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Preventing Medication Errors
TABLE 3-8 Distribution of Errors by System Failure
Errors Attributed
System Failure
%
No.
Drug knowledge dissemination
29
98
Dose and identity checking
12
40
Patient information availability
11
37
Order transcription
9
29
Allergy defense
7
24
Medication order tracking
5
18
Interservice communication
5
17
Device use
4
12
Standardization of doses and frequencies
4
12
Standardization of drug distribution within unit
3
11
Standardization of procedures
3
10
Preparation of intravenous medications
2
6
Transfer/transition procedures
1
4
Conflict resolution
1
4
Others
4
12
TOTALS
100
334
SOURCE: Leape et al., 1995.
lower bounds since the second Brigham and Women’s study (Jha et al., 1998), using more comprehensive detection methods, reported higher rates.
A high proportion of preventable ADEs are caused by system errors that could be eliminated by computerized provider order entry (CPOE).
Sophisticated decision-support tools that address dosing, prophylaxis, and patient monitoring, among other issues, must be built into CPOE systems.
Nursing Homes
Two studies estimated the incidence of preventable ADEs in long-term care (see Table 3-9). Their findings were as follows:
TABLE 3-9 Rates of Preventable ADEs in Nursing Homes
Study
Preventable ADE Rate per Patient Month
Proportion of ADEs Preventable (No. of ADEs in study)
