mortality: a cost of illness model . Arch Intern Med. 1995;155:1949-1956.Crossref 56. Schneider PJ, Gift MG, Lee Y-P, Rothermich EA, Sill BE. Cost of medication related problems at a university hospital . Am J Health Syst Pharm. 1995;52:2415-2418.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 28, 1997

References