Why medication mistakes occur in hospitals

[NRSKarenRN, BSN, RN]

LA Times December 9, 2002

Why mistakes occur in hospitals

An exhaustive study zeroes in on dangerous errors in medication.

By Linda Marsa

Times Staff Writer

December 9 2002

http://www.latimes.com/news/printedition/health/la-he-errors9dec09,0,6478095.story?coll=la%2Dheadlines%2Dpe%2Dhealth

Hospital medication errors occur with alarming frequency, studies have shown, causing thousands of injuries and deaths each year. Now research has pinpointed exactly where, and how often, those mistakes occur.

United States Pharmacopeia, which establishes quality standards for medicines, announced the results last week of the most exhaustive study to date on hospital medication errors. The report said most errors involved the omission of prescribed drugs, dispensing the wrong drug, improper dosages and failure to properly administer prescribed medications. Such information is essential to devising effective strategies to prevent mistakes, said Diane D. Cousins, a USP vice president.

Since a 1999 Institute of Medicine report, which revealed that at least 7,000 Americans die each year from medication errors, hospitals have sought ways to increase patient safety. The new findings show errors are still rampant and underscore the need for patients to be vigilant, even in a setting that seems to be safe, the study's authors said.

The report analyzed medication mistakes in 2001 at 368 community, government and teaching hospitals nationwide, representing slightly more than 6% of the 5,890 hospitals in the United States. Of the 105,603 errors recorded, most were corrected before harm was done, but in 2.4% of the cases, patients were injured. Some required prolonged hospitalization in intensive care, and 14 died.

Most of the injuries were caused by improper administration techniques, such as the incorrect dilution of intravenous drugs or improper dosages of drugs. Incorrect computer entries, poor communication, inaccurate records in patient charts and unclear handwriting were other sources of errors.

The report also identified five "high alert" medications -- insulin, morphine, potassium chloride and the anticoagulants heparin and warfarin -- that have a higher risk of patient injury when dispensed incorrectly. Because the drugs are so often used, the potential for harm is significant. Errors administering these medications were responsible for nearly 28% of medication errors that resulted in extended hospitalizations and death. Insulin alone accounted for about a third of that figure.

Consumers have a responsibility as well, Cousins said, and need to be well-informed and aware of what medicines they're being given. One mishap, for instance, was averted by a patient who noticed a pill was a different color from the one the nurse had dispensed earlier.

"Patients should know what medications they're taking and be involved," Cousins said. "In the case of an acutely ill patient, a friend or family member should be their advocate."

But patient awareness is only part of the solution, experts say. "Hospitals and state oversight agencies need to be more proactive," said Michael R. Cohen, president of the nonprofit Institute for Safe Medication Practices in Huntington Valley, Pa. "If efforts were focused on these known hazards, errors could be drastically reduced."

*--* Reasons for errors The 105,603 errors in the United States Pharmacopeia report fall into 11 categories. Because some errors had more than one cause, the numbers add up to more than 100% Type of error Percentage of total errors

Omission 29%

Improper dose 21

Prescribing 14

Unauthorized drug 13

Wrong time 7

Extra dose 7

Wrong patient 5

Wrong drug prep 4

Wrong dosage form 2

Wrong route 2

Wrong administrative technique 1

*--*

Source: United States Pharmacopeia