TABLE C-3 Hospital Care: Administration Errors

Error rates: general medications

Per 100 opportunities/doses—detection method

2.4 (Taxis et al., 1999) (German part, unit dose system)—direct observation

3 (Dean et al., 1995) (U.K. part)—direct observation

5.1 (Taxis et al., 1999) (German part, traditional system)—direct observation

6.7 (Lisby et al., 2005) (Danish study)—direct observation

6.9 (Dean et al., 1995) (U.S. part)—direct observation

8 (Taxis et al., 1999) (U.K. part)—direct observation

10.8 (Barker et al., 2002)—direct observation

14.9 (Tissot et al., 2003) (French study)—direct observation

Error rates: general medications

Per 1,000 admissions—detection method

5.8 (Winterstein et al., 2004)—prompted reports

Error rates in intensive care units (ICUs)

Per opportunity/dose—detection method

3.3 percent (Calabrese et al., 2001)—direct observation

6.6 percent (Tissot et al., 1999)—direct observation

Error rates: IV medications only

Per opportunity/dose—detection method

34 percent (Wirtz et al., 2003) (U.K. and German study)—direct observation

49 percent (Taxis and Barber, 2003) (U.K. study) (includes both preparation and administration)—direct observation

Preventable ADEs

Per 1,000 admissions—detection method

2.1 (Bates et al., 1995b)—prompted reporting, chart review

17.9 (Nebeker et al., 2005)—review of electronic medical record

for error or dose ranged from 2.4 to 14.9 percent: (1) 2.4 percent in a German hospital using a unit dose system (1,318 opportunities for error) (Taxis et al., 1999); (2) 3 percent in a U.K. tertiary hospital (2,756 opportunities for error) (Dean et al., 1995); (3) 5.1 percent in a German hospital using a traditional system (973 opportunities for error) (Taxis et al., 1999); (4) 6.7 percent in a Danish tertiary hospital (2,467 opportunities for error) (Lisby et al., 2005); (5) 6.9 percent in a U.S. tertiary hospital (919 opportunities for error) (Dean et al., 1995); (6) 8 percent in a U.K. hospital using a ward pharmacy system (842 opportunities for error) (Taxis et al., 1999); (7) 10 percent (excluding wrong time errors) in 24 hospitals in Georgia and Colorado (2,765 medication doses) (Barker et al., 2002); and (8) 11 percent (excluding wrong-time errors) (Tissot et al., 2003) in a French tertiary hospital (523 opportunities for error).



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement